ORCID Profile
0000-0001-9065-0899
Current Organisations
Monash University
,
Baker IDI Heart and Diabetes Institute
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Publisher: Elsevier BV
Date: 07-2012
Publisher: Elsevier BV
Date: 1996
Abstract: To determine the prevalence of left ventricular diastolic dysfunction in patients with biopsy specimen-proved pulmonary sarcoidosis without clinical evidence of cardiac disease. A cross-sectional study. A large tertiary care university teaching hospital. Fifty consecutive subjects had biopsy specimen-proved pulmonary sarcoidosis without suspected cardiac involvement. Those with other conditions known to affect diastolic function were excluded. The control group comprised 30 healthy hospital workers. Clinical examination, 12-lead ECG, and combined echocardiographic honocardiographic examination. Indexes of left ventricular diastolic function, including isovolumic relaxation time, peak velocity of early (E) and late (A) ventricular filling, deceleration rate of early diastolic flow, and the sum of the time velocity integrals of E and A were obtained in each patient and control subject. Systolic function was determined using a modification of Simpson's rule. Diastolic dysfunction was present in 7 (14%) patients, 6 of whom had normal systolic function and normal two-dimensional echocardiographic examination. Those with diastolic dysfunction had a longer duration of illness (15 +/- 7 vs 6 +/- 5 years p = 0.0004), were significantly older (52 +/- 11 vs 38 +/- 9 years p = 0.0009), and had higher systolic BP (130 +/- 13 vs 117 +/- 12 mm Hg p = 0.01) than the sarcoid patients with normal diastolic function. These results demonstrate a significant prevalence of left ventricular diastolic dysfunction in patients with pulmonary sarcoidosis. The cause of this abnormality may be a subclinical sarcoid cardiomyopathy.
Publisher: Elsevier BV
Date: 12-1995
DOI: 10.1016/0002-8703(95)90142-6
Abstract: The efficacy of myocardial perfusion imaging for cardiac-risk stratification of patients undergoing vascular surgery has been disputed recently. In comparison with conventional techniques, positron emission tomography (PET) has the benefit of permitting a true resting scan, allows accurate measurement of the extent of ischemia, and is highly specific for the diagnosis of coronary disease. We therefore investigated the use of PET for risk stratification at the time of vascular surgery and subsequent follow-up in 78 patients (aged 67 +/- 11 years, 52 men), selected for testing before the performance of extensive surgery or because of one or more clinical risk factors. Perfusion images were obtained by using a standard rubidium 82 protocol before and after dipyridamole-handgrip stress. With use of a quantitative color scale in a 24-segment model of the left ventricle, scans were reported as showing normal perfusion, resting defects, or stress-induced defects (deterioration > 15% with stress). After exclusion of 6 patients referred for myocardial revascularization, 72 patients were followed up in the perioperative period and for 18 +/- 12 months for late cardiac death, myocardial infarction, or unstable angina. Perioperative events occurred in 14 patients (5 with myocardial infarction and 9 with unstable angina), 10 of whom had ischemia at PET (sensitivity, 71% predictive value of a positive test, 45%). Isolated resting perfusion defects were not associated with events. The presence of extensive ischemia (more than five segments) had a positive predictive value of 64%, and its absence gave a negative predictive value of 89%.(ABSTRACT TRUNCATED AT 250 WORDS)
Publisher: Elsevier BV
Date: 07-1987
DOI: 10.1016/S0168-8227(87)80043-8
Abstract: The glycemic response following ingestion of carbohydrate in various forms is different. The factors involved are not fully elucidated. In this study the glycemic and insulin responses to 50 g of carbohydrate in the form of white bread (WB), semolina bread (SB), white spaghetti (WS) and wholemeal spaghetti (BS) were compared in ten noninsulin-dependent diabetics. The responses were assessed by calculating the area under the curve. WB and SB had significantly higher glycemic responses compared with WS and BS (P less than 0.01). There was no difference in glycemic response between either form of bread, or either type of spaghetti. Similarly WB and SB had greater insulin responses than WS and BS (P less than 0.05). There was no difference in insulin response between WB and SB but BS had a greater response than WS (P less than 0.01) attributed to the higher protein content of BS. Thus, in this study the physical form of the food was a major factor influencing the glycemic response, and other factors such as particle size and fibre content had negligible effects.
Publisher: Elsevier BV
Date: 10-2020
Publisher: Elsevier BV
Date: 05-2021
Publisher: Elsevier BV
Date: 12-2005
DOI: 10.1016/J.AMJCARD.2005.07.091
Abstract: The metabolic syndrome (MS) is associated with cardiovascular risk exceeding that expected from atherosclerotic risk factors, but the mechanism of this association is unclear. We sought to determine the effects of the MS on myocardial and vascular function and cardiorespiratory fitness in 393 subjects with significant risk factors but no cardiovascular disease and negative stress echocardiographic findings. Myocardial function was assessed by global strain rate, strain, and regional systolic velocity (s(m)) and diastolic velocity (e(m)) using tissue Doppler imaging. Arterial compliance was assessed using the pulse pressure method, involving simultaneous radial applanation tonometry and echocardiographic measurement of stroke volume. Exercise capacity was measured by expired gas analysis. Significant and incremental variations in left ventricular systolic (s(m), global strain, and strain rate) and diastolic (e(m)) function were found according to the number of components of MS (p <0.001). MS contributed to reduced systolic and diastolic function even in those without left ventricular hypertrophy (p <0.01). A similar dose-response association was present between the number of components of the MS and exercise capacity (p <0.001) and arterial compliance. The global strain rate and e(m) were independent predictors of exercise capacity. In conclusion, subclinical left ventricular dysfunction corresponded to the degree of metabolic burden, and these myocardial changes were associated with reduced cardiorespiratory fitness. Subjects with MS who also have subclinical myocardial abnormalities and reduced cardiorespiratory fitness may have a higher risk of cardiovascular disease events and heart failure.
Publisher: Springer Science and Business Media LLC
Date: 26-08-2004
Publisher: Elsevier BV
Date: 06-2015
Publisher: Elsevier BV
Date: 11-2020
Publisher: Springer Berlin Heidelberg
Date: 2009
Publisher: Elsevier
Date: 2022
Publisher: Oxford University Press (OUP)
Date: 28-07-2009
Abstract: Both contrast enhanced (CE) two-dimensional echocardiography (2DE) and three-dimensional echocardiography (3DE) have been proposed as techniques to improve the accuracy of left ventricular (LV) volume measurements. We sought to examine the accuracy of non-contrast (NC) and CE-2DE and 3DE for calculation of LV volumes and ejection fraction (EF), relative to cardiac magnetic resonance imaging (MRI). We studied 50 patients (46 men, age 63 +/- 10 year) with past myocardial infarction who underwent echocardiographic assessment of LV volume and function. All patients sequentially underwent NC-2DE followed by NC-3DE. CE-2DE and CE-3DE were acquired during contrast infusion. Resting echocardiographic image quality was evaluated on the basis of NC-2DE. The mean LV end-diastolic volume (LVEDV) of the group by MRI was 207 +/- 79 mL and was underestimated by 2DE (125 +/- 54 mL, P = 0.005), and less by CE-2DE (172 +/- 58 mL, P = 0.02) or 3DE (177 +/- 64 mL, P = 0.08), but EDV was comparable by CE-3DE (196 +/- 69 mL, P = 0.16). Limits of agreement with MRI were similar for NC-3DE and CE-2DE, with the best results for CE-3D. Results were similar for calculation of LVESV. Patients were categorized into groups of EF ( 50%) by MRI. NC-2DE demonstrated a 68% agreement (kappa 0.45, P = 0.001), CE-2DE a 62% agreement (kappa 0.20, P = 136), NC-3DE a 74% agreement (kappa 0.39, P = 0.005) and CE-3DE an 80% agreement (kappa 0.56, P < 0.001). CE-2DE is analogous to NC-3DE in accurate categorization of LV function. However, CE-3DE is feasible and superior to other NC- and CE-techniques in patients with previous infarction.
Publisher: Oxford University Press (OUP)
Date: 02-06-1997
DOI: 10.1093/EURHEARTJ/18.SUPPL_D.31
Abstract: Adenosine is a naturally occurring vasodilator which has been used for the induction of maximal coronary hyperaemia in the cardiac catheterization laboratory and in conjunction with myocardial perfusion scintigraphy. Its use as a stress agent with echocardiography is dependent upon the development of coronary steal. The sensitivity of adenosine stress echocardiography has been reported to be quite variable, depending on the nature of the population studied. However, in in iduals without previous myocardial infarction, the test has a poor sensitivity, particularly in patients with single vessel coronary disease. Moreover, although the agent is safe, troublesome side effects are frequent. The combination of lower sensitivity than competing techniques, side effects, and cost do not favour the combination of adenosine stress with echocardiography.
Publisher: Elsevier BV
Date: 04-2018
DOI: 10.1016/J.JCMG.2017.12.019
Abstract: Evaluation of the left atrium and left atrial appendage for the presence of thrombus prior to cardioversion and pulmonary vein isolation, and of the entire heart for embolic sources in the setting of cryptogenic stroke, has long been standard medical care. Guidelines have uniformly recommended transesophageal echocardiography (TEE) to accomplish these goals. In recent years, computed tomographic angiography has demonstrated diagnostic accuracy similar to that of TEE for the detection of thrombus. Analysis of the pertinent data and relative merits of the 2 technologies leads to the conclusions that: 1) both modalities have some unique, nonoverlapping capabilities that may dictate their use in specific situations 2) computed tomographic angiography is a reasonable alternative to TEE when the primary aim is to exclude left atrial and left atrial appendage thrombus and in patients in whom the risks associated with TEE outweigh the benefits and 3) both options should be discussed with the patient in the setting of shared decision making.
Publisher: Elsevier BV
Date: 12-1998
DOI: 10.1016/S0002-9149(98)00689-4
Abstract: Dipyridamole single-photon emission computed tomography (SPECT) has a high negative predictive value for perioperative cardiac events, but events are infrequent in patients with a positive test. In contrast, dipyridamole echocardiography is more selective for detection of multivessel disease and thus may have a greater specificity for cardiac events. We therefore compared the ability of dipyridamole SPECT and echocardiography to predict perioperative and long-term cardiac events in 133 patients referred for vascular surgery. The group was also evaluated based on clinical features and ejection fraction. Four patients had surgery cancelled because of high risk and were excluded from further analysis. Among the 129 remaining patients, 21 had coronary revascularization (n=12) or an early cardiac end point (n=9). The sensitivity of SPECT for the prediction of early events (90%) was not significantly different from that of echocardiography (66%, p=NS). The specificity of SPECT (68%) was less than that of echocardiography (88%, p or = 1 event: 6 died from cardiac causes, 4 underwent revascularization, and 3 had myocardial infarction. Thus, the specificity of SPECT and echocardiography for late events were 58% and 80%, respectively (p <0.001). The 3-year survival of patients without ischemia during echocardiography or at SPECT was not different (93% vs 94%, p=NS).
Publisher: Oxford University Press (OUP)
Date: 13-06-2008
Abstract: Transmural extent (TME) of myocardial scar, contractile reserve, and perfusion all predict improvement in regional myocardial function after coronary revascularization. We sought their association with regional remodelling after infarction. We studied 89 patients (age 62 +/- 10 years) with left ventricular (LV) dysfunction, at least 1 month post infarction. Viability was identified by TME 60% uptake on delayed redistribution on TI-201 SPECT (single photon emission computed tomography). Coronary revascularization was performed in 36 patients. Regional LV end-diastolic volume (EDV) and end-systolic volume, and ejection fraction were measured with MRI at baseline and after a median follow-up of 18 months. Of 357 segments identified with subendocardial infarction (TME 0-25%) on ce-MRI, 176 were revascularized. Subendocardial scar segments were associated with reverse regional remodeling during follow-up. Revascularization was an independent correlate of change in EDV, but TME and revascularization showed no interaction with respect to their influence on regional volumes. Contractile reserve was present on DbE in 228 segments, of which 129 were TME 0-25% remodelling was associated with intervention in non-transmural infarcts showing viability by DbE. Viability was identified by TI-201 SPECT in 381 segments (233 with TME 0-25%), but viability by SPECT was not associated with reverse remodelling. No significant reverse remodelling occurred in segments with intermediate scar thickness (TME 26-75%) or transmural scar, independent of revascularization or viability by DbE or TI-SPECT. Reverse regional remodelling is associated with subendocardial infarction, especially in the setting of contractile reserve and revascularization.
Publisher: Springer Science and Business Media LLC
Date: 11-06-2009
DOI: 10.1038/JHH.2009.43
Abstract: The prevalence of diabetes is escalating, and is leading to increased rates of heart failure, myocardial infarction and cardiovascular death. Due to several inter-related biological processes, hypertension is often associated with diabetes, and accelerates these morbid conditions. These points are outlined below.
Publisher: Elsevier BV
Date: 08-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2011
DOI: 10.2215/CJN.06880810
Abstract: Vitamin D is an established important contributor to muscle function and aerobic metabolism. Hypovitaminosis D is highly prevalent in CKD patients and is associated with increased cardiovascular (CV) mortality via unknown mechanisms. Because aerobic-exercise capacity strongly predicts future CV events, we hypothesized that vitamin D status could be linked to CV outcomes via an effect on maximum aerobic-exercise capacity in patients with CKD and that this effect may be mediated in part via its actions on muscle strength and functional ability. Baseline demographic, anthropometric, and biochemical data were collected in a cross-sectional study of patients with moderate CKD. Peak aerobic capacity was determined during treadmill stress testing using metabolic equivalence of tasks. Physical activity was assessed using the Active Australia questionnaire, grip strength by dynamometer, and functional capacity by “Up & Go” testing. The study included 85 participants (age 59.5 ± 9.7 years, 60% male, 44% diabetic, 92% Caucasian mean serum 25-hydroxyvitamin D [25-OHD] 78.4 ± 29.4 nmol/L). We demonstrated that 25-OHD status was independently associated with aerobic-exercise capacity (β = 0.2 P = 0.008). Aerobic-exercise capacity was also predicted by younger age, white race, smaller waist circumference, absence of a previous angina history, and increasing weekly physical activity. However, neither muscle strength nor functional ability were significantly associated with 25-OHD. Vitamin D is independently associated with aerobic capacity in CKD patients, and this finding is not explained by changes in muscle strength or functional ability.
Publisher: Elsevier BV
Date: 12-1997
DOI: 10.1016/S0002-8703(97)70025-5
Abstract: Mitral valve prolapse is sometimes associated with chest pain, but this symptom may also be caused by coexisting coronary disease. The accuracy of exercise echocardiography in diagnosing coronary disease in these patients and the most cost-efficient diagnostic approach are unclear. We studied 96 patients (aged 59 +/- 12 years 70 men) with mitral valve prolapse who underwent exercise electrocardiography, exercise echocardiography, and coronary angiography. The accuracies of seven diagnostic strategies based on the current and expected use of exercise electrocardiography and exercise echocardiography in patients with mitral valve prolapse were examined, with the costs calculated based on Medicare reimbursement. Thirteen (13.5%) patients had significant coronary artery disease. The sensitivity and specificity of exercise electrocardiography in the 71 patients with interpretable electrocardiograms were 50% and 72%, respectively. For the 73 patients who achieved >85% of maximal heart rate, 52 had interpretable exercise electrocardiograms (sensitivity 50% specificity 69%). Exercise echocardiography had a sensitivity of 69% and a specificity of 98% in the 96 patients and a sensitivity of 82% and a specificity of 96% in patients who achieved >85% of maximal heart rate. Approaches adopting Bayes' theorem and restricting further investigation to patients with at least intermediate pretest probability of coronary disease were the least costly. When combined with exercise echocardiography as the initial test, clinical stratification was associated with a false-negative rate of 21%. The utility of exercise electrocardiography is limited by the high prevalence of resting electrocardiographic abnormalities and suboptimal sensitivity and specificity. The best balance of cost and diagnostic accuracy is to perform exercise echocardiography in patients with at least intermediate probability of coronary artery disease.
Publisher: Elsevier BV
Date: 02-2013
DOI: 10.1053/J.AJKD.2012.09.008
Abstract: Abnormalities of cardiac structure and function are common in patients undergoing dialysis, and cardiovascular disease is the major cause of mortality in this group. Heart failure is a common clinical manifestation of cardiovascular disease and is preceded by left ventricular hypertrophy (LVH). There are variable reports about the impact of dialysis on LVH, both deleterious and beneficial. Our study investigated whether the timing of the initiation of dialysis therapy had an impact on cardiac structure and function. Randomized controlled trial. This is a cardiac substudy involving 182 patients with stage 5 chronic kidney disease in the IDEAL (Initiating Dialysis Early and Late) trial. The IDEAL trial randomly assigned patients on the basis of estimated glomerular filtration rate (eGFR), calculated using the Cockcroft-Gault equation, to start dialysis therapy early (GFR, 10-14 mL/min/1.73 m(2)), with the others starting late (GFR, 5-7 mL/min/1.73 m(2)). Echocardiograms were obtained at baseline and 12 months after randomization. Primary outcomes were change in left ventricular mass indexed for height (LVMi) between baseline and 12 months, left ventricular ejection fraction, left ventricular systolic annular velocity, ratio of mitral inflow velocity (E) to mitral annular velocity (Ea) (E/Ea), and left atrial volume indexed for height (LAVi). LVMi at baseline was elevated, but similar in both groups, with no significant change within or between groups at 12 months. E/Ea and LAVi were increased at baseline, consistent with significant diastolic dysfunction there were no differences between groups at 12 months and no changes were observed for left ventricular volumes, left ventricular ejection fraction, stroke volume, and other echocardiographic parameters. Small multicenter study using echocardiography. Advanced cardiac disease in these patients with stage 5 chronic kidney disease did not progress during the 12-month study period and planned early initiation of dialysis therapy did not result in differences in any echocardiographic variables of cardiac structure and function.
Publisher: AMPCo
Date: 08-2014
DOI: 10.5694/MJA14.00032
Abstract: The National Heart Foundation of Australia assembled an expert panel to provide guidance on policy and system changes to improve the quality of care for people with chronic heart failure (CHF). The recommendations have the potential to reduce emergency presentations, hospitalisations and premature death among patients with CHF. Best-practice management of CHF involves evidence-based, multidisciplinary, patient-centred care, which leads to better health outcomes. A CHF care model is required to achieve this. Although CHF management programs exist, ensuring access for everyone remains a challenge. This is particularly so for Aboriginal and Torres Strait Islander peoples, those from non-metropolitan areas and lower socioeconomic backgrounds, and culturally and linguistically erse populations. Lack of data and inadequate identification of people with CHF prevents efficient patient monitoring, limiting information to improve or optimise care. This leads to ineffectiveness in measuring outcomes and evaluating the CHF care provided. Expanding current cardiac registries to include patients with CHF and developing mechanisms to promote data linkage across care transitions are essential. As the prevalence of CHF rises, the demand for multidisciplinary workforce support will increase. Workforce planning should provide access to services outside of large cities, one of the main challenges it is currently facing. To enhance community-based management of CHF, general practitioners should be empowered to lead care. Incentive arrangements should favour provision of care for Aboriginal and Torres Strait Islander peoples, those from lower socioeconomic backgrounds and rural areas, and culturally and linguistically erse populations. Ongoing research is vital to improving systems of care for people with CHF. Future research activity needs to ensure the translation of valuable knowledge and high-quality evidence into practice.
Publisher: Elsevier BV
Date: 11-2012
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2008
Publisher: Elsevier BV
Date: 12-2012
DOI: 10.1016/J.ECHO.2012.09.019
Abstract: Longitudinal strain (LS) imaging is an important tool for the quantification of left ventricular function and deformation, but its assessment is challenging in the presence of echocardiographic contrast agents (CAs). The aim of this study was to test the hypothesis that destruction of microbubbles using high mechanical index (MI) could allow the measurement of LS. LS was measured using speckle strain (speckle-tracking LS [STLS]) and Velocity Vector Imaging (VVI) before and after CA administration in 30 consecutive patients. Low MI was used for left ventricular opacification and three-dimensional high MI for microbubble destruction. Four different settings were tested over 60 sec: (1) baseline LS without contrast, (2) LS after CA administration with low MI (0.3), (3) LS after CA administration with high MI (0.9), and (4) LS after microbubble destruction with high MI and three-dimensional imaging. Baseline feasibility of LS assessment (99.3% and 98.2% with STLS and VVI, respectively) was reduced after CA administration using STLS at low (69%, P < .0001) and high (95.4%, P = .0002) MI as well as with VVI (93.8%, P = .004, and 84.7%, P < .0001, respectively). STLS assessment was feasible with high MI after microbubble destruction (1.7% of uninterpretable segments vs 0.7%, P = .26) but not using VVI (7.2% vs 1.8%, P < .001). Regardless of which microbubbles or image settings were used, VVI was associated with significant variability and overestimation of global LS (for low MI, +4.7%, P < .01 for high MI, +3.3%, P < .001 for high MI after microbubble destruction, +1.3%, P = .04). LS assessment is most feasible without contrast. If a CA is necessary, the calculation of LS is feasible using the speckle-tracking method, if three-dimensional imaging is used as a tool for microbubble destruction 1 min after CA administration.
Publisher: American Diabetes Association
Date: 07-2005
DOI: 10.2337/DIACARE.28.7.1643
Abstract: OBJECTIVE—Type 2 diabetes is associated with reduced exercise capacity, but the cause of this association is unclear. We sought the associations of impaired exercise capacity in type 2 diabetes. RESEARCH DESIGN AND METHODS—Subclinical left ventricular (LV) dysfunction was sought from myocardial strain rate and the basal segmental diastolic velocity (Em) of each wall in 170 patients with type 2 diabetes (aged 56 ± 10 years, 91 men), good quality echocardiographic images, and negative exercise echocardiograms. The same measurements were made in 56 control subjects (aged 53 ± 10 years, 29 men). Exercise capacity was calculated in metabolic equivalents, and heart rate recovery (HRR) was measured as the heart rate difference between peak and 1 min after exercise. In subjects with type 2 diabetes, exercise capacity was correlated with clinical, therapeutic, biochemical, and echocardiographic variables, and significant independent associations were sought using a multiple linear regression model. RESULTS—Exercise capacity, strain rate, Em, and HRR were significantly reduced in type 2 diabetes. Exercise capacity was associated with age (r = −0.37, P & 0.001), male sex (r = 0.26, P = 0.001), BMI (r = −0.19, P = 0.012), HbA1c (A1C r = −0.22, P = 0.009), Em (r = 0.43, P & 0.001), HRR (r = 0.42, P & 0.001), diabetes duration (r = −0.18, P = 0.021), and hypertension history (r = −0.28, P & 0.001). Age (P & 0.001), male sex (P = 0.007), BMI (P = 0.001), Em (P = 0.032), HRR (P = 0.013), and A1C (P = 0.0007) were independent predictors of exercise capacity. CONCLUSIONS—Reduced exercise capacity in patients with type 2 diabetes is associated with diabetes control, subclinical LV dysfunction, and impaired HRR.
Publisher: Springer Science and Business Media LLC
Date: 20-09-2018
Publisher: Elsevier BV
Date: 08-1992
Publisher: Springer Science and Business Media LLC
Date: 14-09-2016
DOI: 10.1038/NRCARDIO.2016.134
Abstract: Heart failure (HF) is a global epidemic affecting millions of in iduals worldwide. Although important progress has been made in the management of HF, this condition remains a common cause of morbidity and death. Since the publication of the previous sets of guidelines for the management of HF, new diagnostic and therapeutic options for HF have emerged. Now, both the ESC and the ACC/AHA/HFSA have simultaneously published an update of their guidelines incorporating, among others, recommendations for the use of new pharmacological therapies for the treatment of HF. For this Viewpoint article, we have asked the chairs of the ESC Task Force, the chairs of the ACC/AHA/HFSA Writing Committee, and an independent opinion leader in the field to offer their expert insight into the new guidelines, highlighting what is new, what the main differences are between the two sets of guidelines, and what steps should be taken to improve the guidelines in future updates.
Publisher: BMJ
Date: 19-07-2006
Publisher: Elsevier BV
Date: 10-2012
DOI: 10.1016/J.JACC.2012.06.025
Abstract: The goal of this study was to make a head-to-head comparison of 2 common forms of multidisciplinary chronic heart failure (CHF) management. Although direct patient contact appears to be best in delivering CHF management overall, the precise form to optimize health outcomes is less clear. This prospective, multicenter randomized controlled trial with blinded endpoint adjudication comprised 280 hospitalized CHF patients (73% male, age 71 ± 14 years, and 73% with left ventricular ejection fraction ≤45%) randomized to home-based intervention (HBI) or specialized CHF clinic-based intervention (CBI). The primary endpoint was all-cause, unplanned hospitalization or death during 12- to 18-month follow-up. Secondary endpoints included type/duration of hospitalization and healthcare costs. The primary endpoint occurred in 102 of 143 (71%) HBI versus 104 of 137 (76%) CBI patients (adjusted hazard ratio [HR]: 0.97 [95% confidence interval (CI): 0.73 to 1.30], p = 0.861): 96 (67.1%) HBI versus 95 (69.3%) CBI patients had an unplanned hospitalization (p = 0.887), and 31 (21.7%) versus 38 (27.7%) died (p = 0.252). The median duration of each unplanned hospitalization was significantly less in the HBI group (4.0 [interquartile range (IQR): 2.0 to 7.0] days vs. 6.0 [IQR: 3.5 to 13] days p = 0.004). Overall, 75% of all hospitalization was attributable to 64 (22.9%) patients, of whom 43 (67%) were CBI patients (adjusted odds ratio: 2.55 [95% CI: 1.37 to 4.73], p = 0.003). HBI was associated with significantly fewer days of all-cause hospitalization (-35% p = 0.003) and from cardiovascular causes (-37% p = 0.025) but not for CHF (-24% p = 0.218). Consequently, healthcare costs ($AU3.93 vs. $AU5.53 million) were significantly less for the HBI group (median: $AU34 [IQR: 13 to 81] per day vs. $AU52 [17 to 140] per day p = 0.030). HBI was not superior to CBI in reducing all-cause death or hospitalization. However, HBI was associated with significantly lower healthcare costs, attributable to fewer days of hospitalization. (Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care [WHICH?] ACTRN12607000069459).
Publisher: Elsevier BV
Date: 04-2013
DOI: 10.1016/J.JACC.2013.01.043
Abstract: This study sought to compare the survival of asymptomatic patients with previous revascularization and ischemia, who subsequently underwent repeat revascularization or medical therapy (MT). Coronary artery disease is progressive and recurring thus, stress myocardial perfusion scintigraphy (MPS) is widely used to identify ischemia in patients with previous revascularization. Of 6,750 patients with previous revascularization undergoing MPS between January 1, 2005, and December 31, 2007, we identified 769 patients (age 67.7 ± 9.5 years 85% men) who had ischemia and were asymptomatic. A propensity score was developed to express the associations of revascularization. Patients were followed up over a median of 5.7 years (interquartile range: 4.7 to 6.4 years) for all-cause death. A Cox proportional hazards model was used to identify the association of revascularization with all-cause death, with and without adjustment for the propensity score. The model was repeated in propensity-matched groups undergoing MT versus revascularization. Among 769 patients, 115 (15%) underwent revascularization a median of 13 days (interquartile range: 6 to 31 days) after MPS. There were 142 deaths mortality with MT and revascularization were 18.3% and 19.1% (p = 0.84). In a Cox proportional hazards model (chi-square test = 89.4) adjusting for baseline characteristics, type of previous revascularization, MPS data, and propensity scores, only age and hypercholesterolemia but not revascularization were associated with mortality. This result was confirmed in a propensity-matched group. Asymptomatic patients with previous revascularization and inducible ischemia on MPS realize no survival benefit from repeat revascularization. In this group of post-revascularization patients, an ischemia-based treatment strategy did not alter mortality.
Publisher: Elsevier BV
Date: 12-2017
Publisher: Elsevier BV
Date: 03-2014
DOI: 10.1016/J.ECHO.2013.11.016
Abstract: Multiparametric scoring of valvular regurgitation may compromise interobserver agreement, as readers weight parameters differently. The aims of this study were to quantify interobserver variability in the grading of chronic tricuspid regurgitation (TR), develop an algorithm for grading TR, and assess the effect of this algorithm on concordance and accuracy. On the basis of current guidelines, two experts graded the severity of TR by consensus in 40 patients with a spectrum of TR severity. A subgroup of patients (n = 18) also had TR severity assessed by cardiac magnetic resonance. Sixteen cardiologists independently graded the first 20 cases as severe or nonsevere TR. After group review, a grading algorithm to differentiate severe and nonsevere TR was devised by consensus. The same observers used the algorithm to grade the second set of cases. Baseline differentiation of severe from nonsevere TR showed modest reliability and accuracy compared with an expert read (multirater κ = 0.55 overall agreement, 78% accuracy, 81%). The consensus algorithm for severe TR was a suggestive color jet and at least one of (1) right atrial area > 18 cm(2) and inferior vena cava diameter > 2.5 cm (2) vena contracta width > 0.7 cm and jet area > 10 cm(2) (3) a dense, triangular TR Doppler profile and (4) holosystolic reversal of hepatic vein flow. Application of this algorithm improved the multirater κ coefficient to 0.80, the level of agreement to 90% (P = .033), and mean reader accuracy to 92% (P = .001). Only modest baseline agreement was found between readers on the distinction of severe and nonsevere TR. An objective, structured grading algorithm improved both interrater agreement and accuracy.
Publisher: Elsevier BV
Date: 12-2012
DOI: 10.1016/J.JACC.2012.07.067
Abstract: The aim of this study was to evaluate the effect of continuous statin treatment on new-onset heart failure (HF) in patients with breast cancer receiving anthracycline-based chemotherapy. In vitro and animal model experimental studies have reported that statins prevent doxorubicin-induced cardiotoxicity. A total of 628 women with newly diagnosed breast cancer (mean age 51.5 ± 10.8 years) treated with anthracycline were retrospectively identified and studied. The primary outcome (incident HF hospitalization) was compared in propensity-matched patients receiving uninterrupted statin therapy through the follow-up period of 2.55 ± 1.68 years and their counterparts not receiving continuous statin therapy. After propensity matching (2:1), the 67 patients (10.7%) receiving uninterrupted statin therapy were combined with 134 controls. New-onset HF was observed in 67 of the 201 matched patients. Multivariate-matched Cox regression analysis showed a significantly lower hazard ratio [HR] of 0.3 (95% confidence interval [CI]: 0.1 to 0.9 p = 0.03) for patients taking uninterrupted statin therapy. Cardiotoxicity risk factors at the time of cancer diagnosis (HR: 5.0 95% CI: 2.2 to 11.1 p < 0.001), baseline ejection fraction <55% (HR: 2.7 95% CI: 1.2 to 6.3 p = 0.02), and trastuzumab use (HR: 3.0 95% CI: 1.3 to 7.2 p = 0.01) were predictors of incident HF. In this analysis of female patients with breast cancer treated with anthracycline chemotherapy, statin use was associated with a lower risk for incident HF. This finding is consistent with prior animal studies and warrants further investigation through prospective randomized clinical trials.
Publisher: Wiley
Date: 16-07-2013
DOI: 10.1111/DME.12178
Publisher: Elsevier BV
Date: 04-2015
DOI: 10.1016/J.AHJ.2015.02.003
Abstract: Although cardiovascular events in hemodialysis (HD) patients are the most frequent on the day after a long (2 days) interdialytic interval (IDT), it has been uncertain whether accumulation or elimination of large extracellular fluid volume, electrolyte, and/or uremic substances is the culprit for this. We sought to test our hypothesis that the long IDT alters echocardiographic parameters at rest and during exercise in stable maintenance HD patients compared with other IDTs. We performed a cross-sectional comparison using 1-way repeated analysis of variance or Friedman test of echocardiograms at 3 different IDTs, just after HD, after short IDT (1 day), and after long IDT, among 80 stable Japanese outpatients (age 61 ± 9 years, 60 males) on thrice weekly maintenance. End-systolic elastance (Ees), arterial elastance (Ea), and pressure-volume area (PVA) were estimated using a noninvasive single-beat technique. Ventricular-arterial coupling was assessed by Ea/Ees ratio. Measurements were repeated after 2-minute handgrip stress to evaluate cardiac reserve. Resting left ventricular end-diastolic volume index and stroke volume index were significantly larger after a 1-day IDT compared with just after HD and even more after a 2-day IDT. Although Ees, Ea, and Ea/Ees ratio at rest remained similar between short and long intervals, stroke work (SW) and PVA were higher after the long interval. During handgrip stress, a significant increase in Ea without corresponding rise in Ees was observed only after long IDT, resulting in decreased stroke volume index, SW, and SW/PVA efficiency. In a selective Japanese outpatient population on maintenance HD, there were no differences in resting cardiovascular function measured by echocardiography at 3 different IDTs. However, exercise-induced afterload mismatch assessed by the changes in Ea, SV, SW, and SW/PVA efficiency was most pronounced in in iduals after the long IDT compared with other IDTs. Our findings report potential pathophysiologic echocardiographic parameters that attempt to explain why cardiovascular events are highest on the day after the long IDT compared to other IDTs in dialysis patients.
Publisher: Elsevier BV
Date: 04-2009
DOI: 10.1016/J.AHJ.2008.09.014
Abstract: Although guidelines recommend the use of beta-adrenoceptor blocking drugs to reduce cardiac events (CEs) after major noncardiac surgery, trial results have varied between showing benefit, ineffectiveness, and harm. We sought whether optimizing beta-blockade (BB) delivery could make them more effective. Intermediate risk patients undergoing major noncardiac surgery (n = 400) were randomized to 2 strategies of BB therapy: universal BB (UBB n = 197) comprising an algorithm-based, nurse-led strategy to optimize dosing and adherence to bisoprolol titration over > or =1 week preoperatively versus usual care (UC n = 203), whereby BB are continued in those already taking them or prescribed for patients identified as high risk based on ischemia (new or inducible wall motion abnormalities) at dobutamine echocardiography (DbE). Daily electrocardiogram and troponin levels were obtained on 3 postoperative days. The primary end point was a major CE (cardiac death or myocardial infarction) within 30 days. There were 25 major CEs (6.3%), occurring in 13 (6.6%) of 197 UBB and 12 (5.9%) of 203 UC patients (OR 1.12, 95% CI 0.52-2.39). Independent predictors of CEs were baseline systolic blood pressure (beta 1.02, P = .005) and postoperative hypotension (beta 1.02, P = .03) but not treatment strategy. Those randomized to UBB had significantly better heart rate control perioperatively, at the cost of bradycardia and hypotension. The negative predictive value of DbE in this study was 95%. These data confirm a persistent CE rate after major noncardiac surgery despite nurse-led dose titration of bisoprolol. Cardiac events were equivalent to a UC strategy based on DbE results.
Publisher: Elsevier BV
Date: 09-2014
DOI: 10.1016/J.METABOL.2014.05.007
Abstract: Autonomic dysfunction may contribute to the etiology and exercise intolerance of subclinical diabetic heart disease. This study sought the efficacy of exercise training for improvement of peak oxygen uptake (VO₂(peak)) and cardiac autonomic function in type 2 diabetic patients with non-ischemic subclinical left-ventricular (LV) dysfunction. Forty-nine type 2 diabetic patients with early diastolic tissue Doppler velocity >1 standard deviation below the age-based mean entered an exercise intervention (n=24) or usual care (n=25) for 6-months (controlled, pre- ost- design). Co-primary endpoints were treadmill VO₂(peak) and 5-min heart-rate variability (by the coefficient of variation of normal RR intervals [CVNN]). Autonomic function was additionally assessed by resting heart-rate (for sympathovagal balance estimation), baroreflex sensitivity, cardiac reflexes, and exercise/recovery heart-rate profiles. Echocardiography was performed for LV function (systolic/diastolic tissue velocities, myocardial deformation) and myocardial fibrosis (calibrated integrated backscatter). VO₂(peak) increased by 11% during the exercise intervention (p=0.001 vs. -1% in controls), but CVNN did not change (p=0.23). Reduction of resting heart-rate in the intervention group (p<0.05) was associated with an improvement in the secondary endpoint of heart-rate variability total spectral power (p<0.05). However, baroreflex sensitivity, cardiac reflexes, and exercise/recovery heart-rate profiles showed no significant benefit. No effects on LV function were observed despite favorable reduction of calibrated integrated backscatter in the intervention group (p<0.05). The exercise intolerance of subclinical diabetic heart disease was amenable to improvement by exercise training. Despite a reduction in resting heart-rate and potential attenuation of myocardial fibrosis, no other cardiac autonomic or LV functional adaptations were detected.
Publisher: Elsevier BV
Date: 08-2009
DOI: 10.1016/J.AHJ.2009.05.031
Abstract: Trastuzumab prolongs survival in patients with human epidermal growth factor receptor type 2-positive breast cancer. Sequential left ventricular (LV) ejection fraction (EF) assessment has been mandated to detect myocardial dysfunction because of the risk of heart failure with this treatment. Myocardial deformation imaging is a sensitive means of detecting LV dysfunction, but this technique has not been evaluated in patients treated with trastuzumab. The aim of this study was to investigate whether changes in tissue deformation, assessed by myocardial strain and strain rate (SR), are able to identify LV dysfunction earlier than conventional echocardiographic measures in patients treated with trastuzumab. Sequential echocardiograms (n = 152) were performed in 35 female patients (51 +/- 8 years) undergoing trastuzumab therapy for human epidermal growth factor receptor type 2-positive breast cancer. Left ventricular EF was measured by 2- and 3-dimensional (2D and 3D) echocardiography, and myocardial deformation was assessed using tissue Doppler imaging and 2D-based (speckle-tracking) strain and SR. Change over time was compared every 3 months between baseline and 12 months. There was no overall change in 3D-EF, 2D-EF, myocardial E-velocity, or strain. However, there were significant reductions seen in tissue Doppler imaging SR (P < .05), 2D-SR (P < .001), and 2D radial SR (P or =1 SD in 2D longitudinal SR was seen in 18 (51%) patients 13 (37%) had a similar drop in radial SR. Of the 18 patients with reduced longitudinal SR, 3 had a concurrent reduction in EF > or =10%, and another 2 showed a reduction over 20 months follow-up. Myocardial deformation identifies preclinical myocardial dysfunction earlier than conventional measures in women undergoing treatment with trastuzumab for breast cancer.
Publisher: Oxford University Press (OUP)
Date: 30-08-2009
DOI: 10.1093/EJECHOCARD/JEP103
Abstract: Previous research has described differences in left ventricular (LV) systolic tissue velocity between genders. This study aimed to determine the association between LV tissue velocity and LV size in healthy controls and in those with type 2 diabetes (T2DM). LV tissue velocities were measured in 71 controls and 222 patients with T2DM by pulsed-wave Doppler and colour-coded tissue Doppler (TDI) during systole (S' and S(m)) and diastole (early, E' and E(m), and late, A' and A(m)) at the basal septum and lateral wall. Both systolic tissue velocities were higher in males than in females within controls (S': 7.3 +/- 1.2 vs. 6.6 +/- 1.0 cm/s P = 0.017, S(m): 6.2 +/- 1.0 vs. 5.5 +/- 0.7 cm/s P = 0.002) but only by colour-coded TDI in patients with T2DM (S(m): 5.7 +/- 1.7 vs. 4.9 +/- 1.7 cm/s P = 0.025). Correction for LV length negated the difference between genders in the controls and patients with T2DM (P > 0.05 for all). In controls, LV length was the strongest predictor of S' (beta = 0.393, P = 0.002), whereas height was the strongest predictor of S(m) (beta = 0.394, P = 0.003). In controls, systolic tissue velocities are significantly higher in males compared with females, which may be explained by the increased chamber size of men.
Publisher: Elsevier BV
Date: 12-1999
DOI: 10.1016/S0002-9149(99)00562-7
Abstract: The clinical importance of an exaggerated systolic blood pressure (BP) response to exercise, or exercise hypertension, is unclear. We have previously reported that exercise hypertension is associated with less severe angiographic coronary artery disease. This study sought to examine the association between exercise hypertension and ischemic "burden," as assessed by thallium-201 single-photon emission computed tomography. The cohort was comprised of consecutive adults (2,216 men, 1,229 women) referred for symptom-limited exercise thallium testing to evaluate known or suspected coronary artery disease. The main variable measured was exercise hypertension, defined as a peak systolic BP > or =210 mm Hg in men and > or =190 mm Hg in women. Thallium perfusion defects were described as: (1) any perfusion abnormality, (2) reversible abnormalities, and (3) any abnormality in > or =3 of 12 myocardial segments ("extensive abnormalities"). Exercise hypertension was present in 1,319 subjects (39%). Patients with exercise hypertension were less likely to have any thallium perfusion abnormality (16% vs 25%, odds ratio [OR] 0.58, 95% confidence intervals [CI] 0.49 to 0.69, p <0.001), reversible thallium abnormalities (7% vs 12%, OR 0.71, 95% CI 0.57 to 0.90, p <0.001), and extensive abnormalities (8% vs 14%, OR 0.53, 95% CI 0.42 to 0.67, p <0.001). After adjusting for possible confounders, the same trend was seen. During 6 years of follow-up there were 283 deaths with no association between exercise hypertension and mortality risk. Thus, exercise hypertension is associated with a lower likelihood of myocardial perfusion abnormalities and is not associated with an increased mortality rate.
Publisher: Wiley
Date: 17-09-2007
Publisher: Elsevier BV
Date: 04-2008
Publisher: Oxford University Press (OUP)
Date: 14-02-2013
DOI: 10.1093/AJH/HPT008
Abstract: Although a hypertensive response to exercise (HRE) is associated with cardiac risk and masked hypertension (MHT), its mechanisms and appropriate treatment remain unclear. We investigated spironolactone as a treatment for abnormal vascular and myocardial stiffness in HRE. In this randomized, double-blind, placebo-controlled study of 115 patients (54 ± 9 years, 57% men) with an HRE (≥210/105 mm Hg in men ≥190/105 mm Hg in women) but no prior history of hypertension or myocardial ischemia, MHT prevalence was 40%. Patients were randomized to spironolactone 25mg daily (n = 58) or placebo (n = 57) and underwent evaluation at baseline and 3 months with exercise echocardiography, VO2max, pulse wave velocity (PWV), exercise and central blood pressure (BP), and 24-hour ambulatory BP. Changes in left ventricular mass index (LVMI), Doppler-derived E/em ratio (LV filling pressure), and myocardial strain were assessed. Baseline 24-hour systolic BP (SBP) was 133 ± 10 mm Hg and peak-exercise SBP was 219 ± 16 mm Hg. Peak systolic strain (0.3 ± 3.6% vs. -0.1 ± 3.2, P = 0.56), E/em (-1.1 ± 2.3 vs. -0.6 ± 1.7, P = 0.30), VO(2max) (0.4 ± 4.9 vs. -0.9 ± 4.1 ml/kg/min, P = 0.15), and adjusted PWV did not significantly change with treatment, despite reduction in exercise SBP, 24-hour SBP, and LVMI. The change in exercise E/em was of borderline significance (-0.3 ± 2.4 vs. 0.8 ± 2.8, P = 0.06) and became significant after adjustment for baseline differences (P = 0.01). Patients with higher LVMI significantly increased VO(2max) (1.1 ± 5.6 vs. -2.4 ± 4.4 ml/kg/min, P < 0.05) and reduced exercise E/e(m) (-0.7 ± 2.7 vs. 1.9 ± 2.8, P < 0.05). In HRE patients without previous hypertension, short-term spironolactone reduced exercise BP, 24-hour ambulatory BP, LVMI, and E/e(m) but did not significantly alter exercise capacity or myocardial strain.
Publisher: Elsevier BV
Date: 08-2004
Publisher: Elsevier BV
Date: 07-1997
DOI: 10.1016/S0002-8703(97)70110-8
Abstract: Approximately 8 million patients at risk for coronary artery disease undergo noncardiac surgery annually in the United States. This study defined the appropriateness and cost of evaluating these patients with stress imaging tests. Before noncardiac surgery, 178 consecutive patients were prospectively studied by stress imaging. Pretest cardiac risk (low, intermediate, high) was established by interviewing the referring physician and separately by a cardiologist on the basis of the nature of noncardiac surgery and Eagle's clinical criteria. Patients were followed-up for alterations in management and perioperative events until hospital discharge. Referring physicians and cardiologists identified low risk in 24% and 54% of patients, respectively (p < 0.0001). Of 96 patients identified as low risk by cardiologists, 75 had minor surgery and 21 had major surgery, but no clinical risk factors. In the remaining 82 patients with major surgery, ischemia and other severe abnormalities were detected in 19 (23%) patients. At follow-up, no perioperative complications occurred in minor surgery one patient with major surgery but no clinical risk factors died from complications related to hypertrophic cardiomyopathy. Patients with at least one clinical risk factor undergoing major surgery but who did not have ischemia on stress testing (n = 63) had two complications (infarction and unstable angina). Intervention (revascularization and surgical cancellation) was probably the explanation for the absence of events in 19 patients with ischemia. With a weighted mean Medicare reimbursement ($386), the use of a simple selection algorithm based on noncardiac surgery and clinical risk to avoid testing low-risk patients would have an average cost of $214 per patient, representing a 45% savings.
Publisher: Elsevier BV
Date: 02-2023
Publisher: Wiley
Date: 17-09-2007
Publisher: Elsevier BV
Date: 10-1999
DOI: 10.1016/S0002-8703(99)70192-4
Abstract: Pulsed-wave Doppler assessment of myocardial velocity (MDV) may permit a more quantitative interpretation of stress echocardiography. This technique has been used with dobutamine echo (DbE), but exercise echo (ExE) may be preferred in patients who are able to exercise maximally. The influence of these stressors on the results of MDV are undefined. This study sought to determine whether differences between the physiology of DbE and ExE could influence the MDV responses to stress and whether interpretative criteria should be different with exercise or dobutamine stress. DbE or ExE was performed in 105 patients tested for known or suspected coronary artery disease. Pulsed-wave MDV was obtained in basal segments of anteroseptal, septal, anterior, posterior, lateral, and inferior walls in the apical views at rest and at peak doses of dobutamine or immediately after exercise. Segments were classified as normal or abnormal (ischemia or scar) according to results of 2-dimensional echocardiography, and MDV obtained at rest and stress was compared by using analysis of variance. Resting heart rate was similar before both dobutamine and exercise, but heart rate at peak dobutamine exceeded that after exercise (137 +/- 10 vs 115 +/- 22, P <.01). For both ExE and DbE, MDV was significantly greater at rest and stress in normal than in abnormal segments. Stress MDV in both normal and abnormal segments was greater with DbE than with ExE (17.0 +/- 4.8 cm/s vs 10. 3 +/- 3.4 cm/s, P <.001 for normal segments and 10.7 +/- 4.4 cm/s vs 7.9 +/- 3.3 cm/s, P <.001 for abnormal segments. Increase in MDV/Deltaheart rate induced by DbE was greater than by ExE in normal (0.14 +/- 0.07 cm/s. beat for DbE and 0.09 +/- 0.08 cm/s. beat for ExE P <.05) but similar in abnormal segments (0.06 +/- 0.07 cm/s. beat for DbE and 0.05 +/- 0.09 cm/s. beat for ExE). MDV correlated better with peak heart rate at ExE (r = 0.56, P <.01) than at DbE (r = 0.28, P <.01). MDV responses to exercise and pharmacologic stress appear to be different, reflecting differences in inotropy, loading, and the timing of imaging. These findings may influence the ability of MDV to differentiate normal from abnormal stress echocardiography responses.
Publisher: Elsevier BV
Date: 09-2000
DOI: 10.1016/S0002-9149(00)01036-5
Abstract: Chronotropic incompetence, or an attenuated heart rate response to exercise, has been shown to be associated with an adverse outcome. It is not known whether chronotropic incompetence predicts all-cause mortality independent of angiographic severity of coronary artery disease (CAD). Study subjects included consecutive patients who underwent first-time, symptom-limited exercise treadmill testing and coronary angiography within 90 days no patient was taking beta blockers or had a history of heart failure, valve disease, or prior revascularization. Chronotropic response was measured in 2 ways: (1) failure to reach 85% of the age-predicted maximum heart rate, and (2) a low chronotropic index, a measure of exercise heart rate response that accounts for effects of age, physical fitness, and resting heart rate. Angiographic severity of CAD was assessed using the Duke Prognostic Weight Score, with a score > or = 42 considered to be indicative of severe CAD. Among 384 eligible patients, failure to reach 85% of the age-predicted maximum heart rate occurred in 61 (16%) and a low chronotropic index was noted in 133 (35%). Severe CAD was present in 63 (16%). During 6 years of follow-up there were 56 deaths. Mortality was predicted by failure to reach target heart rate (RR 1.85, 95% confidence interval [CI] 1.01 to 3.39, chi-square = 4, p = 0.05), by severe CAD (RR 2.21, 95% CI 1.24 to 3.95, chi-square = 8, p = 0.007), and, most strongly, by a low chronotropic index (RR 2.72, 95% CI 1.60 to 4.61, chi-square = 15, p = 0.0002). In a multivariable model, low chronotropic index remained predictive of death (adjusted RR 2.22, 95% CI 1.29 to 3.82, p = 0.004), whereas severe CAD no longer predicted death (adjusted RR 1.27, 95% CI 0.70 to 2.31, p > 0.4). Thus, chronotropic incompetence is a strong and independent predictor of death, even after accounting for the angiographic severity of CAD.
Publisher: Elsevier BV
Date: 02-1999
DOI: 10.1016/S0002-9149(98)00908-4
Abstract: This study sought to determine the association of exercise-induced ventricular ectopic activity with thallium perfusion defects and severity of angiographic coronary artery disease (CAD). Two cohorts consisting of adults without heart failure or known severe ventricular ectopic activity at rest were studied. The first cohort consisted of adults (n = 2,743) who underwent maximum exercise thallium stress testing. The second cohort consisted of adults (n = 423) who underwent coronary angiography within 90 days of treadmill testing. Significant exercise-induced ventricular ectopic activity was defined as frequent ventricular premature complexes or nonsustained ventricular tachycardia. Severe CAD was defined as left main CAD (> or = 50% stenosis), 3-vessel CAD (> or = 70% stenosis), or 2-vessel CAD with > or = 70% stenosis of the proximal left anterior descending artery. In the thallium cohort, exercise-induced ventricular ectopic activity was associated with a greater frequency of thallium defects (35.2% vs 18.7%, odds ratio [OR] 2.35, 95% confidence intervals [CI] 1.62 to 3.42, p <0.001) after adjusting for possible confounders, this association persisted (for any defect adjusted OR 1.66, 95% CI 1.09 to 2.53, p = 0.02 for septal defect adjusted OR 2.77, 95% CI 1.51 to 5.07, p <0.001). There was no association between exercise-induced ventricular ectopic activity and mortality during 2 years of follow-up. In the angiographic cohort, there was no association of exercise-induced ventricular ectopy with severe CAD (19% vs 20%, OR 0.93, 95% CI 0.41 to 2.09, p = NS). Exercise-induced ventricular ectopic activity was associated with a greater likelihood of thallium perfusion defects, but was not associated with angiographic severity of coronary disease or with short-term mortality.
Publisher: SAGE Publications
Date: 05-2008
Abstract: Current guidelines for the diagnosis and risk assessment of patients presenting with myocardial infarction recommend a single decision cut-off point for cardiac troponin (cTn) based on the 99th centile of a reference population. The 99th centile level for eight troponin assays was determined in an apparently cardio-healthy Australian reference population. Nine laboratories measured troponin in serum and plasma collected from 111 reference in iduals. An imprecision profile was determined using up to 10 serum s les analysed on 10 separate days. Method comparison using 100 routinely tested plasma s les was performed to estimate method concordance. Generally 99th centile values determined in this study were lower than, or the same as manufacturers' levels, except for cTnI by Architect (0.020 vs. 0.012 μg/L), and imprecision at the 99th centile was 20% coefficient of variation (CV) or higher. Troponin concentrations at 10% CV were greater than those quoted in the manufacturer's package insert except by AxSYM, 0.06 vs. 0.16 μg/L cTnI, and by E-170, 0.02 vs. 0.03 μg/L cTnT. In the method comparison 74, 70, 65, 75, 58, 66, 58 and 77 s les measured by Access, Architect, AxSYM, Centaur, Dimension RxL, E-170, i-STAT and Vitros ECi assays, respectively, had troponin concentrations above the study 99th centile. Depending on the selected reference population for troponin, there is likely to be variability in the 99th centile as shown in this study. Some differences in s le concordance at the 99th centile cut-off were observed between cTn methods and may result in different clinical classification.
Publisher: Elsevier BV
Date: 12-2004
Publisher: Elsevier BV
Date: 09-2005
DOI: 10.1016/J.ECHO.2005.03.027
Abstract: Left atrial (LA) volume (LAV) is a prognostically important biomarker for diastolic dysfunction, but its reproducibility on repeated testing is not well defined. LA assessment with 3-dimensional (3D) echocardiography (3DE) has been validated against magnetic resonance imaging, and we sought to assess whether this was superior to existing measurements for sequential echocardiographic follow-up. Patients (n = 100 81 men age 56 +/- 14 years) presenting for LA evaluation were studied with M-mode (MM) echocardiography, 2-dimensional (2D) echocardiography, and 3DE. Test-retest variation was performed by a complete restudy by a separate sonographer within 1 hour without alteration of hemodynamics or therapy. In all, 20 patients were studied for interobserver and intraobserver variation. LAVs were calculated by using M-mode diameter and planimetered atrial area in the apical 4-chamber view to calculate an assumed sphere, as were prolate ellipsoid, Simpson's biplane, and biplane area-length methods. All were compared with 3DE. The average LAV was 72 +/- 27 mL by 3DE. There was significant underestimation of LAV by M-mode (35 +/- 20 mL, r = 0.66, P < .01). The 3DE and various 2D echocardiographic techniques were well correlated: LA planimetry (85 +/- 38 mL, r = 0.77, P < .01), prolate ellipsoid (73 +/- 36 mL, r = 0.73, P = .04), area-length (64 +/- 30 mL, r = 0.74, P < .01), and Simpson's biplane (69 +/- 31 mL, r = 0.78, P = .06). Test-retest variation for 3DE was most favorable (r = 0.98, P < .01), with the prolate ellipsoid method showing most variation. Interobserver agreement between measurements was best for 3DE (r = 0.99, P < .01), with M-mode the worst (r = 0.89, P < .01). Intraobserver results were similar to interobserver, the best correlation for 3DE (r = 0.99, P < .01), with LA planimetry the worst (r = 0.91, P < .01). The 2D measurements correlate closely with 3DE. Follow-up assessment in daily practice appears feasible and reliable with both 2D and 3D approaches.
Publisher: Elsevier BV
Date: 07-1997
DOI: 10.1016/S0735-1097(97)00217-9
Abstract: We sought to determine the relative influence of estimated functional capacity and thallium-201 (Tl-201) single-photon emission computed tomographic (SPECT) findings on prediction of short-term all-cause and cardiac-related mortality. Decreased functional capacity and abnormal Tl-201 SPECT findings are predictive of increased cardiovascular risk and mortality. However, the relative importance of these variables as predictors of all-cause mortality is not well established. Analyses were based on 3,400 consecutive adults undergoing symptom-limited exercise Tl-201 SPECT testing at the Cleveland Clinic Foundation between September 1990 and December 1993 none had previous invasive procedures, heart failure or valve disease. Estimated functional capacity, classified by age and gender, and thallium perfusion defects, expressed as a stress extent thallium score on a 12-segment scale, were analyzed to determine their relative prognostic importance during 2 years of follow-up. Of 3,400 patients, 108 (3.2%) died during follow-up 32 deaths were identified as cardiac related. On univariable analysis, estimated functional capacity was a strong predictor of death, with 62 (57%) deaths occurring in patients achieving < 6 metabolic equivalents (METs) (log-rank chi-square 86, p < 0.0001). On multivariable analysis, the strongest independent predictors of all-cause mortality were fair or poor functional capacity (adjusted relative risk [RR] 3.96, 95% confidence interval [CI] 2.36 to 6.64, chi-square 27, p < 0.0001) and age (adjusted RR for 10 years 2.25, 95% CI 1.80 to 2.80, chi-square 27, p < 0.0001). The presence of SPECT thallium perfusion defects was a less powerful predictor of death (for each two additional segments with defects, adjusted RR 1.21, 95% CI 1.03 to 1.43, chi-square 5, p = 0.02). Cardiac mortality was predicted by both fair or poor functional capacity (adjusted RR 4.37, 95% CI 1.59 to 12.00, chi-square 8, p = 0.004) and by stress extent thallium score (adjusted RR 1.62, 95% CI 1.25 to 2.11, chi-square 13, p = 0.0003). In this clinically low risk group, estimated functional capacity was a strong and overwhelmingly important independent predictor of all-cause mortality among patients undergoing exercise Tl-201 SPECT testing. The extent of myocardial perfusion defects was of comparable importance for the prediction of cardiac mortality.
Publisher: Elsevier BV
Date: 05-1992
DOI: 10.1016/S0894-7317(14)80342-8
Abstract: Both exercise echocardiography and rubidium-82 positron emission tomography are used in the detection and characterization of coronary artery disease. This study compared results of both in 74 patients with known coronary anatomy, by use of exercise echocardiography before and after treadmill exercise and positron emission tomography with intravenous dipyridamole-handgrip stress. Significant (greater than 50%) coronary stenoses were present in 70 patients exercise echocardiography and positron emission tomography each identified 63 patients (sensitivity 90%). Significant stenoses without previous myocardial infarction were present in 34 patients 29 (85%) were identified by exercise echocardiography and 28 by positron emission tomography (82%, p = NS). Four patients had no significant coronary disease, and were all identified as normal by both methods. Segments were classified as either normal or showing stress or resting abnormalities, and the diagnoses were compared in the territories of the three major coronary arteries. Results were concordant with respect to the presence or absence of coronary disease in 185 of 222 territories (83%). The remaining 37 regions had abnormalities by exercise echocardiography or positron emission tomography but not both. Stress defects were identified by only one of the tests in 24 areas (in 12 [50%], angiographic findings correlated with positron emission tomography). Resting defects were diagnosed by only one modality in 13 regions (angiographic findings correlated with the results of positron emission tomography in 9 [69%] of these). Both exercise echocardiography and positron emission tomography are sensitive for the identification of coronary artery disease, although on a regional basis, positron emission tomography appears to be more specific for the diagnosis of resting perfusion defects.
Publisher: Elsevier BV
Date: 04-2003
DOI: 10.1016/S0002-9343(03)00052-4
Abstract: To determine the effects of aggressive lipid lowering on markers of ischemia, resistance vessel function, atherosclerotic burden, and symptom status in patients with symptomatic coronary artery disease. Sixty consecutive patients with coronary artery disease that was unsuitable for revascularization were assigned randomly to either usual therapy of lipids for patients with a low-density lipoprotein (LDL) cholesterol target level <116 mg/dL, or to a more aggressive lipid-lowering strategy involving up to 80 mg/d of atorvastatin, with a target LDL cholesterol level <77 mg/dL. The extent and severity of inducible ischemia (by dobutamine echocardiography), vascular function (brachial artery reactivity), atheroma burden (carotid intima-media thickness), and symptom status were evaluated blindly at baseline and after 12 weeks of treatment. After 12 weeks of treatment, patients in the aggressive therapy group had a significantly greater decrease in mean (+/- SD) LDL cholesterol level than those in the usual care group (29 +/- 38 mg/dL vs. 7 +/- 24 mg/dL, P = 0.03). Patients in the aggressive therapy group had a reduction in the number of ischemic wall segments (mean between-group difference of 1.3 95% confidence interval: 0.1 to 2.0 P = 0.04), flow-mediated dilatation (mean between-group difference of 5.9% 95% confidence interval: 2.5% to 9.4% P = 0.001), and angina score after 12 weeks. There were no significant changes in atherosclerotic burden in either group. Patients with symptomatic coronary artery disease who are treated with aggressive lipid lowering have improvement of symptom status and ischemia that appears to reflect improved vascular function but not atheroma burden.
Publisher: American Diabetes Association
Date: 04-2005
Publisher: Springer Science and Business Media LLC
Date: 2000
Abstract: Recognition of abnormal wall motion during dobutamine echocardiography requires an expert observer. Anatomical M-mode echocardiography may offer a novel quantitative approach to interpretation, amenable to less expert readers. We studied the application of this new modality to 124 patients (80 with known coronary anatomy and 44 patients at low probability of coronary disease) who underwent dobutamine echocardiography, using a standard protocol. Wall motion was interpreted by an experienced reader, using digitally stored 2-dimensional echocardiographic images at rest and peak stress. Percentage of systolic thickening was measured offline using anatomical M-mode echocardiography in the basal and mid segments at rest and peak dose, and compared with wall motion scores and coronary angiography. Of 729 segments, wall motion was identified as normal in 449, ischemic or viable in 171 and showed resting WM abnormalities only in 109 segments. After exclusion of the apex, anatomical M-mode measurements were feasible in 729 of 960 possible basal- and mid-zone segments (76%). Measurement of systolic thickening at peak dose was reproducible within (r2 = 0.83) and between observers (r2 = 0.93). Systolic thickening was significantly greater in segments with normal wall motion (37 +/- 2%) compared with ischemic or viable segments (30 +/- 2%, p < 0.001), and scar segments (23 +/- 3%, p 70% diameter) was present in 59 patients. Systolic thickening showed significant variation between segments interpreted by wall motion scoring and angiography as true and false positive and true and false negative (p < 0.05). Measurement of systolic thickening using anatomical M-mode echocardiography offers an objective method to quantify systolic thickening at dobutamine echocardiography but has limited clinical feasibility.
Publisher: Elsevier BV
Date: 08-2008
DOI: 10.1016/J.ECHO.2008.01.011
Abstract: The helical arrangement of myocardial fibers leads to left ventricular (LV) torsion, a vital contributor to systolic and diastolic function. Rotation and torsion can now be measured we sought to determine the utility of torsion as a marker of LV function at rest and after stress in patients with myocardial infarctions (MIs) and ischemia. Dobutamine echocardiography was performed in 125 patients. After the exclusion of 40 patients with suboptimal images, LV systolic rotation and torsion were measured offline using speckle-tracking echocardiography in 44 patients with and 41 without prior MIs. Hemodynamic findings and the extent of infarction and ischemia were correlated with length-corrected torsion measurements at baseline and at peak-dose dobutamine. Resting global and regional LV systolic torsion were significantly reduced in patients with compared with those without previous MIs (1.16 +/- 1.15 degrees /cm vs 3.16 +/- 1.3 degrees /cm, P < .001), and global systolic torsion was an independent correlate of LV ejection fraction (LVEF) (P = .04). There was no difference in global LV systolic torsion in patients with anteroapical or inferoposterior infarcts (1.81 +/- 1.13 degrees /cm vs 2.27 +/- 1.18 degrees /cm, P = NS) and no differences in regional torsion. Torsion was most impaired in patients with multiple areas of infarction (1.03 +/- 0.89 degrees /cm, P < .001). However, dobutamine-induced ischemia (2.59 +/- 1.14 ischemic segments) had no effect on global and regional systolic torsion at peak dose or change in torsion from rest to peak dose. The influence of MI on LV systolic torsion appears to be related to infarct size rather than site, and torsion was an independent determinant of resting function. LV torsion was not significantly influenced by stress-induced myocardial ischemia.
Publisher: Elsevier BV
Date: 04-2007
DOI: 10.1016/J.AHJ.2007.01.028
Abstract: The outcome of patients with chronic kidney disease (CKD) is influenced by overt left ventricular (LV) abnormalities. We sought the predictive value and treatment response of subclinical LV dysfunction in CKD. Resting and dobutamine stress echocardiography were used to identify LV enlargement, dysfunction, or ischemia in 176 patients with CKD. In 129 patients who had normal dobutamine stress echocardiography, myocardial tissue characterization was performed using tissue Doppler imaging and integrated backscatter. Clinical, biochemical, and echocardiographic parameters were recorded at baseline, and patients were followed up for cardiac events and all-cause mortality over 2.4 years. Follow-up echocardiographic and tissue characterization parameters were performed in 80 patients. Previous cardiac history (HR 5.2, P = .002) and serum phosphate (HR 6.2, P = .001) were independent clinical predictors of events (model chi2 = 20.9). Diastolic tissue velocity (HR 0.8, P = .05) was an independent predictor of outcome, and its addition to clinical assessment added incremental prognostic information (model chi2 = 24.8, P < .001). Patients who underwent transplantation (n = 45) showed reduction of wall thickness (P < .001) and LV volumes (P < .001) and increases in diastolic tissue velocity (P = .007) and strain (P = .001), whereas these measurements worsened in those who remained on dialysis. In patients with CKD, subclinical LV dysfunction is associated with adverse outcome. Subclinical disease can be improved by transplantation but progresses in patients who continue on dialysis.
Publisher: Elsevier BV
Date: 09-1998
DOI: 10.1016/S0002-9149(98)00447-0
Abstract: Myocardial Doppler velocity (MDV) imaging was evaluated as a quantitative method for interpretation of dobutamine echocardiography by comparison with regional wall motion abnormalities in 70 patients with known or suspected coronary artery disease. Ischemic segments had the lowest increment of systolic MDV from rest to peak dose, and using a peak MDV of <12 cm/s to define an abnormal response, the sensitivity and specificity of MDV for ischemia was 86% and 96% for basal segments, and 81% and 89% for mid segments.
Publisher: Springer Berlin Heidelberg
Date: 2009
Publisher: Oxford University Press (OUP)
Date: 07-12-2006
Publisher: Oxford University Press (OUP)
Date: 06-2003
DOI: 10.1016/S0195-668X(03)00113-1
Abstract: Patients with known or suspected coronary disease are often investigated to facilitate risk assessment. We sought to examine the cost-effectiveness of strategies based on exercise echocardiography and exercise electrocardiography. We studied 7656 patients undergoing exercise testing of whom half underwent exercise echocardiography. Risk was defined with the Duke treadmill score for those undergoing exercise electrocardiography alone, and by the extent of ischaemia by exercise echocardiography. Cox proportional hazards models, risk adjusted for pretest likelihood of coronary artery disease, were used to estimate time to cardiac death or myocardial infarction. Costs (including diagnostic and revascularisation procedures, hospitalisations, and events) were calculated, inflation-corrected to year 2000 using Medicare trust fund rates and discounted at a rate of 5%. A decision model was employed to assess the marginal cost effectiveness (cost/life year saved) of exercise echo compared with exercise electrocardiography. Exercise echocardiography identified more patients as low-risk (51% vs 24%, p<0.001), and fewer as intermediate- (27% vs 51%, p<0.001) and high-risk (22% vs 4%) survival was greater in low- and intermediate-risk and less in high-risk patients. Although initial procedural costs and revascularisation costs (in intermediate-high risk patients) were greater, exercise echocardiography was associated with a greater incremental life expectancy (0.2 years) and a lower use of additional diagnostic procedures when compared with exercise electrocardiography (especially in lower risk patients). Using decision analysis, exercise echocardiography ( in 2615/life year saved) was more cost effective than exercise electrocardiography. Exercise echocardiography may enhance cost-effectiveness for the detection and management of at risk patients with known or suspected coronary disease.
Publisher: Elsevier BV
Date: 2020
Publisher: Elsevier BV
Date: 02-2015
Publisher: Elsevier BV
Date: 08-2004
Publisher: Elsevier BV
Date: 02-2021
Publisher: Elsevier BV
Date: 06-2015
Publisher: Oxford University Press (OUP)
Date: 04-1992
Abstract: The case is reported of a young woman with the Maroteaux-Lamy syndrome (mucopolysaccharidosis type VI) who presented with rapidly progressive dyspnoea due to mitral stenosis. Mitral valve replacement was performed and the appearance of the valve was typical of mucopolysaccharide infiltration. Dyspnoea in patients with the Maroteaux-Lamy syndrome may be due primarily to cardiac valve involvement, and in this setting, valve surgery is safe and effective.
Publisher: Oxford University Press (OUP)
Date: 03-05-2019
Abstract: To develop a cost-effectiveness model to address the outcome and economic implications of different thresholds for surgery in the management of aortopathy associated with bicuspid aortic valve disease. A model was created from the perspective of an Australian healthcare funding agency. The index case was a 65-year-old with bicuspid aortic valve (BAV) and ascending aorta diameter of 5.0 cm. Health states were defined as: pre-operative with dilated aorta, post-operative without complications, post-complication, and death. The mean and variance of risks and transition probabilities were taken from a local surgical database and local costs and utilities of elective and urgent thoracic aortic surgery (AoS) with or without aortic valve replacement, with a sensitivity analysis based on a systematic review. Scenario analyses were provided for other aortic dimensions. Implications for survival, quality-adjusted life years (QALYs), and costs were calculated from healthcare delivery and economic perspectives. After 10 000 simulations for the reference case, the utility of watchful waiting (WW) exceeded that of elective AoS (13 ± 4 vs. 10 ± 5 QALY). The net monetary benefit was A$351 063 ± 304 965 with immediate AoS vs. 534 797 ± 198 570 with WW surveillance. The most important variables affecting effectiveness were utility value of survivors, rate of aortic growth, and probability of acute aortic event during WW. This decision-analytic model informed by our practice, as well as a systematic analysis, shows that AoS in a BAV patient with aorta cm diameter is costlier and less effective than WW.
Publisher: Elsevier BV
Date: 03-2021
Publisher: Springer Science and Business Media LLC
Date: 03-02-2023
DOI: 10.1186/S12872-023-03060-X
Abstract: We sought to apply a simple cardiovascular health tool not requiring laboratory tests (the Fuster-BEWAT score, FBS) to predict subclinical atherosclerosis. This study included 2657 young adults ( 40 years of age). In the prognostic group (n = 894, followed for 13 years until aged 40–50 years at follow-up), the primary outcome was presence of carotid plaque measured by carotid ultrasound at follow-up. Of these 894 participants, 86 (9.6%) had unilateral, and 23 participants (2.6%) had bilateral, carotid plaques at follow-up. The baseline FBS was predictive of carotid plaque at follow-up [odds ratio OR = 0.86 (95% CI 0.77–0.96) per 1-SD increase in FBS], similar to prediction from Pooled Cohort Equation [PCE, OR = 0.72 (0.61–0.85) per 1-SD decrease in PCE]. Risk scores at baseline predicted outcomes more strongly than those at follow-up, and did so independently of any changes over 13 years of follow-up. Similar discrimination for predicting carotid plaque after 13 years was found for both baseline FBS [C-statistic = 0.68 (95% CI 0.62–0.74)] and PCE [C-statistic = 0.69 (95% CI 0.63–0.75)]. Application of this FBS prognostic information to a contemporary cohort of 1763 young adults anticipates the future development of plaque in 305 (17.3%), especially in the 1494 participants (85%) with ≤ 2 metrics of ideal health. In conclusions, FBS measured in young adulthood predicted atherosclerosis 13 years later in middle age, independent of score changes over the follow-up period, emphasizing the importance of early damage to vascular health. FBS may be a simple and feasible risk score for engaging low-risk young people with reduction of future cardiovascular risk.
Publisher: Wiley
Date: 12-2011
Abstract: The Exercise Joins Education: Combined Therapy to Improve Outcomes in Newly-discharged Heart Failure (EJECTION-HF) study will evaluate the impact of a supervised exercise training programme (ETP) on clinical outcomes in recently hospitalized heart failure patients attending a disease management programme (DMP). Methods This multisite, pragmatic randomized controlled trial enrols patients discharged from participating hospitals with clinical evidence of heart failure who are willing and able to participate in a DMP and considered clinically safe to exercise. Enrolment includes participants with impaired and preserved left ventricular systolic function. Baseline assessment and programme commencement occur within 6 weeks of hospital discharge. The control group DMP includes in idualized education and follow-up from a multidisciplinary heart failure team a weekly education programme for 12 weeks self-management advice and medical follow-up. Home exercise is recommended for all participants. In addition, intervention participants are offered 36 supervised, structured gym-based 1 h exercise sessions over 24 weeks. Sessions are tailored to exercise capacity and include aerobic, resistance, and balance exercises. Enrolment target is 350 participants. Primary outcome is 12-month mortality and readmissions. Secondary outcomes include blinded evaluation of depressive symptoms, sleep quality, cognition, and functional status (activities of daily living, 6 min walk distance, grip strength) at 3 and 6 months. A cost-utility analysis will be conducted. This study will enrol a representative group of hospitalized heart failure patients and measure a range of patient and health service outcomes to inform the design of post-hospital DMPs for heart failure. Enrolment will be completed in 2013. ACTRN12608000263392.
Publisher: BMJ
Date: 25-02-2020
DOI: 10.1136/HEARTJNL-2019-316297
Abstract: To compare variability of echocardiographic and cardiovascular magnetic resonance (CMR) measured left ventricular (LV) function parameters and their relationship to cancer therapeutics-related cardiac dysfunction (CTRCD). We prospectively recruited 60 participants (age: 49.8±11.6 years), 30 women with human epidermal growth factor receptor 2-positive breast cancer (15 with CTRCD and 15 without CTRCD) and 30 healthy volunteers. Patients were treated with anthracyclines and trastuzumab. Participants underwent three serial CMR (1.5T) and echocardiography studies at ~3-month intervals. Cine-CMR for LV ejection fraction (LVEF), myocardial tagging for global longitudinal strain (GLS) and global circumferential strain (GCS), two-dimensional (2D) echocardiography for strain and LVEF and three-dimensional (3D) echocardiography for LVEF measurements were obtained. Temporal, interobserver and intraobserver variability were calculated as the coefficient of variation and as the SE of the measurement (SEM). Minimal detected difference (MDD) was defined as 2xSEM. Patients with CTRCD demonstrated larger mean temporal changes in all parameters compared with those without: 2D-LVEF: 4.6% versus 2.8% 3D-LVEF: 5.2% vs 2.3% CMR-LVEF: 6.6% versus 2.7% 2D-GLS: 1.9% versus 0.7%, 2D-GCS: 2.5% versus 2.2% CMR-GCS: 2.7% versus 1.6% and CMR-GLS: 2.1% versus 1.4%, with overlap in 95% CI for 2D-LVEF, 2D-GCS, CMR-GLS and CMR-GCS. The respective mean temporal variability/MDD in healthy volunteers were 3.3%/6.5%, 1.8%/3.7%, 2.2%/4.4%, 0.8%/1.5%, 1.9%/3.7%, 1.8%/3.6% and 1.4%/2.8%. Although the mean temporal variability in healthy volunteers was lower than the mean temporal changes in CTRCD, at the in idual level, 2D-GLS, 3D-LVEF and CMR-LVEF had the least overlap. 2D-GLS and CMR-LVEF had the lowest interobserver/intraobserver variabilities. Temporal changes in 3D-LVEF, 2D-GLS and CMR LVEF in patients with CTRCD had the least overlap with the variability in healthy volunteers however, 2D-GLS appears to be the most suitable for clinical application in in idual patients.
Publisher: The Endocrine Society
Date: 09-2005
DOI: 10.1210/JC.2005-0681
Abstract: To explore whether aldosterone excess can induce adverse cardiovascular effects independently of effects on blood pressure (BP), we sought evidence of disturbed cardiovascular structure or function in normotensive in iduals with primary aldosteronism. Eight normotensive subjects with genetically proven familial hyperaldosteronism type I (FH-I) were compared with 24 age- and sex-matched normotensive controls in terms of BP, biochemical parameters, pulse wave velocity, and echocardiographic characteristics. Subjects with FH-I demonstrated higher serum aldosterone levels and aldosterone/renin ratios than controls, as expected. Despite having similar 24-h ambulatory BPs, subjects with FH-I demonstrated evidence of concentric remodeling with greater septal (mean +/- sd, 9.4 +/- 1.1 vs. 7.9 +/- 0.9 mm P < 0.001), posterior wall (9.2 +/- 1.7 vs. 7.7 +/- 1.0 mm P < 0.01), and relative wall (0.29 +/- 0.03 vs. 0.24 +/- 0.02 P < 0.001) thicknesses, and lower mitral early peak velocities (0.74 +/- 0.10 vs. 0.90 +/- 0.16 m/sec P < 0.05), ratios of early to late peak diastolic transmitral flow velocity (1.56 +/- 0.24 vs. 2.06 +/- 0.41 P < 0.01), and myocardial early peak velocities (8.3 +/- 1.8 vs. 10.3 +/- 2.6 cm/sec P < 0.05). There were no significant differences in pulse wave velocity or left ventricular ejection fraction, long axis strain rate, peak systolic strain, cyclic variation of integrated backscatter, or posterior wall calibrated integrated backscatter. Aldosterone excess is associated with increased left ventricular wall thicknesses and reduced diastolic function, even in the absence of hypertension.
Publisher: Portland Press Ltd.
Date: 12-02-2008
DOI: 10.1042/CS20070295
Abstract: To date, the main cardiovascular application of TDI (tissue Doppler imaging) has been in myocardial evaluation. In the present study, we investigated the feasibility and reproducibility of assessing arterial elasticity using the DC (distensibility coefficient) measured by TDI, the correlation of this with the DC obtained by other methods and the DC in patients with various degrees of cardiovascular risk. We studied 450 subjects (256 men age, 51±10 years) with and without risk factors of cardiovascular disease. Arterial displacement was measured from TDI, and B-mode and M-mode images of the common carotid artery in the longitudinal plane, and the DC with each method was compared. Linear regression showed a good correlation between all three methods. The results for TDI and B-mode were comparable [(21±10) compared with (21±10)×10−3/kPa respectively P=not significant], but there were significant differences between TDI and M-mode [(21±10) compared with (31±13)×10−3/kPa respectively P& .0001] and between B-mode and M-mode [(21±10) compared with (31±13)×10−3/kPa respectively P& .0001]. Similarly, Bland–Altman analysis showed the least variability in the DC between TDI and B-mode, and there were no significant differences between the average measurements. The TDI DC also had the lowest paired difference for inter-observer variability [(−0.1±1.1)×10−3/kPa P=not significant]. In conclusion, the results of the present study suggest that TDI of the carotid arteries is feasible, comparable with B-mode measurements, more robust than M-mode and less variable than the other methods.
Publisher: Springer International Publishing
Date: 2015
Publisher: Wiley
Date: 11-1999
DOI: 10.1111/J.1540-8175.1999.TB00140.X
Abstract: In the current literature, pharmacologic stress techniques are the focus of interest and excitement regarding new technologies and new indications such as the diagnosis of viable myocardium. In contrast, exercise echocardiography has evolved less and is less amenable to the introduction of new technologies. This article reviews the indications for exercise echocardiography (especially in contrast to pharmacologic stress), its accuracy relative to other testing, and application to clinical decision making. Exercise echocardiography remains to be well accepted as a diagnostic and risk-assessment technique, and in some clinical situations it provides valuable data that are not available during pharmacologic stress testing.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2006
DOI: 10.1161/01.HYP.0000223013.60612.72
Abstract: Exercise brachial blood pressure (BP) predicts mortality, but because of wave reflection, central (ascending aortic) pressure differs from brachial pressure. Exercise central BP may be clinically important, and a noninvasive means to derive it would be useful. The purpose of this study was to test the validity of a noninvasive technique to derive exercise central BP. Ascending aortic pressure waveforms were recorded using a micromanometer-tipped 6F Millar catheter in 30 patients (56±9 years 21 men) undergoing diagnostic coronary angiography. Simultaneous recordings of the derived central pressure waveform were acquired using servocontrolled radial tonometry at rest and during supine cycling. Pulse wave analysis of the direct and derived pressure signals was performed offline (SphygmoCor 7.01). From rest to exercise, mean arterial pressure and heart rate were increased by 20±10 mm Hg and 15±7 bpm, respectively, and central systolic BP ranged from 77 to 229 mm Hg. There was good agreement and high correlation between invasive and noninvasive techniques with a mean difference (±SD) for central systolic BP of −1.3±3.2 mm Hg at rest and −4.7±3.3 mm Hg at peak exercise (for both r =0.995 P .001). Conversely, systolic BP was significantly higher peripherally than centrally at rest (155±33 versus 138±32 mm Hg mean difference, −16.3±9.4 mm Hg) and during exercise (180±34 versus 164±33 mm Hg mean difference, −15.5±10.4 mm Hg for both P .001). True myocardial afterload is not reliably estimated by peripheral systolic BP. Radial tonometry and pulse wave analysis is an accurate technique for the noninvasive determination of central BP at rest and during exercise.
Publisher: Elsevier BV
Date: 10-1997
DOI: 10.1016/S0002-9149(97)00537-7
Abstract: Myocardial perfusion imaging using positron emission tomography (PET) may be more accurate for the diagnosis of coronary artery disease (CAD) than conventional imaging. The purpose of this study was to evaluate the prognostic implications of perfusion abnormalities in 685 patients (age 62 +/- 11 years, 199 women) studied by PET, and to assess the incremental value of these data in relation to prognostic implications of clinical and angiographic findings. Rubidium (Rb)-82 PET was performed before and after dipyridamole stress. Transient defects were detected in 227 patients (33%), and were moderate or greater in severity (> 15% of the left ventricle) in 84 (12%). Resting defects were present in 435 (64%) and were moderate or greater in severity in 216 (32%). The total extent of abnormally perfused myocardium was small ( 3 months after PET). Normal scans had a 90% event-free survival, compared with 87% in patients with small, 75% with moderate, and 76% with extensive defects (log rank chi-square 30, p <0.0001). Functional class, extent of CAD, and the presence and extent of perfusion defects (both at rest and during stress) were independent predictors of cardiac death and total cardiac events. In sequential Cox proportional-hazards models, the results of PET were incremental to those of clinical and angiographic evaluation. Thus, the presence and extent of damaged and jeopardized myocardium are independent and incremental predictors of outcome in patients undergoing Rb-82 PET.
Publisher: Oxford University Press (OUP)
Date: 10-08-2019
Abstract: In patients with non-ischaemic cardiomyopathy (NICM), the mortality benefit of a primary prevention implantable cardioverter-defibrillator (ICD) has been challenged. Left ventricular (LV) scar identified by cardiac magnetic resonance (CMR) imaging is associated with a high risk of malignant arrhythmia in NICM. We aimed to determine the impact of LV scar on the mortality benefit from a primary prevention ICD in NICM. We recruited 452 consecutive heart failure patients [New York Heart Association (NYHA) Class II/III] with NICM and LV ejection fraction ≤35% from a state-wide CMR service. All patients fulfilled European Society of Cardiology guidelines for primary prevention ICD implantation however, the decision to implant was at the treating physician's discretion. Baseline clinical and CMR data were recorded prospectively and heart failure mortality risk (MAGGIC score) was calculated. The primary study outcome measurement was all-cause mortality based on presence or absence of ICD, stratified by LV scar. Median follow-up was 37.9 months and there was no difference in MAGGIC score between those who did and did not receive a primary prevention ICD (19.30 ± 5.46 vs. 18.90 ± 5.67, P = 0.50). In patients without LV scar, ICD implantation was not associated with improved mortality [hazard ratio (HR) = 1.22, 95% confidence interval (CI): 0.53-2.78, P = 0.64]. In patients with LV scar, ICD implantation was independently associated with reduced mortality (HR = 0.45, 95% CI: 0.26-0.77, P = 0.003). In patients with NICM, primary prevention ICD implantation is only associated with reduced mortality in patients with LV scar. This may enable more effective selection of NICM patients for ICD implantation compared with current guidelines.
Publisher: The Korean Society of Cardiology
Date: 2016
Publisher: Elsevier BV
Date: 02-2018
DOI: 10.1016/J.JCMG.2017.11.017
Abstract: Left ventricular (LV) ejection fraction (LVEF) is a simple measure of global systolic function that pervades the risk evaluation and management of many cardiovascular diseases. However, this parameter is limited not only by technical challenges, but also by pathophysiological entities where the ratio of stroke volume to LV cavity size is preserved. The assessment of global longitudinal strain (GLS) from speckle-tracking analysis of 2-dimensional echocardiography has become a clinically feasible alternative to LVEF for the measurement of myocardial function. Evidence gathered over the last decade has shown GLS to be more sensitive to left ventricular dysfunction (LVD) than LVEF and to provide additional prognostic information. The technology is validated, reproducible within an acceptable range, and widely available. GLS has been proposed as the test of choice in guidelines for monitoring of asymptomatic cardiotoxicity related to chemotherapy. It also has the potential to improve risk stratification, redefine criteria for disease classification, and determine treatment in asymptomatic LVD resulting from a variety of etiologies. GLS provides utility across the spectrum of heart failure (and LVEF) as well as in the evaluation of valvular heart disease. There is a strong case for incorporation of GLS into clinical decision making. This review appraises the evidence addressing the utility of GLS as a complementary metric to LVEF for incorporation into mainstream clinical practice.
Publisher: Oxford University Press (OUP)
Date: 12-07-2005
DOI: 10.1093/NDT/GFH980
Abstract: Cardiac events (CE cardiac death, non-fatal myocardial infarction and acute coronary syndrome) are the principal causes of death in patients with chronic kidney disease (CKD). We sought to devise and validate a cardiac risk score to risk-stratify patients with CKD. Clinical history and biochemical data were obtained in 167 CKD patients. CE were recorded over a median follow-up of 22 months. The hazard ratio (HR) of each independent variable using Cox regression analysis was used to derive a cardiac risk score for the prediction of events. The cardiac risk score was then applied to a validation population of 99 CKD patients to confirm its validity in predicting CE. CE occurred in 20 patients in the derivation group. The independent predictors of CE were cardiac history (HR 9.83, P = 0.001), body mass index (BMI HR 1.15, P = 0.002), dialysis duration (HR 1.24, P = 0.004) and serum phosphate (HR 4.29, P = 0.001). The resulting cardiac risk score (range 26-67) gave an area under the receiver operating characteristic curve of 0.86. CE occurred in 25 patients in the validation group the ROC curve area was similar (0.84, P = 0.11). An optimal cardiac risk score cut-off of 50 assigned high risk to 29% of the derivation and 35% of the validation group (P = 0.26). CE occurred in 35 and 57% of the high-risk derivation and validation groups, respectively (P = 0.09), and in 2 and 8% of the low-risk groups (P = 0.15). Application of a cardiac risk score using cardiac history, dialysis duration, BMI and phosphate identifies CKD patients at risk of future CE.
Publisher: BMJ
Date: 09-1999
DOI: 10.1136/HRT.82.3.357
Abstract: To validate a simplified estimate of peak power (SPP) against true (invasively measured) peak instantaneous power (TPP), to assess the feasibility of measuring SPP during exercise and to correlate this with functional capacity. Development of a simplified method of measurement and observational study. Tertiary referral centre for cardiothoracic disease. For validation of SPP with TPP, seven normal dogs and four dogs with dilated cardiomyopathy were studied. To assess feasibility and clinical significance in humans, 40 subjects were studied (26 patients 14 normal controls). In the animal validation study, TPP was derived from ascending aortic pressure and flow probe, and from Doppler measurements of flow. SPP, calculated using the different flow measures, was compared with peak instantaneous power under different loading conditions. For the assessment in humans, SPP was measured at rest and during maximum exercise. Peak aortic flow was measured with transthoracic continuous wave Doppler, and systolic and diastolic blood pressures were derived from brachial sphygmomanometry. The difference between exercise and rest simplified peak power (Delta SPP) was compared with maximum oxygen uptake (VO(2)max), measured from expired gas analysis. SPP estimates using peak flow measures correlated well with true peak instantaneous power (r = 0.89 to 0.97), despite marked changes in systemic pressure and flow induced by manipulation of loading conditions. In the human study, VO(2)max correlated with Delta SPP (r = 0.78) better than Delta ejection fraction (r = 0.18) and Delta rate-pressure product (r = 0.59). The simple product of mean arterial pressure and peak aortic flow (simplified peak power, SPP) correlates with peak instantaneous power over a range of loading conditions in dogs. In humans, it can be estimated during exercise echocardiography, and correlates with maximum oxygen uptake better than ejection fraction or rate-pressure product.
Publisher: Elsevier BV
Date: 07-2014
DOI: 10.1016/J.IJCARD.2014.04.164
Abstract: We compared the longer-term impact of the two most commonly applied forms of post-discharge management designed to minimize recurrent hospitalization and prolong survival in typically older patients with chronic heart failure (CHF). We followed a multi-center randomized controlled trial cohort of Australian patients hospitalized with CHF and initially allocated to home-based or specialized CHF clinic-based intervention for 1368 ± 216 days. Blinded endpoints included event-free survival from all-cause emergency hospitalization or death, all-cause mortality and rate of all-cause hospitalization and stay. 280 patients (73% male, aged 71 ± 14 years and 73% left ventricular systolic dysfunction) were initially randomized to home-based (n=143) or clinic-based (n=137) intervention. During extended follow-up (complete for 274 patients), 1139 all-cause hospitalizations (7477 days of hospital stay) and 121 (43.2%) deaths occurred. There was no difference in the primary endpoint 20 (14.0%) home-based versus 13 (7.4%) clinic-based patients remained event-free (adjusted HR 0.89, 95% CI 0.70 to 1.15 p=0.378). Significantly fewer home-based (51/143, 35.7%) than clinic-based intervention (71/137, 51.8%) patients died (adjusted HR 0.62, 95% CI 0.42 to 0.90: p=0.012). Home-based versus clinic-based intervention patients accumulated 592 and 547 all-cause hospitalizations (p=0.087) associated with 3067 (median 4.0, IQR 2.0 to 6.8) versus 4410 (6.0, IQR 3.0 to 12.0) days of hospital stay (p<0.01 for rate and duration of hospital stay). Relative to clinic-based intervention, home-based intervention was not associated with prolonged event-free survival. Home-based intervention was, however, associated with significantly fewer all-cause deaths and significantly fewer days of hospital stay in the longer-term. Australian New Zealand Clinical Trials Registry number 12607000069459 (www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=81803).
Publisher: Elsevier BV
Date: 04-2011
DOI: 10.1016/J.JACC.2010.10.057
Abstract: We sought to determine whether pharmacologic interventions changed exercise capacity, diastolic function, and mortality in a meta-analysis of trials in heart failure with preserved ejection fraction. Treatment strategies for heart failure with preserved ejection fraction remain unproven despite several large-scale trials. Trials were included in the systematic review where clear comparisons between trial drug and diuretic or placebo were available. Exercise tolerance was assessed by treadmill time, and changes in diastolic function were quantified by transmitral flow (E/A ratio). The primary outcome was all-cause mortality. Weighted mean differences (MDs) and relative risks (RRs), along with their corresponding 95% confidence intervals (CIs), were computed using random-effects models for continuous and dichotomous variables, respectively. The impact of potential covariates was assessed by meta-regression. Data from 53,878 patients enrolled in 30 published reports were collated, including 18 randomized controlled trials (n = 11,253) and 12 observational studies (n = 42,625). In the randomized controlled trials, exercise tolerance was improved by combined therapy (n = 183 weighted MD = 51.5 95% CI: 27.3 to 75.7 p < 0.001), whereas E/A ratio was not (n = 472 weighted MD = -0.01, 95% CI: -0.02 to 0.02 p = 0.54) even after accounting for baseline E/A (p = 0.87). Over a mean follow-up of 18.6 months, all-cause mortality was not improved by therapy in randomized controlled trials (RR: 0.99, 95% CI: 0.92 to 1.06 p = 0.70), despite accounting for baseline ejection fraction (p = 0.72). In observational reports, there was a reduction in all-cause mortality with therapy in the unadjusted analyses (RR: 0.80, 95% CI: 0.66 to 0.97 p = 0.27), but not after adjustment for clinical and demographic data (RR: 0.93, 95% CI: 0.84 to 1.02 p = 0.10). Pharmacotherapy of heart failure with preserved ejection fraction demonstrates a quantifiable improvement in exercise tolerance but not mortality.
Publisher: Springer International Publishing
Date: 2015
Publisher: Elsevier BV
Date: 10-2015
Publisher: BMJ
Date: 12-07-2012
DOI: 10.1136/HEARTJNL-2012-302178
Abstract: Current guidelines recommend the use of aldosterone antagonists (AA) in patients with moderately severe to severe symptoms [New York Heart Association (NYHA) class III to IV] and systolic heart failure. To determine the efficacy of AA in improving ejection fraction (EF) and functional capacity and to assess whether this effect was influenced by baseline NYHA classification. Meta-analysis of randomized controlled trials. Data extraction performed independently by two researchers. MEDLINE and the Cochrane Library. Prospective randomized controlled trials using AA were included if there was a clear description of the baseline NYHA classification and change in EF in patients from study initiation to completion. Data from 1,575 patients enrolled in fourteen studies were included. Overall, there was a weighted mean improvement in EF of 3.2% and in NYHA classification of 0.13 in subjects treated with AA when compared to controls (p<0.001). A mixed effects meta-regression analysis revealed that baseline NYHA was not predictive of improvement in EF (p=0.67) nor NYHA status (p=0.18). The results of this meta-analysis suggest that AA is associated with significant improvements in EF and functional class independent of baseline functional capacity. This supports and expands on the recently published EMPHASIS-HF trial and suggests that the current restriction of AA use to patients with NYHA class III-IV symptoms should be reconsidered.
Publisher: Elsevier BV
Date: 04-2015
DOI: 10.1016/J.IJCARD.2015.06.059
Abstract: Clinical guidelines represent statements that seek to synthesize the best evidence to guide a course of action to improve health outcomes and more cost-effective use of resources. However, even when the evidence is not definitive, comprehensive documents are still needed to guide clinical decision-making. In these circumstances, guidelines are inevitably affected by perceptions of the problem and their possible solutions. From 1998 to 2014, 10 different international guidelines have focused on the aortopathy related to bicuspid aortic valves. Recommended thresholds for intervention started at a cutoff level of 5.5cm in 1998, reached a nadir of 4 to 4.5cm in 2010, and returned to a 5.5cm cutoff level in 2014. During this time, no conclusive objective proof was published to support either an aggressive or conservative strategy. The consequence was that an undefined number of patients underwent surgery (and potential complications thereof) at an earlier disease stage than might have been necessary. This experience might provide a clue as to how guidelines evolve, and provide insight as to how to avoid a similar process in the future.
Publisher: Elsevier BV
Date: 03-2002
Abstract: Endothelial function plays a key role in the local regulation of vascular tone. Alterations in endothelial function may result in impaired release of endothelium-derived relaxing factors or increased release of endothelium-derived contracting factors. Heart failure may impair endothelial function by means of reduced synthesis and release of nitric oxide (NO) or by increased degradation of NO and increased production of endothelin-1. Endothelial dysfunction may worsen heart function by means of peripheral effects, causing increased afterload and central effects such as myocardial ischemia and inducible nitric oxide synthase (iNOS)-induced detrimental effects. Evidence from clinical studies has suggested that there is a correlation between decreased endothelial function and increasing severity of congestive heart failure (CHF). Treatments that improve heart function may also improve endothelial dysfunction. The relationship between endothelial dysfunction and heart failure may be masked by the stage of endothelial dysfunction, the location of vessels being tested, and the state of endothelial-dependent vasodilatation response.
Publisher: Portland Press Ltd.
Date: 24-08-2005
DOI: 10.1042/CS20050212
Abstract: Inactivity is associated with endothelial dysfunction and the development of cardiovascular disease. Exercise training has a favourable effect in the management of hypertension, heart failure and ischaemic heart disease. These beneficial effects are probably mediated through improvements of vascular function and, in this issue of Clinical Science, Hägg and co-authors propose a coronary artery effect. The use of a Doppler technique for non-invasive assessment of coronary flow reserve in a small animal model is an exciting aspect of this study. If feasible in the hands of other investigators, the availability of sequential coronary flow measurements in animal models may help improve our understanding of the mechanisms of disorders of the coronary circulation.
Publisher: Elsevier BV
Date: 07-1999
DOI: 10.1016/S0002-9149(99)00192-7
Abstract: Previous studies of dobutamine echocardiography (DE) and positron emission tomography (PET) showed similar accuracy for predicting improvement in resting wall motion after revascularization, although limited direct comparative data are available. We sought to compare the relative accuracy of detecting contractile reserve, ischemia, perfusion, and myocardial metabolism for predicting functional recovery after coronary bypass surgery in 94 consecutive patients (aged 63+/-11 years) with chronic coronary disease and depressed left ventricular function (ejection fraction 28+/-5%). PET imaging comprised rest and dipyridamole stress myocardial perfusion images, with fluorodeoxyglucose to define metabolism-perfusion mismatch. A standard dobutamine-atropine stress was used, with evaluation of low- and peak-dose echocardiographic responses. Regional function was assessed after 13+/-16 weeks at rest in 68 patients who underwent isolated coronary bypass operation without evidence of perioperative infarction, and at rest and stress in a subgroup of 29 patients. Concordance between methods for evaluating abnormal segments (ischemic, viable, and scar) and accuracy of both tests for predicting improvement in regional function were identified. Concordance between PET and DE for identifying viable or nonviable myocardium was 63% using a 16-segment model. For predicting improved resting function after surgery, the sensitivity of PET (84%) was superior to DE (69%, p<0.001), but DE was more specific (78% vs. 37%, p<0.0001) and more accurate (75% vs. 53%, p<0.001) in predicting recovery at rest. Analysis of postoperative recovery of segmental function during stress also showed the specificity of DE to exceed that of PET (89% vs. 32%, p<0.001). The accuracy of DE was enhanced by evaluation of function during stress (86%, p<0.001), but this was not altered with PET (52%, p = NS). Thus, PET is more sensitive than DE in predicting functional recovery, but DE is more specific than PET. Evaluation of left ventricular functional recovery during stress may be preferable to assessment at rest.
Publisher: Wiley
Date: 27-06-2011
Publisher: Oxford University Press (OUP)
Date: 02-06-1997
DOI: 10.1093/EURHEARTJ/18.SUPPL_D.68
Abstract: The aim of this review was to define the place of stress (exercise, dobutamine, and vasodilator) echocardiography in the context of perfusion scintigraphic techniques for the detection of coronary artery disease. Echocardiography and nuclear imaging have their strong and weak points. Echocardiography has the benefit of widespread availability, relatively low cost, portability, absence of radiation, safety, and determination of ischaemic threshold. However, echocardiographic imaging cannot be performed during treadmill exercise, the echocardiographic windows are variable with sometimes poor echogenicity, and interpretation is subjective and requires an important learning curve. Diagnostic comparisons were focused on studies involving echocardiographic and nuclear imaging in the same patients. These direct comparisons show that exercise or dobutamine echocardiography and perfusion imaging have similar accuracies for the detection and localization of coronary artery disease. Perfusion imaging may be more sensitive in the detection of mild coronary artery disease echocardiography, however, has a better specificity. Vasodilator perfusion imaging is superior to vasodilator echocardiography, although the new dipyridamole-atropine echocardiography test will make future reassessment necessary. Once the condition of adequate echocardiographic training is fulfilled, we believe that the selection of one or other test should be tailored to clinical circumstances rather than be a uniform decision.
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.KINT.2019.06.025
Abstract: Chronic kidney disease (CKD) is a major risk factor for valvular heart disease (VHD). Mitral annular and aortic valve calcifications are highly prevalent in CKD patients and commonly lead to valvular stenosis and regurgitation, as well as complications including conduction system abnormalities and endocarditis. VHD, especially mitral regurgitation and aortic stenosis, is associated with significantly reduced survival among CKD patients. Knowledge related to VHD in the general population is not always applicable to CKD patients because the pathophysiology may be different, and CKD patients have a high prevalence of comorbid conditions and elevated risk for periprocedural complications and mortality. This Kidney Disease: Improving Global Outcomes (KDIGO) review of CKD and VHD seeks to improve understanding of the epidemiology, pathophysiology, diagnosis, and treatment of VHD in CKD by summarizing knowledge gaps, areas of controversy, and priorities for research.
Publisher: Springer Science and Business Media LLC
Date: 21-01-2010
DOI: 10.1038/JHH.2009.92
Abstract: There are several methods of assessing total arterial compliance (TAC) based on the two element Windkessel model, which is a ratio of pressure and volume, but the optimal technique is unclear. In this study, three methods of estimating TAC were compared to determine which was the most robust in a large group of patients with and without cardiovascular risk. In all, 320 patients (170 men age 55+/-10) were studied TAC was determined by the pulse-pressure method (PPM), the area method (AM) and the stroke volume ulse-pressure method (SVPP). We obtained arterial waveforms using radial applanation tonometry, dimensions using two-dimensional echocardiography and flow data by Doppler. Clinical data, risk factors, echo parameters and TAC by all three methods were then compared. TAC (ml mm Hg(-1)) by the PPM was 1.24+/-0.51, by the AM 1.84+/-0.90 and by the SVPP 1.96+/-0.76 (P<0.0001 between groups). Correlation was good between all methods: PPM/AM r=0.83, PPM/SVPP r=0.94 and AM/SVPP r=0.80 (all P<0.0001). Subgroup analysis showed significant differences between patients with and those without cardiovascular risk for all three methods TAC-AM and TAC-SVPP values were similar and significantly higher than TAC-PPM. The only significant relationships observed with TAC and echo parameters were in left ventricular (LV) septal thickness (R(2)=0.07 P<0.0001) and LV mass (R(2)=0.04 P=0.004). Normal and abnormal values of TAC vary according to method, which should be expressed. Each of the techniques shows good correlation with each other, however, values for TAC-PPM are significantly lower. TAC-PPM and TAC-SVPP are comparable in determining differences between groups with and without cardiovascular risk.
Publisher: Elsevier BV
Date: 10-1998
DOI: 10.1016/S0735-1097(98)00321-0
Abstract: The purpose of this study was to assess whether the presence or absence of myocardial viability during dobutamine echocardiography (DE) predicts survival in patients with coronary artery disease (CAD) and severe left ventricular (LV) dysfunction. In patients with CAD, the presence of myocardial viability during DE identifies viable myocardium and predicts recovery of LV systolic function after revascularization. However, there is little data on the relation between myocardial viability and clinical outcome in patients with CAD and severe LV dysfunction. We studied 318 patients with CAD and a LV ejection fraction (EF) < or =35% who underwent DE and were followed for 18+/-10 months. Patients were classified into four groups. Group I (n=85) consisted of patients who had evidence of myocardial viability and subsequently underwent revascularization. Group II (n=119) consisted of patients with myocardial viability who did not undergo revascularization. Group III (n=30) consisted of patients who did not have myocardial viability and underwent revascularization. Finally, group IV (n=84) patients lacked myocardial viability and did not undergo revascularization. The four groups had similar baseline characteristics and rest LVEF. During follow-up there were 51 deaths (16%). The mortality rate was 6% in group I, 20% in group II, 17% in group III and 20% in group TV (p=0.01, group I vs. other groups). In patients with CAD and severe LV dysfunction who demonstrated myocardial viability during DE, revascularization improved survival compared with medical therapy.
Publisher: Elsevier BV
Date: 06-2021
Publisher: Elsevier BV
Date: 03-2018
Publisher: BMJ
Date: 2006
Publisher: Elsevier BV
Date: 09-2001
DOI: 10.1016/S0301-5629(01)00406-9
Abstract: Concerns have been raised about the reproducibility of brachial artery reactivity (BAR), because subjective decisions regarding the location of interfaces may influence the measurement of very small changes in lumen diameter. We studied 120 consecutive patients with BAR to address if an automated technique could be applied, and if experience influenced reproducibility between two observers, one experienced and one inexperienced. Digital cineloops were measured automatically, using software that measures the leading edge of the endothelium and tracks this in sequential frames and also manually, where a set of three point-to-point measurements were averaged. There was a high correlation between automated and manual techniques for both observers, although less variability was present with expert readers. The limits of agreement overall for interobserver concordance were 0.13 +/- 0.65 mm for the manual and 0.03 +/- 0.74 mm for the automated measurement. For intraobserver concordance, the limits of agreement were - 0.07 +/- 0.38 mm for observer 1 and - 0.16 +/- 0.55 mm for observer 2. We concluded that BAR measurements were highly concordant between observers, although more concordant using the automated method, and that experience does affect concordance. Care must be taken to ensure that the same segments are measured between observers and serially.
Publisher: Springer Science and Business Media LLC
Date: 04-11-2020
DOI: 10.1007/S10554-019-01717-3
Abstract: T1 mapping by cardiac magnetic resonance (CMR) allows detection of abnormal myocardium. A number of myocardial abnormalities affects the signal captured in T1 mapping. We performed a systematic review and meta-analysis of native T1 and extracellular volume (ECV) in subjects with and without cardiac disease (1) to determine the normal ranges of T1 values and ECV by sequences as well as parameters influencing them, and (2) to summarize the differences in T1 values and ECV of the diseases relative to the normal ranges. Three databases (EMBASE, SCOPUS, and MEDLINE) were systematically searched for native T1 time and ECV. Only human studies with a s le size of ≥ 20 subjects were included. A random effect model was used to pool data. The 69 selected articles included 1954 healthy subjects and 3186 with disease. T1 of normal healthy was different among MOLLI variants: in 1.5T sequences, ShMOLLI had the shortest (944 ms [95% confidence interval 925, 963]), followed by MOLLI 3(3)3(3)5 flip-angle 50°, 967 [959, 975] and flip-angle 35°, 969 [951, 988]. 3T had longer T1 than 1.5T by approximately 100-200 ms. ECV of the normal healthy was consistent among the studies (ranging from 25 to 27%), irrespective of subjects' factors, sequences, vendors, and contrast type. Many diseases demonstrated longer native T1 than normal subjects, but T1 was shorter in Fabry disease and iron overload. In contrast, all disease states showed either normal or increased ECV. Diagnostic accuracy of native T1 time was minimally affected by the difference in the sequences. ECV is less influenced by methodology than T1 time among normal subjects. Different myocardial diseases are associated with shorter or longer T1 times, whereas ECV is consistently increased independent of the underlying pathophysiology.
Publisher: Springer Science and Business Media LLC
Date: 27-03-2012
DOI: 10.1038/IJO.2012.44
Publisher: Elsevier BV
Date: 08-1989
DOI: 10.1016/S0272-6386(89)80185-4
Abstract: The diagnosis of coronary artery disease remains a major problem in patients with end-stage renal disease. Screening with conventional noninvasive techniques is limited by the poor exercise capacity of these patients. This study evaluated the accuracy of digital subtraction fluorography in detecting coronary calcification as a noninvasive, nonexercise screening test for coronary artery disease. Eighty-six patients under evaluation for renal transplantation and considered at increased risk of coronary artery disease were studied by coronary arteriography and digital subtraction fluorography for coronary calcification. Significant coronary disease (greater than or equal to 50% obstruction in at least one vessel) was present in 36 (42%) patients. The detection of coronary calcification by digital subtraction fluorography had a sensitivity of 78% and a specificity of 66%. The probability of disease being present in the absence of coronary calcification in this group was 18%. The detection of coronary calcification by digital subtraction fluorography appears to be a satisfactory and inexpensive screening test in this setting.
Publisher: Wiley
Date: 04-09-2022
DOI: 10.1111/IMJ.15769
Abstract: Screening for atrial fibrillation is recommended for patients 65 years on current guidelines. Targeted screening may be more efficient, however the appropriate location for screening programs has not been well defined. Our aim was to compare the cost‐effectiveness of unselected electrocardiographic (ECG) screening for atrial fibrillation (AF), and selective screening based on an abnormal echocardiogram. Two strategies of portable ECG screening for AF were compared in the base case of a hypothetical asymptomatic 65‐year‐old man (CHA 2 DS 2 ‐VASC = 3 based on hypertension and diabetes mellitus) with previous echocardiography but without a cause for AF (e.g. mitral valve disease, left ventricular (LV) dysfunction). With age‐based screening (AgeScreen 3% AF detection rate) all patients underwent ECG. With imaging‐guided screening (ImagingScreen 5% detection rate), only patients with left atrial (LA) volume ≥34 mL/m 2 and LA reservoir strain % or LV global longitudinal strain −18% underwent ECG screening. A Markov model was informed by published transition probabilities, costs and quality‐adjusted life years (QALY). Costs, effects and incremental cost‐effectiveness ratio were assessed for each screening strategy over a 20‐year period. The willingness‐to‐pay threshold was $53 000/QALY. ImagingScreen dominated AgeScreen, with a lower cost ($54 823 vs $57842) and better outcome (11.56 vs 11.52 QALY over 20 years). Monte Carlo simulation demonstrated that 61% of observations were more efficacious with ImagingScreen, with cost below willingness to pay. The main cost determinants were annual costs of stroke or heart failure and AF detection rates. ImagingScreen was more cost‐effective for AF detection rates up to 14%, and more cost‐effective across a range of annual stroke ($24 000–$102 000) and heart failure ($4000–$12 000) costs. In patients with a previous echocardiogram, AF screening of those with baseline clinical and imaging risk parameters is more cost‐effective than age‐based screening.
Publisher: Elsevier BV
Date: 09-2011
Publisher: Elsevier BV
Date: 06-1998
DOI: 10.1016/S0002-9149(98)00162-3
Abstract: Left ventricular (LV) cavity obliteration during dobutamine echocardiography (DE) indicates a vigorous inotropic response to stress. Such a response may suggest the absence of coronary artery disease (CAD), but a small LV cavity may also preclude recognition of wall motion abnormalities. We sought to determine the frequency, correlates, accuracy, and prognostic value of the LV cavity obliteration response in 336 consecutive patients who underwent coronary angiography within 1 year of DE. Cavity obliteration was defined by contact of the opposite walls in the apical views during DE, and ischemia by detection of a new or worsening wall motion abnormality. Sensitivity was based on comparison with coronary anatomy in 220 patients without prior revascularization. The prognostic implications of cavity obliteration were examined by follow-up of 324 patients (96%) over 23 +/- 9 months for death, myocardial infarction, and late revascularization. Cavity obliteration was present in 86 of the 336 DE studies (26%). Baseline and stress hemodynamics were not predictive of cavity obliteration, which was associated with LV hypertrophy and female gender (p <0.0001), and inversely related to LV systolic dysfunction and use of angiotensin-converting enzyme inhibitors or diuretics (p <0.02). The sensitivity of DE was less in patients with cavity obliteration than the remainder, especially in single vessel (46% vs 92%, p <0.001) but also in multivessel CAD (73% vs 95%, p = 0.01). Irrespective of DE and angiographic results, cavity obliteration was a negative predictor for cardiac events (RR 0.42, 95% confidence interval [CI] 0.21 to 0.87, p = 0.02) and death (RR 0.14, 95% CI 0.02 to 1.09, p = 0.06). Even after exclusion of patients with LV dysfunction, cavity obliteration was an independent predictor of freedom from events (RR 0.41, 95% CI 0.19 to 0.88, p = 0.02). Thus, LV cavity obliteration is a frequent response to DE, which compromises the sensitivity of DE but is correlated paradoxically with a favorable clinical outcome.
Publisher: Oxford University Press (OUP)
Date: 24-11-2013
DOI: 10.1093/JAC/DKT447
Publisher: Elsevier BV
Date: 09-2009
DOI: 10.1016/J.ARTMED.2009.05.002
Abstract: HIV treatment failure is commonly associated with drug resistance and the selection of a new regimen is often guided by genotypic resistance testing. The interpretation of complex genotypic data poses a major challenge. We have developed artificial neural network (ANN) models that predict virological response to therapy from HIV genotype and other clinical information. Here we compare the accuracy of ANN with alternative modelling methodologies, random forests (RF) and support vector machines (SVM). Data from 1204 treatment change episodes (TCEs) were identified from the HIV Resistance Response Database Initiative (RDI) database and partitioned at random into a training set of 1154 and a test set of 50. The training set was then partitioned using an L-cross (L=10 in this study) validation scheme for training in idual computational models. Seventy six input variables were used for training the models: 55 baseline genotype mutations the 14 potential drugs in the new treatment regimen four treatment history variables baseline viral load CD4 count and time to follow-up viral load. The output variable was follow-up viral load. Performance was evaluated in terms of the correlations and absolute differences between the in idual models' predictions and the actual DeltaVL values. The correlations (r(2)) between predicted and actual DeltaVL varied from 0.318 to 0.546 for ANN, 0.590 to 0.751 for RF and 0.300 to 0.720 for SVM. The mean absolute differences varied from 0.677 to 0.903 for ANN, 0.494 to 0.644 for RF and 0.500 to 0.790 for SVM. ANN models were significantly inferior to RF and SVM models. The predictions of the ANN, RF and SVM committees all correlated highly significantly with the actual DeltaVL of the independent test TCEs, producing r(2) values of 0.689, 0.707 and 0.620, respectively. The mean absolute differences were 0.543, 0.600 and 0.607log(10)copies/ml for ANN, RF and SVM, respectively. There were no statistically significant differences between the three committees. Combining the committees' outputs improved correlations between predicted and actual virological responses. The combination of all three committees gave a correlation of r(2)=0.728. The mean absolute differences followed a similar pattern. RF and SVM models can produce predictions of virological response to HIV treatment that are comparable in accuracy to a committee of ANN models. Combining the predictions of different models improves their accuracy somewhat. This approach has potential as a future clinical tool and a combination of ANN and RF models is being taken forward for clinical evaluation.
Publisher: Elsevier BV
Date: 06-2015
Publisher: Elsevier BV
Date: 1991
DOI: 10.1016/S0894-7317(14)80166-1
Abstract: Contrast echocardiography is useful for detecting intrapulmonary right-to-left shunt lesions. In a patient with suspected pulmonary arteriovenous fistula, contrast transesophageal echocardiography was used to demonstrate the presence of a right-to-left shunt. By use of a combination of two-dimensional echocardiography, contrast injection, and pulsed Doppler echocardiography, each pulmonary vein was successfully interrogated for evidence of contrast shunting. This case demonstrates that contrast transesophageal echocardiography is useful for the detection of intrapulmonary fistulas and that it has the potential for localization of the shunt lesion.
Publisher: Springer Science and Business Media LLC
Date: 04-2005
DOI: 10.1007/S10554-004-3565-5
Abstract: We studied the relationship between brain natriuretic peptide (BNP) levels and viable myocardium and ischemic myocardium, regional scar and regional contractile function. Fifty-nine patients underwent dobutamine echocardiography and magnetic resonance imaging and resting BNP levels were determined. By magnetic resonance imaging, total extent of dysfunctional myocardium correlated strongest with BNP (r = 0.60, p < 0.0001). The extent of scar, viability and ischemia also correlated. At dobutamine echocardiography, a composite of dysfunctional and ischemic myocardium was the strongest correlate of BNP (r = 0.48, p < 0.0001), with less strong correlations by global parameters. The extent of dysfunctional myocardium, rather than its nature determines BNP levels.
Publisher: Elsevier BV
Date: 11-2006
DOI: 10.1016/J.JACC.2006.07.050
Abstract: This study sought to differentiate the transmural extent of infarction (TME) by assessment of the short-axis and long-axis function of the left ventricle (LV) using 2-dimensional (2D) strain. The differentiation of subendocardial infarction from transmural infarction has significant prognostic and clinical implications. Contrast-enhanced magnetic resonance imaging (CE-MRI) and dobutamine stress echocardiography (DBE) were performed in 80 patients (age 63 +/- 10 years) with chronic ischemic LV dysfunction. Myocardial function was assessed in the short axis at the midventricular level using peak strain rate (SR) and strain (S) in circumferential and radial dimensions, and was assessed in the long axis using longitudinal SR and S. Wall motion analysis was performed during DBE to assess for contractile reserve. Transmural infarct segments had lower circumferential S (-10.7 +/- 6.3) and SR (-1.0 +/- 0.4) than subendocardial infarcts (S: -15.4 +/- 7.0, p < 0.0001 SR: -1.4 +/- 0.8, p = 0.02) and normal myocardium (S: p < 0.0001 SR: p < 0.0001). Transmural and subendocardial infarct segments had similar radial S and SR. Subendocardial infarct segments showed significant reduction of longitudinal S (-13.2 +/- 5.6) and SR (-0.91 +/- 0.45) compared with normal myocardium (S: -17.8 +/- 5.4, p < 0.0001 SR: -1.1 +/- 0.41, p < 0.0001), but there were no significant differences between subendocardial and transmural infarct segments (p = 0.09). Wall motion analysis by DBE could not identify subendocardial infarction on CE-MRI (TME 1% to 50%: DBE scar 38%, DBE viable 38%, DBE ischemic 24%, p = NS). The combined assessment of long-axis and short-axis function using 2D strain may be used to identify TME.
Publisher: Elsevier BV
Date: 08-2001
DOI: 10.1016/S0002-9149(01)01687-3
Abstract: The subjective interpretation of dobutamine echocardiography (DBE) makes the accuracy of this technique dependent on the experience of the observer, and also poses problems of concordance between observers. Myocardial tissue Doppler velocity (MDV) may offer a quantitative technique for identification of coronary artery disease, but it is unclear whether this parameter could improve the results of less expert readers and in segments with low interobserver concordance. The aim of this study was to find whether MDV improved the accuracy of wall motion scoring in novice readers, experienced echocardiographers, and experts in stress echocardiography, and to identify the optimal means of integrating these tissue Doppler data in 77 patients who underwent DBE and angiography. New or worsening abnormalities were identified as ischemia and abnormalities seen at rest as scarring. Segmental MDV was measured independently and previously derived cutoffs were applied to categorize segments as normal or abnormal. Five strategies were used to combine MDV and wall motion score, and the results of each reader using each strategy were compared with quantitative coronary angiography. The accuracy of wall motion scoring by novice (68 +/- 3%) and experienced echocardiographers (71 +/- 3%) was less than experts in stress echocardiography (88 +/- 3%, p <0.001). Various strategies for integration with MDV significantly improved the accuracy of wall motion scoring by novices from 75 +/- 2% to 77 +/- 5% (p <0.01). Among the experienced group, accuracy improved from 74 +/- 2% to 77 +/- 5% (p <0.05), but in the experts, no improvement was seen from their baseline accuracy. Integration with MDV also improved discordance related to the basal segments. Thus, use of MDV in all segments or MDV in all segments with wall motion scoring in the apex offers an improvement in sensitivity and accuracy with minimal compromise in specificity.
Publisher: Elsevier BV
Date: 06-2017
DOI: 10.1016/J.JCMG.2017.04.001
Abstract: Type 2 diabetes mellitus (T2DM) and obesity are important contributors to nonischemic heart failure (HF) and atrial fibrillation. There is a 2- to 5-fold increase in HF associated with T2DM, and there is a 5% in HF risk in men and 7% increment in women for every unit increment in body mass index, after adjustment for traditional cardiovascular risk factors. Likewise, the risk of atrial fibrillation increases by about 6% per unit increase in body mass index. Metabolic cardiomyopathy leads to a number of changes in cardiac structure and function that can be recognized by imaging in the asymptomatic phase, and these parameters can be used for monitoring the progression of disease or the response to therapy. The purpose of this review is to familiarize clinicians with the potential benefits of early detection of preclinical myocardial abnormalities, as well as the mechanisms that might inform interventions to prevent disease progression in patients with T2DM and obesity.
Publisher: Springer Science and Business Media LLC
Date: 23-08-2017
Publisher: Wiley
Date: 17-09-2007
Publisher: Elsevier BV
Date: 12-2011
DOI: 10.1016/J.JCMG.2011.08.014
Abstract: The purpose of this study was to identify the effects of spironolactone on left ventricular (LV) structure and function, and serological fibrosis markers in patients with metabolic syndrome (MS) taking angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Myocardial fibrosis may be an important contributor to myocardial impairment in MS, and aldosterone antagonism may reduce fibrosis. Eighty patients (age 59 ± 11 years) with MS, already being treated with angiotensin II inhibition, were randomized to spironolactone 25 mg/day or placebo for 6 months. Each patient underwent baseline and follow-up conventional echocardiography and color tissue Doppler imaging. Raw data files were used to measure calibrated integrated backscatter and to calculate radial and longitudinal strain. Blood was obtained at baseline and follow-up to measure fibrosis markers (procollagen type III amino-terminal propeptide and procollagen type I carboxy-terminal propeptide [PICP]). The spironolactone group showed significant improvement of LV function, myocardial reflectivity, and LV hypertrophy, with a parallel decrease in levels of PICP and procollagen type III amino-terminal propeptide. No analogous changes were seen in the placebo group. Baseline strain (β = 0.47, p < 0.0001), spironolactone therapy (β = -0.38, p < 0.0001), and change in PICP level (β = -0.19, p < 0.03) were independently associated with LV systolic function improvement (increase in strain). Correlates of LV diastolic function improvement (increase in early diastolic mitral annular velocity) were baseline early diastolic mitral annular velocity (β = 0.47, p < 0.0001), spironolactone therapy (β = -0.21, p < 0.03), change in PICP level (β = -0.23, p < 0.02), and age (β = 0.22, p < 0.04). Favorable effects of spironolactone on cardiac function were not demonstrated in patients with less fibrosis (the lower baseline PICP tertile) or preserved function (the upper baseline strain tertile). Addition of spironolactone to standard angiotensin II inhibition improved myocardial abnormalities and decreased fibrotic markers in MS. The magnitude of benefit on cardiac performance is determined mainly by baseline LV dysfunction and collagen turnover as well its response to intervention.
Publisher: Elsevier BV
Date: 08-1996
DOI: 10.1016/S0002-9149(96)00277-9
Abstract: Considerable controversy exists regarding whether women are less likely than men to be referred to coronary angiography after an abnormal noninvasive test. This prospective cohort study analyzed consecutive subjects (2,351 men and 1,318 women) with no prior history of invasive cardiac procedures who were referred for treadmill thallium testing at the Cleveland Clinic Foundation. The primary end point was performance of coronary angiography within 90 days of treadmill thallium testing. A secondary end point was all-cause mortality during 1.8 years of follow-up. Women were less likely than men to undergo coronary angiography (6% vs 14%, odds ratio [OR] 0.42, 95% confidence interval [Cl] 0.33 to 0.54, p < 0.001), but were also less likely to have an abnormal thallium scan (8% vs 29%, p 0.9). Women were less likely to have severe coronary disease on angiography (15% vs 30%, p = 0.006). During 1.8 years of follow-up there were 26 deaths (2%) among women and 84 deaths (4%) among men. After adjusting for age, thallium abnormalities, and clinical characteristics in Cox regression analyses, women had a lower mortality rate than men (relative risk 0.58, 95% Cl 0.36 to 0.94, p = 0.03). Thus, gender-related differences in referral for coronary angiography after treadmill thallium testing can be explained by a higher rate of abnormal tests in men. No evidence of a post-test gender bias was detected, but a pretest bias affecting referral to nuclear testing cannot be excluded. Furthermore, women have a lower prevalence of severe coronary disease and a lower adjusted mortality rate.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2013
DOI: 10.2215/CJN.10141012
Abstract: CKD is associated with poor cardiorespiratory fitness (CRF). This predefined substudy determined the effect of exercise training and lifestyle intervention on CRF and explored the effect on cardiovascular risk factors and cardiac and vascular function. Between February 2008 and March 2010, 90 patients with stage 3–4 CKD were screened with an exercise stress echocardiogram before enrollment. Patients ( n =83) were randomized to standard care (control) or lifestyle intervention. The lifestyle intervention included multidisciplinary care (CKD clinic), a lifestyle program, and aerobic and resistance exercise training for 12 months. CRF (peak V[Combining Dot Above]O 2 ), left ventricular function, arterial stiffness, anthropometric, and biochemical data were collected at baseline and 12 months. Ten percent of randomized patients had subclinical myocardial ischemia at screening and completed the study without incident. There was no baseline difference among 72 patients who completed follow-up (36 in the lifestyle intervention group and 36 in the control group). The intervention increased peak V[Combining Dot Above]O 2 (2.8±0.7 ml/kg per minute versus −0.3±0.9 ml/kg per minute P =0.004). There was small weight loss (−1.8±4.2 kg versus 0.7±3.7 kg P =0.02) but no change in BP or lipids. Diastolic function improved (increased e’ of 0.75±1.16 cm/s versus −0.47±1.0 cm/s P =0.001) but systolic function was well preserved and did not change. The change in arterial elastance was attenuated (0.11±0.76 mmHg/ml versus 0.76±0.96 mmHg/ml P =0.01). Δ peak V[Combining Dot Above]O 2 was associated with group allocation and improved body composition. Exercise training and lifestyle intervention in patients with CKD produces improvements in CRF, body composition, and diastolic function.
Publisher: Oxford University Press (OUP)
Date: 17-02-2010
DOI: 10.1093/EJECHOCARD/JEQ006
Abstract: Recent developments in echocardiographic speckle tracking have enabled the quantification of myocardial deformation. In addition to technical barriers, recent research has identified differences in strain measurements between vendors, reflecting differences in myocardial tracking, and how speckle strain is calculated and displayed. In this context, a paper in this issue of the journal emphasizes similarity of global longitudinal (but not radial and circumferential strain) between two vendors. The implications of these findings for the clinical application of strain are discussed.
Publisher: Elsevier BV
Date: 05-2003
Publisher: Elsevier BV
Date: 05-2011
DOI: 10.1016/J.JSAMS.2010.11.003
Abstract: It is unclear whether the glucose lowering effects of an exercise session are augmented by training. Therefore, we sought to assess the effects of a four-week exercise training program on the acute response of blood glucose to a single exercise session in patients with T2DM. A Quasi experimental design was used. Thirty-four patients with T2DM (18 males) completed a four-week exercise regime consisting of two 1-h supervised sessions and one 30 min unsupervised home session per week. The sessions contained cardiorespiratory and resistance exercises. Blood glucose was measured prior to and after each training session. Resting heart rate (HR), blood pressure (BP), body composition, lipid profile and cardiorespiratory fitness (VO2max) were determined before and after the four week training program. Decreases in blood glucose (pre to post exercise session) over the four weeks were (mean±SD) week 1: 13.3±18.6%, week 2: 19.7±18.5%, week 3: 18.1±20.8%, week 4: 22.8±17.9%. General linear modelling with repeated measures ANCOVA showed that there was a significant (p<0.01) time effect over this period. Additionally, there were small, but significant decreases in resting heart rate (-6.6±10.3 bpm, p=0.001), systolic blood pressure (-5.6±14.9 mmHg, p=0.043) and fat mass (-1.6±3.2%, p=0.024) and an increase in VO(2max) (1.6±3.7 ml/kg/min, p=0.025) over the four weeks. Four weeks of exercise training augments the exercise-induced decrease in blood glucose that occurs in a single exercise session.
Publisher: Elsevier BV
Date: 05-2012
DOI: 10.1016/J.AMJCARD.2011.12.030
Abstract: Comparisons between transcatheter aortic valve implantation without replacement (TAVI) and tissue aortic valve replacement (AVR) in clinical trials might not reflect the outcomes in standard clinical practice. This could have important implications for the relative cost-effectiveness of these alternatives for management of severe aortic stenosis in high-risk patients for whom surgery is an option. The mean and variance of risks, transition probabilities, utilities, and cost of TAVI, AVR, and medical management derived from observational studies were entered into a Markov model that examined the progression of patients between relevant health states. The outcomes and cost were derived from 10,000 simulations. Sensitivity analyses were based on variations in the likelihood of mortality, stroke, and other commonly observed outcomes. Both TAVI and AVR were cost-effective compared to medical management. In the reference case (age 80 years, the perioperative TAVI and AVR mortality was 6.9% vs 9.8%, and annual mortality was 21% vs 24%), the utility of TAVI was greater than that of AVR (1.78 vs 1.72 quality-adjusted life years) and the lifetime cost of TAVI exceeded that of AVR ($59,503 vs $56,339). The incremental cost-effectiveness ratio was $52,773/quality-adjusted life years. Threshold analyses showed that variation in the probabilities of perioperative and annual mortality after AVR and after TAVI and annual stroke after TAVI were important determinants of the favored strategy. Sensitivity analyses defined the thresholds at which TAVI or AVR was the preferred strategy with regard to health outcomes and cost. In conclusion, TAVI satisfies current metrics of cost-effectiveness relative to AVR and might provide net health benefits at acceptable cost for selected high-risk patients among whom AVR is the current procedure of choice.
Publisher: Springer Science and Business Media LLC
Date: 2002
Abstract: Integrated backscatter (IB) changes with ischemia, but most prior studies have involved parasternal imaging, which limited the number of evaluable segments. We sought to assess the efficacy and feasibility of IB from the apical views, and compare this to myocardial Doppler findings and wall motion analysis during dobutamine echocardiography. Forty-one patients undergoing dobutamine echocardiography had gray scale images and color myocardial Doppler acquired in three apical views. Cyclic variation IB (CVIB), time to peak IB (tIB, corrected for QT interval) and Doppler peak velocity (PV) in the same segment at rest and peak stress were assessed offline from digital cineloops at 80-120 frames/s. Significant coronary disease was defined by quantitative angiography as > 50% stenosis. Analysis of the waveform in the apical views was feasible in 82% of segments. The backscatter curve was shown to be biphasic, with correlation of the first peak with peak tissue velocity, and significant regional variation. However, the response to normal segments was different with tissue Doppler (increased velocity) and backscatter (no change). Ischemia was associated with a lower peak tissue velocity and lower CVIB. Only resting tissue velocity and tIB (not CVIB) distinguished scar from ischemic segments. Using an optimal cutoff of < 5.3 dB at rest achieved a sensitivity of 55%, a specificity of 76% and an accuracy of 75% when compared to angiography. The same cutoff at peak achieved a sensitivity of 58%, a specificity of 80% and an accuracy of 76%. CVIB and tissue velocity responses to stress are different, but both may be used to identify abnormal segments in patients with CAD. However, while measurement of CVIB is feasible in the apical views, the variability caused by anisotropy limits the accuracy of a single cutoff.
Publisher: Elsevier BV
Date: 02-2003
DOI: 10.1016/S0735-1097(02)02869-3
Abstract: We sought to determine whether disturbances of myocardial contractility and reflectivity could be detected in diabetic patients without overt heart disease and whether these changes were independent and incremental to left ventricular hypertrophy (LVH). Left ventricular (LV) dysfunction is associated with diabetes mellitus, but LVH is common in this population and the relationship between diabetic LV dysfunction and LVH is unclear. We studied 186 patients with normal ejection fraction and no evidence of CAD: 48 with diabetes mellitus only (DM group), 45 with LVH only (LVH group), 45 with both diabetes and LVH (DH group), and 48 normal controls. Peak strain and strain rate of six walls in apical four-chamber, long-axis, and two-chamber views were evaluated and averaged for each patient. Calibrated integrated backscatter (IB) was assessed by comparison of the septal or posterior wall with pericardial IB intensity. All patient groups (DM, DH, LVH) showed reduced systolic function compared with controls, evidenced by lower peak strain (p < 0.001) and strain rate (p = 0.005). Calibrated IB, signifying myocardial reflectivity, was greater in each patient group than in controls (p < 0.05). Peak strain and strain rate were significantly lower in the DH group than in those in the DM alone (p < 0.03) or LVH alone (p = 0.01) groups. Diabetic patients without overt heart disease demonstrate evidence of systolic dysfunction and increased myocardial reflectivity. Although these changes are similar to those caused by LVH, they are independent and incremental to the effects of LVH.
Publisher: Wiley
Date: 10-2019
DOI: 10.1111/IMJ.14214
Abstract: Low socioeconomic status is associated with cardiovascular diseases, and an association with atrial fibrillation (AF) could guide screening. To investigate if indices of advantage/disadvantage (IAD), index of education/occupation (IEO) and index of economic resources were associated with incident AF, independent of risk factors and cardiac function. We studied community-based participants aged ≥65 years with AF risk factors (n = 379, age 70 ± 4 years, 45% men). The CHARGE-AF score (a well validated AF risk score) was used to assess 5-year risk of developing AF. Participants also had baseline echocardiograms. IAD, IEO and index of economic resources were obtained from the 2011 Socio-Economic Indexes for Areas score, in which higher decile ranks indicate more advantaged areas. Patients were followed up for incident AF (median 21 (range 5-31) months), with AF diagnosed by clinical review, including 12-lead electrocardiogram (ECG), as well as single-lead portable ECG monitoring used to record 60 s ECG tracings five times/day for 1 week. Cox proportional hazards models were used to assess the association between socioeconomic status and incident AF. Subjects with AF (n = 50, 13%) were more likely to be male (64 vs 42%, P = 0.003) and had higher CHARGE-AF score (median 7.1% (5.2-12.8%) vs 5.3% (3.3-8.6%), P < 0.001). Areas with lower socioeconomic status (IAD and IEO) had a higher risk of incident AF independent of LV function and CHARGE-AF score (hazard ratio for IAD 1.16, 95% confidence interval 1.05-1.29, P = 0.005 and hazard ratio for IEO 1.18, 95% confidence interval 1.07-1.30, P = 0.001). Regional socioeconomic status is associated with risk of incident AF, independent of LV function and clinical risk. This association might permit better regional targeting of prevention.
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.JCMG.2017.10.007
Abstract: This study sought to investigate the association of left ventricular (LV) untwisting rate (UT) and E/e' ratio with the response of exercise capacity to spironolactone in heart failure with preserved ejection fraction (HFpEF). In most patients with HFpEF, LV filling abnormalities represent a central component in the development of dyspnea. LV diastolic filling is determined by the interplay of passive (LV stiffness and myocardial collagen content, reflected by E/e' ratio) and active myocardial properties (UT, a precursor to isovolumic pressure decay and contributor to diastolic suction). In 194 patients with HFpEF (64 ± 8 years), a complete echocardiogram (including assessment of myocardial deformation and rotational mechanics) was performed. Echocardiography following maximal exercise was undertaken to assess LV systolic and diastolic responses to stress. A subset of 105 patients with an exercise-induced increase in estimated LV filling pressure were randomly assigned to spironolactone 25 mg (n = 51) or placebo (n = 54) for 6 months. Baseline peak Vo Both active and passive determinants of LV filling, as reflected by UT and E/e', contribute to reduced exercise capacity in HFpEF. Improvement in functional capacity with a 6-month therapy with spironolactone is associated with improvements in both indices. However, the possible mediating effect of this medication is observed only on E/e'.
Publisher: Cold Spring Harbor Laboratory
Date: 31-08-2019
DOI: 10.1101/753202
Abstract: Pyrenophora teres f. teres causes net form net blotch of barley and is an economically important pathogen throughout the world. However, P. teres f. teres is lacking in the genomic resources necessary to characterize the mechanisms of virulence. Recently a high quality reference genome was generated for P. teres f. teres isolate 0-1. Here, we present the reference quality sequence and annotation of four new isolates and we use the five available P. teres f. teres genomes for an in-depth comparison resulting in the generation of hypotheses pertaining to the potential mechanisms and evolution of virulence. Comparative analyses were performed between all five P. teres f. teres genomes examining genomic organization, structural variations, and core and accessory genomic content, specifically focusing on the genomic characterization of known virulence loci and the localization of genes predicted to encode secreted and effector proteins. We showed that 14 of 15 currently published virulence quantitative trait loci (QTL) span accessory genomic regions consistent with these accessory regions being important drivers of host adaptation. Additionally, these accessory genomic regions were frequently found in sub-telomeric regions of chromosomes with 10 of the 14 accessory region QTL localizing to sub-telomeric regions. Comparative analysis of the sub-telomeric regions of P. teres f. teres chromosomes revealed translocation events where homology was detected between non-homologous chromosomes at a significantly higher rate than the rest of the genome. These results indicate that the sub-telomeric accessory genomic compartments not only harbor most of the known virulence loci, but also that these regions have the capacity to rapidly evolve.
Publisher: Elsevier BV
Date: 12-2015
DOI: 10.1016/J.AMJCARD.2015.09.041
Abstract: Right ventricular (RV) pacing has been linked with lead-induced tricuspid regurgitation (TR), left ventricular (LV) dysfunction, and dyssynchrony, but the effect of pacing on RV function is unclear. We sought to investigate the effect of pacing on RV synchrony, RV function, and TR, and their association with LV function. In this substudy of the PROTECT-PACE (Protection of left ventricular function during right ventricular pacing) study of the effects of RV pacing in patients with preserved ejection fraction, 145 patients (76 RV apex and 69 non-RV apex pacing) had measurable RV parameters. We assessed tricuspid annular plane systolic excursion (TAPSE), time difference between peak TAPSE and peak mitral annular plane systolic excursion (TM-APSE-dif), global LV longitudinal strain, E/e', TR vena contracta, and TR peak gradient. Echocardiography was performed just after implantation and at 2 years. TR parameters significantly worsened after 2 years, but pacing site was not associated with changes in RV and TR parameters. No temporal change in TAPSE and TM-APSE-dif was observed overall, but worsening of TM-APSE-dif was associated with worsening TAPSE. Global longitudinal strain and E/e' both deteriorated over 2 years these changes were significantly associated. In a multivariate regression, worsening global longitudinal strain and worsening TM-APSE-dif were significantly associated with deterioration of TAPSE. Furthermore, increased E/e' and its deterioration were associated with worsening TR vena contracta and TR peak gradient, respectively. Decreased TAPSE was also associated with deterioration of TR vena contracta. In conclusion, RV pacing appears to worsen TR, an effect which might be caused by elevated LV filling pressure due to LV dysfunction. In this study, RV pacing did not affect RV function during 2-year follow-up, but such an effect might occur if RV dyssynchrony or LV dysfunction occurred after pacing. The effect of RV pacing site on RV and TR mechanics was minor.
Publisher: Oxford University Press (OUP)
Date: 11-02-2022
Abstract: Myocardial deformation imaging is a very attractive clinical tool for the assessment of right ventricular (RV) systolic performance, providing incremental diagnostic and prognostic information over the traditional indices of RV function. Among various imaging modalities, echocardiography is currently the method of choice for clinical assessment of RV longitudinal strain (RVLS). The methodology of 2D speckle-tracking echocardiography to obtain RVLS has been recently standardized and demonstrated to be feasible, accurate, and robust for clinical use. Inter-technique and inter-vendor comparability and reliability of RVLS are improving. RVLS is advantageous because it is more sensitive to subtle changes in myocardial function than conventional parameters used to assess RV function (i.e. tricuspid annular plane systolic excursion, tissue Doppler systolic velocity, fractional area change, or RV ejection fraction) representing a sensitive tool for the long-term follow-up of patients. Proper interpretation of measurements requires a deep understanding of RV mechanics and pathologic tissue characteristics in different cardiovascular conditions, as well as the influence of loading conditions, image properties, and tracking algorithms on RVLS measurements.
Publisher: American Medical Association (AMA)
Date: 11-2016
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.JCMG.2017.10.008
Abstract: This study sought to establish the diagnostic and prognostic value of a strategy for prediction of abnormal diastolic response to exercise (AbnDR) using clinical, biochemical, and resting echocardiographic markers in dyspneic patients with mild diastolic dysfunction. An AbnDR (increase in left ventricular filling pressure) may indicate heart failure with preserved ejection fraction as the cause of symptoms in dyspneic patients, despite a nonelevated noncardiac at rest. However, exercise testing may be inconclusive in patients with noncardiac limitations to physical activity. In 171 dyspneic patients (64 ± 8 years) with suspected heart failure with preserved ejection fraction but resting peak early diastolic mitral inflow velocity eak early diastolic mitral annular velocity ratio (E/e') 14). Patients were followed over 26.2 ± 4.6 months for endpoints of cardiovascular hospitalization and death. AbnDR was present in 103 subjects (60%). Independent correlates of AbnDR were resting E/e' (odds ratio [OR]: 8.23 95% confidence interval [CI]: 3.54 to 9.16 p 11.3 and galectin-3 <1.17 ng/ml to select patients for further diagnostic processing would have allowed exercise testing to be avoided in 65% of subjects, at the cost of misclassification of 13%. The composite outcome of cardiovascular hospitalization or death occurred in 47 patients (27.5%). The predictive value of an AbnDR response and the combined strategy (resting echocardiography and galectin-3 or exercise testing in case of an inconclusive first step) showed similar event prediction (36 vs. 34 p = 0.95). The implementation of a 2-step algorithm (echocardiographic evaluation of resting E/e' followed by the assessment of galectin-3) may improve the diagnosis and prognostic assessment of in iduals with suspected heart failure with preserved ejection fraction who are unable to perform a diagnostic exercise test.
Publisher: Elsevier BV
Date: 10-2014
Publisher: Wiley
Date: 25-02-2023
DOI: 10.5694/MJA2.51860
Abstract: To compare the cost‐effectiveness of coronary artery calcium (CAC) score‐guided statin therapy criteria and American College of Cardiology/American Heart Association (ACC/AHA) guidelines (10‐year pooled cohort equation [PCE] risk ≥ 7.5%) with selection according to Australian guidelines (5‐year absolute cardiovascular disease risk [ACVDR] ≥ 10%), for people with family histories of premature coronary artery disease. Markov microsimulation state transition model based on data from the Coronary Artery calcium score: Use to Guide management of Hereditary Coronary Artery Disease (CAUGHT‐CAD) trial and transition probabilities derived from published statin prescribing and adherence outcomes and clinical data. 1083 people with family histories of premature coronary artery disease but no symptomatic cardiovascular disease. Relative cost‐effectiveness over fifteen years, from the perspective of the Australian health care system, compared with usual care (Australian guidelines), assessed as incremental cost‐effectiveness ratios (ICERs), with a notional willingness‐to‐pay threshold of $50 000 per quality‐adjusted life‐year (QALY) gained. Applying the Australian guidelines, 77 people were eligible for statin therapy (7.1%) with ACVDR 5‐year risk ≥ 2% and CAC score 0, 496 people (46%) with ACVDR 5‐year risk ≥ 2% and CAC score ≥ 100, 155 people (14%) and with the ACC/AHA guidelines, 256 people (24%). The ICERs for CAC‐guided selection were $33 108 (CAC ≥ 100) and $53 028 per QALY gained (CAC 0) the ACC/AHA guidelines approach (ICER, $909 241 per QALY gained) was not cost‐effective. CAC score‐guided selection (CAC ≥ 100) was cost‐effective for people with 5‐year ACVDR of at least 5%. Expanding the number of people at low to intermediate CVD risk eligible for statin therapy should selectively target people with subclinical atherosclerosis identified by CAC screening. This approach can be more cost‐effective than simply lowering treatment eligibility thresholds.
Publisher: Springer Science and Business Media LLC
Date: 05-08-2020
DOI: 10.1186/S12933-020-01100-W
Abstract: Observational series suggest a mortality benefit from metformin in the heart failure (HF) population. However, the benefit of metformin in HF with preserved ejection fraction (HFpEF) has yet to be explored. We performed a systematic review and meta-analysis to identify whether variation in EF impacts mortality outcomes in HF patients treated with metformin. MEDLINE and EMBASE were searched up to October 2019. Observational studies and randomised trials reporting mortality in HF patients and the proportion of patients with an EF 50% at baseline were included. Other baseline variables were used to assess for heterogeneity in treatment outcomes between groups. Regression models were used to determine the interaction between metformin and subgroups on mortality. Four studies reported the proportion of patients with a preserved EF and were analysed. Metformin reduced mortality in both preserved or reduced EF after adjustment with HF therapies such as angiotensin converting enzyme inhibitors (ACEi) and beta-blockers (β = − 0.2 [95% CI − 0.3 to − 0.1], p = 0.02). Significantly greater protective effects were seen with EF 50% ( p = 0.003). Metformin treatment with insulin, ACEi and beta-blocker therapy were also shown to have a reduction in mortality (insulin p = 0.002 ACEi p 0.001 beta-blocker p = 0.017), whereas female gender was associated with worse outcomes ( p 0.001). Metformin treatment is associated with a reduction in mortality in patients with HFpEF.
Publisher: Oxford University Press (OUP)
Date: 10-2009
Publisher: Oxford University Press (OUP)
Date: 05-2021
Abstract: We investigated the effects of exposure to very low levels of particulate matter & .5 µm (PM2.5) and nitrogen dioxide (NO2) on coronary calcium score (CCS) in asymptomatic adults who are free of coronary artery disease (CAD). This study included 606 asymptomatic adults (49% men, aged 56±7 years) recruited from communities in three states of Australia during 2017–2018. CCS was measured using coronary computed tomography scan at recruitment. Annual PM2.5 and NO2 concentrations were estimated on the year before recruitment using statistical exposure models and assigned to each participant’s residential address. Medical history, physical measurements, biochemistry, and sociodemographic and socioeconomic status were also recorded. Median concentrations of PM2.5 and NO2 were 6.9 µg/m3 [interquartile range (IQR) 6.0–7.7)] and 3.1 ppb [IQR 2.2–4.5], respectively. Of the 606 participants, 16% had high CCS (≥100) and 4% had very high CCS (≥400). Exposure to higher PM2.5 (per µg/m3) was significantly associated with greater odds of having high CCS (OR 1.20, 95% CI 1.02–1.43) and very high CCS (OR 1.55, 95% CI 1.05–2.29). Similar associations were observed for NO2 and high CCS (OR 1.14, 95% CI 1.02–1.27) and very high CCS (OR 1.23, 95% CI 1.07–1.51). These findings were robust to adjustment for sociodemographic factors, traditional cardiovascular risk factors, renal function, education, and socio-economic status. Ambient air pollution even at low concentration was associated with degree of coronary artery calcification among asymptomatic low cardiovascular risk adults, independent of other risk factors. These findings suggest that air pollution is one of the residual risk factors of CAD.
Publisher: Oxford University Press (OUP)
Date: 23-07-2022
DOI: 10.1093/EURHEARTJ/EHAC393
Abstract: Arterial hypertension remains the most frequent cardiovascular (CV) risk factor, and is responsible for a huge global burden of disease. Echocardiography is the first-line imaging method for the evaluation of cardiac damage in hypertensive patients and novel techniques, such as 2D and D speckle tracking and myocardial work, provide insight in subclinical left ventricular (LV) impairment that would not be possible to detect with conventional echocardiography. The structural, functional, and mechanical cardiac remodelling that are detected with imaging are intermediate stages in the genesis of CV events, and initiation or intensification of antihypertensive therapy in response to these findings may prevent or delay progressive remodelling and CV events. However, LV remodelling—especially LV hypertrophy—is not specific to hypertensive heart disease (HHD) and there are circumstances when other causes of hypertrophy such as athlete heart, aortic stenosis, or different cardiomyopathies need exclusion. Tissue characterization obtained by LV strain, cardiac magnetic resonance, or computed tomography might significantly help in the distinction of different LV phenotypes, as well as being sensitive to subclinical disease. Selective use of multimodality imaging may therefore improve the detection of HHD and guide treatment to avoid disease progression. The current review summarizes the advanced imaging tests that provide morphological and functional data about the hypertensive cardiac injury.
Publisher: Elsevier BV
Date: 09-1996
DOI: 10.1016/S0002-9149(96)00386-6
Abstract: We determined resting echocardiographic features predictive of latent left ventricular (LV) outflow obstruction in 50 consecutive patients with nonobstructive hypertrophic cardiomyopathy (26 provocable, 24 nonprovocable with amyl nitrite inhalation) to have a better understanding of the pathophysiology of this condition and to identify such patients without pharmacologic provocation. Measurements included wall thickness, type of hypertrophy, LV outflow tract diameter, degree of mitral systolic anterior motion, outflow pressure gradient, and ventricular volume. The direction of the ejection streamline was measured to assess the magnitude of the drag force acting on the mitral valve. Thirteen of 16 patients (81%) with proximal septal bulge were provocable, whereas only 3 of 8 patients (38%) with asymmetric septal hypertrophy and 10 of 26 (38%) with concentric hypertrophy were provocable (p < 0.05). LV outflow tract was significantly narrower and the angle between the ejection flow and the mitral valve was larger in provocable patients. The sensitivity for predicting provocable patients by a combination of a narrow outflow tract ( or = 35 degrees) was 65%, with a specificity of 80% and a positive predictive value of 79%. When these criteria were combined with the presence of septal bulge, the sensitivity was 35%, but the specificity and the positive predictive value were both 100%. Patients with nonobstructive hypertrophic cardiomyopathy with proximal septal bulge, a narrow LV outflow tract, and an oblique angle between the ejection flow and the mitral valve appeared to be predisposed for latent outflow obstruction. These features are consistent with the presence of the large Venturi and drag forces. Thus, the left ventricle, which is capable of increasing both the Venturi and the drog forces on the basis of the morphologic change, contributes to the development of outflow obstruction with amyl nitrite inhalation.
Publisher: Elsevier BV
Date: 11-1999
DOI: 10.1016/S0894-7317(99)70142-2
Abstract: A quantitative technique is required to reduce the subjectivity and improve the reproducibility of stress echocardiography. Tissue Doppler imaging may offer these benefits, but its feasibility with exercise echocardiography (ExE) is undefined. This study sought the determinants of the exercise tissue Doppler velocity (TDV) response and the feasibility and accuracy of color TDV during ExE. Fifteen volunteers and 85 patients (age 60 +/- 10 years, 19 women) with known or suspected coronary artery disease were studied with standard 2-dimensional (2D) echocardiography and pulsed wave (PW) and color TDV before and after they underwent exercise treadmill testing. After the study PW TDV was measured in 6 basal segments, and off-line software was used to display color TDV data from all myocardial segments. Color TDV was compared with PW TDV in the basal segments at rest and stress with the use of linear regression. Color TDV in mid and basal segments was compared with wall motion on 2D echocardiography. The predictors of the TDV response to exercise were defined in a multiple linear regression. A logistic regression model was used to integrate clinical, exercise, and TDV variables for prediction of abnormal regional left ventricular function. Color and PW correlated well at rest (r = 0.81) and stress (r = 0.84), but PW was greater than color velocities at rest and stress. On the basis of 2D echocardiography, 752 myocardial segments were classified as normal in patients without evidence of coronary disease, 309 were normal in patients with abnormal wall motion in another territory, and 128 showed ischemia or scar. Segmental comparison of velocities assessed by color TDV showed that scar segments had a lower velocity than normal segments at rest and stress (P <.001). Ischemic segments had a lower peak TDV and less increment in velocity than normal segments. Heart rate, functional capacity, and regional dysfunction (scar or ischemia) were independent predictors of TDV at peak exercise. With the use of receiver operating characteristic analysis, the "correction" of TDV by these other variables increased the accuracy of the technique for the detection of regional left ventricular dysfunction. Color TDV is feasible during ExE. The correlation found between TDV and wall motion analysis of experienced observers indicates that TDV may be useful as a quantitative tool for interpretation of ExE.
Publisher: Elsevier BV
Date: 08-2020
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2022
Publisher: Elsevier BV
Date: 07-1991
DOI: 10.1016/0002-8703(91)90772-A
Abstract: Surgical valve repair for mitral regurgitation has significant advantages over valve replacement, but little is known about the mechanisms of its failure. This echocardiographic study examined abnormalities leading to failed mitral valve repair in two populations: "immediate failure" of the valve repair in the operating room requiring a second run of cardiopulmonary bypass and "late failure" of valve repair necessitating reoperation on another occasion. Intraoperative echocardiography (IOE) after cardiopulmonary bypass was performed in 309 patients undergoing valve repair for mitral regurgitation over a 3-year period. Twenty-six (8%) of these patients had immediate failure of the repair demonstrated by IOE, requiring further repair or replacement during the same thoracotomy. The causes of immediate failure were left ventricular outflow tract obstruction (10 patients), incomplete correction (10 patients), and suture dehiscence (six patients). Echocardiography was performed on 17 patients requiring reoperation for recurrent mitral regurgitation who had undergone previous primary valve repair. These late failures resulted from progressive degenerative leaflet or chordal disease (n = 9) or suture dehiscence of the annular ring or the leaflet resection site (n = 6). In only two patients early in the series did the problem originate from inadequate initial surgery. IOE is an effective marker for unsuccessful mitral valve repair, and affords an understanding of the mechanism of the persistent dysfunction. Immediate failure of mitral repair may be reduced by greater attention to the mechanism of valve dysfunction and by changes in valvuloplasty technique to avoid outflow tract obstruction. Late failure after mitral repair occurs predominantly due to progression of disease, particularly in patients with severe myxomatous or annular abnormalities that are prone to progress.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2002
DOI: 10.1161/01.HYP.0000018040.27363.53
Abstract: Stress echocardiography has been shown to improve the diagnosis of coronary artery disease in the presence of hypertension, but its value in prognostic evaluation is unclear. We sought to determine whether stress echocardiography could be used to predict mortality in 2363 patients with hypertension, who were followed for up to 10 years (mean 4.0±1.8) for death and revascularization. Stress echocardiograms were normal in 1483 patients (63%), 16% had resting left ventricular (LV) dysfunction alone, and 21% had ischemia. Abnormalities were confined to one territory in 489 patients (21%) and to multiple territories in 365 patients (15%). Cardiac death was less frequent among the patients able to exercise than among those undergoing dobutamine echocardiography (4% versus 7%, P 0.001). The risk of death in patients with a negative stress echocardiogram was % per year. Ischemia identified by stress echocardiography was an independent predictor of mortality in those able to exercise (hazard ratio 2.21, 95% confidence intervals 1.10 to 4.43, P =0.0001) as well as those undergoing dobutamine echo (hazard ratio 2.39, 95% confidence intervals 1.53 to 3.75, P =0.0001) other predictors were age, heart failure, resting LV dysfunction, and the Duke treadmill score. In stepwise models replicating the sequence of clinical evaluation, the results of stress echocardiography added prognostic power to models based on clinical and stress-testing variables. Thus, the results of stress echocardiography are an independent predictor of cardiac death in hypertensive patients with known or suspected coronary artery disease, incremental to clinical risks and exercise results.
Publisher: American Medical Association (AMA)
Date: 10-02-1999
Abstract: Chronotropic incompetence, an attenuated heart rate response to exercise, is a predictor of all-cause mortality in healthy populations. This association may be independent of exercise-induced myocardial perfusion defects. To examine the prognostic significance of chronotropic incompetence in a low-risk cohort of patients referred for treadmill stress testing with thallium imaging. Prospective cohort study conducted between September 1990 and December 1993. Tertiary care academic medical center. Consecutive patients (1877 men and 1076 women mean age, 58 years) who were not taking beta-blockers and who were referred for symptom-limited treadmill thallium testing. Association of chronotropic incompetence, defined as either failure to achieve 85% of the age-predicted maximum heart rate or a low chronotropic index, a heart rate response measure that accounts for effects of age, resting heart rate, and physical fitness, with all-cause mortality during 2 years of follow-up. Three hundred sixteen patients (11%) failed to reach 85% of the age-adjusted maximum heart rate, 762 (26%) had a low chronotropic index, and 612 (21%) had thallium perfusion defects. Ninety-one patients died during the follow-up period. After adjustment for age, sex, thallium perfusion defects, and other confounders, failure to reach 85% of the age-predicted maximum heart rate was associated with increased risk of death (adjusted relative risk [RR], 1.84 95% confidence interval [CI], 1.13-3.00 P=.01), as was a low chronotropic index (adjusted RR, 2.19 95% CI, 1.43-3.44 P<.001). Among patients with known or suspected coronary disease, chronotropic incompetence is independently predictive of all-cause mortality, even after considering thallium perfusion defects. Incorporation of chronotropic response into the routine interpretation of stress thallium studies may improve the prognostic power of this test.
Publisher: Elsevier BV
Date: 05-2012
Publisher: Elsevier BV
Date: 07-2018
Publisher: Elsevier BV
Date: 02-2003
DOI: 10.1016/S0002-9149(02)03231-9
Abstract: The left ventricular response to dobutamine may be quantified using tissue Doppler measurement of myocardial velocity or displacement or 3-dimensional echocardiography to measure ventricular volume and ejection fraction. This study sought to explore the accuracy of these methods for predicting segmental and global responses to therapy. Standard dobutamine and 3-dimensional echocardiography were performed in 92 consecutive patients with abnormal left ventricular function at rest. Recovery of function was defined by comparison with follow-up echocardiography at rest 5 months later. Segments that showed improved regional function at follow-up showed a higher increment in peak tissue Doppler velocity with dobutamine therapy than in nonviable segments (1.2 +/- 0.4 vs 0.3 +/- 0.2 cm/s, p = 0.001). Similarly, patients who showed a >5% improvement of ejection fraction at follow-up showed a greater displacement response to dobutamine (6.9 +/- 3.2 vs 2.1 +/- 2.3 mm, p = 0.001), as well as a higher rate of ejection fraction response to dobutamine (9 +/- 3% vs 2 +/- 2%, p = 0.001). The optimal cutoff values for predicting subsequent recovery of function at rest were an increment of peak velocity >1 cm/s, >5 mm of displacement, and a >5% improvement of ejection fraction with low-dose dobutamine.
Publisher: Elsevier BV
Date: 07-2019
Publisher: Elsevier BV
Date: 06-2014
Publisher: Elsevier BV
Date: 1992
DOI: 10.1016/0735-1097(92)90054-Q
Abstract: Despite the high reported accuracy of exercise echocardiography in the detection of coronary artery disease, factors that compromise its sensitivity and specificity are less clear. This study examined the results of 179 post-treadmill stress echocardiograms in 150 consecutive patients who also underwent cardiac catheterization and in 29 normal persons at low risk for coronary artery disease. Of 114 patients who had significant coronary stenoses at angiography, 96 had an abnormal exercise echocardiogram (overall sensitivity 84%). False negative results correlated with the performance of submaximal exercise, single-vessel disease and moderate (50% to 70% diameter) stenoses. After the exclusion of seven patients performing submaximal exercise, the sensitivity was 90%. In 54 patients without previous infarction performing maximal exercise, the sensitivity was 87%, higher in patients with multivessel coronary disease (96%) than in those with single-vessel disease (79%). After the exclusion of patients with nondiagnostic results, due either to the performance of submaximal stress or the presence of electrocardiographic (ECG) changes at rest, exercise echocardiography had a higher sensitivity than did exercise electrocardiography (87% vs. 63%, p = 0.01). In 36 patients without significant coronary disease, exercise echocardiography had an overall specificity of 86%. After the exclusion of patients with a nondiagnostic test, exercise echocardiography had a specificity of 82% compared with 74% specificity for exercise electrocardiography (p = NS). Similarly, of the 29 normal subjects, 93% had a normal exercise echocardiogram and 97% had a normal exercise ECG (p = NS). Similarly, of the 29 normal subjects, 93% had a normal exercise echocardiogram and 97% had a normal exercise ECG (p = NS). Age, gender, body weight and image quality did not significantly influence the accuracy of exercise echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)
Publisher: BMJ
Date: 05-2001
Abstract: To compare the accuracy and feasibility of harmonic power Doppler and digitally subtracted colour coded grey scale imaging for the assessment of perfusion defect severity by single photon emission computed tomography (SPECT) in an unselected group of patients. Cohort study. Regional cardiothoracic unit. 49 patients (mean (SD) age 61 (11) years 27 women, 22 men) with known or suspected coronary artery disease were studied with simultaneous myocardial contrast echo (MCE) and SPECT after standard dipyridamole stress. Regional myocardial perfusion by SPECT, performed with (99m)Tc tetrafosmin, scored qualitatively and also quantitated as per cent maximum activity. Normal perfusion was identified by SPECT in 225 of 270 segments (83%). Contrast echo images were interpretable in 92% of patients. The proportion of normal MCE by grey scale, subtracted, and power Doppler techniques were respectively 76%, 74%, and 88% (p 80% of maximum counts, compared with 65%, 69%, and 61% at < 60% of maximum counts. For each technique, specificity was lowest in the lateral wall, although power Doppler was the least affected. Grey scale and subtraction techniques were least accurate in the septal wall, but power Doppler showed particular problems in the apex. On a per patient analysis, the sensitivity was 67%, 75%, and 83% for detection of coronary artery disease using grey scale, colour coded, and power Doppler, respectively, with a significant difference between power Doppler and grey scale only (p < 0.05). Specificity was also the highest for power Doppler, at 55%, but not significantly different from subtracted colour coded images. Myocardial contrast echo using harmonic power Doppler has greater accuracy than with grey scale imaging and digital subtraction. However, power Doppler appears to be less sensitive for mild perfusion defects.
Publisher: Elsevier BV
Date: 11-2005
DOI: 10.1016/J.ECHO.2005.04.004
Abstract: Qualitative interpretation of myocardial contrast echocardiography (MCE) improves the accuracy of wall-motion analysis for assessment of coronary artery disease (CAD). We examined the feasibility and accuracy of quantitative MCE for diagnosis of CAD. Dipyridamole/exercise stress MCE (destruction-replenishment protocol with real-time imaging) was performed in 90 patients undergoing quantitative coronary angiography, 48 of whom had significant (> 50%) stenoses. MCE was repeated with exercise alone in 18 patients. Myocardial blood flow (A*beta) was obtained from blood volume (A) and time to refill (beta). Quantification of flow reserve was feasible in 88%. The mean A*beta reserve in the anterior wall was significantly impaired for patients with left anterior descending coronary artery disease (n = 28) compared with those with no disease (1.6 +/- 1.2 vs 4.0 +/- 2.5, P < or = .001). This reflected impaired beta reserve, with no difference in the A reserve. Applying a receiver operating characteristic curve derived cutoff of 2.0 for A*beta reserve, quantitative MCE was 76% sensitive and 71% specific for the diagnosis of significant left anterior descending coronary artery stenosis. Posterior circulation results were similar, with 78% sensitivity and 59% specificity for detection of posterior CAD. Overall, quantitative MCE was similarly sensitive to qualitative approach for diagnosis of CAD (88% vs 93%), but with lower specificity (52% vs 65%, P = .07). In 18 patients restudied with pure exercise stress, the mean myocardial blood flow reserve was less than after combined stress (2.1 +/- 1.6 vs 3.7 +/- 1.9, P = .01). Quantitative MCE is feasible for the diagnosis of CAD with dipyridamole/exercise stress. Dipyridamole prolongs postexercise hyperemia, augmenting the degree of hyperemia at the time of imaging.
Publisher: Cleveland Clinic Journal of Medicine
Date: 09-1994
Abstract: Coronary artery disease is a major cause of death in transplant recipients. To review current approaches for the detection, evaluation, and treatment of coronary artery disease in transplant recipients. Renal transplantation promotes the development of coronary artery disease primarily because immunosuppressant medications accentuate known coronary risk factors such as hypertension, hypercholesterolemia, and hyperglycemia that accelerate the progression of coronary artery disease existing before transplantation. Physicians can monitor a patient's risk status by regular inquiries for symptoms and by simple clinical tools such as the Framingham Study Coronary Heart Disease Risk Prediction Chart in asymptomatic patients. Patients found to be at high risk for coronary artery disease can then undergo dobutamine echocardiography or other noninvasive tests, and patients with positive studies can subsequently undergo angiography. The cost-effectiveness of such an approach is presented. In recent studies at our institution, patients with coronary artery disease had decreased numbers of CD2+ and CD3+ circulating lymphocytes. In addition, in immunosuppressed transplant recipients with coronary artery disease, there was a decrease in CD8+ lymphocytes, whereas in nonimmunosuppressed, nontransplant patients there was a decrease in CD4+ lymphocytes. A systematic approach to screening patients for coronary artery disease before transplantation can identify those at highest risk and potentially save money and lives. Possible new avenues of research may focus on the role of the lymphocytes in coronary atherosclerosis.
Publisher: Elsevier BV
Date: 2009
DOI: 10.1016/J.AHJ.2008.08.032
Abstract: Ejection fraction (EF) plays a prominent role in clinical decision making but remains dependent on image quality and left ventricular geometry. Using magnetic resonance imaging (MRI-EF) as the reference standard, we sought whether global longitudinal strain (GLS) could be an alternative to the measurement of EF. Manual and semi-automated tracing was used to measure Simpson's biplane ejection-fraction (2D-EF) and 3D ejection fraction (3D-EF) and MRI in 62 patients with previous infarction. Global longitudinal strain was measured by 2-dimensional strain (2DS) in the apical views. Automated EF was calculated using speckle tracking to detect the end-diastolic and end-systolic endocardial border. Strain curves were derived in all segments, with artifactual curves being excluded. The correlation of GLS with MRI-EF (r = -0.69, P < .0001) was comparable to that between 3D-EF and MRI (r = 0.80, P < .0001), and better than that between 2D-EF (r = 0.58, P < .0001) or automated EF and MRI (r = 0.62, P or =50%), 75% had normal systolic function by GLS, whereas 85% of patients were recognized as having a normal 3D-EF. Fewer patients were recognized as normal by 2D-EF (70%, P = .14) and automated-EF (61%, P = .04). In those with >6 abnormal segments, the correlation of GLS with MRI-EF improved significantly (r = -0.77, P < .0001) and was similar to 3D-EF (r = 0.76, P < .0001). Global longitudinal strain is an effective method for quantifying global left ventricular function, particularly in patients with extensive wall motion abnormalities.
Publisher: Oxford University Press (OUP)
Date: 07-2003
DOI: 10.1016/S0195-668X(03)00192-1
Abstract: Exercise testing has limited efficacy for identifying coronary artery disease (CAD) in the absence of anginal symptoms. Exercise echocardiography is more accurate than standard exercise testing, but its efficacy in this situation has not been defined. We sought to identify whether the Duke treadmill score or exercise echocardiography (ExE) could be used to identify risk in patients without anginal symptoms. We studied 1859 patients without typical or atypical angina, heart failure, or a history or ECG evidence of infarction or CAD, who were referred for ExE, of whom 1832 (age 51+/-15 years, 944 men) were followed for up to 10 years. The presence and extent of ischaemia and scar were interpreted by expert reviewers at the time of the original study. Exercise provoked significant (>0.1mV) ST segment depression in 215 patients (12%), and wall motion abnormalities in 137 (8%). Seventy-eight patients (4%) died before revascularization, only 17 from known cardiac causes. The independent predictors of death were age (RR 1.1, p<0.0001), smoking, Duke treadmill score (RR 0.9, p<0.0001) and resting LV dysfunction (RR 1.9, p<0.04), but did not include ischaemia at ExE. Echocardiography was not predictive of outcome in subgroups with an intermediate or high risk Duke score, nor in patients with two or more risk factors. Patients without anginal symptoms have a low mortality, especially from cardiac causes. If such in iduals undergo exercise testing and a resting echocardiogram, exercise echocardiography does not offer additional prognostic information.
Publisher: Elsevier BV
Date: 12-2020
Publisher: Springer Science and Business Media LLC
Date: 27-12-2017
DOI: 10.1038/IJO.2016.234
Abstract: Overweight and obesity are associated with left ventricular (LV) dysfunction. We sought whether echocardiographic evidence of abnormal adult cardiac structure and function was related to childhood or adult adiposity. This study included 159 healthy in iduals aged 7-15 years and followed until age 36-45 years. Anthropometric measurements were performed both at baseline and follow-up. Cardiac structure (indexed left atrial volume (LAVi), left ventricular mass (LVMi)) and LV function (global longitudinal strain (GLS), mitral e') were assessed using standard echocardiography at follow-up. Conventional cutoffs were used to define abnormal LAVi, LVMi, GLS and mitral annular e'. Childhood body mass index (BMI) was correlated with LVMi (r=0.25, P=0.002), and child waist circumference was correlated with LVMi (r=0.18, P=0.03) and LAVi (r=0.20, P=0.01), but neither were correlated with GLS. One s.d. (by age and sex) increase in childhood BMI was associated with LV hypertrophy (relative risk: 2.04 (95% confidence interval (CI): 1.09, 3.78)) and LA enlargement (relative risk: 1.81 (95% CI: 1.02, 3.21)) independent of adult BMI, but the association was not observed with impaired GLS or mitral e'. Cardiac functional measures were more impaired in those who had normal BMI as child, but had high BMI in adulthood (P 0.33). Childhood adiposity is independently associated with structural cardiac disturbances (LVMi and LAVi). However, functional alterations (GLS and mitral e') were more frequently associated with adult overweight or obesity, independent of childhood adiposity.
Publisher: BMJ
Date: 04-10-2007
Abstract: To assess the feasibility and potential impact of routine three-dimensional (3D) echocardiographic assessment of left ventricular (LV) ejection fraction and volumes on clinical decision-making. Patients referred to three hospital-based echocardiography laboratories underwent 2D echocardiography (2DE) and 3D echocardiography (3DE). Feasibility was assessed in a group of 168 unselected patients and decision-making assessed within an expanded group of 220 patients. The time for acquisition and measurement was obtained. Feasibility was defined by ability to measure LV parameters. The potential of 3DE to alter clinical decisions based on 2DE was evaluated by the ability to identify four clinically relevant measurement thresholds: (1) LV end-systolic volume (LVESV) >50 ml/m(2) (indication for surgery in regurgitant valve disease) (2) LVESV >30 ml/m(2) (prognosis after infarction) (3) LV ejection fraction (LVEF) <35% (indication for implantable defibrillator) and (4) LVEF <40% (indication for heart failure treatment). 3DE was technically feasible in 83% of unselected patients. The additional time for 3D acquisition and measurement was available in 184 patients and was 5.4 (SD 2.0) minutes. The use of 3DE changed categorisation in between 6-11% of patients. Within threshold categories, 3D reallocated 17.5% (11/63) of patients with LVEF <35%, 16.1% (13/81) for LVEF 30 ml/m(2) and 8.5% (5/59) for LVESV >50 ml/m(2). Most of the impact of 3D was within 10 ml/m(2) of selected volume thresholds (>or=75%) and 10% of EF thresholds (>80%). Measurement of LV volumes and EF by 3DE is clinically feasible and has the potential to significantly alter clinical decision-making.
Publisher: Springer Science and Business Media LLC
Date: 23-03-2006
Publisher: Oxford University Press (OUP)
Date: 02-06-1997
DOI: 10.1093/EURHEARTJ/18.SUPPL_D.97
Abstract: Stress echocardiography has become an established tool for the diagnosis of coronary artery disease. However, in the current era of attention to cost effectiveness, the ability of a non-invasive test to predict outcomes, and therefore assist in clinical decision making, is paramount. As a reflection of the relative youth of this technique, there are fewer data using stress echocardiography to assess prognosis than there are using nuclear imaging. However, using both exercise and pharmacological stress echocardiography, the presence of ischaemia is strongly predictive of the recurrence of a subsequent cardiac event. Moreover, during pharmacological stress testing, the ischaemic threshold may be used to further stratify the risk of a positive test. More studies are needed in large populations to establish the prognostic role of stress echocardiography, as in independent predictor of outcome, incremental to clinical and stress testing data.
Publisher: Elsevier BV
Date: 09-1997
DOI: 10.1016/S0002-9149(97)00502-X
Abstract: Dobutamine echocardiography (DE) has been shown to be safe, feasible, and accurate for identification of coronary artery disease (CAD) in mixed populations. The purpose of this study was to examine gender differences in physiologic response and accuracy of DE. We studied 2,886 consecutive DEs, performed in 2,748 patients, 1,209 of whom (44%) were women. A standard incremental protocol (5 to 40 microg/kg/min in 3-minute stages) was followed by atropine and/or an additional stage with 50 microg/kg/min, if the heart rate response was inadequate. Hemodynamic and echocardiographic findings were recorded at each stage. Three hundred sixty-nine patients without previous cardiac intervention (including 135 women) also underwent cardiac catheterization within 1 year of DE. Significant coronary stenoses (defined angiographically as >50% diameter) were present in 67% of women and 65% of men, of whom 55% and 65%, respectively, had multivessel disease. Women had a higher baseline heart rate (76 +/- 13 vs 73 +/- 14 beats/min, p <0.0001), and showed a more rapid increase in heart rate at low dose, with a higher age-predicted maximum heart rate at peak. This led to test termination at target heart rate but a submaximum dose in 22% of women versus 15% of men (p <0.0001) and less frequent administration of atropine (29% vs 34%, p <0.01). Dose-limiting side effects (8% vs 7%) and submaximum heart rate responses (14% vs 17%) were comparable in men and women. Even after the exclusion of negative DE at submaximal heart rate responses, the overall sensitivity was significantly lower in women than men (78% vs 88%, p <0.05), both for single (72% vs 78%, p <0.05) and for multivessel disease (82% vs 93%, p <0.05). The low specificity in both genders (55% vs 46%) probably reflected post-test referral bias. Thus, physiologic responses to dobutamine stress are comparable in men and women, except for a more rapid heart rate response in women, but the accuracy of DE for diagnosis of CAD in women is less than in men.
Publisher: BMJ
Date: 11-2018
DOI: 10.1136/HEARTJNL-2017-312114
Abstract: Most cardiovascular disease (CVD) occurs in patients over the age of 60. However, most evidence-based current cardiovascular guidelines lack evidence in an older population, due to the under-representation of older patients in randomised trials. Blood pressure rises with age due to increasing arterial stiffness, and stricter control results in improved outcomes. Myocardial ischaemia is also more common with increasing age, due to a combination of coronary artery disease and myocardial changes. However, despite higher rates of adverse outcomes, older patients are offered guideline-based therapy less frequently. Frailty is an independent predictor of mortality in adults over the age of 60, yet remains poorly assessed slow gait speed is a key marker for the development of frailty and for adverse outcomes following intervention. Few trials have assessed frailty independent of age however, there is evidence that non-frail older patients derive significant benefit from therapy, highlighting the urgent need to include frailty as a measure in clinical trials of treatment in CVD. In this review, the authors appraise the literature in regard to the cardiovascular changes with ageing, specifically in relation to the systemic and coronary circulation and with a particular emphasis on frailty and its implication in the evaluation and treatment of CVD.
Publisher: Elsevier BV
Date: 10-2011
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.JACC.2019.08.004
Abstract: Historical data suggesting poor survival in patients with aortic stenosis (AS) who do not undergo treatment are largely confined to patients with severe AS. This study sought to determine the prognostic impact of all levels of native valvular AS. Severity of AS was characterized by convention and by statistical distribution in 122,809 male patients (mean age 61 ± 17 years) and 118,494 female patients (mean age 62 ± 19 years), with measured aortic valve (AV) mean gradient, peak velocity, and/or area. The relationship between AS severity and survival was then examined during median 1,208 days (interquartile range: 598 to 2,177 days) of follow-up. Patients with previous aortic valve intervention were excluded. Overall, 16,129 (6.7%), 3,315 (1.4%), and 6,383 (2.6%) patients had mild, moderate, and severe AS, respectively. On an adjusted basis (vs. no AS 5-year mortality 19%), patients with mild to severe AS had an increasing risk of long-term mortality (adjusted hazard ratio: 1.44 to 2.09 p < 0.001 for all comparisons). The 5-year mortality was 56% and 67%, respectively, in those with moderate AS (mean gradient 20.0 to 39.0 mm Hg eak velocity 3.0 to 3.9 m/s) and severe AS (≥40.0 mm Hg, ≥4.0 m/s, or AV area <1.0 cm These data confirm that when left untreated, severe AS is associated with poor long-term survival. Moreover, they also suggest poor survival rates in patients with moderate AS. (National Echocardiographic Database of Australia [NEDA] ACTRN12617001387314).
Publisher: Elsevier BV
Date: 02-2018
DOI: 10.1016/J.AMJCARD.2017.10.031
Abstract: Existing prediction algorithms for the identification of patients with heart failure (HF) at high risk of readmission or death after hospital discharge are only modestly effective. We sought to validate a recently developed predictive model of 30-day readmission or death in HF using an Australia-wide s le of patients. This study used data from 1,046 patients with HF at teaching hospitals in 5 Australian capital cities to validate a predictive model of 30-day readmission or death in HF. Besides standard clinical and administrative data, we collected data on in idual sociodemographic and socioeconomic status, mental health (Patient Health Questionnaire [PHQ]-9 and Generalized Anxiety Disorder [GAD]-7 scale score), cognitive function (Montreal Cognitive Assessment [MoCA] score), and 2-dimensional echocardiograms. The original s le used to develop the predictive model and the validation s le had similar proportions of patients with an adverse event within 30 days (30% vs 29%, p = 0.35) and 90 days (52% vs 49%, p = 0.36). Applying the predicted risk score to the validation s le provided very good discriminatory power (C-statistic = 0.77) in the prediction of 30-day readmission or death. This discrimination was greater for predicting 30-day death (C-statistic = 0.85) than for predicting 30-day readmission (C-statistic = 0.73). There was a small difference in the performance of the predictive model among patients with either a left ventricular ejection fraction of <40% or a left ventricular ejection fraction of ≥40%, but an attenuation in discrimination when used to predict longer-term adverse outcomes. In conclusion, our findings confirm the generalizability of the predictive model that may be a powerful tool for targeting high-risk patients with HF for intensive management.
Publisher: Elsevier BV
Date: 08-2015
DOI: 10.1016/J.JCMG.2014.12.033
Abstract: This study sought to investigate the association of exercise intolerance in type 2 diabetes (T2DM) with skeletal muscle capillary blood flow (CBF) reserve. Exercise intolerance in T2DM strongly predicts adverse prognosis, but associations with muscle blood flow independent of cardiac dysfunction are undefined. In 134 T2DM patients without cardiovascular disease, left ventricular function and contrast-enhanced ultrasound of the quadriceps (for CBF i.e., product of capillary blood volume and velocity) were assessed at rest and immediately following treadmill exercise for peak oxygen uptake (Vo2peak). Left ventricular systolic and diastolic functional reserve indexes were derived from changes in systolic and early diastolic color tissue Doppler velocities. Cardiac index reserve and its constituents (stroke volume and chronotropic indexes) and left ventricular filling pressure (ratio of early diastolic mitral inflow and annular velocities) were also measured. Vo2peak correlated with muscle CBF reserve (β = 0.16, p = 0.005) independent of cardiac index reserve and clinical covariates. This was explained by higher muscle capillary blood velocity reserve (β = 0.18, p = 0.002), rather than blood volume reserve (p > 0.10) in patients with higher Vo2peak. A concurrent association of Vo2peak with cardiac index reserve (β = 0.20, p 0.10), although the systolic functional reserve index was also identified as an independent correlate (β = 0.16, p = 0.028). No associations of Vo2peak with diastolic functional reserve were identified (p > 0.10). Vo2peak is associated with muscle CBF reserve in T2DM, independent of parallel associations with cardiac functional reserve. This is consistent with a multifactorial basis for exercise intolerance in T2DM.
Publisher: Elsevier BV
Date: 08-1995
DOI: 10.1016/S0002-9149(99)80093-9
Abstract: This study compared the efficacy of dobutamine stress testing using 2-dimensional echocardiography and perfusion tomography for the noninvasive identification of coronary artery disease (CAD) in patients with left bundle branch block (LBBB). Twenty-four patients with permanent, complete LBBB (11 with previous myocardial infarction) were studied prospectively with dobutamine echocardiography and perfusion tomography. The presence of > 50% luminal diameter coronary stenosis was compared with the presence of dobutamine-induced fixed or reversible perfusion defects, and with resting or dobutamine-induced abnormalities of wall thickening. For each test, the left anterior coronary artery territory was compared with the circumflex and/or right coronary artery. Significant CAD was found in the left anterior descending coronary artery in 12 patients all (100%) were identified by perfusion imaging, and 10 (83%, p = NS) by 2-dimensional stress echocardiography. In the 12 patients without left anterior descending CAD, scintigraphy was also positive in all (specificity: 0%), and echocardiography in only 1 (specificity: 92%, p < 0.01). The diagnostic accuracy was 50% and 87% (p < 0.05), respectively. This low specificity of perfusion tomography was improved by requiring an associated apical defect to indicate left anterior descending CAD and was corrected by restricting the diagnosis of coronary disease to those patients with partially reversible defects. In the circumflex and/or right coronary artery territory, sensitivity and specificity were similar using both techniques. We conclude that dobutamine-stress echocardiography is a specific and accurate test for the noninvasive identification of CAD, even in the left anterior descending artery territory of patients with LBBB.
Publisher: Elsevier BV
Date: 03-2007
DOI: 10.1016/J.AMJCARD.2006.10.045
Abstract: Left ventricular (LV) diastolic dysfunction and increased arterial stiffness are prevalent in patients with type 2 diabetes mellitus (DM). Because the systemic vasculature plays a pivotal role in myocardial loading, this study aimed to determine the effect of arterial characteristics on LV diastolic function in patients with type 2 DM. Conventional echocardiography and tissue Doppler imaging were performed in 155 patients with type 2 DM (88 men mean age 55 +/- 11 years) with preserved LV ejection fractions (>50%). Patients were stratified into groups on the basis of LV diastolic function (normal, n = 53 delayed relaxation, n = 79 pseudonormal, n = 23). Arterial wave reflection parameters and central blood pressure were determined by radial tonometry. Arterial (brachial and carotid) structure and function were determined by standard ultrasound methods. There were no significant differences among the groups on central pressure or arterial function. LV filling pressure, determined by the ratio of early transmitral inflow velocity to diastolic early tissue velocity (E/E'), was significantly correlated with central pulse pressure (r = 0.21, p <0.05). Late diastolic inflow velocity (A) was significantly associated with central pulse pressure (r = 0.32, p <0.001), total arterial compliance (r = -0.35, p <0.001), and carotid artery stiffness (r = 0.34, p <0.001). Multiple regression analysis found central but not brachial pulse pressure independently predicted E/E' and A. In conclusion, increased central pulse pressure, possibly due to lified pressure wave reflections, is independently associated with abnormal LV diastolic function in patients with type 2 DM.
Publisher: Elsevier BV
Date: 10-1994
DOI: 10.1016/0735-1097(94)90850-8
Abstract: This study was designed to establish the appropriate diagnostic criteria for positive dobutamine electrocardiographic (ECG) stress test results and to compare their accuracy with those of dobutamine two-dimensional echocardiography and perfusion scintigraphy. Conventional criteria for positive findings on ECG exercise testing may not be appropriate for use with dobutamine ECG stress testing. One hundred twenty-nine consecutive patients with an interpretable ECG and without previous myocardial infarction were prospectively studied at the time of coronary arteriography. All completed a standard dobutamine protocol (5 to 40 micrograms/kg body weight per min in 3-min dose increments) without side effects. Significant coronary artery disease, defined as > 50% lumen diameter stenosis of a major epicardial coronary artery on coronary angiography, was present in 83 patients. Empiric receiver operating curves were generated for various ECG criteria derived from computer-averaged signals. The best ECG criterion, with a sensitivity of 42% and a specificity of 83%, was an ST segment shift, relative to baseline, of 0.5 mm 80 ms after the J point. The sensitivity of this criterion was greater than that of the conventional criterion of 1-mm ST segment depression 60 (23%) or 80 (18%) ms after the J point, was comparable to that of chest pain occurring during the test (44%, p = NS) but remained inferior to the sensitivities of technetium-99m methoxyl isobutyl isonitrile (mibi) perfusion (76%) or stress echocardiography (76%, p < 0.001, for both). The specificity of this criterion was not significantly different from that of technetium-99m mibi perfusion tomography (65%) or stress echocardiography (89%) but was superior to that of chest pain (59%, p < 0.025). We conclude that this new criterion for dobutamine electrocardiography is specific but that an imaging technique is still required to accurately predict coronary artery disease.
Publisher: BMJ
Date: 07-1994
DOI: 10.1136/HRT.72.1.31
Abstract: To compare the ability of dobutamine and exercise stress to induce myocardial ischaemia and perfusion heterogeneity under routine clinical circumstances. 86 active patients without previous myocardial infarction were studied by dobutamine and exercise stress protocols and coronary angiography. During both tests patients underwent electrocardiography, digitised echocardiography, and perfusion scintigraphy using Tc-99m methoxybutylisonitrile (MIBI) single photon emission computed tomography. Coronary disease defined as an ST segment depression of > or = 0.1 mV, a resting or stress induced perfusion defect, or a resting or stress induced wall motion abnormality on exercise and dobutamine stress testing. Dobutamine stress was submaximal in 51 patients because of ingestion of beta adrenoceptor blocking agents on the day of the test (n = 25) or failure to attain the peak dose owing to side effects (n = 28). Exercise was limited in 23 patients by non-cardiac symptoms. The peak heart rate with dobutamine was less than that attained with exercise (105 (25) v 132 (24) beats/min, P < 0.0001) the response to maximal dobutamine stress significantly exceeded that to submaximal stress. Peak blood pressure was greatest with exercise (206 (27) v 173 (25) mm Hg, P < 0.001), values at maximal and submaximal dobutamine stress being comparable. Electrocardiographic evidence of ischaemia was induced less frequently by dobutamine than exercise (32% v 77% of the 56 patients with significant coronary disease, P < 0.01), as was abnormal wall motion (54% v 88%, P < 0.001). Ischaemia was induced more readily with maximal stress of either type thus the sensitivities of dobutamine and exercise echocardiography were comparable only in patients undergoing a maximal dobutamine testing (73% v 77%, NS). Perfusion heterogeneity was induced in 58% of patients with coronary disease at submaximal dobutamine stress, 73% at maximal dobutamine stress, and 73% at exercise stress (NS). Among 30 patients without coronary stenoses, normal function was obtained in 83% of echocardiography studies with dobutamine and in 80% with exercise (NS). Normal perfusion was identified in 70% of these patients at exercise MIBI, and 68% at dobutamine stress (NS). In a group of patients studied under normal clinical circumstances antianginal treatment and inability to complete the stress protocol are frequent and compromise the capacity of dobutamine stress to induce ischaemia. In contrast, the induction of perfusion heterogeneity is less susceptible to submaximal stress.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-07-2018
DOI: 10.1161/CIRCULATIONAHA.118.034271
Abstract: Consistent epidemiological data demonstrate that patients with heart failure with preserved ejection fraction (HFpEF) are more likely to be women than men. Exploring mechanisms behind this sex difference in heart failure epidemiology may enrich the understanding of underlying HFpEF pathophysiology and phenotypes, with the ultimate goal of identifying therapeutic approaches for the broader HFpEF population. In this review we evaluate the influence of sex on the key domains of cardiac structure and function, the systemic and pulmonary circulation, as well as extracardiac factors and comorbidities that may explain the predisposition of women to HFpEF. We highlight the potential role of factors exclusive to or more prevalent in women such as pregnancy, preecl sia, and iron deficiency. Finally, we discuss existing controversies and gaps in knowledge, as well as the clinical importance of known sex differences in the context of the potential need for sex-specific diagnostic criteria, improved risk stratification models, and targeted therapies.
Publisher: Elsevier BV
Date: 03-2019
Publisher: Elsevier BV
Date: 02-2021
Publisher: Elsevier BV
Date: 02-2010
Publisher: Elsevier BV
Date: 02-1997
DOI: 10.1016/S0002-8703(97)70201-1
Abstract: This study investigated the association between age and referral to coronary angiography among ambulatory adults with an abnormal treadmill thallium scan. The subjects studied were 416 consecutive adults who were > or = 30 years old, under the care of cardiologists, and had an abnormal treadmill thallium scan between 1990 and 1993 at the Cleveland Clinic Foundation. The primary end point was performance of coronary angiography within 90 days of the treadmill test. Coronary angiography was performed in 163 subjects. Coronary angiography was performed in 46% of patients aged 30-49 years, in 53% of those aged 50 to 64 years, in 33% of those aged 65 to 74 years, and in only 18% of those aged > or = 75 years (chi2 test for trend, p < 0.0001). After adjustment for potential confounders, age remained associated with a lower rate of referral to angiography (p 74 years (cumulative rate 31%, 95% confidence interval 16% to 47%). The number of abnormal thallium scan segments was predictive of death (p = 0.02). These data suggest that increasing age is associated with a lower rate of referral to coronary angiography after an abnormal treadmill thallium test.
Publisher: Elsevier
Date: 2016
Publisher: Elsevier BV
Date: 03-2004
Publisher: Elsevier BV
Date: 08-2017
Publisher: Elsevier BV
Date: 03-2000
DOI: 10.1016/S0002-9149(99)00807-3
Abstract: Myocardial Doppler velocity (MDV) imaging may provide an objective correlate of ischemia, thereby reducing the expertise needed for interpreting stress echocardiography and improving its reproducibility. This study sought to independently validate the results of exercise MDV imaging with single-photon emission computed tomography (SPECT) perfusion imaging in 116 patients (age 60+/-12 years, 28 women) referred for exercise SPECT for diagnostic or prognostic assessment of coronary artery disease. Two-dimensional echocardiography was performed with simultaneous color MDV data acquisition before and after exercise treadmill testing. MDV data were processed off-line to display myocardial velocity profiles in each segment at rest and peak exercise. SPECT was analyzed using a 16-segment model and segments were classified as normal or showing resting or stress defects. Resting defects within segments showing normal function were attributed to attenuation. Color MDV data were compared with SPECT results, and a multivariate analysis (including exercise and SPECT results) was performed to identify the determinants of the exercise MDV response. Patients exercised maximally (peak rate-pressure product 27.6+/-6.1x10(3), and SPECT was abnormal in 33 patients. Of the 1,333 left ventricular segments evaluable by SPECT and MDV, 1,217 segments were classified as normal, 43 showed a stress defect, and 73 a rest defect. Segmental comparison of thallium findings and MDV showed that segments with a rest defect had a lower velocity at rest and stress than normal segments (p<0.001). Segments with a stress defect had a marked reduction in peak exercise velocity and less increment in velocity than normal segments. Heart rate, functional capacity, and presence of abnormally perfused segments were independent predictors of myocardial velocity at peak exercise. Thus, color MDV correlates with independent evidence of ischemia, although it is also influenced by exercise capacity and left ventricular function. This technique may permit a feasible approach to quantitation of exercise echocardiography.
Publisher: Elsevier BV
Date: 10-2014
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.ECHO.2018.12.002
Abstract: The authors used cluster analysis of data from cardiovascular domains associated with exercise intolerance to help define prognostic phenotypes of patients with heart failure with preserved ejection fraction (HFpEF). Resting and postexercise echocardiography was performed in 177 patients with HFpEF and 51 asymptomatic control subjects sharing a common clinical profile. Patterns of features that determine exercise capacity were sought from automated hierarchical clustering of left ventricular (LV) diastolic and systolic function, left atrial function, right ventricular function, ventricular-arterial coupling, chronotropic reserve and myocardial fibrosis. Automated clustering separated a distinct subgroup characterized by a relatively isolated impairment of LV systolic reserve. The clinical factors identified by this process were used to define two phenotypes of patients with symptomatic HFpEF: those with reduced chronotropic and/or diastolic reserve (abnormal CR/DR n = 137) and those with preserved heart rate reserve and exertional E/e' ratio < 14 (normal CR/DR n = 40). Change in global LV strain rate from rest to exercise was similar in patients with abnormal CR/DR (0.16 ± 0.18 sec Diminished LV systolic reserve may represent the major identifiable cardiac functional abnormality associated with exercise intolerance in some patients with HFpEF. Despite significant functional limitation, these patients are characterized by a better prognosis than subjects with HFpEF with more physiologic abnormalities.
Publisher: Elsevier BV
Date: 09-2014
Publisher: BMJ
Date: 15-05-2006
Publisher: Elsevier BV
Date: 2021
Publisher: Elsevier BV
Date: 07-2005
DOI: 10.1016/J.AMJCARD.2005.03.041
Abstract: Impaired coronary flow reserve is widely reported in diabetes mellitus (DM) but its effect on myocardial contrast echocardiography (MCE) is unclear. We sought to identify whether DM influences the accuracy of qualitative and quantitative assessment of coronary artery disease (CAD) using MCE in 83 patients who underwent coronary angiography (60 men, 27 with DM 56 +/- 11 years ). Destruction replenishment imaging was performed at rest and after combined dipyridamole-exercise stress testing. Ischemia was identified by the development of new wall motion abnormalities, qualitative MCE (new perfusion defects apparent 1 second after flash during hyperemia), and quantitative MCE (myocardial blood flow reserve 50% by quantitative angiography) was present in 28 patients (including 8 with DM) 55 patients had no CAD (including 19 with DM). The myocardial blood flow reserve was reduced in patients with coronary stenosis compared with those with no CAD (1.6 +/- 1.1 vs 3.8 +/- 2.5, p <0.001). Among patients with no CAD, those with DM had an impaired flow reserve compared with control patients without DM (2.4 +/- 1.0 vs 4.5 +/- 2.8, p = 0.003). In conclusion, DM significantly influenced the quantitative, but not the qualitative, assessment of MCE, with a marked reduction in specificity in patients with DM.
Publisher: Elsevier BV
Date: 04-2015
DOI: 10.1016/J.DIABRES.2015.01.011
Abstract: Heart failure (HF) is a major cause of mortality and disability in type 2 diabetes mellitus (T2DM). This study sought to improve the assessment of HF risk in patients with T2DM-a step that would be critical for effective HF screening. A systematic literature search was performed on electronic databases including MEDLINE and EMBASE, using MeSH terms 'heart failure', 'risk factor', 'T2DM', 'cardiac dysfunction', 'stage B heart failure', 'incident heart failure', 'risk assessment', 'risk impact', 'risk score', 'predictor', 'prediction' and related free text terms. The search was limited to human studies in full-length publications in English language journal from 1946 to 2014. Univariable and multivariable relative risk (RR) and hazard ratio (HR) were obtained from each study. Twenty-one studies (n=1111,569, including 507,637 subjects with T2DM) were included in this analysis with a follow-up ranging from 1 to 12 years. Associations between incident HF and risk variables described in ≥3 studies were reported. This association was greatest for insulin use (HR 2.48 1.24-4.99), HbA1c 7.0-8.0% (2.41 1.62-3.59), 5 years increase in age (1.47 1.25-1.73), fasting glucose (1.28 1.10-1.51 per standard deviation) and HbA1c (1.18 1.14-1.23 each 1% increase). After adjustment for confounders, there were strong associations with coronary artery disease (1.77 1.31, 2.39), HbA1c ≥ 10% (1.66 1.45-1.89), insulin use (1.43 1.14-1.79), HbA1c 9.0-10.0% (1.31 1.14-1.50), fasting glucose (1.27 1.10-1.47 per standard deviation) and 5 years increase in age (1.26 1.13-1.40). Among patients with T2DM, five common clinical variables are associated with significantly increased risk of incident HF.
Publisher: Springer Science and Business Media LLC
Date: 03-03-2022
DOI: 10.1007/S11912-022-01242-Y
Abstract: Anthracycline chemotherapy carries a risk of myocardial dysfunction and heart failure even at relatively low doses, and the clinical prediction of cancer treatment-related cardiac dysfunction (CTRCD) is inexact. Careful imaging or biomarker surveillance during chemotherapy can identify CTRCD before the development of heart failure. Currently, this surveillance is performed using ejection fraction (EF). While this is a reliable and reproducible test with three-dimensional techniques, the most widely used imaging technique is two-dimensional echocardiography, for which EF measurements have broad confidence intervals. The use of global myocardial strain (GLS) provides a more reliable and reproducible means of assessing global cardiac function and shows meaningful changes before a significant change of EF. Observational studies have shown that although absolute measurements of GLS, both at baseline and during therapy, are predictive of CTRCD risk, the most reliable approach is to assess the change of GLS with therapy — a meaningful relative change of 10–15% being significant. A clinical trial comparing GLS to EF surveillance did not show a significant change of EF in the overall study group, but did show that patients managed with a the GLS-guided approach were less likely to develop a meaningful change of cardiac function to an abnormal level. In at-risk patients, there is good evidence for the protective value of neurohormonal antagonists and statins: the use of GLS enables these benefits to be directed to those most likely to benefit, while minimizing their use in the majority of people, who do not need them. Although GLS requires an element of training and efforts to ensure uniformity, it has proven to be a feasible, robust, and reproducible technique, ready for wide adoption.
Publisher: Elsevier BV
Date: 12-1995
DOI: 10.1016/0735-1097(95)00388-6
Abstract: This study was designed to assess the angiographic and prognostic implications of an exaggerated systolic blood pressure response to exercise ("exercise hypertension") in adults undergoing evaluation for suspected coronary artery disease. The clinical implications of exercise hypertension are unclear. Subjects for this prospective cohort study were derived from a consecutive s le of 9,608 adults who were referred for treadmill testing and who augmented their systolic blood pressure by at least 10 mm Hg. There were 594 subjects who underwent coronary angiography within 90 days of treadmill testing. Exercise hypertension was defined as a peak exercise systolic blood pressure > or = 210 mm Hg in men and > or = 190 mm Hg in women. Severe angiographic coronary disease was defined as left main coronary artery disease (> or = 50% diameter stenosis), three-vessel disease (> or = 70% diameter stenosis) or two-vessel disease with > or = 70% diameter stenosis of the proximal left anterior descending coronary artery. All-cause mortality was assessed during a follow-up period of approximately 2 years. Exercise hypertension was present in 196 subjects (33%). Severe coronary disease was less common in subjects with exercise hypertension (14% vs. 25%, odds ratio 0.51, 95% confidence interval [CI] 0.32 to 0.81, p = 0.004). Exercise hypertension remained associated with a lower rate of severe coronary disease even after adjusting for rest hypertension, age, gender, exercise capacity and other possible confounders. During the follow-up period, there were 23 deaths only 2 occurred in the group with exercise hypertension. After adjusting for severity of coronary disease, exercise hypertension remained associated with a lower mortality rate (adjusted relative risk 0.20, 95% CI 0.05 to 0.84, p = 0.03). In adults evaluated for coronary artery disease, exercise hypertension is associated with a lower likelihood of angiographically severe disease and a lower adjusted mortality rate.
Publisher: Elsevier BV
Date: 02-2004
Publisher: Portland Press Ltd.
Date: 04-2001
DOI: 10.1042/CS20000105
Publisher: Elsevier BV
Date: 03-2017
Publisher: Elsevier BV
Date: 07-2008
Publisher: Elsevier BV
Date: 2020
DOI: 10.1016/J.JCMG.2018.10.039
Abstract: Asymptomatic left ventricular diastolic dysfunction (ALVDD) (diastolic abnormalities and normal ejection fraction in the absence of symptoms) is associated with incident heart failure (HF) and decreased survival. Abnormalities of diastolic function might therefore be included in the definition of stage B HF, which denotes in iduals at risk for the development of HF. Imaging techniques, especially echocardiography, are necessary for the recognition of preclinical left ventricular (LV) diastolic disturbances, as well as further tracking of pathological changes and responses to treatment. The transition of ALVDD to symptomatic HF is underlain by multiple factors, including both cardiovascular and noncardiovascular determinants. The initiation of management strategies targeting cardiovascular and systemic comorbidities in patients identified as having ALVDD may delay symptomatic progression and improve prognosis.
Publisher: Elsevier BV
Date: 1985
DOI: 10.3109/00313028509084770
Abstract: A patient is described with micronodular cirrhosis, partial (heterozygous, MZ) deficiency of alpha-1-antitrypsin (AAT) and hepatocellular carcinoma. The patient did not drink alcohol and all serological markers of infection with hepatitis B virus were absent. Death was due to intra-peritoneal bleeding from a multifocal liver tumour. Histology revealed multiple intracytoplasmic AAT globules in hepatocytes at the periphery of the cirrhotic nodules. Copper granules, present in the same non-neoplastic liver cells may have resulted from minor cholestasis. Within the neoplastic hepatocytes AAT globules were sparse and copper deposits co-existed with the globular variant of Mallory bodies. The case is presented in support of the postulated association of partial deficiency of AAT, chronic liver disease and hepatic neoplasia.
Publisher: Elsevier BV
Date: 11-2006
DOI: 10.1016/J.AHJ.2006.05.007
Abstract: There is limited information regarding the clinical utility of amino-terminal pro-B-type natriuretic peptide (NT-proBNP) for the detection of left ventricular (LV) dysfunction in the community. We evaluated predictors of circulating NT-proBNP levels and determined the utility of NT-proBNP to detect systolic and diastolic LV dysfunction in older adults. A population-based s le of 1229 older adults (mean age 69.4 years, 50.1% women) underwent echocardiographic assessment of cardiac structure and function and measurement of circulating NT-proBNP levels. Predictors of NT-proBNP included age, female sex, body mass index, and cardiorenal parameters (diastolic dysfunction [DD] severity LV mass and left atrial volume right ventricular overload decreasing ejection fraction [EF] and creatinine clearance). The performance of NT-proBNP to detect any degree of LV dysfunction, including mild DD, was poor (area under the curve 0.56-0.66). In contrast, the performance of NT-proBNP for the detection of EF 0.90 regardless of age and sex history of hypertension, diabetes, coronary artery disease or body mass category. The ability of NT-proBNP to detect EF < or = 40% and/or moderate-severe DD was optimized by using age/sex-specific limits. Of "false-positive" tests, 88% (124/141) were explained after considering cardiorenal determinants of NT-proBNP levels. Amino-terminal pro-B-type natriuretic peptide is a suboptimal marker of mild LV dysfunction, but performs strongly as a marker of EF < or = 40% and/or moderate-severe DD in the community. Most subjects with a positive NT-proBNP test, using age/sex-specific cutoffs, had prognostically significant abnormalities of cardiac structure or function.
Publisher: BMJ
Date: 05-2018
Publisher: Elsevier
Date: 2016
Publisher: Cleveland Clinic Journal of Medicine
Date: 1993
DOI: 10.3949/CCJM.60.1.19
Abstract: As the complexity, cost, and risks of cardiac interventions direct attention to careful selection of patients, the ability of diagnostic imaging techniques to provide quantitative documentation of the hemodynamic severity of coronary artery disease will assume greater importance. Among the various techniques currently in use, positron emission tomography yields superior spatial resolution and attenuation correction and has high sensitivity and specificity. The correlation of positron emission tomography results with coronary stenosis severity and the possibility of making quantitative flow measurements using oxygen-15 water suggest that cardiac positron emission tomography may be the best noninvasive approach for diagnostic purposes.
Publisher: Elsevier BV
Date: 07-2020
Publisher: AMPCo
Date: 23-02-2021
DOI: 10.5694/MJA2.50960
Publisher: Elsevier BV
Date: 06-2004
Publisher: Elsevier BV
Date: 12-2020
Publisher: Elsevier BV
Date: 05-1997
DOI: 10.1016/S0735-1097(97)00039-9
Abstract: This study sought to document the safety of dobutamine stress echocardiography as it has evolved at a single center and to define predictors of adverse events. The indications and protocol for dobutamine stress testing have evolved over 5 years of clinical use, but the influence of these changes on the safety and side effects of the test is undefined. Over 5 years, 3,011 consecutive dobutamine stress studies were performed in 2,871 patients, using an incremental protocol from 5 to 40 micrograms/kg body weight per min in 3-min stages, followed by atropine or an additional stage with 50 micrograms/kg per min, if required. Clinical data were gathered prospectively, and hemodynamic and echocardiographic findings were recorded at each stage, including recovery. Dobutamine echocardiography was defined as positive for ischemia in the presence of new or worsening wall motion abnormalities in the absence of ischemia, failure to attain 85% of age-predicted maximal heart rate was identified as a nondiagnostic result. Studies were performed for risk assessment (70%) and symptom evaluation (30%) over the study period, there was an increment in the use of dobutamine echocardiography for preoperative evaluation. Most tests (n = 2,194 [73%]) were terminated due to attainment of peak dose with achievement of target heart rate (> 85% maximal age-predicted heart rate) 455 patients (15%) failed to achieve > 85% maximal predicted heart rate despite maximal doses of dobutamine and atropine. The protocol was stopped prematurely in 230 patients (7.6%) because of side effects, including ventricular (n = 27 [0.9%]) and supraventricular rhythm disorders (n = 22 [0.7%]), severe hypertension (n = 24 [0.8%]) and hypotension or left ventricular outflow tract obstruction (n = 112 [3.8%]). Noncardiac symptoms, such as headache, nausea or anxiety, caused early test termination in 45 patients (1.6%). The remaining tests were stopped because of severe chest pain (n = 106 [3.5%]) or severe ischemia by echocardiography (n = 26 [0.9%]). Serious complications occurred in nine patients, including sustained ventricular tachycardia in five, myocardial infarction in one and other conditions in three requiring hospital admission (sustained supraventricular tachycardia, hypotension, suspected myocardial infarction), but neither ventricular fibrillation nor death occurred. Independent predictors of serious complications could not be defined. Over 5 years, higher dose protocols and more frequent use of atropine have raised the number of diagnostic protocols from 59% to 80%, without increasing the incidence of major side effects. Despite the use of more aggressive protocols and alterations of the indications for testing to include sicker patients, major side effects are a rare complication of dobutamine echocardiography.
Publisher: Elsevier BV
Date: 10-2012
DOI: 10.1016/J.JACC.2012.05.048
Abstract: Accurate assessment of mitral regurgitation (MR) severity is important for clinical decision making, prognostication, and decisions regarding timing of surgical intervention. The most common method for noninvasive assessment of MR has been with 2-dimensional transthoracic echocardiography, which is often used as a qualitative tool. Several newer noninvasive modalities including 3-dimensional echocardiography, cardiac magnetic resonance imaging, and cardiac computed tomography have also become available for this purpose however, their role in routine clinical practice is not clearly defined. In this review, we provide an overview of these newer modalities for quantitative assessment of MR severity.
Publisher: Oxford University Press (OUP)
Date: 06-03-2007
Abstract: Two-dimensional (2D)-strain derived from speckle-tracking is an alternative to tissue velocity imaging (TVI)-based strain. We compared their feasibility and accuracy in 150 patients undergoing dobutamine stress echocardiography (DSE) and coronary angiography. 2D- and TVI-strain were obtained in three apical views at rest and peak stress. Peak systolic strain rate (SR), endsystolic strain (epsilon(end-sys)), and peak strain (epsilon(peak)) were measured off-line at rest and peak stress, and results were compared with wall motion analysis and significant coronary artery disease (CAD > or = 70% diameter stenosis). Optimal cut-offs were derived from receiver operating characteristic (ROC) curves for sentinel segments. The most feasible method was 2D-strain at rest, and TVI-strain at peak stress. The average peak SR and epsilon(end-sys) at peak stress in segments of patients with significant CAD was less than in segments of patients without CAD (P < 0.0001) and mean PSI at peak stress was higher (P < 0.0001) with both 2D- and TVI-strain. Peak systolic SR at peak stress had the best area under the ROC for both 2D- (AUC 0.67) and TVI-strain (AUC 0.71) for the diagnosis of CAD. The accuracy of WMS (75%) for diagnosis of CAD per patient was similar to 2D-SR (69%) and TVI-SR (74%). The accuracy of 2D-SR and TVI-SR at peak stress was 78 vs. 79% (P = NS) for LAD, 67 vs. 73% (P = NS) for LCX, and 59 vs. 74% (P = 0.008) for RCA disease. Measurement of speckle tracking strain during DSE is feasible and similar in accuracy to TVI-strain in the anterior, but not in the posterior circulation.
Publisher: Public Library of Science (PLoS)
Date: 13-04-2017
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2012
DOI: 10.1161/CIRCOUTCOMES.112.966465
Abstract: The risks of repeat thoracotomy can be reduced if thoracic multidetector computed tomographic angiography (CTA) is used to guide preventive surgical strategies (PSS: peripheral cardiopulmonary bypass, circulatory arrest, and nonmedian sternotomy). We sought to define the cost-effectiveness of CTA using a Markov model. We studied outcomes and costs of CTA and non-CTA strategies in a modeled cohort of 10 000 patients undergoing redo coronary artery bypass grafting. Rates of PSS implementation were anticipated to follow identification of risk by CTA. Transitions, costs, and utilities were informed by our experience and the literature. Sensitivity analyses included testing a range of costs of CTA and PSS on model outcome. In the reference case, cost and quality-adjusted life years accrued with the use of CTA ($74 869, 4.63 quality-adjusted life-years) were slightly higher than nonuse ($73 471, 4.59 quality-adjusted life-years), yielding an incremental cost-effectiveness ratio of $34 950/quality-adjusted life-years. Cost of PSS (equipment and operating time) was the most significant determinant of incremental cost-effectiveness ratio. In the reference case (cost of CTA ≈$300), identification and avoidance of potential procedural difficulties with CTA rendered it cost-effective if the cost of PSS was $12 000. Across a range of CTA costs, incremental cost-effectiveness ratio was not materially influenced by outcomes across a broad range of imputed values. The cost of CTA appears justified in the setting of isolated reoperative coronary artery bypass grafting, because it aids in appropriate selection of PSS. The cost-effectiveness of this imaging seems more influenced by the costs of subsequent PSS than by the cost of CTA.
Publisher: Oxford University Press (OUP)
Date: 15-05-2002
Publisher: Wiley
Date: 16-03-2007
DOI: 10.1111/J.1365-2362.2007.01784.X
Abstract: The first derivative of left ventricular (LV) pressure over time (dP/dt max) is a marker of LV systolic function that can be assessed during cardiac catheterization and echocardiography. Radial artery dP/dt max has been proposed as a possible marker of LV systolic function and we sought to test this hypothesis. We compared simultaneously recorded radial dP/dt max (by high-fidelity tonometry) with LV dP/dt max (by high-fidelity catheter and echocardiography parameters analogous to LV dP/dt max). In study 1, beat-to-beat radial dP/dt max and LV dP/dt max were recorded at rest and during supine exercise in 12 males (aged 61 +/- 12 years) undergoing cardiac catheterization. In study 2, 2D-echocardiography and radial dP/dt max were recorded in 54 patients (separate to study 1 39 men aged 64 +/- 10 years) at baseline and peak dobutamine-induced stress. Three basal septum measures were taken as being analogous to LV dP/dt max: 1. Peak systolic strain rate 2. Strain rate (SR-dP/dt max) during isovolumic contraction (IVCT) and 3. Tissue velocity during IVCT. In study 1 there was a significant difference between resting LV dP/dt max (1461 +/- 383 mmHg s(-1)) and radial dP/dt max (1182 +/- 319 mmHg s(-1) P < 0.001), and a poor, but statistically significant, correlation between the variables (R(2) = 0.006 P < 0.05). Similar results were observed during exercise. In study 2 there were weak (R(2) = -0.12 P = 0.01) to non-significant associations between radial dP/dt max and all echocardiographic measures analogous to LV dP/dt max at rest or peak stress. Radial pressure waveform dP/dt max is not a reliable marker of LV systolic function.
Publisher: BMJ
Date: 04-10-2012
DOI: 10.1136/HEARTJNL-2012-302581
Abstract: In the setting of chronic stable angina, successful percutaneous coronary intervention (PCI) of chronic total occlusions (CTO) has been shown to produce significant symptom improvement with some evidence for survival benefit. However, the economic basis for this procedure has not been established compared with optimal medical treatment (OMT) of chronic stable angina. The aim of this study was to determine the cost-effectiveness of CTO-PCI in chronic stable angina using a Markov model. The transition probabilities, utilities and costs related to CTO-PCI and OMT used to inform the model were derived from literature and our experience. Implications with respect to cost and quality of life were calculated. Sensitivity analyses were based on factors noted to influence model outcome. In the reference case, mean age 60 years, rate of successful CTO-PCI 67.9%, and mean transition probabilities, utilities and costs as defined by literature and clinical experience, the strategy of CTO-PCI incurred higher costs relative to OMT (US$31 512 vs US$27 805), but also accumulated greater quality-adjusted life-years (QALYs) (2.38 vs 1.99), yielding a cost-effectiveness ratio of US$9505 per QALY. Sensitivity analyses showed the utility of OMT and utilities postsuccessful and postunsuccessful CTO-PCI to be the most influential drivers of outcome. Procedural success held limited influence over model outcome at particular utility threshold values. On the basis of the supporting evidence, this decision-analytic model suggests that CTO-PCI is cost-effective in a patient population with severe symptoms. Quality-of-life metrics should be employed in future appropriateness criteria developed for CTO-PCI.
Publisher: BMJ
Date: 02-02-2013
DOI: 10.1136/HEARTJNL-2012-303433
Abstract: The last decade has produced a proliferation of techniques for the assessment of left ventricular systolic function, and there now seems to be more choice than seems rational for the questions that we need answers to. In some instances, simple estimation is all that is required-the risk stratification process is inexact, as emphasised by the variety of modalities used to characterise ejection fraction (EF) in studies that validated the efficacy of treatments selected on the basis of EF. Nonetheless, while technical advances often cause disruption and confusion, it would be wrong to dismiss them as lacking benefit. The purpose of this review is to try to provide rational grounds for selecting both test modality and physiological parameter in various specific clinical situations.
Publisher: Elsevier BV
Date: 07-2010
DOI: 10.1016/J.JACC.2010.02.047
Abstract: Myocardial fibrosis is recognized as the pathologic entity of extracellular matrix remodeling. Diffuse, reactive fibrosis is being increasingly recognized in a variety of conditions despite the absence of ischemia. Regardless of the etiology, fibrosis leads to increased myocardial stiffness thereby promoting cardiac dysfunction. This may present clinically with symptoms of cardiac failure although often this is a subclinical disease. Various imaging modalities and collagen biomarkers have been used as surrogate markers to assess the presence, extent, and turnover of myocardial fibrosis. Techniques using echocardiography, cardiac magnetic resonance, and nuclear imaging have been developed to detect early features of systolic and diastolic left ventricular dysfunction and impaired contractile reserve. Further identification of diffuse reactive fibrosis may be possible with evolving cardiac magnetic resonance and molecular techniques. The goal of these approaches is to enable targeted therapy to be instituted earlier, leading to prevention of disease progression and fibrosis accumulation long term.
Publisher: Elsevier BV
Date: 03-1999
DOI: 10.1016/S0735-1097(98)00606-8
Abstract: The study aim was to determine observational differences in costs of care by the coronary disease diagnostic test modality. A number of diagnostic strategies are available with few data to compare the cost implications of the initial test choice. We prospectively enrolled 11,372 consecutive stable angina patients who were referred for stress myocardial perfusion tomography or cardiac catheterization. Stress imaging patients were matched by their pretest clinical risk of coronary disease to a series of patients referred to cardiac catheterization. Composite 3-year costs of care were compared for two patients management strategies: 1) direct cardiac catheterization (aggressive) and 2) initial stress myocardial perfusion tomography and selective catheterization of high risk patients (conservative). Analysis of variance techniques were used to compare costs, adjusting for treatment propensity and pretest risk. Observational comparisons of aggressive as compared with conservative testing strategies reveal that costs of care were higher for direct cardiac catheterization in all clinical risk subsets (range: $2,878 to $4,579), as compared with stress myocardial perfusion imaging plus selective catheterization (range: $2,387 to $3,010, p < 0.0001). Coronary revascularization rates were higher for low, intermediate and high risk direct catheterization patients as compared with the initial stress perfusion imaging cohort (13% to 50%, p 0.20). Observational assessments reveal that stable chest pain patients who undergo a more aggressive diagnostic strategy have higher diagnostic costs and greater rates of intervention and follow-up costs. Cost differences may reflect a diminished necessity for resource consumption for patients with normal test results.
Publisher: Public Library of Science (PLoS)
Date: 07-03-2013
Publisher: Elsevier BV
Date: 2012
Publisher: Elsevier BV
Date: 05-2013
DOI: 10.1016/J.JTCVS.2012.01.088
Abstract: The study objective was to correlate the degree of tricuspid regurgitation with clinical indicators of right-sided heart failure and both qualitative and quantitative measures of right-sided heart morphology and function in patients with degenerative mitral valve disease. From 2001 to 2007, 1833 patients with degenerative mitral valve disease, structurally normal tricuspid valve, and no coronary artery disease underwent surgery. Right-sided heart morphology (right ventricular base-to-apex length, tethering distance and area, and right atrial systolic area) and right ventricular function (tricuspid annular plane systolic excursion, myocardial performance index, and tricuspid valve annular shortening) were measured on preoperative transthoracic echocardiograms for 100 randomly selected patients from each of tricuspid regurgitation grades 0, 1+, and 2+, and for all 93 patients with tricuspid regurgitation grade 3+/4+. Multivariable regression was used to evaluate the association of left- and right-sided heart morphology and function with tricuspid regurgitation. Increasing tricuspid regurgitation grade was associated with higher right ventricular pressure (P < .0001), increased tethering distance (P = .008), larger right atrial size (P = .0002), and worsening right ventricular function, particularly when 3+/4+ tricuspid regurgitation was present. When tricuspid regurgitation was 3+/4+, both tricuspid annular plane systolic excursion and myocardial performance index were almost certainly abnormal. Changes in right-sided heart morphology and right ventricular dysfunction were synergistic in relation to severity of tricuspid regurgitation. Functional tricuspid regurgitation accompanying mitral valve disease is associated with proportional changes in right-sided heart morphology however, severe tricuspid regurgitation is nearly always associated with right ventricular dysfunction, suggesting a synergistic relationship. Right ventricular dysfunction is likely as important as tricuspid regurgitation because it offers an explanation for the negative prognostic impact of tricuspid regurgitation and has implications for the clinical management of patients.
Publisher: Elsevier BV
Date: 08-2014
Publisher: Springer Science and Business Media LLC
Date: 11-10-2008
Publisher: BMJ
Date: 02-05-2015
DOI: 10.1136/HEARTJNL-2014-307391
Abstract: New imaging techniques have permitted the detection of subclinical LV dysfunction (LVD) in up to half of patients with type 2 diabetes mellitus (DM) with a normal EF. However, the connection between early LVD and prognosis is unclear. This study aimed to define the long-term outcome of LVD associated with type 2 DM. In this prospective cohort study, 230 asymptomatic patients with type 2 DM underwent measurement of global longitudinal 2D strain (GLS) for detection of LVD and were followed for up to 10 years. All subjects had normal EF (≥50%) and no evidence of coronary artery disease at recruitment. Outcome data were obtained through centralised state-wide death and hospital admission registries. The primary endpoint was all-cause mortality and hospitalisation. On study entry, almost half (45%) of the cohort had evidence of LVD as detected by GLS. Over a median follow-up of 7.4±2.6 years (range 0.6-9.7 years), 68 patients (30%) met the primary endpoint (LVD: 37% normal LV function: 24%). GLS was independently associated with the primary endpoint (HR=1.10 p=0.04), as was systolic blood pressure (HR=1.02 p<0.001) and levels of glycosylated haemoglobin (HR=1.28 p=0.011). Patients with LVD had significantly worse outcome than those without (χ(2)=4.73 p=0.030). Subclinical LVD is common in asymptomatic patients with type 2 DM, is readily detectable by GLS imaging and is independently associated with adverse outcome. Australian and New Zealand Clinical Trials Registry (ACTRN12612001178831).
Publisher: AMPCo
Date: 30-07-2020
DOI: 10.5694/MJA2.50702
Publisher: Elsevier BV
Date: 2007
DOI: 10.1016/J.TCM.2006.04.008
Abstract: Hypertension, obstructive sleep apnea, and coronary artery disease all contribute to the myocardial dysfunction in obesity. However, the development of sensitive cardiac imaging techniques has enabled detection of myocardial structural and functional changes independently attributable to obesity, at the preclinical stage. This review will evaluate the evidence for myocardial disease in this setting, its significance, important mechanisms, preclinical detection, and possible therapeutic implications.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2011
Publisher: Oxford University Press (OUP)
Date: 06-2005
DOI: 10.1016/J.EUJE.2005.01.004
Abstract: The inexorable growth in the performance of cardiac imaging studies has led to a significant reduction in reimbursement for these services, which are already being reimbursed at levels that are quite similar to their cost. This paper seeks to apply the principles of analysis of cost-effectiveness to echocardiography. Opportunities are summarized for reducing cost and maximizing effectiveness, and different approaches to defining cost-effectiveness are examined for valvular, myocardial and ischemic indications.
Publisher: BMJ
Date: 07-05-2009
Abstract: To identify the effects of a 1-year exercise intervention on myocardial dysfunction in patients with type 2 diabetes mellitus (T2DM). Randomised controlled trial, the Diabetes Lifestyle Intervention Study. University hospital. 223 T2DM patients without occult coronary artery disease, aged 18-75 were randomised to an exercise training group (n = 111) or a usual care group (n = 112). Complete follow-up data were available in 176 (88 exercise, 88 usual care). Exercise training consisted of gym, followed by telephone-monitored home-based exercise training. Tissue Doppler-derived myocardial velocities, strain-rate and strain, body composition, glycated haemoglobin (HbA(1c)), maximum oxygen consumption (VO(2max)) and physical activity. Overall changes in myocardial function were not different between groups despite improvements in waist circumference, fat mass, blood glucose, HbA(1c), insulin sensitivity, VO(2max) and 6-minute walk distance in the intervention group (p<0.05). The latter also spent significantly more time in vigorous activity (p<0.05). A post-hoc analysis revealed that intervention patients who spent more time in both moderate and vigorous activity showed a significant improvement in myocardial tissue velocity (p<0.01), HbA(1c) (p = 0.03) and VO(2max) (p = 0.03) compared to controls. Myocardial strain rate (p = 0.03) and HbA(1c) improved in intervention patients with the greatest increase in moderate activity (p = 0.03). In patients with T2DM, current exercise recommendations led to an improvement in metabolic function, but failed to improve myocardial function in the overall group. Patients with greater increases in both moderate and vigorous activity showed improvements in myocardial function, glycaemic control and cardiorespiratory fitness. ACTRN12607000060448.
Publisher: Wiley
Date: 21-08-2020
DOI: 10.1002/EJHF.1957
Abstract: Cardiovascular (CV) imaging is an important tool in baseline risk assessment and detection of CV disease in oncology patients receiving cardiotoxic cancer therapies. This position statement examines the role of echocardiography, cardiac magnetic resonance, nuclear cardiac imaging and computed tomography in the management of cancer patients. The Imaging and Cardio‐Oncology Study Groups of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) in collaboration with the European Association of Cardiovascular Imaging (EACVI) and the Cardio‐Oncology Council of the ESC have evaluated the current evidence for the value of modern CV imaging in the cardio‐oncology field. The most relevant echocardiographic parameters, including global longitudinal strain and three‐dimensional ejection fraction, are proposed. The protocol for baseline pre‐treatment evaluation and specific surveillance algorithms or pathways for anthracycline chemotherapy, HER2‐targeted therapies such as trastuzumab, vascular endothelial growth factor tyrosine kinase inhibitors, BCr‐Abl tyrosine kinase inhibitors, proteasome inhibitors and immune checkpoint inhibitors are presented. The indications for CV imaging after completion of oncology treatment are considered. The typical consequences of radiation therapy and the possibility of their identification in the long term are also summarized. Special populations are discussed including female survivors planning pregnancy, patients with carcinoid disease, patients with cardiac tumours and patients with right heart failure. Future directions and ongoing CV imaging research in cardio‐oncology are discussed.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-1995
DOI: 10.1097/00001573-199511000-00011
Abstract: Stress echocardiography has found acceptance as a routine technique for the diagnosis and evaluation of coronary artery disease. This review concentrates on recent advances in this technique. New approaches including contrast echocardiography, transesophageal stress echocardiography, and color-enhanced wall motion analysis may augment its feasibility and can be used to assist in the interpretation of these studies. The combination of dobutamine with atropine is safe, effective, and superior to the alternatives in patients who cannot exercise. However, in active patients, exercise appears to provide the optimal stress. Finally, recent studies have documented promising results regarding the efficacy of stress echocardiographic techniques for prognostic evaluation and the diagnosis of viable myocardium.
Publisher: Elsevier BV
Date: 08-2002
Abstract: Tissue Doppler may be used to quantify regional left ventricular function but is limited by segmental variation of longitudinal velocity from base to apex and free to septal walls. We sought to overcome this by developing a composite of longitudinal and radial velocities. We examined 82 unselected patients undergoing a standard dobutamine echocardiogram. Longitudinal velocity was obtained in the basal and mid segments of each wall using tissue Doppler in the apical views. Radial velocities were derived in the same segments using an automated border detection system and centerline method with regional chords grouped according to segment location and temporally averaged. In 25 patients at low probability of coronary disease, the pattern of regional variation in longitudinal velocity (higher in the septum) was the opposite of radial velocity (higher in the free wall) and the combination was homogeneous. In 57 patients undergoing angiography, velocity in abnormal segments was less than normal segments using longitudinal (6.0 +/- 3.6 vs 9.0 +/- 2.2 cm/s, P =.01) and radial velocity (6.0 +/- 4.0 vs 8.0 +/- 3.9 cm/s, P =.02). However, the composite velocity permitted better separation of abnormal and normal segments (13.3 +/- 5.6 vs 17.5 +/- 4.2 cm/s, P =.001). There was no significant difference between the accuracy of this quantitative approach and expert visual wall motion analysis (81% vs 84%, P =.56). Regional variation of uni-dimensional myocardial velocities necessitates site-specific normal ranges, probably because of different fiber directions. Combined analysis of longitudinal and radial velocities allows the derivation of a composite velocity, which is homogeneous in all segments and may allow better separation of normal and abnormal myocardium.
Publisher: Elsevier BV
Date: 06-2016
DOI: 10.1016/J.AMJCARD.2016.03.045
Abstract: A process to identify and target a selected population at risk of heart failure (HF) could facilitate screening and prevention. We sought to develop an effective screening process from clinical characteristics, functional capacity, and electrocardiogram (ECG). Asymptomatic subjects ≥65 years, with ≥1 HF risks were recruited from the community. Subjects with valvular disease, ejection fraction 9.5%) and 6 MW (<501 m) as cutoffs to define low-, intermediate-, and high-risk groups. Abnormal ECG further ided the intermediate group into high and low risks. The 134 subjects identified as high risk by a combined clinical and electrocardiographic strategy showed more echocardiographic features of cardiac dysfunction including LV mass, mitral e', mitral E/e', and longitudinal strain (p <0.01). New HF was significantly more frequent than in the remaining patients (20% vs 10%, p = 0.003 hazard ratio 2.08, 95% confidence interval 1.21 to 3.57, p = 0.008). Thus, initial clinical risk and electrocardiographic assessment facilitate effective HF screening by identifying a high-risk group.
Publisher: Elsevier BV
Date: 03-2010
DOI: 10.1016/J.HLC.2010.01.006
Abstract: For over 30 of its 50-year history, echocardiography has provided noninvasive, widely available and inexpensive imaging. This technique now has a huge evidence base that is incorporated in the guidelines for many cardiac diseases, to the extent that echocardiography (2DE) has a central position in modern cardiac diagnosis and management. The paradox is that in contributing the lion's share of cardiac imaging, echocardiography has become removed from the province of the imaging specialist and its role as an interesting and worthwhile source of investigation and training has been superseded by the newer methodologies including cardiac computed tomography (CCT) and cardiac magnetic resonance (CMR). However, the clinical contribution of potential advances are likely to be realised only if "advanced echocardiography" - including deformation, contrast and three-dimensional imaging - are differentiated from the "plain vanilla" of routine echocardiography. Successful translation of these advances into clinical practice will show that these new techniques are complimentary and in some cases competitive with the new imaging methodologies. This review seeks to provide a perspective of how echocardiography will integrate with the new imaging methodologies for the most common indications for cardiac imaging, with specific attention to the contribution of new methodologies including three-dimensional echocardiography (3DE) and deformation imaging.
Publisher: Elsevier BV
Date: 04-2004
Publisher: Elsevier BV
Date: 03-2014
DOI: 10.1016/J.AMJCARD.2013.12.006
Abstract: The contribution of postimplant optimization of device settings to the beneficial effect of cardiac resynchronization therapy (CRT) in heart failure is uncertain. We performed a meta-analysis to investigate the impact of CRT optimization on the improvement of left ventricular function, exercise capacity, and quality of life. We undertook a systemic review of the evidence from a search of relevant controlled clinical studies in the MEDLINE and EMBASE databases. Changes in left ventricular ejection fraction (LVEF), 6-minute walk distance, and Minnesota Living with Heart Failure score at follow-up were assessed the primary outcome was ejection fraction. A random-effects model was used to combine weighted mean difference (WMD) and 95% confidence intervals (CIs). A metaregression was undertaken to assess the impact of potential covariates. Data were collated from 13 studies enrolling 1,431 patients (919 optimized and 669 controls). Pooled analysis demonstrated that the optimization procedure resulted in a significant increase in LVEF (WMD 2.6%, 95% CI 0.8 to 4.4, p = 0.001) as compared with a nonoptimized CRT. No improvements with the optimization of CRT were seen in 6-minute walk distance and quality of life (WMD 12 m, 95% CI 23 to 48, p = 0.49, and 3.6, 95% CI 2.2 to 9.5, p = 0.22, respectively) however, this part of the analysis was performed using limited data. Thus, these collated data suggest that the optimization of CRT leads to a significant but small improvement in LVEF in patients with heart failure. Additional, adequately powered studies are needed to evaluate the effects of this procedure on exercise tolerance and quality of life.
Publisher: Elsevier BV
Date: 09-2019
Publisher: American Medical Association (AMA)
Date: 14-01-1998
Abstract: Approximately 0.5% of all patients who undergo exercise testing develop a transient left bundle-branch block (LBBB) during exercise, but its prognostic significance is unclear. To determine whether exercise-induced LBBB is an independent predictor of mortality and cardiac morbidity. Matched control cohort study. Between September 1990 and February 10, 1994, 17277 exercise stress tests were performed on patients. Tertiary care, academic medical center. From the cohort, 70 cases of exercise-induced LBBB were identified. The controls comprised 70 in iduals without LBBB at rest or during exercise that matched the 70 cases based on age, test date, sex, prior history of coronary artery disease, hypertension, diabetes, smoking, and beta-blocker use. All-cause mortality, percutaneous coronary intervention, open heart surgery, nonfatal myocardial infarction, documented symptomatic or sustained ventricular tachydysrhythmia, or implantation of a permanent pacemaker or an implantable cardiac defibrillator. A total of 37 events (28 events from the exercise-induced LBBB cases and 9 from the control cohort) occurred in 25 patients (17 exercise-induced LBBB patients and 8 control patients) during a mean follow-up period of 3.7 (0.9 years) (median, 3.8 years [range, 0.9-5.2 years]). There were 7 deaths, of which 5 occurred among patients with exercise-induced LBBB. Four-year Kaplan-Meier event rates were 19% among exercise-induced LBBB patients and 10% among controls (log-rank chi2, 5.2 P=.02). After further adjusting for small differences in age, exercise-induced LBBB remained associated with a higher risk of primary events (adjusted relative risk, 2.78 95% confidence interval, 1.16-6.65 P=.02). Exercise-induced LBBB independently predicts a higher risk of death and major cardiac events.
Publisher: Elsevier BV
Date: 07-1997
DOI: 10.1016/S0735-1097(97)00148-4
Abstract: This study prospectively compared the incremental prognostic benefit of exercise echocardiography with that of exercise testing in a large cohort. Exercise echocardiography is widely accepted as a diagnostic tool, but the prognostic information provided by this test, incremental to clinical and stress testing evaluation, is ill-defined. Clinical, exercise and echocardiographic variables were studied in a consecutive group of 500 patients undergoing exercise echocardiography. After exclusion of patients who underwent revascularization within 3 months of the stress test (n = 16, 3%) and those lost to follow-up (n = 21, 4%), the remaining 463 patients (mean [+/-SD] age 57 +/- 12 years, 302 men) were followed-up for 44 +/- 11 months. Outcome was related to the exercise and echocardiographic findings, and the incremental prognostic benefit of exercise echocardiography was compared with that of standard exercise testing. Cardiac events occurred in 81 patients (17%), including 33 (7%) with spontaneous events (cardiac death, myocardial infarction and unstable angina) and 48 with late revascularizations due to progressive symptoms. In a multivariate Cox proportional hazards model, the likelihood of any cardiac event was increased in the presence of ischemia (relative risk [RR] 5.06, 95% confidence interval [CI] 3.09 to 8.29, p < 0.001) and lessened by more maximal stress, measured as percent age-predicted maximal heart rate (RR per 5% increment 0.84, 95% CI 0.77 to 0.92, p < 0.001). Spontaneous events were more strongly predicted by ischemia (RR 8.20, 95% CI 3.41 to 19.71, p < 0.001) and percent age-predicted maximal heart rate (RR per 5% increment 0.78, 95% CI 0.67 to 0.91, p < 0.001). An interactive logistic regression model showed that the addition of echocardiographic to exercise and clinical data offered incremental predictive value. The presence of ischemia on the exercise echocardiogram can predict whether patients will experience an event. This relation is independent of, and incremental to, clinical and exercise data.
Publisher: Elsevier BV
Date: 2021
Publisher: Elsevier BV
Date: 04-2001
Abstract: Although digital and videotaped images are known to be comparable for the evaluation of left ventricular function, their relative accuracy for assessment of more complex anatomy is unclear. We sought to compare reading time, storage costs, and concordance of video and digital interpretations across multiple observers and sites. One hundred one patients with valvular (90 mitral, 48 aortic, 80 tricuspid) disease were selected prospectively, and studies were stored according to video and standardized digital protocols. The same reviewer interpreted video and digital images independently and at different times with the use of a standard report form to evaluate 40 items (e.g., severity of stenosis or regurgitation, leaflet thickening, and calcification) as normal or mildly, moderately, or severely abnormal. Concordance between modalities was expressed at kappa. Major discordance (difference of >1 level of severity) was ascribed to the modality that gave the lesser severity. CD-ROM was used to store digital data (20:1 lossy compression), and super-VHS videotape was used to store video data. The reading time and storage costs for each modality were compared. Measured parameters were highly concordant (ejection fraction was 52% +/- 13% by both). Major discordance was rare, and lesser values were reported with digital rather than video interpretation in the categories of aortic and mitral valve thickening (1% to 2%) and severity of mitral regurgitation (2%). Digital reading time was 6.8 +/- 2.4 minutes, 38% shorter than with video (11.0 +/- 3.0, range 8 to 22 minutes, P <.001). Compressed digital studies had an average size of 60 +/- 14 megabytes (range 26 to 96 megabytes). Storage cost for video was A$0.62 per patient (18 studies per tape, total cost A$11.20), compared with A$0.31 per patient for digital storage (8 studies per CD-ROM, total cost A$2.50). Digital and video interpretation were highly concordant in the few cases of major discordance, the digital scores were lower, perhaps reflecting unders ling. Use of additional views and longer clips may be indicated to minimize discordance with video in patients with complex problems. Digital interpretation offers a significant reduction in reading times and the cost of archiving.
Publisher: Public Library of Science (PLoS)
Date: 15-05-2015
Publisher: BMJ
Date: 03-08-2012
DOI: 10.1136/HEARTJNL-2012-302353
Abstract: The diagnosis of cardiac amyloidosis (CA) is challenging owing to vague symptomatology and non-specific echocardiographic findings. To describe regional patterns in longitudinal strain (LS) using two-dimensional speckle-tracking echocardiography in CA and to test the hypothesis that regional differences would help differentiate CA from other causes of increased left ventricular (LV) wall thickness. 55 consecutive patients with CA were compared with 30 control patients with LV hypertrophy (n=15 with hypertrophic cardiomyopathy, n=15 with aortic stenosis). A relative apical LS of 1.0, defined using the equation (average apical LS/(average basal LS + mid-LS)), was sensitive (93%) and specific (82%) in differentiating CA from controls (area under the curve 0.94). In a logistic regression multivariate analysis, relative apical LS was the only parameter predictive of CA (p=0.004). CA is characterised by regional variations in LS from base to apex. A relative 'apical sparing' pattern of LS is an easily recognisable, accurate and reproducible method of differentiating CA from other causes of LV hypertrophy.
Publisher: Elsevier BV
Date: 10-2016
Publisher: Oxford University Press (OUP)
Date: 21-01-2023
Publisher: Cleveland Clinic Journal of Medicine
Date: 07-1993
Abstract: We report the case of a 67-year-old man with vertebral-basilar arterial insufficiency who had been receiving warfarin therapy for approximately 2 years. The patient presented with a 3-week history of weight gain, abdominal distension, and mild exertional dyspnea. Transthoracic echocardiography confirmed the presence of a large circumferential pericardial effusion with diastolic collapse of the right atrium, and a pulsed-wave Doppler echocardiographic study of mitral and tricuspid diastolic flow showed respiratory variation consistent with cardiac t onade. The patient's prothrombin time was 30 seconds, which decreased to 17 seconds after treatment with intravenous fresh-frozen plasma and vitamin K. He underwent drainage of 2 L of bloody pericardial fluid over 12 hours by pericardiocentesis. Extensive further studies failed to demonstrate known causes or correlates of pericardial effusion. The patient was discharged and continued to do well without warfarin therapy.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-08-2013
DOI: 10.1161/CIRCULATIONAHA.112.001094
Abstract: The optimal management of low-gradient “severe” aortic stenosis (mean gradient mm Hg, indexed aortic valve area ≤0.6 cm 2 /m 2 ) with preserved left ventricular ejection fraction remains controversial because gradients may be similar after aortic valve replacement (AVR). We compared outcomes of low-gradient severe aortic stenosis with AVR or medical therapy. Comprehensive echocardiographic measurements including hemodynamic calculations were completed in 260 prospectively identified patients with symptomatic low-gradient severe aortic stenosis. Patients were followed up for mortality over 28±24 months. AVR was performed in 123 patients (47%). Compared with AVR patients, medically treated patients had a higher prevalence of diabetes mellitus (25% versus 41%, P =0.009), lower stroke volume index (36.4±8.4 versus 34.4±8.7 mL/m 2 , P =0.02), higher pulmonary artery pressure (38±11 versus 48±21 mm Hg, P =0.001), and higher creatinine level (1.1±0.4 versus 1.22±0.5 mg/dL, P =0.02). These and other clinically relevant variables were entered into a propensity model that reflected likelihood of referral to AVR. This score and other variables were entered into a Cox model to explore the independent effect of AVR on outcome. During follow-up, 105 patients died (40%): 32 (30%) in the AVR group and 73 (70%) in the medical treatment group. AVR (hazard ratio, 0.54 95% confidence interval, 0.32–0.94 P .001) was independently associated with outcome and remained a strong predictor of survival after adjustment for propensity score. Medical therapy was associated with 2-fold greater all-cause mortality than AVR. The protective effect of AVR was similar in 125 patients with normal flow (stroke volume index mL/m 2 P =0.22). AVR is associated with better survival than medical therapy in patients with symptomatic low-gradient severe AS and preserved left ventricular ejection fraction.
Publisher: Elsevier BV
Date: 12-1992
DOI: 10.1016/0735-1097(92)90461-U
Abstract: To simulate a human catheterization laboratory setting of controlled reperfusion during myocardial infarction, regional infusion of commercially available Buckberg cardioplegic solution and peripheral vented bypass were administered in the closed chest dog. Studies in open-chest dogs have demonstrated a significant reduction in infarct size and improvement in regional wall motion with a similar controlled reperfusion method using infusion of substrate-enriched (Buckberg) cardioplegic solution during cardiopulmonary bypass coupled with left ventricular venting. After 100 or 180 min of balloon occlusion of the proximal left anterior descending artery, controlled reperfusion was performed with cardioplegic infusion and vented bypass. Dogs matched for occlusion time underwent balloon deflation without bypass or cardioplegia (uncontrolled reperfusion groups). Microspheres were used to quantify coronary ischemia during balloon inflation. All four groups (n = 8 to 9 per group) were followed up at 1 week to determine regional wall motion and infarct size. Qualitative echocardiographic analysis demonstrated no significant difference among groups in recovery of regional wall motion at 1 week however, wall motion improved significantly in all groups between the ischemia and 1-week recovery periods. The histologic infarct size compared with the area at risk for dogs with uncontrolled versus controlled reperfusion, respectively, was 17.9 +/- 10.5% versus 31.9 +/- 8.3% (p < 0.05) for dogs with 100 min of occlusion and 40.1 +/- 11.7% versus 46.2 +/- 8.4% (p = NS) for dogs with 180 min of occlusion. A greater rate-pressure product in the dogs with controlled reperfusion after 100 min of occlusion (p < 0.05) may explain the larger infarct size observed for that group. These results demonstrate that regional infusion of substrate-enriched cardioplegic solution in combination with peripheral vented bypass does not further reduce infarct size after prolonged ischemia in the closed chest dog (compared with uncontrolled reperfusion).
Publisher: Oxford University Press (OUP)
Date: 05-06-2023
Abstract: Heart failure is a highly heterogeneous disease, and genetic testing may allow phenotypic distinctions that are incremental to those obtainable from imaging. Advances in genetic testing have allowed for the identification of deleterious variants in patients with specific heart failure phenotypes (dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, and hypertrophic cardiomyopathy), and many of these have specific treatment implications. The diagnostic yield of genetic testing in heart failure is modest, and many rare variants are associated with incomplete penetrance and variable expressivity. Environmental factors and co-morbidities have a large role in the heterogeneity of the heart failure phenotype. Future endeavours should concentrate on the cumulative impact of genetic polymorphisms in the development of heart failure.
Publisher: Springer Science and Business Media LLC
Date: 16-02-2021
Publisher: BMJ
Date: 28-09-2009
Publisher: Springer Science and Business Media LLC
Date: 05-04-2019
Publisher: Elsevier BV
Date: 04-2015
Publisher: BMJ
Date: 18-11-2010
Abstract: To optimise an echocardiographic estimation of pulmonary vascular resistance (PVR(e)) for diagnosis and follow-up of pulmonary hypertension (PHT). Cross-sectional study. Tertiary referral centre. Patients undergoing right heart catheterisation and echocardiography for assessment of suspected PHT. PVR(e) ([tricuspid regurgitation velocity ×10/(right ventricular outflow tract velocity-time integral+0.16) and invasive PVR(i) ((mean pulmonary artery systolic pressure-wedge pressure)/cardiac output) were compared in 72 patients. Other echo data included right ventricular systolic pressure (RVSP), estimated right atrial pressure, and E/e' ratio. Difference between PVR(e) and PVR(i) at various levels of PVR was sought using Bland-Altman analysis. Corrected PVR(c) ((RVSP-E/e')/RVOT(VTI)) (RVOT, RV outflow time VTI, velocity time integral) was developed in the training group and tested in a separate validation group of 42 patients with established PHT. PVR(e)>2.0 had high sensitivity (93%) and specificity (91%) for recognition of PVR(i)>2.0, and PVR(c) provided similar sensitivities and specificities. PVR(e) and PVR(i) correlated well (r=0.77, p<0.01), but PVR(e) underestimated marked elevation of PVR(i)-a trend avoided by PVR(c). PVR(c) and PVR(e) were tested against PVR(i) in a separate validation group (n=42). The mean difference between PVR(e) and PVR(i) exceeded that between PVR(c) and PVR(i) (2.8±2.7 vs 0.8±3.0 Wood units p<0.001). A drop in PVR(i) by at least one SD occurred in 10 patients over 6 months this was detected in one patient by PVR(e) and eight patients by PVR(c) (p=0.002). PVR(e) distinguishes normal from abnormal PVR(i) but underestimates high PVR(i). PVR(c) identifies the severity of PHT and may be used to assess treatment response.
Publisher: Elsevier BV
Date: 2003
DOI: 10.1046/J.1444-2892.2003.00212.X
Abstract: Diastolic heart failure (DHF) is reported to account for 30-50% of heart failure presentations, but its prevalence in the absence of overt coronary disease is unclear. Diastolic heart failure is usually defined by exclusion (heart failure with normal left ventricular (LV) systolic function), and few studies have sought a specific diagnosis of diastolic dysfunction. The objective of the present study was to determine the prevalence of isolated DHF and characterise LV diastolic function in patients without clinical evidence of coronary disease, who were referred for LV function assessment. Among 938 consecutive patients referred for assessment of LV function, diastolic dysfunction was sought in patients with clinical heart failure, normal systolic function, and no valvular or coronary disease. The evaluation was based on measurement of early (E) and late (A) transmitral velocities and E wave deceleration time (DT). Pulmonary vein systolic, diastolic and atrial reversal velocities were used to differentiate pseudonormal filling in patients with normal E/A and DT. Normal LV systolic function was present in 331 patients (35%), of whom 53 (6%) met criteria for a clinical diagnosis of DHF. Diastolic dysfunction was confirmed by echocardiography in 38 patients (72% of clinical DHF patients), of whom 27 had impaired LV relaxation, 10 had pseudonormal filling, and one had restrictive filling. Diastolic function was normal in 13 and indeterminate in two patients. Pseudonormal or restrictive LV filling were more prevalent in patients with acute heart failure (7/20, P < 0.05). Carefully defined, isolated DHF is uncommon, but most of these patients demonstrate echocardiographic evidence of diastolic dysfunction.
Publisher: Elsevier BV
Date: 11-2014
DOI: 10.1016/J.DIABRES.2014.08.029
Abstract: Impaired arterial function has been implicated in diabetes-related atherosclerosis, but its determinants in high-risk adults have not been well characterised. We investigated factors associated with impaired arterial function in adults with type 2 diabetes. Flow-mediated dilatation (a marker of endothelial function) and dilator response to glyceryl trinitrate (to assess smooth muscle function) of the brachial artery were assessed at baseline in 193 patients with type 2 diabetes from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study. Traditional risk factors were assessed and a multivariable model was constructed to identify factors independently associated with impaired arterial function. Median age was 64 years (interquartile range, 58-69 61% male) and duration of diabetes was 4 years (interquartile range, 2-9). Flow-mediated dilatation (3.06 ± 0.25%, mean ± SEM) was severely impaired but not significantly associated with other risk factors. Dilator responses to glyceryl trinitrate (10.56 ± 0.52%) were significantly and independently impaired in past and present cigarette smokers (P = 0.005) and in subjects with increased urinary albumin/creatinine ratio (P = 0.01). In adults with type 2 diabetes and known or suspected atherosclerosis, arterial smooth muscle-dependent dilatation was shown to be significantly impaired in cigarette smokers and those with elevated urinary albumin levels.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 21-03-2023
Abstract: The origins of sex differences in cardiovascular diseases are not well understood. We examined the contribution of childhood risk factors to sex differences in adult carotid artery plaques and intima‐media thickness (carotid IMT). Children in the 1985 Australian Schools Health and Fitness Survey were followed up when they were aged 36 to 49 years (2014–19, n=1085–1281). Log binomial and linear regression examined sex differences in adult carotid plaques (n=1089) or carotid IMT (n=1283). Childhood sociodemographic, psychosocial, and biomedical risk factors that might contribute to sex differences in carotid IMT laques were examined using purposeful model building with additional adjustment for equivalent adult risk factors in sensitivity analyses. Women less often had carotid plaques (10%) than men (17%). The sex difference in the prevalence of plaques (relative risk [RR] unadjusted 0.59 [95% CI, 0.43 to 0.80]) was reduced by adjustment for childhood school achievement and systolic blood pressure (RR adjusted 0.65 [95% CI, 0.47 to 0.90]). Additional adjustment for adult education and systolic blood pressure further reduced sex difference (RR adjusted 0.72 [95% CI, 0.49 to 1.06]). Women (mean±SD 0.61±0.07) had thinner carotid IMT than men (mean±SD 0.66±0.09). The sex difference in carotid IMT (β unadjusted −0.051 [95% CI, −0.061 to −0.042]) reduced with adjustment for childhood waist circumference and systolic blood pressure (β adjusted −0.047 [95% CI, −0.057 to −0.037]) and further reduced with adjustment for adult waist circumference and systolic blood pressure (β adjusted −0.034 [95% CI, −0.048 to −0.019]). Some childhood factors contributed to adult sex differences in plaques and carotid IMT. Prevention strategies across the life course are important to reduce adult sex differences in cardiovascular diseases.
Publisher: Oxford University Press (OUP)
Date: 02-2005
Abstract: Prior research is limited with regard to the diagnostic and prognostic accuracy of commonplace cardiac imaging modalities in women. The aim of this study was to examine 5-year mortality in 4234 women and 6898 men undergoing exercise or dobutamine stress echocardiography at three hospitals. Univariable and multivariable Cox proportional hazards models were used to estimate time to cardiac death in this multi-centre, observational registry. Of the 11 132 patients, women had a greater frequency of cardiac risk factors (P<0.0001). However, men more often had a history of coronary disease including a greater frequency of echocardiographic wall motion abnormalities (P<0.0001). During 5 years of follow-up, 103 women and 226 men died from ischaemic heart disease (P<0.0001). Echocardiographic estimates of left ventricular function (P<0.0001) and the extent of ischaemic wall motion abnormalities (P<0.0001) were highly predictive of cardiac death. Risk-adjusted 5-year survival was 99.4, 97.6, and 95% for exercising women with no, single, and multi-vessel ischaemia (P<0.0001). For women undergoing dobutamine stress, 5-year survival was 95, 89, and 86.6% for those with 0, 1, and 2-3 vessel ischaemia (P<0.0001). Exercising men had a 2.0-fold higher risk at every level of worsening ischaemia (P<0.0001). Significantly worsening cardiac survival was noted for the 1568 men undergoing dobutamine stress echocardiography (P /=16% for men with ischaemia on dobutamine stress echocardiography (P<0.0001). Echocardiographic measures of inducible wall motion abnormalities and global and regional left ventricular function are highly predictive of long-term outcome for women and men alike.
Publisher: Elsevier BV
Date: 12-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2006
DOI: 10.2215/CJN.00210106
Publisher: IEEE
Date: 09-2008
Publisher: Elsevier BV
Date: 03-2014
Publisher: Wiley
Date: 04-12-2012
DOI: 10.1111/JCE.12039
Abstract: QT Variability and Sympathetic Dysinnervation. The mechanism of adverse prognosis attributable to proarrhythmic cardiac sympathetic dysinnervation in patients with type 2 diabetes is incompletely understood. This study sought the association of cardiac sympathetic dysinnervation with temporal instability of ventricular repolarization assessed by beat-to-beat QT interval variability. (123) I-metaiodobenzylguanidine ((123) I-MIBG) scintigraphy was analyzed in 31 type 2 diabetic patients for cardiac sympathetic dysinnervation (4-hour heart-to-mediastinum ratio <1.8) and regional sympathetic integrity and washout rate (from 15-minute (123) I-MIBG uptake). Relative QT variability was defined from a continuous 5-minute ECG in the supine position (n = 31) and standing position (subgroup n = 15) by the log ratio of absolute QT variability (QT variance ided by the mean QT interval squared) to heart rate (HR) variability (HR variance ided by the mean HR squared). Patients with (n = 16 52%) versus without cardiac sympathetic dysinnervation demonstrated higher relative QT variability in the supine position (P < 0.001), owing to lower HR variability. However, on standing, absolute QT variability was significantly raised in these patients (P = 0.009) despite similar HR variability in the 2 groups. Correlations of heart-to-mediastinum ratio with standing QT variability (relative [r =-0.63, P = 0.013] and absolute [r =-0.79, P = 0.001]) were superior to corresponding supine measures (relative [r =-0.47, P = 0.008] and absolute [P = NS]). No associations of QT variability with washout rate or regional (123) I-MIBG uptake were identified. Elevated QT variability is associated with cardiac sympathetic dysinnervation in type 2 diabetes and may contribute to adverse prognosis. Moreover, QT variability may be more specific for cardiac sympathetic innervation when measured in the context of sympathetic activation. (J Cardiovasc Electrophysiol, Vol. 24, pp. 305-313, March 2013).
Publisher: Elsevier BV
Date: 09-2017
DOI: 10.1016/J.HLC.2017.05.120
Abstract: The epidemic of atrial fibrillation (AF) is increasingly recognised as a growing health problem worldwide. Although epidemiological studies on AF in the Asia-Pacific region are scarce, given the increasing age and size of populations in this region, the burden of AF is expected to be far greater than in North America and Europe. This is not only due to the growing, ageing population but also an increased incidence of risk factors for AF, such as hypertension, obesity, metabolic syndrome and diabetes, in the Asia-Pacific region. While further, high quality data on such aspects as risk factors, racial disparities and clinical implications is urgently required, there is an immediate need for increased focus on appropriate stroke prophylaxis and risk factor management to minimise the clinical complications and societal burden of AF.
Publisher: Wiley
Date: 19-10-2005
DOI: 10.1111/J.1464-5491.2005.01688.X
Abstract: Cardiovascular disease (CVD) rates are substantially higher among patients with Type 2 diabetes than in the general population. The objective of this study was to identify the determinants of carotid intima media thickness (IMT) in patients with Type 2 diabetes. We measured the thickness of the intima media layer of the carotid artery, a strong predictor of the risk of future vascular events, in 397 Type 2 diabetic patients drawn from the Fenofibrate Intervention and Event Lowering in Diabetes study, prior to treatment allocation. The mean IMT was 0.78 mm [interquartile range (IQR) 0.23 mm], and the maximum IMT was 1.17 mm (IQR 0.36 mm). By multivariate analysis, age, sex, duration of diabetes, triglycerides, and total cholesterol were independently correlated with IMT, as was urine albumin-creatinine ratio (ACR) (P 0.65 mg/mmol, approximately one-fifth the standard clinical threshold for microalbuminuria (P < 0.01). Long-term diabetes, independent of other parameters, was associated with a 50% increase in age-related thickening. IMT in people with Type 2 diabetes is independently and continuously related to urine albumin levels and to the duration of diabetes. These results support previous data linking urine albumin measurements within the normal range with increased ischaemic cardiac mortality in the setting of Type 2 diabetes, and strongly suggest that urine albumin levels within this range should trigger a formal evaluation for CVD.
Publisher: BMJ
Date: 20-04-2010
Abstract: To examine the contribution of exercise echocardiography (ExE) to the diagnosis of heart failure with preserved ejection fraction (HFpEF). Cross-sectional study of patients undergoing ExE. 436 patients with fatigue or dyspnoea presenting for ExE were studied. Current criteria for the diagnosis of HFpEF (evidence of symptoms or signs of heart failure, EF>50%, abnormal transmitral flow and supplementary tissue Doppler measurements (E/e') suggesting raised left ventricular filling pressure) were applied to this population. The impact of reclassification of clinical status based on exercise E/e' >13 and ischaemia was evaluated. Of 436 patients, 37 had E/e' >15 and 111 had E/e' 8-15, with supplementary echocardiography criteria indicating HFpEF (n=148). Only 36 patients fulfilling the diagnosis of HFpEF had reduced exercise capacity. Fifteen of these patients had evidence of raised E/e' with exercise, half (7) of whom had inducible myocardial ischaemia. Of 13 patients with raised filling pressure at rest or exercise, objective exercise intolerance and no ischaemia, five did not reach the current criteria for HFpEF. The current classification for HFpEF may include patients with preserved functional status and many with ischaemia and normal exercise E/e'. Reduced exercise capacity, increase of E/e' with exercise and ischaemia are three objective aspects of the HFpEF syndrome that might be considered for incorporation in the definition.
Publisher: SAGE Publications
Date: 10-2007
DOI: 10.1177/0310057X0703500504
Abstract: Intravenous fluid administration is often used in critical care with the goal of improving haemodynamics and consequently tissue perfusion and oxygen delivery. While inotropic and vasoactive drugs are often necessary to correct haemodynamic instability, resuscitation usually begins with fluid therapy. As fluid challenge can result in clinical deterioration, the ability to predict haemodynamic response is desirable. In this way it might be possible to avoid unnecessary volume replacement in critically ill patients. Cardiac preload is a concept that accounts for the relationship between ventricular filling and stroke volume. It has been challenging to apply this concept to clinical practice. For this reason, the study of fluid responsiveness is of increasing research and clinical interest. The clinical application of predicting fluid responsiveness requires an understanding of relevant physiological principles. Furthermore, an improved understanding of these principles should assist the clinician in appraising published data, which has been characterised by significant methodological differences. This review aims to assist the clinician by detailing the physiological principles that underlie the prediction of fluid responsiveness in the critically ill. In addition, the potential importance of methodological differences in the current literature will be considered.
Publisher: Wiley
Date: 12-10-2019
DOI: 10.1002/CNCR.31806
Abstract: With improved cancer survivorship, cardiovascular disease (CVD) and other noncancer events compete with cancer as the underlying cause of death, but the risks of mortality in competing-risk settings have not been well characterized. The authors identified 21,637 in iduals who had a first cancer registered between 2006 and 2013, with follow-up to 2015, in the Australian population-based Tasmanian Cancer Registry. The cumulative incidence of deaths from specific competing events was assessed in competing-risk analyses. Standardized mortality ratios (SMRs) and absolute excess risks (AERs) for deaths from noncancer causes were calculated for comparison with the general population. Overall, 8844 deaths were observed, with 1946 (22%) from competing events. The cumulative incidence of deaths from CVD increased significantly with age at first cancer diagnosis and exceeded other competing events at age ≥65 years. The risk of death from CVD was more common than expected in the first year of follow-up (SMR, 1.44 [95% confidence interval, 1.26-1.64] AER, 36.8 per 10,000 person-years). The SMR and AER for CVD deaths varied by first cancer site, indicating increased risks after a first diagnosis of lung cancer, hematologic malignancy, and urinary tract cancer. For other noncancer events, the SMRs increased significantly for deaths from infectious disease and respiratory disease and were highest in the first year of follow-up. CVD was the leading cause of competing mortality among Tasmanian patients with cancer who were diagnosed from 2006 to 2013. The higher than expected occurrence of death from CVD and other noncancer events during the first year after a cancer diagnosis highlights the importance of early preventive interventions.
Publisher: Elsevier BV
Date: 06-2013
DOI: 10.1016/J.IJCARD.2011.10.065
Abstract: Health outcomes associated with atrial fibrillation (AF) continue to be poor and standard management often does not provide clinical stability. The Standard versus Atrial Fibrillation spEcific managemenT studY (SAFETY) compares the efficacy of a post-discharge, nurse-led, multi-disciplinary programme to optimise AF management with usual care. SAFETY is a prospective, multi-centre, randomised controlled trial with blinded-endpoint adjudication. A target of 320 hospitalised patients with a chronic form of AF will be randomised (stratified by "rate" versus "rhythm" control) to usual post-discharge care or the SAFETY Intervention (SI). The SI involves home-based assessment, extensive clinical profiling and the application of optimal gold-standard pharmacology which is in idually tailored according to a "traffic light" framework based on clinical stability, risk profile and therapeutic management. The primary endpoint is event-free survival from all-cause death or unplanned readmission during 18-36 months follow-up. Secondary endpoints include rate of recurrent hospital stay, treatment success (i.e. maintenance of rhythm or rate control and/or application of anti-thrombotic therapy without a bleeding event) and cost-efficacy. With study recruitment to be completed in early 2012, the results of this study will be available in early 2014. If positive, SAFETY will represent a potentially cost-effective and readily applicable strategy to improve health outcomes in high risk in iduals discharged from hospital with chronic AF.
Publisher: Elsevier BV
Date: 06-2016
Publisher: Elsevier BV
Date: 06-2019
DOI: 10.1016/J.TOXLET.2019.03.002
Abstract: Cardiorenal syndrome (CRS) remains a global health burden with a lack of definitive and effective treatment. Protein-bound uremic toxin (PBUT) overload has been identified as a non-traditional risk factor for cardiac, renal and vascular dysfunction due to significant albumin-binding properties, rendering these solutes non-dialyzable upon the state of irreversible kidney dysfunction. Although limited, experimental studies have investigated possible mechanisms in PBUT-mediated cardiac, renal and vascular effects. The ultimate aim is to identify relevant and efficacious targets that may translate beneficial outcomes in disease models and eventually in the clinic. This review will expand on detailed knowledge on mechanisms involved in detrimental effects of PBUT, specifically affecting the heart, kidney and vasculature, and explore potential effective intracellular targets to abolish their effects in CRS initiation and/or progression.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2013
DOI: 10.1161/CIRCIMAGING.112.000138
Abstract: Although the recent surgical treatment of ischemic heart failure substudy reported that revascularization of viable myocardium did not improve survival, these results were limited by the viability imaging technique used and the lack of inducible ischemia information. We examined the relative impact of stress-rest rubidium-82/F-18 fluorodeoxyglucose positron emission tomography identified ischemia, scar, and hibernating myocardium on the survival benefit associated with revascularization in patients with systolic dysfunction. The extent of perfusion defects and metabolism-perfusion mismatch was measured with an automated quantitative method in 648 consecutive patients (age, 65±12 years 23% women mean left ventricular ejection fraction, 31±12%) undergoing positron emission tomography. Follow-up time began at 92 days (to avoid waiting-time bias) deaths before 92 days were excluded from the analysis. During a mean follow-up of 2.8±1.2 years, 165 deaths (27.5%) occurred. Cox proportional hazards modeling was used to adjust for potential confounders, including a propensity score to adjust for nonrandomized treatment allocation. Early revascularization was performed within 92 days of positron emission tomography in 199 patients (33%). Hibernating myocardium, ischemic myocardium, and scarred myocardium were associated with all-cause death ( P =0.0015, 0.0038, and 0.0010, respectively). An interaction between treatment and hibernating myocardium was present such that early revascularization in the setting of significant hibernating myocardium was associated with improved survival compared with medical therapy, especially when the extent of viability exceeded 10% of the myocardium. Among patients with ischemic cardiomyopathy, hibernating, but not ischemic, myocardium identifies which patients may accrue a survival benefit with revascularization versus medical therapy.
Publisher: Elsevier BV
Date: 10-2011
Publisher: Elsevier BV
Date: 03-1998
Publisher: BMJ
Date: 15-05-2006
Publisher: Elsevier BV
Date: 02-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-08-2004
DOI: 10.1161/01.CIR.0000138680.89536.A9
Abstract: Background— Specific treatments targeting the pathophysiology of hypertensive heart disease are lacking. As aldosterone has been implicated in the genesis of myocardial fibrosis, hypertrophy, and dysfunction, we sought to determine the effects of aldosterone antagonism on myocardial function in hypertensive patients with suspected diastolic heart failure by using sensitive quantitative echocardiographic techniques in a randomized, double-blinded, placebo-controlled study. Methods and Results— Thirty medically treated ambulatory hypertensive patients (19 women, age 62±6 years) with exertional dyspnea, ejection fraction %, and diastolic dysfunction (E/A , E deceleration time m/sec) and without ischemia were randomized to spironolactone 25 mg/d or placebo for 6 months. Patients were overweight (31±5 kg/m 2 ) with reduced treadmill exercise capacity (6.7±2.1 METS). Long-axis strain rate (SR), peak systolic strain, and cyclic variation of integrated backscatter (CVIB) were averaged from 6 walls in 3 standard apical views. Mean 24-hour ambulatory blood pressure at baseline (133±17/80±7mm Hg) did not change in either group. Values for SR, peak systolic strain, and CVIB were similar between groups at baseline and remained unchanged with placebo. Spironolactone therapy was associated with increases in SR (baseline: −1.57±0.46 s −1 versus 6-months: −1.91±0.36 s −1 , P .01), peak systolic strain (−20.3±5.0% versus −26.9±4.3%, P .001), and CVIB (7.4±1.7dB versus 8.6±1.7 dB, P =0.08). Each parameter was significantly greater in the spironolactone group compared with placebo at 6 months ( P =0.05, P =0.02, and P =0.02, respectively), and the increases remained significant after adjusting for baseline differences. The increase in strain was independent of changes in blood pressure with intervention. The spironolactone group also exhibited reduction in posterior wall thickness ( P =0.04) and a trend to reduced left atrial area ( P =0.09). Conclusions— Aldosterone antagonism improves myocardial function in hypertensive heart disease.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2016
Publisher: Oxford University Press (OUP)
Date: 20-05-2015
DOI: 10.1093/EHJCI/JEV076
Abstract: Hypertension remains a major contributor to the global burden of disease. The measurement of blood pressure continues to have pitfalls related to both physiological aspects and acute variation. As the left ventricle (LV) remains one of the main target organs of hypertension, and echocardiographic measures of structure and function carry prognostic information in this setting, the development of a consensus position on the use of echocardiography in this setting is important. Recent developments in the assessment of LV hypertrophy and LV systolic and diastolic function have prompted the preparation of this document. The focus of this work is on the cardiovascular responses to hypertension rather than the diagnosis of secondary hypertension. Sections address the pathophysiology of the cardiac and vascular responses to hypertension, measurement of LV mass, geometry, and function, as well as effects of treatment.
Publisher: Elsevier BV
Date: 02-2017
DOI: 10.1016/J.AMJCARD.2016.10.043
Abstract: Identifying patients at risk is now important as there are demonstrable ways to alter disease progression which could potentially prevent atrial fibrillation (AF) and its complications. We sought whether impaired functional capacity was associated with risk of AF, independent of myocardial dysfunction. In this community-based study, asymptomatic participants aged ≥65 years were recruited if they had ≥1 risk factor (e.g., hypertension, diabetes mellitus, and obesity). Participants underwent baseline echocardiography (including measurement of myocardial mechanics) and six-minute walk test. The CHARGE-AF score was used to calculate 5-year risk of developing AF. Receiver operating characteristic curves were used to assess for independent risk factors for AF. A total of 607 patients (age 71 ± 5 years, men 47%) were studied at baseline and followed for at least 6 months. Patients in the higher AF risk groups were older and had increased rates of hypertension, diabetes mellitus, and ischemic heart disease (p <0.05). Greater AF risk was associated with lower exercise capacity, independent of lower mean global longitudinal strain, global circumferential strain, greater mean E/e' ratio, indexed left atrial volume and LV mass. Multivariate linear regression confirmed association of LV and functional capacity parameters with AF risk. Although functional capacity is impaired in AF, this association precedes the onset of AF. In conclusion, poor functional status is associated with AF risk, independent of LV function.
Publisher: The Endocrine Society
Date: 08-2004
DOI: 10.1210/ER.2003-0012
Publisher: Springer Science and Business Media LLC
Date: 24-01-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-1992
Abstract: The presence of persistent myocardial uptake of 18F-deoxyglucose (FDG) within hypoperfused, dysfunctional segments has been shown to predict the recovery of regional contractile function after revascularization. The spectrum of metabolic responses of such hibernating tissue to revascularization is less clear. Sixteen patients with previous infarction were studied before and after revascularization by myocardial perfusion imaging using 82Rb positron emission tomography, digitized two-dimensional echocardiography, and imaging of postexercise FDG uptake. Hibernation was identified in 35 of 85 segments showing perfusion and wall motion disturbances before intervention. At follow-up (4.9 +/- 2.6 months after revascularization), hibernating segments were characterized by reduction of wall motion score (p less than 0.001), improvement of perfusion (p less than 0.001), and reduction of FDG activity (p less than 0.001). Of the 35 hibernating segments, however, 10 still had abnormal elevation of FDG uptake (greater than 2 SD above normal) without differing from other hibernating segments with respect to postoperative perfusion or wall motion score. Segments with persistently abnormal metabolism were characterized before intervention by more severe malperfusion (p less than 0.01) and greater FDG activity (p less than 0.01). Although wall motion and perfusion improve with revascularization of hibernating tissue, myocardial metabolism remains abnormal in a significant proportion of segments. These segments are characterized by more extensive perfusion and metabolic changes before revascularization.
Publisher: Wiley
Date: 10-2019
DOI: 10.1002/EHF2.12481
Publisher: Elsevier BV
Date: 10-2021
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 29-05-2001
DOI: 10.1161/01.CIR.103.21.2566
Abstract: Background —In studies generally involving short follow-up, exercise echocardiography has been shown to predict composite end points. We sought to study the prediction of mortality with this test and to devise a strategy for combination with standard exercise testing. Methods and Results —Clinical, exercise testing, and echocardiographic data were collected in 5375 patients (aged 54±14 years, 3880 men) undergoing exercise echocardiography. The Duke treadmill score was derived from the results of treadmill exercise testing. Resting left ventricular (LV) function and the presence and severity of ischemia were interpreted by expert observers. Follow-up at 10.6 years (mean 5.5±1.9 years) was complete in 5211 patients (97%). The Duke score classified 59% of patients as low risk, 39% as intermediate risk, and 2% as high risk. Resting LV dysfunction was present in 1445 patients (27%), and the exercise echocardiogram was abnormal in 2525 patients (47%). Death occurred in 649 patients (12%). Over the first 6 years of follow-up, those with normal exercise echocardiograms had a mortality of 1% per year. Ischemia was an independent predictor of mortality. In sequential Cox models, the predictive power of clinical data was strengthened by adding the Duke score, resting LV function, and the results of exercise echocardiography. Exercise echocardiography was able to substratify patients with intermediate-risk Duke scores into groups with a yearly mortality of 2% to 7%. Conclusions —A normal exercise echocardiogram confers a low risk of death, and positive results are an independent predictor of death ischemia is incremental to other data. This test may be particularly useful in patients with intermediate-risk Duke treadmill scores.
Publisher: Elsevier BV
Date: 2018
DOI: 10.1016/J.JACC.2017.11.019
Abstract: Heart failure is a complex clinical syndrome, the incidence and prevalence of which is increased in diabetes mellitus, pre-diabetes, and obesity. Although this may arise from underlying coronary artery disease, it often occurs in the absence of significant major epicardial coronary disease, and most commonly manifests as heart failure with preserved ejection fraction. Despite epidemiological evidence linking diabetes to heart failure incidence and outcome, the presence of a distinct primary "diabetic" cardiomyopathy has been difficult to prove, because the link between diabetes and heart failure is confounded by hypertension, microvascular dysfunction, and autonomic neuropathy. Nonetheless, several mechanistic associations at systemic, cardiac, and cellular/molecular levels explain different aspects of myocardial dysfunction, including impaired cardiac relaxation, compliance, and contractility. This review seeks to describe recent advances and limitations pertinent to integrating molecular mechanisms, clinical screening, and potential therapeutic avenues for this condition.
Publisher: Elsevier BV
Date: 12-2013
DOI: 10.1016/J.JCMG.2013.08.009
Abstract: Aneurysm of the ascending aorta may cause acute type A aortic dissection, and the primary aim of a prophylactic operation is avoidance of this life-threatening complication. Current guidelines recommend prophylactic replacement of the aneurysmal ascending aorta at a diameter of ≥5.5 cm. However, several reports have shown that nearly 50% of patients with an acute type A aortic dissection present with an aortic diameter <5.5 cm. It is controversial how to best respond to these observations. Because surgical advances have led to a reduction of early surgical mortality between 1% and 3%, many clinicians believe that surgery is warranted in smaller aortas. Given the frequency of a bicuspid aortic valve (BAV), such a strategy has health implications for this population.
Publisher: Elsevier BV
Date: 07-1993
DOI: 10.1016/0735-1097(93)90830-T
Abstract: This study was conducted to examine the efficacy of dobutamine stress two-dimensional echocardiography and perfusion scintigraphy for the detection of coronary artery disease in routine practice, to establish the causes of erroneous results and to derive appropriate criteria for the selection of either or both tests. Dobutamine stress combined with echocardiography or perfusion scintigraphy may be used to detect coronary artery disease. Although both imaging approaches have demonstrated similar levels of accuracy, it is not known whether there may be particular indications for the use of one or the other technique or a rationale for their combination. Two hundred seventeen patients without previous infarction were studied prospectively with dobutamine stress echocardiography and technetium-99m methoxy isobutyl nitrile (sestamibi) single-photon emission computed tomography at the time of diagnostic coronary angiography. The presence of coronary stenoses of > or = 50% diameter was compared with the presence of rest or stress-induced abnormalities of perfusion and regional function. The extent of these abnormalities was correlated with an equivalent score of extent of angiographic disease. Significant coronary artery disease was found in 142 patients 102 (72%) were identified by dobutamine echocardiography and 108 (76%, p = NS) by perfusion imaging. In 75 patients without significant disease, the specificity of dobutamine echocardiography was 83% compared with 67% for scintigraphy (p = 0.05). Echocardiographic sensitivity was lower in patients unable to complete the test because of side effects (n = 64) than in the remainder (59% vs. 77%, p = 0.02) this influence was less apparent with scintigraphy (71% vs. 78%, p = NS). Selective use of scintigraphy in the 31 patients with a negative submaximal stress echocardiogram led to a sensitivity of 80% for this combination. Patients with left ventricular hypertrophy accounted for most of the difference in specificity between echocardiography and scintigraphy (94% vs. 59%, p = 0.02). Their respective accuracies were 76% and 73%. Dobutamine stress echocardiography and perfusion scintigraphy have equivalent accuracy. In patients with left ventricular hypertrophy, echocardiography appears to be the test of choice. Selective use of sestamibi scintigraphy in patients with a negative submaximal echocardiogram enhances the accuracy of stress echocardiography alone.
Publisher: BMJ
Date: 2007
Publisher: Elsevier BV
Date: 2021
Publisher: Elsevier BV
Date: 02-2016
DOI: 10.1016/J.JACC.2015.10.096
Abstract: Heart failure with preserved ejection fraction (HFpEF) has a complex etiology. Factors responsible for development of impaired exercise tolerance and disease progression are incompletely defined. The authors sought to define the contributions of contractile reserve, ventriculo-arterial coupling (VAC) reserve, and chronotropic response to the progression of HFpEF. We performed echocardiography at rest and immediately post-cardiopulmonary exercise test in 207 patients (63 ± 8 years of age) with stage C heart failure (HF) (exertional dyspnea, New York Heart Association functional class II to III, exercise capacity 50%, and diastolic dysfunction) and 60 patients with stage B HF (normal exercise tolerance with left ventricular hypertrophy, and/or reduced global longitudinal strain, with diastolic dysfunction). Symptomatic patients were grouped as stage C1 (ratio of peak early diastolic mitral flow velocity to peak early diastolic mitral annular velocity [E/e'] 13 only at exercise n = 118), and C3 (E/e' >13 both at rest and exercise n = 26) HF. Exercise capacity and cardiovascular functional reserve were less impaired in stage C1 than in stages C2 and C3. Chronotropic response was more disturbed in stage C3 than C1 and C2. Changes from rest to exercise in E/e' (-0.6 ± 1.7 vs. 3.7 ± 2.8 p < 0.0001), global longitudinal strain (2.9 ± 2.0 vs. 1.6 ± 2.8 p < 0.002), VAC (-0.21 ± 0.17 vs. -0.09 ± 0.15 p < 0.0001), and in VO2-HR gradient (0.30 ± 0.07 vs. 0.26 ± 0.11 p < 0.01) were significantly different in stages B and C. Normal E/e' response to exertion in symptomatic HFpEF is associated with less profound impairment of exercise capacity and is accompanied by derangements of contractile state and VAC. The transition from asymptomatic to overt HFpEF is linked to diastolic, systolic, and chronotropic deficits and an increasing degree of hemodynamic disturbances in stage C HF.
Publisher: Elsevier BV
Date: 06-1997
DOI: 10.1016/S0002-8703(97)70171-6
Abstract: Left ventricular (LV) hypertrophy increases the vulnerability of the myocardium to ischemia. The purpose of this study was to determine whether LV diameter or wall thickness was the principal determinant of the effect of LV mass on the development of ischemia, measured by exercise thallium perfusion imaging, in a population with coronary artery disease (CAD). We studied 109 patients with CAD but no prior myocardial infarction who underwent exercise thallium imaging within 1 year of coronary angiography. Thallium perfusion defects were present in 76% of patients. LV mass index was associated with thallium perfusion abnormalities (odds ratio 2.09 for 50 gm increments), an association that persisted after adjusting for extent of CAD. LV end-diastolic diameter had a strong correlation with a thallium defect (odds ratio 3.7 for 10 mm increments), but LV wall thickness had no correlation (odds ratio 1.0 for 5 mm increments). In a stepwise regression model that included extent of CAD and other potential clinical variables, LV end-diastolic diameter was the strongest predictor of thallium defects (adjusted odds ratio 4.5). This study confirms the association of LV hypertrophy with ischemia in patients with CAD, specifically in patients with eccentric hypertrophy.
Publisher: Springer Science and Business Media LLC
Date: 2006
DOI: 10.1007/S11892-006-0049-0
Abstract: Heart failure and diabetes mellitus are frequently associated, with diabetes potentiating the development of heart failure after other myocardial insults. This review documents the evidence in support of a specific primary myocardial disease in diabetes. The strongest clinical evidence relates to the detection of otherwise unexplained diastolic dysfunction in apparently healthy diabetic subjects, but recent studies with sensitive echocardiographic markers have shown systolic disturbances as well. The mechanism of this myocardial disease is multifactorial, with contributions from metabolic effects on the myocyte, structural changes in the myocardium and interstitium, autonomic neuropathy, and perhaps coronary vascular disease. The common pathway appears to be related to glycemic control and new evidence suggests better metabolic control to be beneficial, as well as angiotensin-converting enzyme inhibition and cross-link breakers.
Publisher: Wiley
Date: 20-01-2013
DOI: 10.1111/ANS.12068
Abstract: This study aims to determine whether tricuspid regurgitation (TR) ≥ 2+ requires attention during mitral valve surgery. From April 1999 to 2009, 161 patients undergoing primary, isolated mitral valve procedures were assessed. Preoperative moderate TR (≥2+) was present in 56 of 161 patients and tricuspid valve repair (TVR: ring annuloplasty) was carried out on 22 of 56 patients with TR ≥ 2+. Baseline echocardiogram included TR severity (ASE criteria), TR velocity, estimated right atrial pressure, visual assessment of right ventricular failure and strain. Follow-up was 47 ± 33 months (96% complete) 91 of 161 patients overall (57%) and 44 of 45 patients with TR ≥ 2+ had follow-up echocardiogram. Patients with moderate TR had worse baseline functional class and operative risks, both worst in the non-TVR group. Overall mortality was 15% (n = 23), comprising 2.5% (4/161) 30-day mortality and 12% (9/157) late death. Poorer preoperative TR was associated with worse survival by univariate analysis (P = 0.046), after correction for right ventricular function and pulmonary artery pressure (P = 0.049), age and diabetes (P = 0.041). Despite lower risk of TR ≥ 2+ with TVR, 5-year survival was 42%, which was less than TR < 2+ and that of non-TVR group (90%, P = 0.003). Improvement in overall functional class (NYHA) was better in the non-TVR group (TVR: preoperative 2.1 ± 1.5 post-operative 1.2 ± 1.1 (P = 0.02) versus non-TVR: preoperative 1.8 ± 1.4, post-operative 1.2 ± 0.9 (P < 0.0001)). There was no difference in quality of life (QOL) indices (SF-36 questionnaire) at follow-up between patients with TR < 2+ and TR ≥ 2+ preoperatively, or across all levels of TR before or after surgical repair. Preoperative TR ≥ 2+, non-TVR group had more favourable functional class and mid-term survival with comparable QOL and echocardiographic parameters to the TVR group.
Publisher: Elsevier BV
Date: 04-2019
DOI: 10.1016/J.JACC.2019.01.059
Abstract: Defining left atrial (LA) function has recently emerged as a powerful parameter, particularly in evaluation of left ventricular (LV) diastolic dysfunction (LVDD) and heart failure with preserved ejection fraction. Echocardiographic assessment of LVDD by echocardiography remains a challenging task recent recommendations provide a simpler approach than previous. However, the shortcomings of the proposed approach (including transmitral flow, tissue velocity, maximum left atrial volume [LAV], and estimated pulmonary artery systolic pressure), lead to the presence and severity of LVDD remaining undetermined in a significant proportion of patients. Maximum LAV is a surrogate measure of the chronicity and severity of LVDD, but LAV alone is an insensitive biomarker of early phases of LVDD, because the LA may take time to remodel. Because the primary function of the LA is to modulate LV filling, it is not surprising that functional LA changes become evident at the earliest stages of LVDD. Moreover, LA function may provide additive value, not only in diagnosing LVDD, but also in grading its severity and in monitoring the effects of treatment. The current review provides a critical appraisal on the existing evidence for the role of LA metrics in evaluation of LVDD and consequent heart failure with preserved ejection fraction.
Publisher: Elsevier BV
Date: 05-2003
DOI: 10.1016/S0272-6386(03)00199-9
Abstract: Abnormalities of the left ventricle are common in patients with end-stage renal disease (ESRD) both before and after the start of renal replacement therapy. The purpose of this study is to identify possible causes of subclinical left ventricular (LV) dysfunction in patients with ESRD. In particular, we sought to determine whether the presence of ESRD was itself associated with dysfunction independent of LV hypertrophy and coronary artery disease. Assessment of cardiovascular risk factors and dialysis adequacy was completed in 145 unselected patients with ESRD who were recruited from the renal dialysis unit and compared with age- and sex-matched controls. Among the 68 patients with ESRD who had undergone a dobutamine stress echocardiogram with normal findings, regional cardiac function was quantified by myocardial Doppler velocity, LV volumes and mass were measured using three-dimensional echocardiography, and vascular function was assessed using brachial artery reactivity (BAR). LV diastolic velocity was impaired in patients with ESRD, but there was no significant difference in systolic velocity compared with control patients of similar age. Age, diabetes mellitus, hypertension, and LV mass were independent predictors of diastolic velocity (model R2 = 0.45 P < 0.001), whereas age and risk factor number were predictors of systolic velocity (model R2 = 0.19 P = 0.002). Increasing risk factor number had no significant relationship with LV mass or volume. There was no detected association between BAR and incremental risk factors (P = 0.51). Subclinical LV dysfunction occurs in patients with ESRD, but is evidenced as abnormal myocardial diastolic, rather than systolic, function. Correlates of abnormal function are age, diabetes mellitus, hypertension, and LV mass, rather than ESRD alone, dialysis adequacy, or abnormal endothelial function.
Publisher: MDPI AG
Date: 09-02-2022
DOI: 10.3390/JCM11040912
Abstract: The load dependence of global longitudinal strain (GLS) means that changes in systolic blood pressure (BP) between visits may confound the diagnosis of cancer-treatment-related cardiac dysfunction (CTRCD). We sought to determine whether the estimation of myocardial work, which incorporates SBP, could overcome this limitation. In this case–control study, 44 asymptomatic patients at risk of CTRCD underwent echocardiography at baseline and after oncologic treatment. CTRCD was defined on the basis of the change in the ejection fraction. Those with CTRCD were ided into subsets with and without a follow-up SBP increment mmHg (CTRCD+BP+ and CTRCD+BP−), and matched with patients without CTRCD (CTRCD−BP+ and CTRCD−BP−). The work index (GWI), constructive work (GCW), wasted work (GWW), and work efficiency (GWE) were assessed in addition to the GLS. The largest increases in the GWI and GCW at follow-up were found in CTRCD−BP+ patients. The CTRCD+BP− patients demonstrated significantly larger decreases in GWI and GCW than their CTRCD+BP+ and CTRCD−BP− peers. ROC analysis for the discrimination of LV functional changes in response to increased afterload in the absence of cardiotoxicity revealed higher AUCs for GCW (AUC = 0.97) and GWI (AUC = 0.93) than GLS (AUC = 0.73), GWW (AUC = 0.51), or GWE (AUC = 0.63, all p-values 0.001). GCW (OR: 1.021 95% CI: 1.001–1.042 p 0.04) was the only feature independently associated with CTRCD−BP+. Myocardial work is superior to GLS in the serial assessments in patients receiving cardiotoxic chemotherapy. The impairment of GLS in the presence of an increase in GWI and GCW indicates the impact of elevated afterload on LV performance in the absence of actual myocardial impairment.
Publisher: Elsevier BV
Date: 11-1996
DOI: 10.1016/S0735-1097(96)00281-1
Abstract: A formal evaluation of the health equity impact of a new intervention is hardly ever performed as part of a health technology assessment to understand its value. This should change, in our view. An evidence-based quantitative assessment of the health equity impact can help decision makers develop coverage policies, programme designs, and quality initiatives focused on optimizing both total health and health equity given the treatment options available. We outline the conceptual basis of how a new intervention can impact health equity and adopt distributional cost-effectiveness analysis based on decision-analytic models to assess this quantitatively, using a newly US FDA-approved drug for Alzheimer's disease (aducanumab) as an ex le. We argue that gaps in the evidence base for the new intervention, for ex le, due to limited clinical research participation among racial and ethnic minority groups, do not preclude such an evaluation. Understanding these uncertainties has implications for fair pricing, decision making, and future research. If we are serious about population-level decision making that not only is focused on improving total health but also aims to improve health equity, we should consider routinely assessing the health equity impact of new interventions.
Publisher: Elsevier BV
Date: 06-2017
DOI: 10.1016/J.AHJ.2017.02.032
Abstract: The Carillon Mitral Contour System has been studied in 3 nonrandomized trials in patients with symptomatic congestive heart failure and functional mitral regurgitation. The REDUCE FMR study is a uniquely designed, double-blind trial evaluating the impact of the Carillon device on reducing regurgitant volume, as well as assessing the safety and clinical efficacy of this device. Carillon is a coronary sinus-based indirect annuloplasty device. Eligible patients undergo an invasive venogram to assess coronary sinus vein suitability for the Carillon device. If the venous dimensions are suitable, they are randomized on a 3:1 basis to receive a device or not. Patients and assessors are blinded to the treatment assignment. The primary end point is the difference in regurgitant volume at 1 year between the implanted and nonimplanted groups. Other comparisons include clinical parameters such as heart failure hospitalizations, 6-minute walk test, Kansas City Cardiomyopathy Questionnaire (KCCQ), and other echocardiographic parameters. An exercise echo substudy will also be included.
Publisher: Elsevier BV
Date: 05-2017
DOI: 10.1016/J.JCMG.2016.06.012
Abstract: This study sought to show the degree to which experience and training affect the precision and validity of global longitudinal strain (GLS) measurement and to evaluate the variability of strain measurement after feedback. The application of GLS for the detection of subclinical dysfunction has been recommended in an expert consensus document and is being used with increasing frequency. The role of experience in the precision and validity of GLS measurement is unknown, as is the efficacy of training. Fifty-eight readers, ided into 4 groups on the basis of their experience with GLS, calculated GLS from speckle strain analysis of 9 cases with various degrees of image quality. Intraclass correlation coefficients (ICCs), mean difference, SD, and coefficient of variation (CV) were compared against the measurements of a reference group that had experience with >1,000 cases of strain measurement. In idualized feedback was distributed, and repeat measurements were performed by 40 readers. Comparisons with the baseline variation provided information about whether feedback was effective. The ICC for GLS was significantly greater than that for ejection fraction regardless of image quality. Experience with strain measurement affected the concordance in strain values among the readers the group with the highest level of experience showed significantly better ICC than those with no experience, although the ICC of the inexperienced readers was still very good (0.996 vs. 0.975 p = 0.0002). As experience increased, the mean difference, SD, and CV became significantly smaller. The CV of segmental strain analysis showed significant improvement after training, regardless of experience. The favorable interobserver agreement of GLS makes it more attractive than ejection fraction for follow-up of left ventricular function by multiple observers. Although experience is important, the precision of GLS was high for all groups. Training appears to be of most value for the assessment of segmental strain.
Publisher: Elsevier BV
Date: 05-2022
Publisher: Cleveland Clinic Journal of Medicine
Date: 03-1995
DOI: 10.3949/CCJM.62.2.89
Publisher: Elsevier BV
Date: 06-2011
Publisher: Springer Science and Business Media LLC
Date: 2009
DOI: 10.1186/AR2668
Publisher: Elsevier BV
Date: 06-2023
Publisher: Elsevier BV
Date: 11-2014
Publisher: Springer Science and Business Media LLC
Date: 15-06-2012
DOI: 10.1007/S00259-012-2171-3
Abstract: LV mechanical dyssynchrony (LVMD) is a risk marker in narrow QRS cardiomyopathy, but its association with treatment outcome is not well defined. We determined the incremental prognostic value of LVMD in ischemic cardiomyopathy, and assessed its interaction with scar, myocardium in jeopardy and subsequent revascularization. Stress and rest (82)Rb gated PET were performed in 486 consecutive patients (66 ± 11 years of age, 82 % men, LV ejection fraction 26 ± 6 %) with ischemic cardiomyopathy and QRS <120 ms. LVMD was determined as the standard deviation (SD) of the regional time to minimum volume on phase analysis of the gated PET scan. A propensity score was determined to adjust for nonrandomized referral after imaging to coronary artery bypass grafting (CABG). In a Cox proportional hazards model used to determine the association between measures of LVMD and survival time, CABG was included as a time-dependent covariate and the use of an implantable cardiac defibrillator (ICD) after imaging was modeled as a stratification factor. Over 1.9 ± 1.4 years, 96 patients (20 %) underwent CABG and 108 (22 %) died. LVMD was a predictor of mortality (HR 1.16. 95 % CI 1.03 .30, per 10° increase in phase SD, p = 0.02) after adjusting for baseline covariates, prior ICD use, the use of postimaging CABG, and other imaging data. There was a significant interaction between phase SD and CABG. Nested Cox models showed that LVMD carried prognostic information incremental to clinical variables, ejection fraction and CABG. LVMD is an independent predictor of all-cause mortality in ischemic cardiomyopathy, and may identify patients with a differential survival benefit from CABG versus medical therapy.
Publisher: Elsevier BV
Date: 05-2011
DOI: 10.1016/J.JCMG.2011.03.008
Abstract: Emergency department presentations with chest pain are expensive and often unrelated to coronary artery disease (CAD). Coronary computed tomographic angiography (CTA) may allow earlier discharge of low-risk patients, resulting in cost savings. We modeled clinical and economic outcomes of diagnostic strategies in patients with chest pain and at low risk of CAD: exercise electrocardiography (ECG), stress single-photon emission computed tomography (SPECT), stress echocardiography, and a CTA strategy comprising an initial CTA scan with confirmatory SPECT for indeterminate results. Our results suggest that a 2-step diagnostic strategy of CTA with SPECT for intermediate scans is likely to be less costly and more effective for the diagnosis of a patient group at low risk of CAD and a prevalence of 2% to 30%. The CTA strategies were cost saving (lower costs, higher quality-adjusted life-years) compared with stress ECG, echocardiography, and SPECT. Confirming intermediate/indeterminate CTA scans with SPECT results in cost savings and quality-adjusted life-year gains due to reduced hospitalization of patients who returned false-positive initial CTA test. However, CTA may be associated with a higher event rate in negative patients than SPECT, and the diagnostic and prognostic information for the use of CTA in the emergency department is evolving. Large comparative, randomized, controlled trials of the different diagnostic strategies are needed to compare the long-term costs and consequences of each strategy in a population of defined low-risk patients in the emergency department.
Publisher: Elsevier BV
Date: 04-2015
DOI: 10.1016/J.IJCARD.2015.03.071
Abstract: A number of composite outcomes have been developed to capture the perspective of the patient, clinician and objective measures of health in assessing heart failure outcomes. To date there has been a limited examination in the composition of these outcomes. Three commonly used scoring systems in heart failure trials: Packer's composite, Patient Journey and the African American Heart Failure Trial (A-HeFT) scores were compared in assessing outcomes from the Which heart failure intervention is most cost-effective & consumer friendly in reducing hospital care (WHICH(?)) Trial. Comparability and interpretability of these outcomes and the influence of each component to the final outcome were examined. Despite all three composite outcomes incorporating mortality, hospitalisation and quality of life (QoL), the contribution of each in idual component to the final outcomes differed. The component with the most influence in deteriorating condition for the Packer's composite was hospitalisation (67.7%), while in Patient Journey it was QoL (61.5%) and for A-HeFT composite score it was mortality (45.4%). The contribution made by each component varied in subtle, but important ways. This study emphasises the importance of understanding the value system of the composite outcomes to enable meaningful interpretation of results.
Publisher: Elsevier BV
Date: 08-2013
DOI: 10.1016/J.AMJCARD.2013.04.028
Abstract: The standard echocardiographic evaluation of left ventricular (LV) mass, particularly in ischemic cardiomyopathy (IC) is challenging because it is based on geometric assumptions. The aim of this study was to assess the accuracy of LV mass calculation using echocardiographic modalities compared with cardiac magnetic resonance (CMR) in IC and in nonischemic cardiomyopathy (non-IC). Echocardiography was performed in 104 patients (mean age 55 ± 15 years) referred for CMR: 63 with IC and 41 with non-IC. CMR, M-mode echocardiography, 2-dimensional echocardiography, and 3-dimensional echocardiography (3DE) were analyzed using standard commercial tools to obtain LV mass. LV mass on 3DE showed a higher correlation with CMR than 2-dimensional echocardiography (r = 0.87 vs r = 0.70, p <0.001). M-mode echocardiography overestimated LV mass (bias +30%) and 2-dimensional echocardiography underestimated LV mass (bias -11%), whereas measurements on 3DE showed only minimal bias (-2%). LV mass on 3DE in non-IC showed a significantly higher correlation with CMR than in IC (r = 0.92 vs r = 0.84, z = 2.3, p <0.05). In non-IC, the mean difference was -2 g (-1% of the mean), with 95% limits of agreement of ±33 g (±19% of the mean). In IC, the mean difference was -7 g (-4% of the mean), with limits of agreement of ±56 g (±31% of the mean). There was a correlation between the absolute LV mass differences (3DE derived and CMR derived) and scar percentage (infarcted mass/total LV mass) using delayed-hyperenhancement images (r = 0.40, p <0.05). The net reclassification index with 3DE was +16% for concentric LV hypertrophy. In conclusion, the most accurate and reliable echocardiographic measurement of LV mass is 3DE, but underestimation and variability remain challenges in IC.
Publisher: Elsevier BV
Date: 05-2013
DOI: 10.1016/J.IJCARD.2011.08.048
Abstract: Current guidelines propose mitral valve repair in asymptomatic chronic mitral regurgitation (MR) when the likelihood of repair is 90% or more. As this figure is not evidence-based, we sought whether the results of a decision-analytic model could facilitate the selection between early surgery (ES) and watchful waiting (WW) based on current guidelines. A Markov model was developed to reflect the anticipated health states in MR (pre-operative, post-operative, post-complication and death). Risks and transitions were informed by the literature. Implications of the strategies for survival, quality-adjusted life years (QALYs), cost and cost-effectiveness were calculated from a US healthcare provider perspective. In the reference case (90% repair), QALY with ES was superior to WW (11.2 [0.4-21.3] vs 10.7 [95%CI: 1.0-21.3]) at an incremental cost-effectiveness of $54,659 ($45,030-$64,288) per QALY. Sensitivity analyses of health benefit showed the main variables influencing outcome were repair rate, operative mortality and risks of heart failure and death with medical management. At the registry repair rate (50%), outcomes of ES were worse than WW, and threshold analysis showed that a repair rate of 84% was required for ES to be superior. High medical risk (yearly heart failure risk 5.6 ± 6.6% and mortality 2.5 ± 4%) was the most favorable scenario for surgery ES was more effective when mortality in the WW group was >3.5%/year. A Markov model might be used to guide the selection of asymptomatic patients for mitral repair, based on local variations in risk and complications as well as repair rate.
Publisher: Oxford University Press (OUP)
Date: 13-08-2008
DOI: 10.1016/J.EUJE.2007.06.011
Abstract: Three-dimensional echocardiography (3DE) appears to show incremental benefit over two-dimensional echocardiography (2DE), but it's uptake has been slow. We tested attendees before and after an intensive interactive training course to identify its efficacy. Attendees (n = 35, 23 cardiologists, 12 sonographers) were shown how to use 3DE review software and asked to identify the pathology of five patients (wall motion abnormality, peri-prosthetic mitral regurgitation, subaortic membrane, small ventricular septal defect, submitral stenosis) on 2D and 3D images. In the following one and a half-day interactive teaching course, brief presentations on application of 3DE for assessment of wall motion, valve and congenital abnormalities were followed by review of 3D datasets, during which the attendees made their own interpretations before being shown the optimal viewing strategy. Test cases were not discussed and the test was repeated at the end of the course. Most attendees (57%) had access but with little or no use of a 3DE system. Three-dimensional echocardiography had no incremental value before training. After training, overall correct responses significantly improved compared with baseline interpretation, although improvement was not the same for all diagnoses. All groups (cardiologists vs. sonographers, inexperienced vs. moderately experienced reviewers) improved similarly. Incorporation of 3DE into standard practice may be limited by inexperience. An interactive teaching course with rehearsal and direct mentoring appears to overcome this limitation and may improve the uptake of this technique.
Publisher: American Medical Association (AMA)
Date: 11-06-2012
DOI: 10.1001/ARCHINTERNMED.2012.1355
Abstract: Although exercise echocardiography (ExE) of asymptomatic patients early (2 years after percutaneous coronary intervention [PCI] or 5 years after coronary bypass graft surgery [CABG]) after revascularization is considered inappropriate, the appropriateness of later testing is indeterminate. Treatment responses to positive test results in either setting have uncertain outcome implications. We sought to identify whether predictors of increased risk by ExE could lead to interventions that change outcome in asymptomatic patients with previous coronary revascularization. Exercise echocardiography was performed in 2105 asymptomatic patients (mean [SD] age, 64 [10] years 310 [15%] were women 845 [40%] had a history of myocardial infarction 1143 [54%] had undergone PCI and 962 [46%] had undergone CABG 4.1 [4.7] years prior to the ExE). Ischemia was identified as a new or worsening wall motion abnormality. Patients were followed for a mean (SD) period of 5.7 (3.0) years for cardiac mortality. The association of ischemia during ExE with survival was assessed using Cox proportional hazard models, and an interaction with revascularization was sought. Of 262 patients with ischemia (13%), only 88 (34%) underwent subsequent revascularization. Mortality (97 patients [4.6%]) was associated with ischemia (hazard ratio, 2.10 95% CI, 1.05-4.19 P=.04) in groups tested both early (P=.03) and late (≥2 years after PCI or ≥ 5 years after CABG) (P=.001). However, the main predictors of outcome were clinical and stress testing findings rather than echocardiographic features. Subgroup analysis showed that asymptomatic patients without diabetes mellitus, with normal ejection fraction (≥50%), and normal exercise capacity (>6 METs [metabolic equivalent for task]) were unlikely to have a positive test result or events. Even high-risk patients did not seem to benefit from repeated revascularization. Asymptomatic patients who undergo ExE after coronary revascularization may be identified as being at high risk but do not seem to have more favorable outcomes with repeated revascularization. From a health economic standpoint, appropriateness of such testing must be carefully reviewed.
Publisher: Springer Science and Business Media LLC
Date: 08-2007
Abstract: Obesity is becoming a worldwide phenomenon. Myocardial changes associated with the obese state are increasingly recognized, independent of hypertension, obstructive sleep apnea and coronary artery disease. The existence of a cardiomyopathy of obesity is supported by a range of evidence: epidemiologic study findings, which have shown an association between obesity and heart failure clinical studies that have confirmed the association of adiposity with left ventricular dysfunction, independent of hypertension, coronary artery disease and other heart disease and experimental evidence of structural and functional changes in the myocardium in response to increased adiposity. The most important mechanisms in the development of obesity cardiomyopathy are metabolic disturbances (insulin resistance, increased free fatty acid levels, and also increased levels of adipokines), activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, myocardial remodeling, and small-vessel disease (both microangiopathy and endothelial dysfunction). In the first part of this two-part Review, we seek to evaluate the emerging evidence for the existence of a cardiomyopathy of obesity and clarify the responsible mechanisms.
Publisher: Elsevier BV
Date: 04-2013
DOI: 10.1016/J.ULTRASMEDBIO.2012.11.021
Abstract: Strain imaging quantifies myocardial deformation in both overt and subclinical myocardial diseases. Strain values have been shown to vary between vendors. The aim of this study was to investigate whether this variation reflects differences of image characteristics or analysis software. We enrolled 45 patients (age 54 ± 14 years, 26 males) who underwent two echocardiograms on the same day with two different commercially available ultrasound systems. Three apical views were analyzed by two vendor-specific and two digital imaging and communications in medicine (DICOM)-based software packages. The results were compared in two ways comparison of global longitudinal strain (GLS) by nine different combinations of ultrasound systems and strain software, and comparison of strains by wall, view and global levels. Comparison of GLS between two vendor-specific software packages yielded poor correlation (ρ = 0.35). The use of the same software on the images from different vendors was concordant (ρ = 0.74 and 0.64 bias = 0.0 and -0.5). There were no significant differences in correlation coefficients among the comparisons with DICOM-based software. There was no significant difference in correlation coefficients among three views (4CV vs. 3CV, p = 0.44 4CV vs. 2CV, p = 0.47). Comparison of walls showed the septum to have the best correlation (ρ = 0.73), and the posterior wall (ρ = 0.31 p = 0.005 vs. septum) had the worst. Use of the same software to measure strain in images from different vendors minimizes the variation of GLS. Post-processing is the most important determinant in inter-vendor variation, with differences in acquisition having a small effect. These findings should be examined and confirmed with other combinations of ultrasound machines and deformation software.
Publisher: University Library System, University of Pittsburgh
Date: 06-01-2017
Abstract: Introuduction: Tobacco smoking is considered to be the key preventable risk factor for morbidity and mortality at the global level. The aim of this study was to determine the prevalence of tobacco smoking and factors associated with the initiation of smoking among university students in Dhaka, Bangladesh.Methods: A cross-sectional survey study was conducted with 264 students of Jahangirnagar University, Dhaka, Bangladesh in 2015. A standard, self-administered questionnaire consisting of questions on socio-demographic variables, tobacco smoking status, family and peer tobacco smoking history, attitudes and beliefs about tobacco smoking, as well as knowledge about the negative health consequences of tobacco smoking was administered to participants. Data were analyzed using logistic regression models, chi square, and Fisher exact tests.Results: The overall prevalence of tobacco smoking was 60.2%, where males smoked at higher rates than females (68.81% and 19.56%, respectively). The influence of friends was the most significant reason for initiating tobacco smoking (OR: 0.862 CI: 0.810-0.917). Perception regarding tobacco smoking was significantly related to continuing tobacco use. Logistic regression models identified that smoking-related attitudes, potential health problems, and family members dying from cardiovascular disease and cancer were significantly associated with tobacco smoking.Conclusion: The current tobacco smoking prevalence among university students in Bangladesh is over 60%. We suggest adopting WHO Framework Convention on Tobacco Control (FCTC) policies, especially for university students.
Publisher: BMJ
Date: 11-07-2011
DOI: 10.1136/HEARTJNL-2011-300134
Abstract: Strain and strain rate measure local deformation of the myocardium and have been used to evaluate phasic atrial function in various disease states. The aim of this study was to define normal values for tissue Doppler-derived atrial strain measurements and examine age-related changes by decade in healthy in iduals. Transthoracic echocardiograms were performed on 188 healthy subjects. Tissue Doppler-derived strain and strain rate were measured from the apical four and two-chamber views of the left atrium, and global values were calculated as the mean of all segments. Measurements included peak systolic strain, systolic strain rate, early and late diastolic strain rate. Phasic left atrial volumes and fractions were calculated. Mitral inflow and tissue Doppler imaging were employed to estimate left ventricular diastolic function. A significant reduction in global systolic strain was observed from decade 6. Alterations in atrial strain rate were apparent from decade 5 systolic strain rate and early diastolic strain rate decreased, while late diastolic strain rate increased significantly. Changes in phasic atrial volume and function occurred in conjunction with age-related changes in left ventricular diastolic function. Importantly, age-related changes in global atrial systolic strain rate and early diastolic strain rate occurred a decade before corresponding changes in atrial phasic volume parameters. Atrial strain and strain rate can be used to quantify atrial phasic function and appear to be altered before traditional parameters with ageing. Strain analysis may therefore be more sensitive in detecting subclinical atrial dysfunction with alterations in strain rate parameters observed before traditional parameters.
Publisher: Elsevier BV
Date: 2004
DOI: 10.1053/J.AJKD.2003.09.012
Abstract: Cardiac mortality is the main cause of death in patients with chronic kidney disease (CKD). In this study, we sought the efficacy of long-term intensive lipid level lowering on atherosclerotic burden in patients with CKD. Patients with CKD (n = 38 age, 64 +/- 11 years) and a similar group of patients with coronary artery disease (CAD n = 31) were treated prospectively with atorvastatin, up to 80 mg/d. Lipid profile, carotid intima-media thickness (IMT a marker of atherosclerotic burden), and dobutamine echocardiography were measured at baseline and 2 years. Predictors of change in maximal IMT were sought in a linear model. Despite similar cholesterol level lowering, patients with CAD showed an improvement in maximum IMT, whereas those with CKD did not (mean between-group difference, 0.07 mm 95% confidence interval, 0.01 to 0.12). Change in maximal IMT was associated with kidney disease (R2 = 0.09 P = 0.013), smoking (R2 = 0.083 P = 0.017), baseline low-density lipoprotein cholesterol (LDL-C) level (R2 = 0.064 P = 0.045), very low density cholesterol (VLDL-C) level (R2 = 0.084 P = 0.021), and calcium channel blocker use (R2 = 0.094 P = 0.01). In a multivariate model, kidney disease and baseline LDL-C and VLDL-C levels remained independent predictors of change in maximal IMT (model R2 = 0.24 P = 0.004). Only patients with CAD decreased their number of ischemic segments (2.5 +/- 1.4 to 1.2 +/- 1.5 segments P = 0.002). Overall change in ischemic segment number correlated with change in maximal IMT (r = 0.32 P = 0.019). Patients with CKD undergoing intensive lipid level lowering do not show the same changes in atherosclerotic or ischemic burden as patients with CAD. Independent predictors of change in maximal IMT were CKD and baseline LDL-C and VLDL-C levels.
Publisher: University Library System, University of Pittsburgh
Date: 14-03-2018
Abstract: Introduction: School children in the developing countries are susceptible to nutrition related health problems due to demographic and socio-economic factors, as well as limited access to food. Since BMI is a common proxy measure used to evaluate nutritional status, the aim of this study was to investigate the BMI categories in school-aged children in Dhaka, Bangladesh.Methods: A cross sectional study of 155 children, aged 6-12 years was conducted at Jahangirnagar University School in Dhaka, Bangladesh. The data collection was performed by in-person interviews and semi-structured questionnaires. Descriptive statistics, χ2 test, Fisher’s exact test, and One-Way ANOVA test were performed to compare the variables based on BMI percentiles. Data were analyzed using the Microsoft Excel program (version 2010).Results: Mean BMI of the students was 17.27 (SD=3.16). The prevalence of underweight and overweight/obesity was 11.0% and 25.8%, respectively. Categories of BMI percentiles were associated with birth order (p=0.026), personal hygiene practices (washing hands after coming home from outside (p .001) and before meal (p=0.045)), brushing teeth (p .001), the number of food items consumed daily (p .001), and mothers’ occupation (p=0.006). In context of basic hygiene practice, 61.3 % of respondents washed hands after coming home from outside, and 93.5 % reported washing hands before the meals.Conclusions: This study revealed that more than one third of the students had abnormal BMI. BMI screening in rural schools needs to be recommended in early grades for all children.
Publisher: Wiley
Date: 22-07-2021
DOI: 10.1002/EHF2.13510
Abstract: Fluid congestion is a leading cause of hospital admission, readmission, and mortality in heart failure (HF). We performed a systematic review and meta‐analysis to determine the effectiveness of an advanced fluid management programme (AFMP). The AFMP was defined as an intervention providing tailored diuretic therapy guided by intravascular volume assessment, in hospitalized patients or after discharge. The AFMP group was compared with patients who received standard care treatment. The aim of this systematic review and meta‐analysis was to determine the effectiveness of an AFMP in improving patient outcomes. A systematic review of randomized controlled trials, case–control studies, and crossover studies using the terms ‘heart failure’, ‘fluid management’, and ‘readmission’ was conducted in PubMed, CINAHL, and Scopus up until November 2020. Studies reporting the association of an AFMP on readmission and/or mortality were included in our meta‐analyses. Risk of bias was assessed in non‐randomized studies using the Newcastle–Ottawa Scale. From 232 retrieved studies, 12 were included in the data synthesis. The 6040 patients in the included studies had a mean age of 72 ± 4 years and mean left ventricular ejection fraction of 39 ± 8%, there were slightly more men ( n = 3022) than women, and the follow‐up period was a mean of 4.8 ± 3.1 months. Readmission data were available in 5362 patients of these, 1629 were readmitted. Mortality data were available in 5787 patients of these, 584 died. HF patients who had an AFMP in hospital and/or after discharge had lower odds of all‐cause readmission (odds ratio—OR 0.64 [95% confidence interval—CI 0.44, 0.92], P = 0.02) with moderate heterogeneity ( I 2 = 46.5) and lower odds of all‐cause mortality (OR 0.82 [95% CI 0.69, 0.98], P = 0.03) with low heterogeneity ( I 2 = 0). The use of an AFMP was equally effective in reducing readmission and mortality regardless of age and follow‐up duration. Effective pre‐discharge diuresis was associated with significantly lower readmission odds (OR 0.43 [95% CI 0.26, 0.71], P = 0.001) compared with a fluid management plan as part of post‐discharge follow‐up. An effective AFMP is associated with improving readmission and mortality in HF. Our results encourage attainment of optimal volume status at discharge and prescription of optimal diuretic dose. Ongoing support to maintain euvolaemia and effective collaboration between healthcare teams, along with effective patient education and engagement, may help to reduce adverse outcomes in HF patients.
Publisher: Oxford University Press (OUP)
Date: 03-10-2019
DOI: 10.1093/EHJCI/JEZ240
Abstract: Although both left atrial (LA) and ventricular (LV) dysfunction has been accepted as an important risk factor of atrial fibrillation (AF), usefulness of LA and LV strain has not been fully compared for prediction of AF. The aims of this study were to clarify the associations of both LA and LV strain with AF and to compare their predictive values in the risk stratification for AF. We evaluated 531 consecutive patients (median age 67 years, 56% male), with no history of AF who underwent echocardiography after cryptogenic stroke. Standard echocardiographic parameters were measured, and speckle-tracking was used to measure LA (reservoir, pump, and conduit strain) and LV strain (global longitudinal strain, GLS). The baseline clinical and echocardiographic parameters of the patients who developed AF and those who did not were compared. Median 36 months of follow-up, 61 patients (11%) had newly diagnosed AF. LA pump strain and GLS were significantly and independently associated with AF and provided incremental predictive value over clinical and standard echocardiographic parameters. Areas under the receiver-operating curves for GLS (0.841) were comparable to LA pump (0.825) and reservoir (0.851) strain. However, predictive value of both strains was different between patients with and without LA enlargement at the time of transthoracic echocardiography screening. LA strain was more useful than LV strain in patients with normal LA volumes, while LV strain was more useful than LA strain in patients with abnormal LA volumes. Both LA and LV strain are significantly and independently associated with AF and provide incremental predictive value over clinical and standard echocardiographic parameters. However, priorities of strain assessment are different depends on patients’ condition at the time of echocardiography.
Publisher: The Endocrine Society
Date: 09-2011
DOI: 10.1210/JC.2011-0354
Publisher: BMJ
Date: 11-2004
DOI: 10.1136/EBM.9.6.174
Publisher: Elsevier BV
Date: 02-2001
DOI: 10.1016/S0002-9343(00)00695-1
Abstract: Atherosclerotic vascular disease is the main cause of morbidity and mortality in patients with end-stage renal disease, but the independent contribution of renal failure rather than associated risk factors is unclear. We sought to examine the relative contribution of these factors to the severity of atherosclerosis by measuring intima-medial thickness and brachial artery reactivity in uremic patients and controls. Cardiovascular risk factors, including lipid and homocysteine levels, were evaluated in 213 patients (69 on hemodialysis, 60 on peritoneal dialysis, and 82 nonuremic controls). High-resolution B-mode ultrasonography with automated off-line analysis was used to measure the intima-medial thickness in the common carotid artery and to measure the lumen diameter of the brachial artery at rest, during reactive hyperemia, and after sublingual nitroglycerine. The correlations of risk factors with intima-medial thickness and brachial reactivity were examined using a general linear regression model. Patients with renal failure had a greater mean (+/- SEM) maximum intima-medial thickness than controls (0.83 +/- 0.02 mm versus 0.70 +/- 0.02 mm, P 0.05). The uremic state was an independent predictor of intima-medial thickness (r2 = 0.16, P < 0.001) but not of brachial artery reactivity (P = 0.99). The atherosclerotic burden in patients with renal failure, as indicated by an increased intima-medial thickness, may reflect effects of uremia that are independent of cardiovascular risk factors.
Publisher: Springer Science and Business Media LLC
Date: 03-1996
DOI: 10.1016/S1071-3581(96)90001-X
Abstract: Although reversible perfusion defects, perfusion-metabolism mismatch and match patterns are important for differentiating viable from nonviable myocardium, the frequency of these scintigraphic patterns has not been reported. The study objective was to establish the incidence of these scintigraphic patterns to estimate the clinical need for metabolic positron emission tomography for evaluating tissue viability in patients with prior myocardial infarction (MI). 82Rb perfusion images were interpreted to identify reversible or irreversible defects, followed by determination of their 18F-fluorodeoxyglucose (18F-FDG) uptake pattern. In 155 patients with prior MI, analysis of 613 abnormal segments showed reversible perfusion defects in 13%. The 87% irreversible defects, 18% showed perfusion-metabolism mismatch, whereas 69% showed the match pattern. Reversible perfusion defects and perfusion-metabolism mismatches were noted in 20% (31/155) and 29% (45/155) of patients, respectively, whereas the match pattern was noted in 51% (79/155) of patients. Irreversible perfusion defects were common in our patients with prior MI, and distinction between viable and nonviable tissue was not possible by perfusion imaging alone. The identification of hibernating myocardium was possible only with the additional 18F-FDG imaging in about one third of patients. This indicates a significant clinical demand for 18F-FDG imaging that identifies patients who will benefit from revascularization.
Publisher: Elsevier BV
Date: 03-2016
DOI: 10.1016/J.JCMG.2015.11.012
Abstract: Quality control is pervasive in most modern business, but, surprisingly, is in its infancy in medicine in general-and cardiovascular imaging in particular. The increasing awareness of the cost of cardiovascular imaging, matched by a desire to show benefits from imaging to patient outcome, suggests that this deficiency should be reassessed. Demonstration of improved quality has been proposed to require a focus on several domains: laboratory organization, patient selection, image acquisition, image interpretation, and results communication. Improvement in these steps will require adoption of a variety of interventions, including laboratory accreditation, appropriate use criteria, and continuous quality control and enhancements in reporting, but the evidence base for the benefit of interventions on these steps has been sparse. The purpose of this review is to evaluate the current status and future goals of developing the evidence base for these processes in cardiovascular imaging.
Publisher: Portland Press Ltd.
Date: 19-08-2002
DOI: 10.1042/CS1030283
Abstract: Abnormal left ventricular (LV) filling is common, but not universal, in hypertensive LV hypertrophy (LVH). We sought to elucidate the relative contributions of myocardial structural changes, loading and hypertrophy to LV dysfunction in 113 patients: 85 with hypertensive LVH and 28 controls without LVH and with normal filling. Patients with normal dobutamine stress echocardiography and no history of coronary artery disease were selected, in order to exclude a contribution from ischaemia or scar. Abnormal LV filling was identified in 65 LVH patients, based on Doppler measurement of transmitral filling and annular velocities. All patients underwent grey-scale and colour tissue Doppler imaging from three apical views, which were stored and analysed off line. Integrated backscatter (IB) and strain rate imaging were used to detect changes in structure and function average cyclic variation of IB, strain rate and peak systolic strain were calculated by averaging each segment. Calibrated IB intensity, corrected for pericardial IB intensity, was measured in the septum and posterior wall from the parasternal long-axis view. Patients with LVH differed significantly from controls with respect to all backscatter and strain parameters, irrespective of the presence or absence of abnormal LV filling. LVH patients with and without abnormal LV filling differed with regard to age, LV mass and incidence of diabetes mellitus, but also showed significant differences in cyclic variation (P& .01), calibrated IB in the posterior wall (P& .05) and strain rate (P& .01), although blood pressure, heart rate and LV systolic function were similar. Multivariate logistic regression analysis demonstrated that age, LV mass index and calibrated IB in the posterior wall were independent determinants of abnormal LV filling in patients with LVH. Thus structural and functional abnormalities can be detected in hypertensive patients with LVH with and without abnormal LV filling. In addition to age and LVH, structural (not functional) abnormalities are likely to contribute to abnormal LV filling, and may be an early sign of LV damage. IB is useful for the detection of myocardial abnormalities in patients with hypertensive LVH.
Publisher: Elsevier BV
Date: 06-2016
DOI: 10.1016/J.IJCARD.2016.02.137
Abstract: Cancer chemotherapy increases the risk of heart failure. This cost-effectiveness model compared strain-guided cardioprotection with other protective strategies using a health care payer perspective and five-year time horizon. Three cardioprotection strategies were assessed: 1) usual care (EF-guided cardioprotection, EFGCP) with cardioprotection initiated on diagnosis of LVEF-defined cardiotoxicity (EF-CTX), 2) universal cardioprotection (UCP) for all such patients, and 3) strain-guided cardioprotection (SGCP - treatment of patients with subclinical cardiotoxicity [S-CTX]). A Markov model, informed by the published literature on transitional probabilities, costs and quality-adjusted life years (QALYs) was developed to assess the incremental cost-effectiveness ratio (ICER). Costs, effects and ICER of each specified cardioprotective strategy were assessed over a 5-year range, with sensitivity analyses for significant variables. In the reference case of a 49year old woman with stage IIb breast cancer treated with sequential anthracyclines and trastuzumab, strain-guided cardioprotection (3.79 QALYS and $4159 cost over 5years) dominated both UCP (3.64 QALYs and $5967 cost over 5years) and EFGCP (3.53 QALYs and $7033 cost over five years). Model results were dependent on the probabilities of patients developing subclinical LV dysfunction, with UCP dominating alternative strategies at probabilities ≥51%. Variations in the cost of cardioprotective medications and probabilities of cardioprotection side-effects had no effect on model conclusions. In patients at risk of chemotherapy-related cardiotoxicity, strain-guided cardioprotection provides more QALYs at lower cost than standard care or uniform cardioprotection.
Publisher: Elsevier BV
Date: 06-2014
DOI: 10.1016/J.ECHO.2014.02.009
Abstract: Increased left ventricular (LV) dimensions are an indication for surgery in patients with asymptomatic mitral regurgitation, but M-mode or two-dimensional measurements have known limitations. The aim of this study was to determine the value of three-dimensional echocardiography in predicting postoperative outcomes after mitral surgery. Sixty-seven patients with severe asymptomatic or minimally symptomatic mitral regurgitation (69% men mean age, 62 ± 13 years) who underwent mitral valve surgery from January 2010 to December 2011 were studied. In addition to standard echocardiography, baseline three-dimensional echocardiography was performed for accurate quantification of LV size. Patients were followed over a median time of 1 month (interquartile range, 0-8 months) for postoperative development of atrial fibrillation or LV dysfunction. A multivariate regression analysis was performed to identify associations with events. Postoperative LV dysfunction developed in 15 patients (22%), and 21 patients (31%) had postoperative atrial fibrillation. There was no association between two-dimensional end-systolic volume index and outcomes (hazard ratio, 1.02 P = .18). Postoperative atrial fibrillation or LV dysfunction was associated with baseline three-dimensional LV end-systolic volume index (hazard ratio, 1.06 95% confidence interval, 1.04-1.16), independent of age and presence of coronary artery disease. LVESVi ≥ 40 mL/m(2) was the best cutoff value to predict postoperative events (sensitivity, 80% specificity, 85%). After adding LVESVi to a model containing clinical and echocardiographic parameters, net reclassification improvement was 0.27 (95% confidence interval, 0.25-0.29 P = .024). LVESVi from three-dimensional echocardiography is an independent predictor of postoperative outcomes in patients with severe mitral regurgitation that is incremental to other clinical and echocardiographic variables.
Publisher: Oxford University Press (OUP)
Date: 02-06-1993
DOI: 10.1093/EURHEARTJ/14.6.799
Abstract: Coronary artery disease may be difficult to diagnose in the elderly because its clinical symptomatology is frequently atypical and because the performance of submaximal tests makes exercise stress testing sometimes unreliable. Dobutamine stress testing may be a useful alternative in such patients. This study compared the safety and accuracy of dobutamine stress echocardiography in 73 'young' ( or = 60 years old) patients without previous myocardial infarction undergoing diagnostic coronary angiography. The sensitivity in young patients (79%, (67-91, 95% CI)) was similar to that in old patients (80% (69-91, 95% CI)). Similar levels of specificity (88% (75-101, 95% CI) vs 75% (54-96, 95% CI)) were found in the two groups. Both groups showed a trend to a higher sensitivity for multi-vessel disease than for single-vessel disease. No major side effect occurred during the entire study and peak dose (40 micrograms.kg-1.min-1) was attained with similar frequency in both groups (56% vs 49%). Minor side effects occurred equally in 'young' and 'old' patients and never persisted more than a few minutes after ending the first infusion of dobutamine. Dobutamine echocardiography appears to be safe and accurate for the detection of coronary artery disease regardless of age.
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.CJCA.2015.12.020
Abstract: Chest irradiation is a commonly used treatment for malignancy, with demonstrated symptomatic and survival benefit. The frequency and presentation of cardiovascular complications of radiotherapy remains unclear. We performed a systematic review to evaluate the prevalence and manifestations of myocardial dysfunction (asymptomatic and symptomatic) in long-term cancer survivors treated with radiotherapy. Thoracic radiotherapy is associated with increased risk of heart failure in long-term follow-up, with hazard ratios ranging from 2.7 to 7.4 for Hodgkin lymphoma, and 1.5-2.4 for breast cancer. Although ejection fraction is often normal, systolic dysfunction has been more widely reported with modern techniques including 2-dimensional speckle strain and cardiac magnetic resonance. This might have implications for the selection of patients for cardioprotection. Despite common emphasis, diastolic functional abnormalities were infrequent in the long term. A limited amount of data suggest that right ventricular dysfunction is important in this population. The reports were heterogeneous, used different treatments, end points, and definitions of myocardial dysfunction, and most studies on the cardiac consequences of radiotherapy involved small numbers of patients and were published decades ago, making it difficult to formulate definitive conclusions for the current era.
Publisher: Springer Science and Business Media LLC
Date: 03-11-2022
Publisher: American Medical Association (AMA)
Date: 03-2019
DOI: 10.1001/JAMACARDIO.2019.0052
Abstract: The cornerstones of imaging in heart failure (HF) are the measurement of systolic and diastolic function and left ventricular (LV) filling pressure. Ejection fraction and the assessment of LV filling pressure and diastolic dysfunction using the ratio of early transmitral flow and LV relaxation (E/e') are conventional imaging markers of LV function. Despite their extensive use in HF guidelines, both have significant detractions, especially in an era when HF with preserved ejection fraction is becoming the dominant presentation. In contrast, strain imaging has provided a new window into myocardial mechanics. Myocardial strain is now well validated, robust, and can easily be performed on most modern echocardiography machines. This Review summarizes the evidence in 9 situations across the stages of HF where LV global longitudinal strain and other strain parameters may provide information on risk prediction, diagnosis, assessment of treatment response, and follow-up. The evolution of myocardial deformation imaging from research tool to clinical practice will provide clinicians with a useful additional imaging parameter to facilitate the assessment and risk evaluation of patients with HF.
Publisher: Elsevier BV
Date: 02-2020
DOI: 10.1016/J.JCMG.2019.03.025
Abstract: The aim of this study was to assess the association between left ventricular mechanical dispersion (LVMD) and the incidence of ventricular arrhythmias (VAs). Recent, mainly single-center, studies have demonstrated that LVMD assessed using speckle tracking might be a powerful marker in risk stratification for VA. A systematic review and meta-analysis provides a means of understanding the prognostic value of this parameter, relative to other parameters, the most appropriate cutoff for designating risk. A systemic review of studies reporting the predictive value of LVMD for VA was undertaken from a search of MEDLINE and Embase. VA events were defined as sudden cardiac death, cardiac arrest, documented ventricular tachyarrhythmia, and appropriate implantable cardioverter-defibrillator (ICD) therapy. Hazard ratios were extracted from univariate and multivariate models reporting on the association of LVMD and VA and described as pooled estimates with 95% confidence intervals. In a meta-analysis, the predictive value of LVMD was compared with that of left ventricular ejection fraction and global longitudinal strain. Among 3,198 patients in 12 published studies, 387 (12%) had VA events over follow-up ranging from 17 to 70 months. Patients with VAs had greater LVMD than those without (weighted mean difference -20.3 ms 95% confidence interval: -27.3 to -13.2 p < 0.01). Each 10 ms increment of LVMD was significantly and independently associated with VA events (hazard ratio: 1.19 95% confidence interval: 1.09 to 1.29 p < 0.01). The predictive value of LVMD was superior to that of left ventricular ejection fraction or global longitudinal strain. LVMD assessed using speckle tracking provides important predictive value for VA in patients with a number of cardiac diseases and appears to have superior predictive value over left ventricular ejection fraction and global longitudinal strain for risk stratification.
Publisher: Elsevier BV
Date: 11-1995
DOI: 10.1016/S0894-7317(05)80010-0
Abstract: Coronary flow reserve may be measured with Doppler-derived coronary blood-flow velocity or scintigraphic assessment of myocardial perfusion. The purpose of this study was to compare coronary flow velocity and perfusion measures of flow reserve with respect to their extent and time course. Coronary flow velocity reserve in the proximal left anterior descending coronary artery measured by pulsed-wave Doppler at transesophageal echocardiography, with measures of perfusion reserve obtained in the corresponding territory, were measured by a standard O15 water technique at positron emission tomography. Eighteen male volunteers underwent both tests on different days in random order, with dipyridamole stress (0.56 mg/kg). After correction of resting flow and perfusion measurements to a standard cardiac workload (to compensate for heterogeneity in hemodynamics between the two studies), coronary flow reserve was calculated as the ratio between dipyridamoleand corrected resting flow. The uncorrected perfusion reserve measured by positron emission tomography was 3.7 +/- 1.2, compared with a corrected perfusion reserve of 2.3 +/- 0.7. This correlated with a corrected flow velocity reserve of 2.9 +/- 1.0 at transesophageal echocardiography (R = 0.92 p < 0.001). The mean difference between these results was 0.58 +/- 0.41 discrepant results occurred at higher flows, in the presence of discordant blood pressure responses to stress, and because of intersubject variations in the timing of the peak coronary flow response, which were detected by continuous monitoring at transesophageal echocardiography. Measurement of coronary flow reserve at transesophageal echocardiography correlates well with measurements at positron emission tomography, and discrepancies are minimized if measurements are taken at the same time after dipyridamole.
Publisher: Elsevier BV
Date: 06-2006
DOI: 10.1016/J.AMJCARD.2005.12.063
Abstract: Two-dimensional (2-D) strain (epsilon2-D) on the basis of speckle tracking is a new technique for strain measurement. This study sought to validate epsilon2-D and tissue velocity imaging (TVI)-based strain (epsilonTVI) with tagged harmonic-phase (HARP) magnetic resonance imaging (MRI). Thirty patients (mean age 62 +/- 11 years) with known or suspected ischemic heart disease were evaluated. Wall motion (wall motion score index 1.55 +/- 0.46) was assessed by an expert observer. Three apical images were obtained for longitudinal strain (16 segments) and 3 short-axis images for radial and circumferential strain (18 segments). Radial epsilonTVI was obtained in the posterior wall. HARP MRI was used to measure principal strain, expressed as maximal length change in each direction. Values for epsilon2-D, epsilonTVI, and HARP MRI were comparable for all 3 strain directions and were reduced in dysfunctional segments. The mean difference and correlation between longitudinal epsilon2-D and HARP MRI (2.1 +/- 5.5%, r = 0.51, p <0.001) were similar to those between longitudinal epsilonTVI and HARP MRI (1.1 +/- 6.7%, r = 0.40, p <0.001). The mean difference and correlation were more favorable between radial epsilon2-D and HARP MRI (0.4 +/- 10.2%, r = 0.60, p <0.001) than between radial epsilonTVI and HARP MRI (3.4 +/- 10.5%, r = 0.47, p <0.001). For circumferential strain, the mean difference and correlation between epsilon2-D and HARP MRI were 0.7 +/- 5.4% and r = 0.51 (p <0.001), respectively. In conclusion, the modest correlations of echocardiographic and HARP MRI strain reflect the technical challenges of the 2 techniques. Nonetheless, epsilon2-D provides a reliable tool to quantify regional function, with radial measurements being more accurate and feasible than with TVI. Unlike epsilonTVI, epsilon2-D provides circumferential measurements.
Publisher: Public Library of Science (PLoS)
Date: 04-06-2020
Publisher: Elsevier BV
Date: 08-2022
DOI: 10.1016/J.JCMG.2022.03.007
Abstract: Current guidelines distinguish stage B heart failure (SBHF) (asymptomatic left ventricular [LV] dysfunction) from stage A heart failure (SAHF) (asymptomatic with heart failure [HF] risk factors) on the basis of myocardial infarction, LV remodeling (hypertrophy or reduced ejection fraction [EF]) or valvular disease. However, subclinical HF with preserved EF may not be identified with these criteria. The purpose of this study was to assess the prediction of incident HF with global longitudinal strain (GLS) in patients with SAHF and SBHF. The authors analyzed echocardiograms (including GLS) in 447 patients (age 65 ± 11 years 77% male) enrolled in a prospective study of HF in in iduals at risk of incident HF, with normal or mildly impaired EF (≥40%). Long-term follow-up was obtained via data linkage. Analysis was performed using a competing risks model. After a median of 9 years of follow-up, 50 (10%) of the 447 patients had new HF admissions, and 87 (18%) died. In multivariable analysis, all imaging variables were independent predictors of HF admissions, including left ventricular ejection fraction (LVEF) (HR: 0.97 [95% CI: 0.94-0.99]), LV mass index (HR: 1.01 [95% CI: 1.00-1.02]), left atrial volume index (HR: 1.02 [95% CI: 1.00-1.05]), and E/e' (HR: 1.05 [95% CI: 1.01-1.24]), incremental to clinical variables (age and Charlson comorbidity score). However, the addition of GLS provided value incremental to both clinical and other echocardiographic parameters (P = 0.004). Impaired GLS (<18%) (HR: 4.09 [95% CI: 1.87-8.92]) was independent and incremental to all clinical and other echocardiographic variables in predicting HF, and impaired LVEF, left ventricular hypertrophy, left atrial enlargement, high E/e', or SBHF were not predictive. The inclusion of GLS as a criterion for SBHF would add independent and incremental information to standard markers of SBHF for the prediction of subsequent HF admissions.
Publisher: Elsevier BV
Date: 2007
DOI: 10.1016/J.PCAD.2006.08.006
Abstract: Left ventricular dysfunction associated with metabolic disorders has a number of features that might shed light on the integrity of heart failure with normal ejection fraction. First, although these patients may be dyspneic and have a normal ejection fraction, their diastolic dysfunction is not isolated. Both experimental models and sensitive new parameters in humans have shown abnormal systolic function, even though the less sensitive parameters (such as ejection fraction) become abnormal only with stress. Moreover, the mechanistic contributors to myocardial dysfunction, including structural changes and metabolic influences on the cardiac myocyte, interstitial fibrosis, vascular disease, and altered loading, are likely to influence systolic as much as diastolic function. The responses of systolic and diastolic heart failure to exercise training show analogies, particularly with respect to the importance of peripheral adaptation, as well as a similar training response. Together, these features are more supportive of a continuum of pathophysiology between systolic and diastolic heart failure, rather than the 2 representing discreet phenomena.
Publisher: Elsevier BV
Date: 1994
DOI: 10.1016/S0002-9149(97)00871-0
Abstract: Exercise treadmill testing is frequently performed to screen for coronary artery disease (CAD) in asymptomatic in iduals however, its clinical value is unclear. We examined a consecutive cohort of asymptomatic adults undergoing exercise treadmill testing at the Cleveland Clinic Foundation between September 1990 and December 1993. End points included (1) identification of subjects with severe CAD and (2) performance of any second diagnostic study within 90 days of the index exercise treadmill test. Screening exercise treadmill testing was performed in 4,334 adults (median age 51, 89% men) only 34% had > or = 1 cardiac risk factor and 15% exhibited an abnormal response to exercise. A second test after treadmill testing was performed in 215 patients (in 110, coronary angiography in 105, stress thallium scintigraphy, followed by coronary angiography in 16). The strongest predictor of referral for a second test was an ischemic ST-segment response (adjusted odds ratio [OR] 34, 95% confidence intervals [Cl] 24 to 47, p < 0.0001). The only clinical variable independently associated with referral for a second test was female gender (adjusted OR 0.35, 95% CI 0.21 to 0.60, p <0.0001). Of the 126 patients who underwent coronary angiography, severe CAD was identified in only 19 in iduals (10.44% of the original cohort, 95% CI 0.26% to 0.62%) coronary artery bypass grafting was performed in 14 of these patients. The estimated cost of exercise treadmill testing to identify 1 case of severe CAD for which surgical revascularization may provide a survival benefit was $39,623. The estimated cost per year of life saved was at least $55,274. Thus, as used in actual practice in 1 center, screening exercise treadmill testing has a low yield and is costly. This is perhaps in part because of the low-risk population that was selected and the failure to incorporate pretest variables, increasing probability of disease into post-test clinical decision making.
Publisher: Elsevier BV
Date: 03-2016
DOI: 10.1016/J.ECHO.2015.11.010
Abstract: The distinction between right ventricular (RV) dysfunction due to an acute etiology (pulmonary embolism [PE]) or chronic afterload (pulmonary arterial hypertension [PAH]) has important therapeutic implications. The aim of this study was to test the hypothesis that RV remodeling would alter RV free wall strain (RVFWS) and differentiate chronic from acute RV afterload. In this retrospective study, patients with PE (n = 45) who underwent echocardiography within 48 hours of computed tomographic pulmonary angiography were matched 1:1 for age, gender, and pulmonary artery systolic pressure with patients with PAH (n = 45) and a larger unmatched PAH control group (n = 116). RV function was evaluated with end-diastolic area, fractional area change (FAC), and RVFWS by two-dimensional speckle-tracking. The ability of RVFWS to distinguish acute from chronic RV dysfunction was assessed using receiver operating characteristic curves, and its incremental value was sought with stepwise models. RV end-diastolic area, FAC, and RVFWS were significantly impaired in patients with PE (P < .001), with no significant differences in other clinical variables. In matched patients, receiver operating characteristic curve analysis revealed that RVFWS had significantly better discriminative power than the McConnell sign (P = .02), with a cutoff of -17.9%, sensitivity of 87.5%, specificity of 62.5%, and an area under the curve of 0.76. Sequential logistic regression demonstrated an incremental and independent benefit of using RVFWS to predict acute PE versus chronic PAH (P = .01). Observer concordance was superior for RVFWS compared with FAC (P < .01). RVFWS is more predictive than RV end-diastolic area and less variable than FAC in distinguishing acute from chronic RV pressure overload. RVFWS adds incremental and independent information to standard measures of RV function in assessing the acuity of pulmonary hypertension.
Publisher: Oxford University Press (OUP)
Date: 08-2011
DOI: 10.1038/AJH.2011.75
Abstract: A hypertensive response to exercise (HRE defined as normal clinic blood pressure (BP) and exercise systolic BP (SBP) ≥210 mm Hg in men or ≥190 mm Hg in women, or diastolic BP (DBP) ≥105 mm Hg) independently predicts mortality. The mechanisms remain unclear but may be related to masked hypertension. This study aimed to assess the prevalence of masked hypertension and its association with cardiovascular risk factors, including left ventricular (LV) mass, in patients with a HRE. Comprehensive clinical and echocardiographic evaluation (including central BP, aortic pulse wave velocity by tonometry) and 24-h ambulatory BP monitoring (ABPM) were performed in 72 untreated patients with HRE (aged 54 ± 9 years 60% male free from coronary artery disease confirmed by exercise stress echocardiography). Masked hypertension was defined according to guidelines as daytime ABPM ≥135/85 mm Hg and clinic BP 0.05 for both). The strongest independent determinant of LV mass index was the presence of masked hypertension (unstandardized β = 5.6 P = 0.007), which was also independently related to LV RWT (unstandardized β = 0.04 P = 0.03). Masked hypertension is highly prevalent in HRE patients with a normal resting office BP and is associated with increased LV mass index and RWT. Clinicians should consider measuring ABPM or home BP in HRE patients.
Publisher: Elsevier BV
Date: 08-1999
DOI: 10.1016/S0733-8651(05)70094-1
Abstract: The main predictors of outcome after infarction (exercise capacity, ejection fraction, and extent of jeopardized myocardium) can all be identified using stress echocardiography. This review addresses the place of stress echocardiography in postinfarct risk evaluation, relative to clinical evaluation, and other technologies. The test is accurate for identification of multivessel disease and for predicting outcomes, is versatile, and can be used early after infarction.
Publisher: Springer Science and Business Media LLC
Date: 09-2007
Abstract: Obesity is associated with an increased risk of heart failure. Apparently healthy obese in iduals can, however, exhibit subclinical left ventricular dysfunction. The use of myocardial imaging techniques to detect this subclinical change could have important management implications with respect to initiating prophylactic therapy. In this Review, we evaluate possible pharmacologic and nonpharmacologic strategies for treating obesity cardiomyopathy in the context of currently understood mechanisms, including myocardial remodeling and small vessel disease, and more speculative mechanisms such as insulin resistance, and activation of the renin-angiotensin-aldosterone and sympathetic nervous systems.
Publisher: Wiley
Date: 07-09-2016
DOI: 10.1111/ECHO.13355
Abstract: Cardiac amyloidosis results in increased left ventricular (LV) wall thickness and diastolic dysfunction (DD). Strain measurements using velocity vector imaging (VVI) may further characterize myocardial dysfunction. A total of 43 AL amyloidosis patients were compared to age-matched normals and hypertensive patients (HT). Subgroup analysis within the amyloid group was performed based on LV wall thickness (≤14 mm, >14 mm) and diastolic dysfunction (DD) (Group 1: normal and impaired relaxation, Group 2: pseudonormal, Group 3: restrictive). LV strain (longitudinal, circumferential, and radial strain (S) and strain rate [Sr]) were measured using velocity vector imaging (VVI). Increased LV wall thickness and DD were observed in the amyloid group. Global longitudinal (-13.9±4.1% vs -16.7±3.8% P=.002) and radial (27.4±13.4% vs 38.8±15.7% P 14 mm however, circumferential strain was also altered when severe DD (restrictive filling) was present. Reduction in longitudinal and radial S and Sr was evident using VVI strain analysis in amyloidosis, with segmental heterogeneity in longitudinal S. There was relative preservation of circumferential strain, which was reduced only in patients with severe DD.
Publisher: Oxford University Press (OUP)
Date: 26-02-2019
DOI: 10.1093/EHJCI/JEZ027
Abstract: Improvement in left ventricular (LV) systolic reserve, including exertional increase in global longitudinal strain (GLS), may contribute to the clinical benefit from therapeutic interventions in heart failure with preserved ejection fraction (HFpEF). However, GLS is an afterload-dependent parameter, and its measurements may not adequately reflect myocardial contractility recruitment with exercise. The estimation of myocardial work (MW) allows correction of GLS for changing afterload. We sought to investigate the associations of GLS and MW parameters with the response of exercise capacity to spironolactone in HFpEF. We analysed 114 patients (67 ± 8 years) participating in the STRUCTURE study (57 randomized to spironolactone and 57 to placebo). Resting and immediately post-exercise echocardiograms were performed at baseline and at 6-month follow-up. The following indices of MW were assessed: global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency. The amelioration of exercise intolerance at follow-up in the spironolactone group was accompanied by a significant improvement in exertional increase in GCW (P = 0.002) but not in GLS and other MW parameters. Increase in exercise capacity at 6 months was independently correlated with change in exertional increase in GCW from baseline to follow-up (β = 0.24 P = 0.009) but not with GLS (P = 0.14) however, no significant interaction with the use of spironolactone on peak VO2 was found (P = 0.97). GCW as a measure of LV contractile response to exertion is a better determinant of exercise capacity in HFpEF than GLS. Improvement in functional capacity during follow-up is associated with improvement in exertional increment of GCW.
Publisher: Elsevier BV
Date: 06-1999
Publisher: Informa UK Limited
Date: 1992
DOI: 10.1080/17843286.1992.11718203
Abstract: Immunoassay-based anti-nuclear antibody (ANA) screens are increasingly used in the initial evaluation of autoimmune disorders, but these tests offer no "pattern information" comparable to the information from indirect fluorescence assay-based screens. Thus, there is no indication of "next steps" when a positive result is obtained. To improve the utility of immunoassay-based ANA screening, we evaluated a new method that combines a multiplex immunoassay with a k nearest neighbor (kNN) algorithm for computer-assisted pattern recognition. We assembled a training set, consisting of 1,152 sera from patients with various rheumatic diseases and non-diseased patients. The clinical sensitivity and specificity of the multiplex method and algorithm were evaluated with a test set that consisted of 173 sera collected at a rheumatology clinic from patients diagnosed by using standard criteria, as well as 152 age- and sex-matched sera from presumably healthy in iduals (sera collected at a blood bank). The test set was also evaluated with a HEp-2 cell-based enzyme-linked immunosorbent assay (ELISA). Both the ELISA and multiplex immunoassay results were positive for 94% of the systemic lupus erythematosus (SLE) patients. The kNN algorithm correctly proposed an SLE pattern for 84% of the antibody-positive SLE patients. For patients with no connective tissue disease, the multiplex method found fewer positive results than the ELISA screen, and no disease was proposed by the kNN algorithm for most of these patients. In conclusion, the automated algorithm could identify SLE patterns and may be useful in the identification of patients who would benefit from early referral to a specialist, as well as patients who do not require further evaluation.
Publisher: Elsevier BV
Date: 04-2008
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2013
Publisher: Elsevier BV
Date: 05-2008
Publisher: Springer Science and Business Media LLC
Date: 2006
DOI: 10.1007/S10354-005-0242-9
Abstract: Cardiovascular (CV) disease is increased in patients with chronic inflammatory disease, including rheumatoid arthritis (RA). Furthermore it has become clear at a pathophysiological level, that atherosclerosis has striking similarities with autoimmune disease. This realization has come at a time of paradigm shift in how rheumatologists manage RA, with the availability of biological agents targeting key inflammatory cytokines. This review will focus on the possible causes of increased vascular disease in RA, including the role of traditional CV risk factors. Mechanisms potentially at play, such as C-reactive protein (CRP), altered coagulation, and cyclooxygenase (COX)-2 inhibitors will be covered in brief. The receptor for advanced glycation end products (RAGE) has been identified as a candidate molecule influencing response to ongoing inflammation and autoimmunity. There will be a focus on the role of RAGE in CV disease and RA. As has been the case with many novel molecules, functional polymorphisms are thought to alter disease expression and assist us in coming to terms with the biological activities of the parent molecule. The review will conclude with a discussion of the potential role of the RAGE Glycine 82 Serine polymorphism.
Publisher: Elsevier BV
Date: 12-2009
DOI: 10.1016/J.AMJCARD.2009.07.018
Abstract: The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) showed that the angiotensin receptor blocker telmisartan 80 mg was not inferior to the angiotensin-converting enzyme inhibitor ramipril 10 mg, and the combination no more effective than ramipril alone, in decreasing morbidity and mortality in patients with cardiovascular disease or high-risk diabetes. Although therapy targeting angiotensin II is known to decrease left ventricular (LV) mass and volume, the relative influence of angiotensin-converting enzyme inhibitor inhibitors and angiotensin receptor blocker, and their combination, on the heart remains unclear in this population. Magnetic resonance imaging was performed in 287 patients enrolled in ONTARGET, across 8 centers in 6 countries, at randomization and after 2-year treatment (90, 100, and 97 patients in the ramipril, telmisartan, and combination therapy groups, respectively). Baseline patient characteristics showed higher frequencies of coronary artery disease, Asian ethnicity, and use of statins and beta blockers than the main ONTARGET trial. LV mass decreased in all groups (p <0.0001 for each), but there were no significant differences in change in LV mass or volume among groups, except that LV mass index decreased more on combination versus telmisartan (p = 0.04). Key determinants of LV mass decrease were a history of hypertension (p = 0.03), baseline mass (p <0.0001), and decrease in systolic blood pressure (p <0.0001). The best magnetic resonance imaging predictor of composite events was end-systolic volume (p <0.0001). In conclusion, telmisartan and ramipril had similar effects on LV mass and volume, and combination therapy was not more effective, in high-risk patients with cardiovascular disease. These results are consistent with the major outcome findings of the main ONTARGET study.
Publisher: Elsevier BV
Date: 04-2011
Publisher: Elsevier BV
Date: 03-2019
Publisher: Elsevier BV
Date: 07-2015
DOI: 10.1016/J.JSAMS.2014.07.005
Abstract: Reduced functional capacity is associated with poor prognosis. In patients with chronic kidney disease the factors that contribute to low cardiorespiratory fitness are unclear. The objective of this study was to evaluate the cardiorespiratory and cardiovascular response to exercise in chronic kidney disease patients, and secondly investigate the relationships between cardiorespiratory fitness and cardiovascular burden. Cross-sectional analysis. Baseline demographic, anthropometric and biochemical data were examined in 136 patients with moderate chronic kidney disease (age 59.7±9.6yrs, eGFR 40±9ml/min/1.73m(2), 55% male, 39% with a history of cardiovascular disease, 38% diabetic and 17% current smokers). Cardiorespiratory fitness was measured as peak VO2, left ventricular morphology and function using echocardiography, central arterial stiffness by aortic pulse wave velocity and left ventricular afterload using augmentation index. Physical activity levels were assessed using the Active Australia questionnaire. Peak VO2 (22.9±6.5ml/kg/min) and peak heart rate (148±22bpm) were 17% and 12% lower than the age-predicted values, respectively. The low fit group were significantly older, and were more likely to have type II diabetes, cardiovascular disease, a higher BMI and be less active than the high fit group (P<0.05). The independent predictors of peak VO2 were age, type II diabetes, hemoglobin level, physical activity, aortic pulse wave velocity, augmentation index, and global longitudinal strain. In patients with chronic kidney disease, the peak VO2 and heart rate response is markedly impaired. Reduced cardiorespiratory fitness is independently associated with increased aortic stiffness, increased left ventricle afterload, poor left ventricle function and higher burden of cardiovascular risk.
Publisher: Springer Science and Business Media LLC
Date: 20-12-2005
Publisher: Informa UK Limited
Date: 2001
Publisher: Elsevier BV
Date: 12-2015
DOI: 10.1016/J.JCMG.2015.10.005
Abstract: The outcomes associated with heart failure after myocardial infarction are still poor. Both global and regional left ventricular (LV) remodeling are associated with the progression of the post-infarct patient to heart failure, but although global remodeling can be accurately measured, regional LV remodeling has been more difficult to investigate. Preliminary evidence suggests that post-MI assessment of LV mechanics using stress and strain may predict global (and possibly regional) LV remodeling. A method of predicting both global and regional LV remodeling might facilitate earlier, targeted, and more extensive clinical intervention in those most likely to benefit from novel interventions such as cell therapy.
Publisher: American Medical Association (AMA)
Date: 13-02-2002
Publisher: BMJ
Date: 31-10-2013
Publisher: Elsevier BV
Date: 04-2019
Publisher: Elsevier BV
Date: 09-2000
Publisher: Elsevier BV
Date: 08-2004
Publisher: Wiley
Date: 27-01-2022
DOI: 10.1002/EJHF.2428
Abstract: Subclinical left ventricular dysfunction (LVD) is a prelude to symptomatic heart failure (HF). We hypothesised that screening‐guided treatment with spironolactone would prevent incident HF in at‐risk patients. We randomised asymptomatic, community‐dwelling subjects aged ≥65 years old, with at least one non‐ischaemic HF risk factor (hypertension, type 2 diabetes mellitus or obesity) to echocardiography‐guided therapy or usual care. Spironolactone therapy was triggered by the detection of subclinical LVD (global longitudinal strain [GLS] ≤16%) or diastolic abnormalities (at least one of E/e′ , E/e′ with left atrial enlargement [LAE] or impaired relaxation [E/A 0.8, IR], LAE with IR), or borderline GLS (17%) with IR or borderline GLS with LAE. The primary outcome was incident HF at 24 months. Secondary outcomes were change in 6‐min walk test (6MWT) and change in left ventricular function. LVD was identified in 161 (46%) of 349 participants (age 70 [68–73] years, 201 [58%] women). The trial was stopped because of a 55% rate of spironolactone discontinuation, due primarily to decline in renal function. Incident HF developed in 11 (3.5%) of 310 participants completing follow‐up, with no difference between usual care and intervention (4 [2.5%] vs. 7 [4.7%], p = 0.29), decline in 6MWT distance ( p = 0.28), persistent or new LVD ( p = 0.58), nor change in GLS with intervention ( p = 0.15). A per‐protocol analysis of 131 patients with baseline LVD and a follow‐up echocardiogram, showed resolution of LVD with spironolactone therapy (59% vs. 33%, p = 0.01). The study was underpowered to determine whether screening‐guided spironolactone therapy reduced incident HF because spironolactone was frequently discontinued due to renal function criteria. However, LVD resolved in more patients treated with spironolactone than in untreated patients. Future trials should use less conservative renal criteria for spironolactone discontinuation.
Publisher: Elsevier BV
Date: 02-2003
DOI: 10.1054/JCAF.2003.2
Publisher: Elsevier BV
Date: 04-2016
DOI: 10.1016/J.JDIACOMP.2015.12.014
Abstract: Subclinical left ventricular dysfunction has been associated with impaired exercise capacity in type 2 diabetes mellitus. In this community-based study of 274 asymptomatic T2DM patients (71±4 years, 55% men) with preserved ejection fraction, a comprehensive resting echocardiogram was performed to gather sensitive systolic and diastolic function parameters (including speckle tracking echocardiography), and a standard six-minute walk test was performed. Tertiles of increasing waist circumference were associated with worsening walk distance. In this community-based study, we found an association of waist circumference with impaired exercise capacity, independent of age, gender, diabetes duration, insulin and angiotensin blockade, LV mass, systolic and diastolic function.
Publisher: Elsevier BV
Date: 07-0005
Publisher: Elsevier BV
Date: 08-2011
Publisher: Elsevier BV
Date: 11-2004
DOI: 10.1016/J.ULTRASMEDBIO.2004.08.026
Abstract: We sought to improve the feasibility of strain rate imaging (SRI) during dobutamine stress echocardiography (DSE) in 56 subjects at low risk of coronary disease. The impact of several SRI changes during acquisition were studied, including: (1) changing from fundamental to harmonic imaging (2) parallel beamforming (3) alteration of spatial resolution and (4) narrow sector acquisition. We assessed SR signal quality, a quantitative measure of signal noise and measurements of SRI. Of 1462 segments evaluated, 6% were uninterpretable at rest and 8% at peak stress. Signal quality was optimised by increasing temporal (p = 0.01) and spatial resolution (p < 0.0001 vs. baseline imaging) at rest and peak. Increasing spatial resolution also minimised signal noise (p < 0.0001). Inter-observer variability of time to peak SR and peak SR were less with high temporal and spatial resolution. SRI quality can be improved with harmonic imaging and higher temporal resolution but optimisation of spatial resolution is critical.
Publisher: Elsevier BV
Date: 07-1998
DOI: 10.1016/S0002-8703(98)70183-8
Abstract: Dobutamine and exercise echocardiography are accepted as tests of comparable efficacy for the diagnosis of coronary artery disease. Although dobutamine has been classified as "exercise simulating," the mechanisms of ischemia with dobutamine and exercise have not been well studied. This study sought to compare the determinants of myocardial oxygen consumption. We studied 54 patients with coronary artery disease undergoing dobutamine and exercise stress. A subgroup of 13 patients with comparable degrees of wall motion abnormalities and ST-segment changes during both stresses were selected to compare the determinants of ischemia in comparable circumstances. Dobutamine was infused to a mean maximal dose of 32+/-8 microg/kg/min, and exercise was stopped at an average of 135+/-25 W. The mean regional wall motion score was not statistically different between the two protocols (p = 0.27). At the onset of wall motion abnormalities and peak stress, the heart rate increased significantly less during dobutamine than during exercise (106+/-23 vs 126+/-19 beats/min, p < 0.001). The same was true of systolic blood pressure (155+/-21 vs 205+/-24 mm Hg, p < 0.001) and the rate-pressure product (16.5+/-4.6 vs 25.9+/-5, p < 0.001). Cardiac volumes were similar during both tests. Ischemia occurs at a lower level of external cardiac work during dobutamine than during exercise stress. We suspect that additional mechanisms, such as the oxygen wasting effect of dobutamine, may be responsible for this observation.
Publisher: Elsevier BV
Date: 08-2018
DOI: 10.1016/J.AMJCARD.2018.04.051
Abstract: The risk of heart failure (HF) readmission may be reduced by disease management programs, but the resource-intensive nature of these requires targeting to the greatest need. As socioeconomic status (SES) is related to other health outcomes, we sought whether regional markers of SES were associated with days at home (alive and out of hospital) after discharge. This study used statewide data of 1,391 HF patients who had their first ever HF admission to a public hospital in Tasmania (Australia) during 2009 to 2012. Measurements of residential SES included four indexes and a remoteness index generated by the Australian Bureau of Statistics. The primary outcome was days at home. Secondary outcomes included 30- and 90-day readmission or death, number of readmissions, and days to first readmission. Our HF patients had a median of 352 days at home [interquartile range 167, 361]. All four SES indexes and the remoteness index (p <0.001) were adversely associated with days at home, independent of other clinical and nonclinical factors. Findings for readmission at 30 and 90 days of discharge were inconsistent the index of Relative Socioeconomic Advantage and Disadvantage (but not other SES indexes) was independently associated with 30-day readmission (odds ratio 1.58, p = 0.008) and remoteness index was significantly associated with 90-day readmission (odds ratio = 1.99, p = 0.009). Analyzing days to first readmission did not show any significant differences among categories of SES (log-rank test p = 0.81) or remoteness index (log-rank test p = 0.47). Thus, residential SES is associated with adverse outcome in HF, and might be useful in planning services to reduce HF readmission.
Publisher: Elsevier BV
Date: 02-2006
DOI: 10.1016/J.ECHO.2005.08.020
Abstract: Left ventricular (LV) volumes have important prognostic implications, but are commonly underestimated. We sought accuracy and reproducibility of LV volume measurement by live 3-dimensional (3D) echocardiography (3DE) and TI-201 single photon emission computed tomography (SPECT), compared with cardiac magnetic resonance imaging (MRI). In all, 30 patients (age 62 +/- 9 years, 23 men) underwent LV volume assessment with 3DE, SPECT, and cardiac MRI after myocardial infarction. LV volumes were measured using a semiautomated border detection algorithm for 3DE, gated SPECT software for SPECT, and a 3D display for MRI. Results of 3DE and SPECT volumes were compared with MRI as the standard of reference. The 3DE volumes showed excellent correlation with cardiac MRI (end-diastolic volume [EDV], r = 0.90, P = .001 end-systolic volume [ESV], r = 0.94, P = .001), as did SPECT (EDV, r = 0.89, P = .001 ESV, r = 0.95, P = .001). However, both 3DE and SPECT underestimated LV volumes. The mean MRI EDV was 179 +/- 56 mL compared with 3DE (mean difference, -10 +/- 26 mL, P = .04) and SPECT (mean difference, -58 +/- 28 mL, P < .001). There was a significant difference between SPECT EDV and 3DE (mean difference, -48 +/- 31 mL, P < .001). The mean MRI ESV was 96 +/- 54 mL and this was underestimated by SPECT (mean difference, -22 +/- 19 mL, P < .001), but not by 3DE (mean difference, -0.9 +/- 19 mL, P = not significant). ESV was also underestimated when SPECT was compared with 3DE (mean difference, -22 +/- 27 mL, P < .001). The results of 3DE were reproducible with excellent intraobserver (ESV, r = 0.98, -2 +/- 6 mL EDV, r = 0.98, -1 +/- 6 mL, P = .001) and interobserver (ESV, r = 0.97, -2 +/- 6 mL EDV, r = 0.95, -3 +/- 10 mL, P = .001) correlation. We have shown that 3DE is accurate and reproducible for the measurement of LV volumes for risk assessment in chronic ischemic heart disease and dilated cardiomyopathy. Furthermore, 3DE is more accurate than TI-201 SPECT with less underestimation of LV volumes.
Publisher: Elsevier
Date: 2019
Publisher: Elsevier BV
Date: 05-2015
DOI: 10.1016/J.PCAD.2015.03.005
Abstract: Microbubbles are an excellent intravascular tracer, and both the rate of myocardial opacification (analogous to coronary microvascular perfusion) and contrast intensity (analogous to myocardial blood volume) provide unique insights into myocardial perfusion. A strong evidence base has been accumulated to show comparability with nuclear perfusion imaging and incremental diagnostic and prognostic value relative to wall motion analysis. This technique also provides the possibility to measure myocardial perfusion at the bedside. Despite all of these advantages, the technique is complicated, technically challenging, and has failed to scale legislative and financial hurdles. The development of targeted imaging and therapeutic interventions will hopefully rekindle interest in this interesting modality.
Publisher: Elsevier BV
Date: 2011
DOI: 10.1016/J.AMJCARD.2010.08.071
Abstract: The aim of this study was to determine if left atrial (LA) phasic function evaluated by Doppler tissue imaging-derived strain and strain rate would be differentially decreased in patients with hypertrophic cardiomyopathy (HC) compared to patients with hypertension and to normal controls. Thirty-seven patients with HC were compared to 44 patients with systemic hypertension (SH) and 65 normal controls using transthoracic echocardiography. Maximal and minimal LA volume and LA volume just before active atrial contraction (pre-P LA volume) were measured, and phasic LA volumes were calculated. Global and segmental systolic strain rate, early diastolic strain rate, and late diastolic strain rate (A-Sr) and strain were measured from Doppler tissue imaging. Left ventricular mass was increased in the HC and SH groups compared to normal controls, but diastolic dysfunction was greater in the HC group. LA volumes were increased in patients with HC compared to those with SH and to normal controls, with corresponding reductions in A-Sr and atrial strain in the HC group. In contrast, only early diastolic strain rate was decreased in the SH group compared to controls. A-Sr remained reduced in patients with HC compared to the SH group, even after adjusting for left ventricular mass. When left ventricular mass, parameters of diastolic function (peak E and E' velocity), and the effect of patient group (SH vs HC) were examined in a stepwise regression model, patient group (SH vs HC) was the only independent determinant of A-Sr. In conclusion, HC results in LA enlargement with reduced LA phasic function that is reflected in reductions in A-Sr and atrial strain. Atrial enlargement is a likely consequence of the greater diastolic dysfunction in the HC group.
Publisher: AMPCo
Date: 22-04-2021
DOI: 10.5694/MJA2.51040
Publisher: BMJ
Date: 17-06-2011
Abstract: The use of cardiovascular imaging is growing inexorably and concerns have been expressed about its cost and radiation safety. In this study, the relative environmental impact of MRI, single photon emission tomography and cardiac ultrasound (echo) for the diagnosis of coronary artery disease were examined. The results emphasise that echo causes the least environmental impact at each stage of its life cycle. The effect of one echo on human health, ecosystem effects and resource use was of the order of 1-20% of those of the alternative methods. Although there are circumstances in which one imaging modality is preferred on clinical grounds, when everything else is equal, these results support the selection of echocardiography as the preferred test on environmental grounds.
Publisher: Elsevier BV
Date: 04-2022
Publisher: Elsevier BV
Date: 2004
DOI: 10.1016/S0167-5273(03)00109-8
Abstract: We sought to define the influence of revascularisation and contractile reserve on left ventricular (LV) remodelling in patients with LV dysfunction after myocardial infarction. Revascularisation of viable myocardium is associated with improved regional function, but the effect on remodelling is undefined. We studied 70 patients with coronary artery disease and LV dysfunction, 31 of whom underwent revascularisation. A standard dobutamine stress echocardiogram (DbE) was carried out. All patients underwent standard medical treatment the decision to revascularise was made clinically, independent of this study. LV volumes and ejection fraction were measured by 3D echocardiography at baseline and after an average of 40 weeks. There was no significant difference in baseline ejection fraction or volumes between patients who underwent revascularisation and the remainder. Compared to medically treated patients, revascularised patients had significant improvements in ejection fraction and end-systolic volume in follow-up. The impact of baseline variables on remodelling was assessed by iding patients into tertiles of LV ejection fraction and volumes. Revascularised patients in the lowest tertile of ejection fraction at baseline ( 38% did not show significant improvement in volumes compared to baseline. Revascularised patients in the largest tertiles of end-systolic (>88 ml) or end-diastolic volume (>149 ml) at baseline had a significant improvement in end-systolic volume. Remodeling appears to occur independent of the presence of regional contractile reserve but does correlate with the volume response to low-dose dobutamine.
Publisher: Elsevier BV
Date: 11-1992
DOI: 10.1016/0735-1097(92)90248-L
Abstract: This study was designed to assess the accuracy of two-dimensional and Doppler echocardiography in determining the mechanism of mitral regurgitation, as compared with direct inspection of the valve at operation. Valve repair for mitral regurgitation offers substantial advantages over valve replacement, but it is technically more demanding and requires understanding of the mechanism of dysfunction. We studied 286 patients undergoing mitral valve repair. Intraoperative two-dimensional echocardiography was used to classify mitral leaflet motion as excessive, normal or restricted. Doppler color flow mapping was used to evaluate the direction and origin of the mitral regurgitant jet. Two-dimensional and Doppler echocardiography were compared with intraoperative surgical determination of the mechanism of dysfunction, which also classified leaflet motion as excessive, normal or restricted. Two-dimensional and Doppler echocardiography accurately diagnosed the mechanism of mitral regurgitation in 123 (93%) of 132 patients with posterior leaflet prolapse or flail, 30 (94%) of 32 patients with anterior leaflet prolapse or flail, 11 (44%) of 25 patients with bileaflet prolapse or flail, 6 (75%) of 8 patients with papillary muscle elongation or rupture, 31 (91%) of 34 patients with restricted leaflet motion or rheumatic thickening, 21 (72%) of 29 patients with ventricular-annular dilation and 8 (62%) of 13 patients with a leaflet perforation or cleft. Of 13 patients with two mechanisms of dysfunction by surgical inspection, two-dimensional and Doppler echocardiography correctly diagnosed one of the two mechanisms in 12 patients (92%), and both mechanisms in 5 patients (38%). Overall, echocardiographic determination of leaflet motion and Doppler determination of jet direction accurately diagnosed the mechanism of dysfunction in 242 (85%) of 286 patients. Echocardiography before mitral valvuloplasty provides a dynamic appraisal of the mechanism of dysfunction, enabling the surgeon to systematically understand the dysfunction and successfully apply the correct procedures to eliminate mitral regurgitation without valve replacement.
Publisher: BMJ
Date: 12-2005
Publisher: BMJ
Date: 31-07-2008
Publisher: Elsevier BV
Date: 07-2008
DOI: 10.1016/J.JCMG.2008.02.009
Abstract: We sought to study: 1) the accuracy and reproducibility of real-time 3-dimensional echocardiographic (RT3DE) analysis of left ventricular (LV) volumes in a multicenter setting, 2) interinstitutional differences in relationship with the investigators' specific experience, and 3) potential sources of volume underestimation. Reproducibility and accuracy of RT3DE evaluation of LV volumes has not been validated in multicenter studies, and LV volumes have been reported to be underestimated compared to cardiac magnetic resonance (CMR) standard. A total of 92 patients with a wide range of ejection fractions underwent CMR and RT3DE imaging at 4 different institutions. Images were analyzed to obtain LV end-systolic volume (ESV) and end-diastolic volume (EDV). Reproducibility was assessed using repeated analyses. The investigation of potential sources of error included: phantom imaging, intermodality analysis-related differences, and differences in LV boundary identification, such as inclusion of endocardial trabeculae and mitral valve plane in the LV volume. The RT3DE-derived LV volumes correlated highly with CMR values (EDV: r = 0.91 ESV: r = 0.93), but were 26% and 29% lower consistently across institutions, with the magnitude of the bias being inversely related to the level of experience. The RT3DE measurements were less reproducible (4% to 13%) than CMR measurements (4% to 7%). Minimal changes in endocardial surface position (1 mm) resulted in significant differences in measured volumes (11%). Exclusion of trabeculae and mitral valve plane from the CMR reference eliminated the intermodality bias. The RT3DE-derived LV volumes are underestimated in most patients because RT3DE imaging cannot differentiate between the myocardium and trabeculae. To minimize this difference, tracing the endocardium to include trabeculae in the LV cavity is recommended. With the understanding of these intermodality differences, RT3DE quantification of LV volume is a reliable tool that provides clinically useful information.
Publisher: Elsevier
Date: 2012
Publisher: Oxford University Press (OUP)
Date: 2009
DOI: 10.1093/EJECHOCARD/JEN321
Abstract: To determine if perfusion stress echocardiography (PSE) with Imagify (perflubutane polymer microspheres) is comparable to stress perfusion imaging using (99m)Tc single photon emission computed tomography (SPECT) for coronary artery disease (CAD) detection. PSE is a novel technique for evaluating myocardial perfusion. RAMP (real-time assessment of myocardial perfusion)-1 and -2 were international, Phase 3 trials that evaluated the ability of PSE with Imagify, to detect CAD. Chronic, stable, chest pain patients (n=662) underwent Imagify PSE and gated SPECT imaging at rest and during dipyridamole stress. Independent blinded cardiologists [three PSE readers per trial, and four SPECT readers (one for RAMP-1, three for RAMP-2)] interpreted images. CAD was defined by quantitative coronary angiography or 90-day outcome with clinical review. Accuracy, sensitivity, and specificity were evaluated using non-inferiority analysis (one-sided alpha=0.025) compared with SPECT. SPECT results for RAMP-1 and -2 were: accuracy (70%, 67%), sensitivity (78%, 61%), and specificity (64%, 76%). Accuracy of all six PSE readers was non-inferior to SPECT (66-71%, P<or=0.004). Four demonstrated non-inferior sensitivity (68-77%, P<or=0.002), three demonstrated non-inferior specificity (72-88%, P<or=0.013). Three PSE readers (RAMP-2) were superior for sensitivity. Two PSE readers (RAMP-1) were superior for specificity. Area under the multi-reader receiver operating characteristics curve (0.72) was equal for both modalities. Majority of adverse events followed dipyridamole dosing, and were mild, transient, and required no treatment. Imagify PSE was well-tolerated. Its diagnostic performance in chest pain patients is comparable with SPECT perfusion imaging.
Publisher: Elsevier BV
Date: 06-1995
Publisher: Elsevier BV
Date: 08-2014
DOI: 10.1016/J.ECHO.2014.04.013
Abstract: The outcomes of patients with mixed aortic valve disease (MAVD concurrent aortic stenosis [AS] and aortic regurgitation [AR]) and its optimum management are undefined. The aim of this study was to evaluate the natural history of MAVD. Between 2000 and 2005, 524 asymptomatic adults (mean age, 66 ± 14 years 306 men) were identified who had mixed AS and AR, who did not undergo early intervention with surgery. The severity of AS and AR was defined using American Society of Echocardiography guideline criteria. Patients were followed over 5.5 ± 3.1 years. Aortic valve replacement (AVR) was performed in 349 patients (67%), and 88 (17%) died. Angina, dyspnea, or syncope developed in 292 patients (84%) before AVR baseline left ventricular mass and the severity of AS and AR were independent predictors of progression to AVR in the overall group. Survival was associated with younger age (hazard ratio, 1.08 P < .001) and valve replacement (hazard ratio, 0.61 P = .02). Most patients with MAVD in the moderate category progressed to severe AS or AR by the time of surgery (n = 51 [27%]) symptoms were the main indication in 22 patients. In this group, AVR was associated with age, left ventricular function, valve area, and the change in peak gradient over follow-up. In patients with moderate MAVD, coronary artery disease was present in 38 (20%) at baseline and developed in 21 (21%) during follow-up but was not associated with surgery. The average time to an event (AVR or death) in patients with MAVD was 4 years. Careful surveillance of patients with MAVD is warranted, bearing in mind the composite severity of both AS and AR and their combined hemodynamic effects.
Publisher: Elsevier BV
Date: 03-1999
DOI: 10.1016/S0735-1097(98)00642-1
Abstract: The aim of this study was to evaluate whether preoperative clinical and test data could be used to predict the effects of myocardial revascularization on functional status and quality of life in patients with heart failure and ischemic LV dysfunction. Revascularization of viable myocardial segments has been shown to improve regional and global LV function. The effects of revascularization on exercise capacity and quality of life (QOL) are not well defined. Sixty three patients (51 men, age 66+/-9 years) with moderate or worse LV dysfunction (LVEF 0.28+/-0.07) and symptomatic heart failure were studied before and after coronary artery bypass surgery. All patients underwent preoperative positron emission tomography (PET) using FDG and Rb-82 before and after dipyridamole stress the extent of viable myocardium by PET was defined by the number of segments with metabolism-perfusion mismatch or ischemia. Dobutamine echocardiography (DbE) was performed in 47 patients viability was defined by augmentation at low dose or the development of new or worsening wall motion abnormalities. Functional class, exercise testing and a QOL score (Nottingham Health Profile) were obtained at baseline and follow-up. Patients had wall motion abnormalities in 83+/-18% of LV segments. A mismatch pattern was identified in 12+/-15% of LV segments, and PET evidence of viability was detected in 30+/-21% of the LV. Viability was reported in 43+/-18% of the LV by DbE. The difference between pre- and postoperative exercise capacity ranged from a reduction of 2.8 to an augmentation of 5.2 METS. The degree of improvement of exercise capacity correlated with the extent of viability by PET (r = 0.54, p = 0.0001) but not the extent of viable myocardium by DbE (r = 0.02, p = 0.92). The area under the ROC curve for PET (0.76) exceeded that for DbE (0.66). In a multiple linear regression, the extent of viability by PET and nitrate use were the only independent predictors of improvement of exercise capacity (model r = 0.63, p = 0.0001). Change in Functional Class correlated weakly with the change in exercise capacity (r = 0.25), extent of viable myocardium by PET (r = 0.23) and extent of viability by DbE (r = 0.31). Four components of the quality of life score (energy, pain, emotion and mobility status) significantly improved over follow-up, but no correlations could be identified between quality of life scores and the results of preoperative testing or changes in exercise capacity. In patients with LV dysfunction, improvement of exercise capacity correlates with the extent of viable myocardium. Quality of life improves in most patients undergoing revascularization. However, its measurement by this index does not correlate with changes in other parameters nor is it readily predictable.
Publisher: Elsevier BV
Date: 08-2014
DOI: 10.1016/J.ECHO.2014.04.015
Abstract: The distinction of hypertrophic cardiomyopathy (HCM) or cardiac amyloidosis (CA) from hypertensive heart disease may be difficult. The aim of this study was to determine the impact of parametric (polar) maps of regional longitudinal strain on identification of the etiology of mild to moderate left ventricular hypertrophy (LVH). Twenty-four consecutive echocardiographic studies with mild to moderate LVH (eight with CA, eight with HCM, and eight with hypertensive heart disease) were selected on the basis of the availability of adequate images to assess longitudinal strain and absence of electrocardiographic criteria for low voltage or LVH or a pseudoinfarct pattern. Twenty level 3-trained readers provided the most likely of three diagnoses (CA, HCM, or hypertensive heart disease) and scored their confidence in making the diagnosis from two-dimensional images and diastolic parameters. A teaching exercise was provided on the interpretation of longitudinal strain in these cohorts, and interpretation was repeated with the addition of the strain polar map. Baseline concordance among the readers was poor (κ = 0.28) and improved with the addition of strain data (κ = 0.57). Accuracy was improved with the addition of polar maps for the entire study cohort (P < .001), with 22% of cases reclassified correctly. The largest improvements in sensitivity (from 40% to 86%, P < .001), specificity (from 84% to 95%, P < .001), and accuracy (from 70% to 92%, P < .001) were seen for CA. The strain polar map significantly improved reader confidence in making the correct diagnosis overall (P < .001). Regional variations in strain are easily recognizable, accurate, and reproducible means of differentiating causes of LVH. The detection of LVH etiology may be a useful clinical application for strain.
Publisher: The Endocrine Society
Date: 10-2008
DOI: 10.1210/JC.2008-1017
Abstract: Context: Obesity and insulin resistance (IR) may produce disturbances of left ventricular (LV) function. Obese women with polycystic ovary syndrome (PCO), characterized by hormonal and metabolic abnormalities, are thought to be at particularly increased cardiovascular risk. Objectives: We sought to determine the influence of IR on LV function in obese young women with and without PCO and without other comorbidities. Design: This was a cross-sectional study. Setting: The study was performed at a university hospital. Patients: A total of 150 women aged younger than 40 yr with a body mass index (BMI) of 30 kg/m2 or more was classified into three groups: with both PCO and IR, without PCO and with IR, and without either PCO or IR. Main Outcome Measures: Tissue Doppler-derived myocardial velocities, strain-rate and strain, and metabolic and hormonal measurements were calculated. Results: Subclinical impairment of LV systolic and diastolic function as indicated by lower peak strain (P & 0.001), peak systolic strain rate (P & 0.001), peak early diastolic strain rate (P & 0.001), and peak early diastolic velocity (P & 0.01) was demonstrated in both groups with IR. IR subjects with and without PCO did not differ in any LV function indices. Strain was independently associated with fasting insulin (β = −0.39 P & 0.001), urinary albumin excretion (UAE) (β = −0.36 P & 0.001), and BMI (β = −0.22 P & 0.03), and peak early diastolic strain rate was associated with UAE (β = −0.35 P & 0.001), fasting insulin (β = −0.24 P & 0.02), BMI (β = −0.23 P & 0.02), and SHBG (β = 0.20 P & 0.04). Conclusions: In obese young women, fasting insulin, BMI, SHBG, and UAE are independent correlates of impaired LV performance. The contribution of PCO to LV function abnormalities is linked to IR, but not to other hormonal aberrations associated with this condition.
Publisher: AMPCo
Date: 14-05-2018
DOI: 10.5694/MJA17.00809
Abstract: To investigate whether enrolment of patients in management programs after hospitalisation for heart failure (HF) reduces the likelihood of post-hospital adverse outcomes. Cohort study in which associations between adverse outcomes at 30 and 90 days for people hospitalised for HF and baseline clinical, socio-demographic and blood pathology factors, and with post-discharge management strategies, were assessed. Setting, participants: 906 patients with HF were prospectively enrolled in five Australian states at cardiology departments with expertise in treating people with HF. All-cause re-admissions and deaths at 30 and 90 days after discharge from the index admission. 58% of patients were men the mean age was 72.5 years (SD, 13.9 years). By hospital, 30-day re-admission rates ranged from 17% to 33%, and 90-day rates from 40% to 55% 30-day mortality rates were 0-13%, 90-day rates 4-24%. Factors associated with increased odds of re-admission or death at 30 or 90 days included living alone, cognitive impairment, depression, NYHA classification, left atrial volume index, and Charlson index score. Nurse-led disease management programs and reviews within 7 days were associated with reduced odds of re-admission (but not of death) at 30 and 90 days exercise programs were associated with reduced odds at 90 days. Significant between-hospital differences in re-admission rates were reduced after adjustment for post-discharge management programs, and abolished by further adjustment for echocardiography findings. Between-hospital differences in mortality were largely explained by differences in echocardiographic findings. Differences in early re-admission rates after hospitalisation for HF are primarily explained by differences in post-discharge management.
Publisher: Elsevier BV
Date: 08-2019
Publisher: Wiley
Date: 2004
Publisher: Elsevier BV
Date: 07-2012
DOI: 10.1016/J.ECHO.2012.03.018
Abstract: Accurate assessment of right ventricular (RV) size (RVS) and RV systolic function (RVSF) is vital in the management of various conditions, but their assessment is challenging using echocardiography. The aim of this study was to determine the accuracy and interobserver concordance of qualitative and quantitative RV echocardiography. Fifteen readers evaluated RV function in 12 patients (360 readings) who underwent echocardiography and cardiac magnetic resonance for RV assessment. Readers qualitatively estimated RVS and RVSF as normal, mild, moderate, or severe and then reassessed quantitatively by adding RV dimensions, fractional area change, S', tricuspid annular plane systolic excursion, and RV index of myocardial performance. Cardiac magnetic resonance was used as the reference standard for grading RVS and RVSF. Quantitative measurements increased accuracy and interreader agreement compared to qualitative assessment alone, especially in normal categories. Readers' accuracy for diagnosing normal and severe RVS increased from 38% to 78% (P = .001) and from 70% to 97% (P = .018), and readers' accuracy for diagnosing normal and mild RVSF increased from 52% to 84% (P < .001) and from 36% to 56% (P = .001). Interreader agreement for classification of the subjects as normal or abnormal improved from a κ value of 0.40 to 0.77 (fair to good agreement) for RVS and from 0.43 to 0.66 (moderate to good agreement) for RVSF. Visual estimation of RVS and RVSF is inaccurate and has wide interobserver variability. Quantitation improves accuracy and reliability, especially in distinction of normal and abnormal. The reliability of mild and moderate grades remains inadequate, and further guidance is needed for the classification of abnormal categories.
Publisher: Elsevier BV
Date: 2019
DOI: 10.1016/J.JCMG.2018.08.040
Abstract: Left ventricular (LV) systolic dysfunction is an adverse consequence of the pressure overload of severe aortic stenosis (AS). The enlargement of the interstitial space with reactive fibrosis and subsequently with replacement fibrosis and cell death has been suggested to be the main driver of the transition to symptoms, heart failure, and adverse cardiovascular events even after aortic valve replacement (AVR). Early and accurate recognition of myocardial dysfunction offers the potential to optimize the timing of intervention in severe AS. In the asymptomatic patient, an LV ejection fraction (EF) cutpoint of <50% has been used for this purpose. However, in most asymptomatic patients, an LVEF <50% is uncommon, and patients with an LVEF of 50% to 59% fare almost as badly. Moreover, the presence of a small LV cavity, the reliability and automation of the global longitudinal strain (GLS) signal, and the independent prognostic role of GLS are reasons why GLS could be expected to be a better marker of subclinical LV dysfunction in these patients. This review seeks to define whether the existing EF cutoff in AS should be modified or whether GLS should replace it as the marker of subclinical LV dysfunction.
Publisher: Elsevier BV
Date: 07-2019
Publisher: SAGE Publications
Date: 10-2001
Abstract: The financial and personal burden of chronic cardiac disease is high. Costs are likely to increase over the next few decades. Promising applications of telehealth have appeared in the diagnosis and management of cardiac disease and there are indications that telehealth services can improve the management of chronic cardiac disease as well as extend services to remote and rural populations. Telehealth has been applied to the capture of symptoms of cardiac disease with electrocardiography and echocardiography, to the management and rehabilitation of recently discharged patients, and in peer-to-peer consultation where remote expertise can facilitate diagnosis. Telehealth promises cost reductions in service delivery, although there is a need for properly controlled cost-effectiveness trials to underpin telehealth with a firm evidence base.
Publisher: Elsevier BV
Date: 03-1988
DOI: 10.1016/0167-5273(88)90051-4
Abstract: A case is described where severe hypophosphataemia was induced by a widely used protocol for glucose-insulin-potassium (GIK) infusion. Hypophosphataemia was found to be a universal sequel to the use of this infusion. A new regimen for administering this agent was designed, and shown to lack the potentially serious side effect of phosphate depletion.
Publisher: Elsevier BV
Date: 05-2012
DOI: 10.1016/J.AHJ.2012.02.017
Abstract: Noninvasive estimates of central blood pressure (BP) predict cardiovascular morbidity and mortality independent of brachial BP. However, there are limited data on the usefulness of central BP in clinical practice. This study aims to test the value of central BP as a management tool for physicians treating patients with essential hypertension. Participants with uncomplicated essential hypertension (N = 284) will be randomized to 12 months of treatment decisions guided by usual care (based on office, home, and 24-hour ambulatory brachial BP) or, in addition, by central BP estimated using radial tonometry (based on age- and sex-specific normal central systolic BP values). Recommendations regarding titration of antihypertensive medication (increase, decrease, or maintain dose) will be provided to each participant's general practitioner as well as the participant themselves. Relevant clinical information (eg, comorbidities, left ventricular [LV] mass, blood biochemistry, and BP-related symptoms) will be considered when making titration recommendations in all participants. The primary outcome measures will be (1) change in LV mass (by real-time 3-dimensional echocardiography), (2) amount of medication used, and (3) quality of life. Analysis will be by intention to treat. It is expected that there will be no significant difference in LV mass between groups. However, it is hypothesized that there will be significantly reduced use of medication and improved quality of life in the central BP group because more appropriate titration choices will be made to maintain normal central systolic BP. Results are expected in 2012.
Publisher: Wiley
Date: 21-04-2020
DOI: 10.1111/ECHO.14657
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2009
DOI: 10.1161/HYPERTENSIONAHA.109.133066
Abstract: Augmentation index (AIx), a correlate of mortality, is thought to be influenced by left ventricular contractility and wave reflections. However, the relationship of AIx with left ventricular contractility changes has never been assessed, and the wave reflection theory has recently been questioned. This study sought to examine arterial waveform changes in response to reduced “wave reflection” and increased left ventricular contractility induced by dobutamine. Simultaneous radial tonometry (for AIx) and tissue Doppler echocardiography (for peak longitudinal systolic strain rate [SR] as an analogue of left ventricular contractility) were recorded at rest and peak dobutamine-induced stress in 50 patients (41 men aged 62±10 years). From baseline to peak stress there was an increase in heart rate (70±11 to 127±17 bpm P .001) and SR (−0.88±0.23 to −1.81±0.43 1/s P .001), whereas AIx decreased (27±9% to −7±15% P .001). There was also a greater increase in the systolic (compared with diastolic) pressure-time integral relative to cardiac cycle length (3.2±1.9 versus 1.8±1.1 mm Hg P .001), indicating that wave reflection was not shifted into diastole as per the current belief. AIx was significantly associated with ejection duration ( r =0.88), heart rate ( r =−0.81), and SR ( r =0.72 P .001 for all). However, when SR was heart rate corrected, there was no significant association with AIx ( r =0.18 P =0.11). The strongest independent correlate of AIx was ejection duration, accounting for 78% variance (β=0.88 model R 2 =0.77 P .001). Neither SR (β=0.12 P =0.18) nor heart rate–corrected SR (β=0.02 P =0.72) was associated with AIx. We conclude that AIx is determined by chronotropic rather than inotropic effects, as well as factors other than wave reflection.
Publisher: Elsevier BV
Date: 09-2009
DOI: 10.1016/J.AMJCARD.2009.04.035
Abstract: There are variable reported effects of patient-prosthesis mismatch (P-PM) on outcome. It was hypothesized that the adverse effect attributed to P-PM is actually due to left ventricular diastolic dysfunction (DD) in patients with small hearts. The aim of this study was therefore to determine the association among P-PM, DD, and outcomes. Doppler echocardiography was performed in 156 patients after aortic valve replacement. In vivo effective orifice areas for each prosthesis type and size were obtained from published references values of normally functioning prostheses. P-PM was identified from the predicted indexed orifice area, obtained by iding the effective orifice area by body surface area. DD was classed as normal, delayed relaxation (prolonged deceleration time for age), or increased left atrial pressure (increased E/E' ratio, left atrial enlargement, short deceleration time). Events (cardiac-related hospitalizations and all-cause mortality after aortic valve replacement) were determined over a median follow-up periods of 3.5 years (interquartile range 2.1 to 5.7). P-PM was found in 91 patients (58%). Of the patients with P-PM, no DD was present on postoperative echocardiography in 15 patients (16%), delayed relaxation in 35 (39%), and increased left atrial pressure in 41 (45%). There were 61 total events (18 deaths and 43 hospitalizations): 4 (7%) in the no-DD group, 26 (42%) in the delayed relaxation group, and 31 (51%) in the increased left atrial pressure group. DD (p = 0.034) but not age (p = 0.09), the left ventricular ejection fraction (p = 0.60), or the presence of mismatch (p = 0.20) was associated with events. In conclusion, P-PM was associated with 14% mortality and a 39% composite event rate over 2-year follow-up. Events were significantly associated with DD.
Publisher: Elsevier BV
Date: 08-2018
Publisher: BMJ
Date: 2003
Abstract: Glucose-insulin-potassium (GIK) infusion improves cardiac function and outcome during acute ischaemia. To determine whether GIK infusion benefits patients with chronic ischaemic left ventricular dysfunction, and if so whether this is related to the presence and nature of viable myocardium. 30 patients with chronic ischaemic left ventricular dysfunction had dobutamine echocardiography and were given a four hour infusion of GIK. Segmental responses were quantified by improvement in wall motion score index (WMSI) and peak systolic velocity using tissue Doppler. Global responses were assessed by left ventricular volume and ejection fraction, measured using a three dimensional reconstruction. Myocardial perfusion was determined in 15 patients using contrast echocardiography. WMSI (mean (SD)) improved with dobutamine (from 1.8 (0.4) to 1.6 (0.4), p < 0.001) and with GIK (from 1.8 (0.4) to 1.7 (0.4), p < 0.001) there was a similar increment for both. Improvement in wall motion score with GIK was observed in 55% of the 62 segments classed as viable by dobutamine echocardiography, and in 5% of 162 classed as non-viable. There was an increment in peak systolic velocity after both dobutamine echocardiography (from 2.5 (1.8) to 3.2 (2.2) cm/s, p < 0.01) and GIK (from 3.0 (1.6) to 3.5 (1.7) cm/s, p < 0.001). The GIK effects were not mediated by changes in pulse, mean arterial pressure, lactate, or catecholamines, nor did they correlate with myocardial perfusion. End systolic volume improved after GIK (p = 0.03), but only in 25 patients who had viable myocardium on dobutamine echocardiography. In patients with viable myocardium and chronic left ventricular dysfunction, GIK improves wall motion score, myocardial velocity, and end systolic volume, independent of effects on haemodynamics or catecholamines. The response to GIK is observed in areas of normal and abnormal perfusion assessed by contrast echocardiography.
Publisher: Informa UK Limited
Date: 30-03-2011
DOI: 10.3109/08037051.2011.566251
Abstract: Masked hypertension (MH) independently predicts mortality but cannot be diagnosed from clinic blood pressure (BP) taken under resting conditions. We sought to determine if MH could be identified from BP taken during a single bout of low-intensity exercise. BP was recorded at rest and during brief low-level cycling exercise (60-70% of age-predicted maximal heart rate) in 75 untreated subjects with a hypertensive response to exercise (aged 54 ± 9 years). All subjects underwent 24-h ambulatory BP monitoring (ABPM) and MH was defined as clinic BP < 140/90 mmHg and ABPM BP ≥ 130/80 mmHg. There were 42 (56%) patients with MH, and at rest systolic (SBP) was higher in subjects with MH compared with those without MH (127 ± 9 vs 120 ± 9 mmHg p < 0.05). During exercise, MH subjects had significantly higher SBP (188 ± 22 vs 168 ± 15 mmHg p < 0.05), with a greater change from baseline (61 ± 21 vs 48 ± 15 mmHg p < 0.05). Low-level exercise SBP was independently associated with MH, and if ≥ 175 mmHg, identified MH with 74% sensitivity and 67% specificity (p < 0.001). MH can be identified in untreated in iduals from low-intensity exercise SBP. Further research on the diagnostic value of BP during early phases of exercise stress testing is needed.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2011
Publisher: Elsevier BV
Date: 08-2018
Publisher: Elsevier BV
Date: 09-2002
Abstract: Diastolic dysfunction induced by ischemia may alter transmitral blood flow, but this reflects global ventricular function, and pseudonormalization may occur with increased preload. Tissue Doppler may assess regional diastolic function and is relatively load-independent, but limited data exist regarding its application to stress testing. We sought to examine the stress response of regional diastolic parameters to dobutamine echocardiography (DbE). Sixty-three patients underwent study with DbE: 20 with low probability of coronary artery disease (CAD) and 43 with CAD who underwent angiography. A standard DbE protocol was used, and segments were categorized as ischemic, scar, or normal. Color tissue Doppler was acquired at baseline and peak stress, and waveforms in the basal and mid segments were used to measure early filling (Em), late filling (Am), and E deceleration time. Significant CAD was defined by stenoses >50% vessel diameter. Diastolic parameters had limited feasibility because of merging of Em and Am waves at high heart rates and limited reproducibility. Nonetheless, compared with normal segments, segments subtended with significant stenoses showed a lower Em velocity at rest (6.2 +/- 2.6 cm/s vs 4.8 +/- 2.2 cm/s, P <.0001) and peak (7.5 +/- 4.2 cm/s vs 5.1 +/- 3.6 cm/s, P <.0001). Abnormal segments also showed a shorter E deceleration time (51 +/- 27 ms vs 41 +/- 27 ms, P =.0001) at base and peak. No changes were documented in Am. The same pattern was seen with segments identified as ischemic with wall motion score. However, in the absence of ischemia, segments of patients with left ventricular hypertrophy showed a lower Em velocity, with blunted Em responses to stress. Regional diastolic function is sensitive to ischemia. However, a number of practical limitations limit the applicability of diastolic parameters for the quantification of stress echocardiography.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2009
DOI: 10.1161/CIRCIMAGING.109.862334
Abstract: Background— Although global left ventricular systolic function is an important determinant of mortality, standard measures such as ejection fraction (EF) and wall motion score index (WMSI) have important technical limitations. The aim of this study was to compare global longitudinal speckle strain (GLS), an automated technique for measurement of long-axis function, with EF and WMSI for the prediction of mortality. Methods and Results— Of 546 consecutive in iduals undergoing echocardiography for assessment of resting left ventricular function, 91 died over a period of 5.2�1.5 years. In addition to Simpson biplane EF, WMSI was determined by 2 experienced readers and GLS was calculated from 3 standard apical views using 2D speckle tracking. The incremental value of EF, WMSI, and GLS to significant clinical variables was assessed in nested Cox models. Clinical factors associated with outcome (model χ 2 =20.2) were age (hazard ratio [HR], 1.46 P .01), diabetes (HR, 1.88 P =0.01), and hypertension (HR, 1.59 P .05). Although addition of EF (HR, 1.23 P =0.03) or WMSI (HR, 1.28 P .01) added to the predictive power of clinical variables, the addition of GLS (HR, 1.45 P .001) caused the greatest increment in model power (χ 2 =34.9, P .001). GLS also provided incremental value in subgroups with EF % and those with and without wall motion abnormalities. A GLS ≥−12% was found to be equivalent to an EF ≤35% for the prediction of prognosis. Intraobserver and interobserver variations for EF and GLS were similar. Conclusions— GLS is a superior predictor of outcome to either EF or WMSI and may become the optimal method for assessment of global left ventricular systolic function.
Publisher: Elsevier BV
Date: 09-1999
DOI: 10.1016/S0735-1097(99)00269-7
Abstract: This study was performed to determine whether a delayed decline in systolic blood pressure (SBP) after graded exercise is an independent correlate of angiographic coronary disease. The predictive importance of the rate of SBP decline after exercise relative to blood pressure changes during exercise has not been well explored. Among adults who underwent symptom-limited exercise treadmill testing and who underwent coronary angiography within 90 days, a delayed decline in SBP during recovery was defined as a ratio of SBPs at 3 min of recovery to SBP at 1 min of recovery >1.0. Severe angiographic coronary artery disease was defined as left main disease, three-vessel disease or two-vessel disease with involvement of the proximal left anterior descending artery. There were 493 subjects eligible for analyses (age 59 +/- 11 years, 78% male). Severe angiographic coronary disease was noted in 102 (21%). There were associations noted between a delayed decline in SBP during recovery and severe angiographic coronary disease (34% vs. 17%, odds ratio [OR] 2.59, confidence interval [CI] 1.58 to 4.25, p = 0.001). In multivariate logistic regression analyses adjusting for SBP changes during exercise and other potential confounders, a delayed decline in SBP during recovery remained predictive of severe angiographic coronary disease (adjusted OR 2.22, 95% CI 1.27 to 3.87, p = 0.005). A delayed decline in SBP during recovery is associated with a greater likelihood of severe angiographic coronary disease even after accounting for the change in SBP during exercise.
Publisher: Elsevier BV
Date: 07-2016
DOI: 10.1016/J.CJCA.2016.05.001
Abstract: An increasing awareness of chemotherapy and radiotherapy as preventable causes of cardiac failure among large numbers of patients surviving cancer has contributed to the development of cardio-oncology as a subspecialty. Perhaps the most important driver has been that the aging of the population undergoing cancer therapy has provided an increasing number of patients at risk for the development of heart failure. Cardio-oncology has many unresolved questions. In this article the 6 most important unresolved issues requiring additional research are discussed: (1) the frequency of overt heart failure as a manifestation of cardiotoxicity (2) the optimal diagnostic approach to cardiotoxicity in the context of large numbers of patients requiring repeated testing (3) the need for better risk prediction (4) alternatives to the use of ejection fraction as the cornerstone of evaluation (5) definition of the best strategy for protection and (6) the need for evidence-based algorithms to guide late follow-up. When this evidence base is mature, we will have a better understanding of the magnitude of the problem of cardiotoxicity, who best to screen (and how), who justifies the use of cardioprotective therapy, and how all at-risk patients should be followed over the decades following cancer therapy.
Publisher: BMJ
Date: 10-2016
Publisher: Elsevier BV
Date: 03-2014
Publisher: Elsevier BV
Date: 02-2007
DOI: 10.1016/J.AMJCARD.2006.08.026
Abstract: Echocardiographic follow-up of left ventricular (LV) volumes is difficult because of the test-retest variation of 2-dimensional echocardiography (2DE). We investigated whether the accuracy and reproducibility of real-time 3-dimensional echocardiography (RT3DE) would make this modality more feasible for serial follow-up of LV measurements. We performed 2DE and RT3DE and cardiac magnetic resonance imaging (MRI) in 50 patients with previous infarction and varying degrees of LV function (44 men 61 +/- 11 years of age) at baseline and after 1-year follow-up. Images were obtained during breath-hold and measurements of LV volumes and ejection fraction were made offline. Over follow-up, end-diastolic volume decreased from 192 +/- 53 to 187 +/- 60 ml (p <0.01), end-systolic volume decreased from 104 +/- 51 to 95 +/- 53 ml (p <0.01), and ejection fraction increased from 48 +/- 12% to 51 +/- 12% (p <0.01). MRI showed that LV mass shrank from 183 +/- 39 to 182 +/- 37 g (p <0.01). The correlation between change in RT3DE and change in MRI was greater than the correlations of 2DE with MRI for measurement of end-diastolic volume (r = 0.47 vs 0.02, p <0.01), end-systolic volume (r = 0.44 vs 0.17, p <0.01), and ejection fraction (r = 0.58 vs -0.03, p <0.01). The change in end-diastolic volume between baseline and follow-up with RT3DE (-4 +/- 20, p <0.01) was similar to that with MRI but was unrecognized by 2DE (4 +/- 19, p = 0.09). There was good test-retest and inter- and intraobserver correlation within RT3DE for volumes, ejection fraction, and mass. In conclusion, if sequential measurement of LV volumes is used to guide management decisions, 3DE appears preferable to 2DE.
Publisher: BMJ
Date: 07-2021
DOI: 10.1136/BMJOPEN-2020-045896
Abstract: Effective identification and management of subclinical left ventricular (LV) dysfunction (LVD) and subclinical atrial fibrillation (AF) by screening elderly populations might be compromised by mild cognitive impairment (MCI). We sought to characterise the prevalence and profile of MCI and evaluate associations with LV and left atrial (LA) dysfunction and AF, in a trial of screening for subclinical LVD and AF. Cross-sectional. Australian, community-based intervention trial. Adults aged ≥65 years with ≥1 LVD risk factors without ischaemic heart disease (n=337). The Montreal cognitive assessment (MoCA) was obtained. Subclinical LVD was defined as echocardiographic global longitudinal strain ≤16%, diastolic dysfunction or LV hypertrophy abnormal LA reservoir strain (LARS) was defined as %. Subclinical AF was detected using a single-lead portable electrocardiographic device in those without pre-existing AF who gave consent (n=293). Subclinical LVD was found in 155 (46%), abnormal LARS in 9 (3.6%) and subclinical AF in 11 (3.8%). MoCA score consistent with MCI ( ) was found in 101 (30%) executive function (69%) and delayed recall (93%), were the most frequently abnormal domains. Compared with normal cognition, MCI was associated with non-adherence to AF screening (25% vs 40%, p=0.01). In multivariable logistic regression modelling, educational achievement, systolic blood pressure, body mass index and waist-to-hip ratio were independently associated with MCI. However, neither subclinical AF nor any measure of cardiac dysfunction, were associated with MCI. The 30% prevalence of MCI among elderly subjects with risk factors for subclinical LVD and AF has important implications for screening strategies and management. However, MCI is not associated with subclinical myocardial dysfunction nor subclinical AF. Australian New Zealand Clinical Trials Registry (ACTRN12617000116325).
Publisher: Elsevier BV
Date: 08-2012
DOI: 10.1016/J.JACC.2012.02.073
Abstract: This study sought to determine the utility of quantitation of right ventricular (RV) function in predicting RV failure in patients undergoing left ventricular assist device (LVAD) implantation. Clinical evaluation alone seems insufficient for predicting RV failure, an important cause of morbidity and mortality after LVAD implantation. Clinical, hemodynamic, and echocardiographic data were collected on 117 patients undergoing LVAD implantation. Standard pre-procedural echocardiographic RV measurements were supplemented by velocity vector imaging of RV free wall longitudinal strain. RV failure was defined as the need for placement of an RV assist device, or the use of inotropic agents for >14 days. Receiver operating characteristic curves were derived, with res ling to generate valid estimates of prediction accuracy. A net reclassification index was calculated for comparison of risk scores. RV failure occurred in 47 of 117 patients (40%). There was a significant difference in peak strain between patients with and without RV failure (-9.0% vs. -12.2% p < 0.01). A peak strain cutoff of -9.6% predicted RV failure with 76% specificity and 68% sensitivity. In a multivariate logistic regression analysis including variables from the established Michigan RV risk score, peak strain remained an independent predictor of RV failure. RV strain was incremental to the Michigan risk score as a predictor of RV failure (area under the receiver operating characteristic curve: 0.77 vs. 0.66 p < 0.01). The net reclassification index with strain was +10.4%. Reduced RV free wall peak longitudinal strain was associated with an increased risk for RV failure among patients undergoing LVAD implantation.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-1991
Abstract: We performed transcranial Doppler ultrasound (TCD) and transesophageal contrast echocardiography simultaneously in four patients. In one patient with a patent foramen ovale and another patient with pulmonary A-V fistulae, we detected micro air bubbles in the right middle cerebral artery three to five cardiac cycles after their appearance in the left atrium following intravenous injection of contrast. In two patients without right-to-left shunts, we did not detect air bubbles in the left atrium or middle cerebral artery following injection of contrast. These results show that TCD can identify patients with right-to-left cardiac or pulmonary shunts.
Publisher: American Diabetes Association
Date: 06-2002
DOI: 10.2337/DIACARE.25.6.1042
Abstract: OBJECTIVE—This study sought to determine whether stress echocardiography using exercise (when feasible) or dobutamine echo could be used to predict mortality in patients with diabetes. RESEARCH DESIGN AND METHODS—Stress echo was performed in 937 patients with diabetes (aged 59 ± 13 years, 529 men) for symptom evaluation (42%) and follow-up of known coronary artery disease (CAD) (58%). Stress echocardiography using exercise was performed in 333 patients able to exercise maximally, and dobutamine echo using a standard dobutamine stress was used in 604 patients. Patients were followed for ≤9 years (mean 3.9 ± 2.3) for all-cause mortality. RESULTS—Normal studies were obtained in 567 (60%) patients 29% had resting left ventricular (LV) dysfunction, and 25% had ischemia. Abnormalities were confined to one territory in 183 (20%) patients and to multiple territories in 187 (20%) patients. Death (in 275 [29%] patients) was predicted by referral for pharmacologic stress (hazard ratio [HR] 3.94, P & 0.0001), ischemia (1.77, P & 0.0001), age (1.02, P = 0.002), and heart failure (1.54, P = 0.01). The risk of death in patients with a normal scan was 4% per year, and this was associated with age and selection for pharmacologic stress testing. In stepwise models replicating the sequence of clinical evaluation, the predictive power of independent clinical predictors (age, selection for pharmacologic stress, previous infarction, and heart failure model χ2 = 104.8) was significantly enhanced by addition of stress echo data (model χ2 = 122.9). CONCLUSIONS—The results of stress echo are independent predictors of death in diabetic patients with known or suspected CAD. Ischemia adds risk that is incremental to clinical risks and LV dysfunction.
Publisher: Springer Science and Business Media LLC
Date: 24-06-2015
Publisher: Elsevier BV
Date: 08-2002
DOI: 10.1016/S0002-9149(02)02461-X
Abstract: The risk of cardiac events in patients undergoing major noncardiac surgery is dependent on their clinical characteristics and the results of stress testing. The purpose of this study was to develop a composite approach to defining levels of risk and to examine whether different approaches to prophylaxis influenced this prediction of outcome. One hundred forty-five consecutive patients (aged 68 +/- 9 years, 79 men) with >1 clinical risk variable were studied with standard dobutamine-atropine stress echo before major noncardiac surgery. Risk levels were stratified according to the presence of ischemia (new or worsening wall motion abnormality), ischemic threshold (heart rate at development of ischemia), and number of clinical risk variables. Patients were followed for perioperative events (during hospital admission) and death or infarction over the subsequent 16 +/- 10 months. Ten perioperative events occurred in 105 patients who proceeded to surgery (10%, 95% confidence interval [CI] 5% to 17%), 40 being cancelled because of cardiac or other risk. No ischemia was identified in 56 patients, 1 of whom (1.8%) had a perioperative infarction. Of the 49 patients with ischemia, 22 (45%) had 1 or 2 clinical risk factors 2 (9%, 95% CI 1% to 29%) had events. Another 15 patients had a high ischemic threshold and 3 or 4 risk factors 3 (20%, 95% CI 4% to 48%) had events. Twelve patients had a low ischemic threshold and 3 or 4 risk factors 4 (33%, 95% CI 10% to 65%) had events. Preoperative myocardial revascularization was performed in only 3 patients, none of whom had events. Perioperative and long-term events occurred despite the use of beta blockers 7 of 41 beta blocker-treated patients had a perioperative event (17%, 95% CI 7% to 32%) these treated patients were at higher anticipated risk than untreated patients (20 +/- 24% vs 10 +/- 19%, p = 0.02). The total event rate over late follow-up was 13%, and was predicted by dobutamine-atropine stress echo results and heart rate response.
Publisher: Elsevier BV
Date: 07-1988
DOI: 10.1016/0002-9149(88)91398-7
Abstract: Krüppel-like factor 4 (KLF4) is a zinc finger transcription factor that functions as an oncogene or tumor suppressor in a highly tissue-specific cell-dependent manner. However, its precise role in breast cancer and metastasis remains unclear. Here, we show that transient adenoviral expression of KLF4 in the 4T1 orthotopic mammary cancer model significantly attenuated primary tumor growth as well as micrometastases to the lungs and liver. These results can be attributed, in part, to decreased proliferation and increased apoptosis. Further supporting a tumor-suppressive role for KLF4 in the breast, we found that KLF4 expression is lost in a mouse model of HER2/NEU/ERBB2-positive breast cancer. To determine whether enforced KLF4 expression could alter tumor latency in these mice, we used a doxycycline-inducible expression model in the context of the MMTV-Neu transgene. Surprisingly, tumors that developed in this model also lost KLF4 expression, suggesting negative selection for sustained expression. We have previously reported that KLF4 inhibits epithelial-to-mesenchymal transition (EMT), a preliminary step in metastatic progression. Overexpression of KLF4 in 4T1 cells led to a significant reduction in the expression of Snail, a key mediator of EMT and metastasis. Conversely, KLF4 silencing increased Snail expression in the nontransformed MCF-10A cell line. Collectively, these data demonstrate the first functional, in vivo evidence for KLF4 as a tumor suppressor in breast cancer cells. Furthermore, our findings suggest an inhibitory role for KLF4 during breast cancer metastases that functions, in part, through repression of Snail.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2018
DOI: 10.1161/CIRCIMAGING.114.002077
Abstract: Infarct heterogeneity has been shown to be independently associated with adverse outcomes in previous smaller studies. However, it is unknown whether infarct characterization is an independent predictor of all-cause mortality in patients with advanced ischemic cardiomyopathy, after adjusting for clinical risk factors, severity of ischemic mitral regurgitation, incomplete revascularization, and device therapy. A total of 362 patients with ischemic cardiomyopathy (left ventricular dysfunction with % stenosis in ≥1 epicardial coronary artery) underwent delayed hyperenhancement-magnetic resonance imaging and coronary angiography between 2002 and 2006. Total myocardial scar and peri-infarct (PI) area were measured using various threshold techniques. Multivariate survival analysis (primary end point of all-cause mortality) was conducted. One hundred fifty-seven deaths occurred during a mean 5.4-year follow-up (mean left ventricular ejection fraction, 23±9% mean end-systolic volume index, 113±48 mL mean total myocardial scar %, 25.5±16.0% mean PI%, 5.7±2.9%). PI% (β=2.07 P .001) was an independent predictor of survival, independent of age, end-systolic volume, sex, mitral regurgitation, diabetes mellitus, dyslipidemia, coronary artery disease severity, implantable cardioverter defibrillator, and incomplete revascularization. PI% using 2 to 3 SD technique yielded the highest incremental prognostic power (χ 2 score 149). In advanced ischemic cardiomyopathy, PI% is a powerful independent and incremental predictor of all-cause mortality. Infarct heterogeneity offers substantial further risk stratification when compared with quantification of total myocardial scar % alone even after adjusting for clinical risk factors, end-systolic volume index, mitral regurgitation, incomplete revascularization, and implantable cardioverter defibrillator implantation.
Publisher: Elsevier BV
Date: 2002
Abstract: Systolic myocardial Doppler velocity accurately identifies coronary artery disease. However, these velocities may be affected by age, hemodynamic responses to stress, and left ventricular cavity size. We sought to examine the influences of these variables on myocardial velocity during dobutamine stress in patients with normal wall motion. One hundred seventy-nine consecutive patients with normal dobutamine echocardiograms were studied. Color myocardial tissue Doppler data were obtained at rest and peak stress, and peak systolic myocardial velocity (PSV) was measured in all basal and midventricular segments. Velocities at rest and peak stress were compared with left ventricular diastolic and systolic volumes, blood pressure, heart rate, and age by Pearson correlation and interdecile analysis by use of analysis of variance. The only clinical variable correlating with velocity was age PSV showed only mild correlation with age at rest (r2 = 0.01, P =.001) and peak stress (r2 = 0.02, P =.001), but the normal peak velocity was significantly different between the extremes of age ( 74 years). There was very weak correlation of PSV with systolic and diastolic blood pressure (r2 < 0.01), heart rate (r2 < 0.01), systemic vascular resistance (r2 = 0.08), and left ventricular volumes (r2 < 0.01). Peak systolic velocity during dobutamine stress is relatively independent of hemodynamic factors and left ventricular cavity size. The extremes of age may influence peak systolic Doppler velocities. These results suggest that peak systolic velocity may be a robust quantitative measure during dobutamine echocardiography across most patient subgroups.
Publisher: Oxford University Press (OUP)
Date: 18-12-2014
DOI: 10.1093/EHJCI/JEU184
Abstract: Recognizing the critical need for standardization in strain imaging, in 2010, the European Association of Echocardiography (now the European Association of Cardiovascular Imaging, EACVI) and the American Society of Echocardiography (ASE) invited technical representatives from all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. As an initial product of the work of the EACVI/ASE/Industry initiative to standardize deformation imaging, we prepared this technical document which is intended to provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocardiography and thus create a common standard.
Publisher: Springer Science and Business Media LLC
Date: 04-04-2009
DOI: 10.1007/S00392-009-0014-4
Abstract: The ONTARGET and TRANSCEND clinical trials were designed to investigate the cardioprotective effects of telmisartan 80 mg and ramipril 10 mg, alone and in combination, in patients at high risk of cardiovascular disease. Cardiac MRI enables investigation of mechanistic effects of these agents on cardiac structural and functional variables. Here, we report the design, analysis protocol, reproducibility and relevant quality control procedures, and baseline patient characteristics of the ONTARGET/TRANSCEND cardiac MRI substudy. MRI was undertaken in 330 subjects enrolled in ONTARGET, and 38 subjects in TRANSCEND, across eight centers in six countries. Analyses were performed by two independent analysts using guide-point modeling. Cases with discrepancies in LV mass (LVM) of >5% were independently reanalyzed. Cases with discrepancies in end-diastolic volume (EDV) of >5%, or end-systolic volume (ESV) of >12%, were then reconciled by consensus. Baseline characteristics were broadly similar to the main ONTARGET/TRANSCEND trials, except for a higher frequency of coronary artery disease and Asian ethnicity in the substudy. Reproducibility of MRI analyses (mean +/- SD) were 2.8 +/- 3.7 ml in EDV, -0.3 +/- 3.6 ml in ESV, 3.1 +/- 3.3 ml in SV, 1.1 +/- 1.8% in EF, and 0.4 +/- 4.5 g in LVM. Subgroup analyses revealed increased ESV and LVM, and reduced EF, in subjects with a history of either coronary artery disease or myocardial infarction. The ONTARGET/TRANSCEND cardiac MRI substudy protocol provides for a reliable assessment of the effects of telmisartan and ramipril, alone and in combination, on cardiac structural and functional parameters over a 2-year follow-up period.
Publisher: Wiley
Date: 05-02-2018
DOI: 10.1002/EHF2.12257
Publisher: Springer Science and Business Media LLC
Date: 19-11-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2019
Publisher: Wiley
Date: 10-2014
DOI: 10.1111/IMJ.12532
Abstract: Improvements in survival from cancer have led to a large population who are at risk of late complications of chemotherapy. One of the most serious cardiovascular complications is chemotherapy-related cardiomyopathy (CRC), which may become clinically overt years or even decades after treatment and has over threefold higher mortality rate compared with idiopathic dilated cardiomyopathy. The early stages of this condition appear to respond well to cardioprotective medications (i.e. angiotensin-converting enzyme inhibitors, β-blockers). Periodic cardiac monitoring is necessary in this population to identify patients who would benefit from treatment. Cardio-oncology clinics have been established in recognition of this hazard in survivorship. This review summarises the epidemiology and pathophysiology of CRC, the evidence base for different non-invasive imaging modalities for screening and diagnosis and the rationale for treatment.
Publisher: SAGE Publications
Date: 04-2006
DOI: 10.1177/0310057X0603400218
Abstract: B-type natriuretic peptide (BNP) is the first biomarker of proven value in screening for left ventricular dysfunction. The availability of point-of-care testing has escalated clinical interest and the resultant research is defining a role for BNP in the investigation and treatment of critically ill patients. This review was undertaken with the aim of collecting and assimilating current evidence regarding the use of BNP assay in the evaluation of myocardial dysfunction in critically ill humans. The information is presented in a format based upon organ system and disease category. BNP assay has been studied in a spectrum of clinical conditions ranging from acute dyspnoea to subarachnoid haemorrhage. Its role in diagnosis, assessment of disease severity, risk stratification and prognostic evaluation of cardiac dysfunction appears promising, but requires further elaboration. The heterogeneity of the critically ill population appears to warrant a range of cut-off values. Research addressing progressive changes in BNP concentration is hindered by infrequent assay and appears unlikely to reflect the critically inpatient's rapidly changing haemodynamics. Multi-marker strategies may prove valuable in prognostication and evaluation of therapy in a greater variety of illnesses. Scant data exist regarding the use of BNP assay to alter therapy or outcome. It appears that BNP assay offers complementary information to conventional approaches for the evaluation of cardiac dysfunction. Continued research should augment the validity of BNP assay in the evaluation of myocardial function in patients with life-threatening illness.
Publisher: BMJ
Date: 10-2007
Publisher: Elsevier BV
Date: 10-2017
DOI: 10.1016/J.JACC.2017.07.792
Abstract: Type 2 diabetes mellitus (T2DM) may alter cardiac structure and function, but obesity, hypertension (HTN), or aging can induce similar abnormalities. This study sought to link cardiac phenotypes in T2DM patients with clinical profiles and outcomes using cluster analysis. Baseline echocardiography and a composite endpoint (cardiovascular mortality and hospitalization) were evaluated in 842 T2DM patients from 2 prospective cohorts. A cluster analysis was performed on echocardiographic variables, and the association between clusters and clinical profiles and outcomes was assessed. Three clusters were identified. Cluster 1 patients had the lowest left ventricular (LV) mass index and ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e') ratio, had the highest left ventricular ejection fraction (LVEF), and were predominantly male with the lowest rate of obesity or HTN. Cluster 2 patients had the highest strain and highest E/e' ratio, were the oldest, were predominantly female, and had the lowest rate of isolated T2DM (without HTN or obesity). Cluster 3 patients had the highest LV mass index and volumes and the lowest LVEF and strain, were predominantly male, and shared similar age and rate of obesity and HTN as cluster 1 patients. After follow-up of 67 months (interquartile range: 40 to 87), the composite endpoint occurred in 56 of 521 patients (10.8%). Clusters 2 (hazard ratio: 2.37 95% confidence interval: 1.15 to 4.88) and 3 (hazard ratio: 2.19 95% confidence interval: 1.00 to 4.82) had a similar outcome, which was worse than cluster 1. Cluster analysis of echocardiographic variables identified 3 different echocardiographic phenotypes of T2DM patients that were associated with distinct clinical profiles and highlighted the prognostic value of LV remodeling and subclinical dysfunction.
Publisher: Wiley
Date: 16-01-2019
DOI: 10.1002/EJHF.1399
Publisher: Elsevier BV
Date: 11-2019
DOI: 10.1016/J.JCMG.2018.08.017
Abstract: The aim of this study was to evaluate the relative value of baseline and follow-up echocardiographic assessment of pulmonary artery systolic pressure (PASP) and right ventricular (RV) function in assessing response to vasodilator therapy in pulmonary arterial hypertension (PAH). Routine follow-up of PASP and RV function is widely obtained in patients undergoing treatment for PAH, but the value of this reassessment is uncertain. Of 162 prospectively recruited patients with PAH, 96 were included in this analysis of patients with ≥3 sequential echocardiographic studies. PASP and RV function (including right ventricular free wall strain [RVFWS]) were measured at baseline and on follow-up 2-dimensional echocardiography. Univariate and multivariate Cox regression with nested models was used to determine incremental and independent predictors of all-cause mortality. Changes between visits were minimal for all parameters (RVFWS, p = 0.46 RV end diastolic area, p = 0.48 tricuspid annular plane systolic excursion, p = 0.32 PASP, p = 0.66 right atrial area, p = 0.39 and inferior vena cava, p = 0.25). Over 3 years of follow-up, 29 patients died. Baseline RVFWS was an independent predictor of outcome (hazard ratio [HR]: 0.90 95% confidence interval [CI]: 0.83 to 0.97 p = 0.007), incremental to PASP and other clinical covariates (C statistic = 0.74, p = 0.001). Those who died showed no differences in RVFWS (p = 0.50), PASP (p = 0.90), and tricuspid annular plane systolic excursion (p = 0.83) between visits. When baseline measures and follow-up time were accounted for, mean changes in RVFWS (HR: 0.78 95% CI: 0.63 to 0.96 p = 0.002), right atrial area (HR: 1.20 95% CI: 1.07 to 1.40 p = 0.003), and inferior vena cava (HR: 66.5 95% CI: 8.5 to 520.5 p < 0.001) over follow-up were significant in predicting outcome. In PAH, baseline RV function (RVFWS) is a strong predictor of outcome, independent of PASP. Changes throughout therapy appear minimal, and only changes in RVFWS, inferior vena cava, size, and right atrial area were associated with outcome.
Publisher: Portland Press Ltd.
Date: 11-2003
DOI: 10.1042/CS20030211
Abstract: The detection of preclinical heart disease is a new direction in diabetes care. This comment describes the study by Vinereanu and co-workers in this issue of Clinical Science in which tissue Doppler echocardiography has been employed to demonstrate subtle systolic and diastolic dysfunction in Type II diabetic patients who had normal global systolic function and were free of coronary artery disease. The aetiology of early ventricular dysfunction in diabetes relates to complex intramyocardial and extramyocardial mechanisms. The initiating event may be due to insulin resistance, and involves abnormal myocardial substrate utilization and uncoupling of mitochondrial oxidative phosphorylation. Dysglycaemia plays an important role via the effects of oxidative stress, protein kinase C activation and advanced glycosylation end-products on inflammatory signalling, collagen metabolism and fibrosis. Extramyocardial mechanisms involve peripheral endothelial dysfunction, arterial stiffening and autonomic neuropathy. The clinical significance of the ventricular abnormalities described is unknown. Confirmation of their prognostic importance for cardiac disease in diabetes would justify routine screening for presymptomatic ventricular dysfunction, as well as clinical trials of novel agents for correcting causal mechanisms. These considerations could also have implications for patients with obesity and the metabolic syndrome.
Publisher: Elsevier BV
Date: 11-1992
DOI: 10.1016/0735-1097(92)90359-U
Abstract: The purpose of this study was to determine the role of intraoperative echocardiography in planning the site and extent of myectomy and in ensuring adequate control of the left ventricular outflow tract gradient. Although intraoperative echocardiography has been found to be beneficial in patients undergoing valve repair, its impact on surgical decisions in patients undergoing septal myectomy for hypertrophic cardiomyopathy has not been described. In 50 patients undergoing septal myectomy over a 5-year period, epicardial echocardiography was performed before cardiopulmonary bypass to establish the extent of outflow tract obstruction, locate its site and plan the myectomy. In 30 patients, transesophageal echocardiography was also used to corroborate data on outflow tract anatomy and examine the mitral valve. In 40 patients (80%) the initial myectomy resulted in a reduction of the maximal outflow tract gradient from 88 +/- 45 to 24 +/- 11 mm Hg, measured by epicardial continuous wave Doppler echocardiography. Ten patients (20%) were shown by postbypass intraoperative echocardiography to have an unsatisfactory result, based on a persistent gradient > 50 mm Hg (n = 7) or persistent mitral regurgitation of greater than moderate severity (n = 3). The postbypass two-dimensional echocardiogram was then used to direct the surgeon toward the most likely site of continued obstruction, and cardiopulmonary bypass was reinstituted to permit further myectomy (n = 9) or mitral valve repair (n = 1). After the second or subsequent period of cardiopulmonary bypass, the outflow tract gradient (26 +/- 14 mm Hg) was substantially reduced and was not significantly different from the postbypass gradient (24 +/- 11 mm Hg) in the group with initial surgical success. At postoperative follow-up (20 +/- 37 weeks), the maximal measured outflow tract gradient (22 +/- 21 mm Hg) showed no difference between patients with immediate surgical success and those requiring a second period of cardiopulmonary bypass for further resection. Intraoperative echocardiography proved a useful tool to guide the site and extent of septal myectomy, leading to more adequate surgical resection and to persistence of satisfactory control of the outflow tract obstruction into the early follow-up period.
Publisher: Elsevier BV
Date: 08-2014
DOI: 10.1016/J.AHJ.2014.04.004
Abstract: Cardiac magnetic resonance (CMR) identifies important prognostic variables in ischemic cardiomyopathy (ICM) patients such as left ventricular (LV) volumes, LV ejection fraction (LVEF), peri-infarct zone, and myocardial scar burden (MSB). It is unknown whether Doppler-based diastolic dysfunction (DDF) retains its prognostic value in ICM patients, in the context of current imaging, medical, and device therapies. Diastolic function was evaluated in ICM patients (LVEF ≤ 40% and ≥ 70% stenosis in ≥ 1 coronary artery) who underwent transthoracic echocardiogram and delayed hyperenhancement CMR studies within 7 days. The association of DDF with the combined end point was assessed after risk-adjustment using Cox proportional hazards models. A total of 360 patients with severe LV dysfunction (LVEF = 24 ± 9%) and extensive MSB (31 ± 17%) were evaluated DDF was present in all patients (stage 1%-44%, stage 2%-25%, stage 3%-31%). There were 130 events (124 deaths and 6 heart transplants) over a median follow-up of 5.8 years (IQR, 3.7-7.4 years). On multivariable analysis, DDF > stage 1 (HR, 1.37 P = .007) was associated with the combined end-point, independent of clinical risk score (HR, 2.40 P < .0001), implantable cardioverter defibrillator implantation (HR, 0.60 P = .009), incomplete revascularization (HR, 1.32 P = .003), mitral regurgitation (HR, 3.37 P = .01), peri-infarct zone area (HR, 1.04 P = 0.02), and MSB (HR, 1.02 P = .01). DDF had incremental prognostic value for the combined end-point (model χ(2) increased from 89 to 95, P = .02). DDF is a powerful predictor of mortality in ICM patients with significant LV dysfunction, independent of clinical and CMR data. DDF assessment provides incremental value, improving risk stratification.
Publisher: Elsevier BV
Date: 11-2019
Publisher: Wiley
Date: 09-1989
Publisher: Elsevier BV
Date: 03-2022
Publisher: Oxford University Press (OUP)
Date: 04-09-2006
Abstract: Technological advances in cardiac imaging have led to dramatic increases in test utilization and consumption of a growing proportion of cardiovascular healthcare costs. The opportunity costs of strategies favouring exercise echocardiography or SPECT imaging have been incompletely evaluated. We examined prognosis and cost-effectiveness of exercise echocardiography (n = 4884) vs. SPECT (n = 4637) imaging in stable, intermediate risk, chest pain patients. Ischaemia extent was defined as the number of vascular territories with echocardiographic wall motion or SPECT perfusion abnormalities. Cox proportional hazard models were employed to assess time to cardiac death or myocardial infarction (MI). Total cardiovascular costs were summed (discounted and inflation-corrected) throughout follow-up. A cost-effectiveness ratio < Dollars 50,000 per life year saved (LYS) was considered favourable for economic efficiency. The risk-adjusted 3-year death or MI rates classified by extent of ischaemia were similar, ranging from 2.3 to 8.0% for echocardiography and from 3.5 to 11.0% for SPECT (model chi2 = 216 P < 0.0001 interaction P = 0.24). Cost-effectiveness ratios for echocardiography were < Dollars 20,000/LYS when the annual risk of death or MI was 2%, cost-effectiveness ratios for echocardiography vs. SPECT were in the range of Dollars 66,686-Dollars 419,522/LYS. For patients with established coronary disease (i.e. > or = 2% annual event risk), SPECT ischaemia was associated with earlier and greater utilization of coronary revascularization (P < 0.0001) resulting in an incremental cost-effectiveness ratio of Dollars 32,381/LYS. Health care policies aimed at allocating limited resources can be effectively guided by applying clinical and economic outcomes evidence. A strategy aimed at cost-effective testing would support using echocardiography in low-risk patients with suspected coronary disease, whereas those higher risk patients benefit from referral to SPECT imaging.
Publisher: AMPCo
Date: 02-2006
DOI: 10.5694/J.1326-5377.2006.TB00173.X
Abstract: To estimate the prevalence of heart failure (HF) and left ventricular (LV) systolic dysfunction in a population-based s le of older Australians. A cross-sectional survey of 2000 randomly selected residents of Canberra, aged 60-86 years, conducted between February 2002 and June 2003. Participants were assessed by history, physical examination by a cardiologist, and echocardiography. Age- and sex-specific prevalence rates of clinical HF and LV systolic dysfunction (defined as LV ejection fraction < or = 50%). Of 1846 people eligible for our study, 1388 (75%) agreed to participate and 1275 completed all investigations (mean age, 69.4 years 50% men). In the study s le, 72 subjects (5.6% 95% CI, 4.4%-7.1%) had clinical HF that had been previously diagnosed and was confirmed by our assessment. A further 0.6% (95% CI, 0.3%-1.2%) had undiagnosed clinical HF (ie, evidence of structural heart disease and symptoms/signs of cardiac insufficiency without a previous diagnosis of clinical HF). Thus, the overall prevalence of clinical HF in the s le was 6.3% (95% CI, 5.0%-7.7%). Clinical HF increased in prevalence with advancing age (a 4.4-fold increase from the 60-64-years age group to the 80-86-years age group P < 0.0001). Of the 75 subjects (5.9% 95% CI, 4.7%-7.3%) with LV systolic dysfunction, 44 (59%) were in the preclinical stage of disease. Diagnosed HF cases represent the "tip of the iceberg" for the national burden of HF and LV systolic dysfunction. Clinically identifiable HF cases can remain undiagnosed, and the majority of people with LV systolic dysfunction are in a preclinical stage of the disease.
Publisher: Springer Science and Business Media LLC
Date: 21-10-2021
DOI: 10.1007/S10554-021-02444-4
Abstract: Afterload is an important determinant of left ventricular (LV) and atrial (LA) function, including myocardial strain. Central blood pressure (CBP) is the major component of cardiac afterload and independently associated with cardiovascular risk. However, the optimal means of calibrating CBP is unclear-standard CBP assessment uses systolic (SBP) and diastolic blood pressure (DBP) from brachial waveforms, but calibration with mean pressure (MAP) and DBP purports to be more accurate. Therefore, we sought to determine which CBP is best associated with LA and LV strain. CBP was measured using both standard and MAP based calibration methods in 546 participants (age 70.7 ± 4.7 years, 45% male) with risk factors for heart failure. Echocardiography was performed in all patients and strain analysis conducted to assess LA/LV function. The associations of CBP with LA and LV strain were assessed using linear regression. MAP-derived CSBP (150 ± 20 mmHg) was higher than standard CSBP (128 ± 15 mmHg) and brachial SBP (140 ± 17 mmHg, p 0.05), however was independently associated with LA reservoir strain (p 0.05). MAP-derived CBP was more accurate in identifying patients with abnormal LA and LV strain than brachial SBP and standard CBP calibration. In conclusion, CBP calibrated using MAP and DBP may be more accurate in identifying patients with abnormal LA and LV function than standard brachial calibration methods.
Publisher: Elsevier BV
Date: 10-2016
Publisher: BMJ
Date: 12-2003
Abstract: The clinical applications of tissue Doppler imaging in the assessment of left ventricular diastolic function have moved from the experimental lab to clinical practice.
Publisher: BMJ
Date: 10-2020
DOI: 10.1136/BMJOPEN-2020-036960
Abstract: Hypertension confers a poor prognosis in moderate or severe aortic stenosis (AS), however, antihypertensive therapy (AHT) is often not prescribed due to the perceived deleterious effects of vasodilation and negative inotropes. To assess the efficacy and safety outcomes of AHT in adults with moderate or severe AS. Systematic review and meta-analysis. The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and grey literature were searched without language restrictions up to 9 September 2019. Two independent reviewers performed screening, data extraction and risk of bias assessments from a systematic search of observational studies and randomised controlled trials comparing AHT with a placebo or no AHT in adults with moderate or severe AS for any parameter of efficacy and safety outcomes. Conflicts were resolved by the third reviewer. Meta-analysis with pooled effect sizes using random-effects model, were estimated in R . Mortality, Left Ventricular (LV) Mass Index, systolic blood pressure, diastolic blood pressure and LV ejection fraction From 3025 publications, 31 studies (26 500 patients) were included in the qualitative synthesis and 24 studies in the meta-analysis. AHT was not associated with mortality when all studies were pooled, but heterogeneity was substantial across studies. The effect size of AHT differed according to drug class. Renin–angiotensin–aldosterone system inhibitors (RAASi) were associated with reduced risk of mortality (Pooled HR 0.58, 95% CI 0.43 to 0.80, p=0.006), The differences in changes of haemodynamic or echocardiographic parameters from baseline with and without AHT did not reach statistical significance. AHT appears safe, is well tolerated. RAASi were associated with clinical benefit in patients with moderate or severe AS.
Publisher: Oxford University Press (OUP)
Date: 07-2016
DOI: 10.1093/EHJCI/JEW135
Abstract: Load dependence is an important source of variation in left ventricular (LV) deformation. This impacts on the precision of information obtained from serial measurements. However, it is clinically important to distinguish actual myocardial dysfunction from changes associated with altered loading conditions. We sought to investigate the association of changes of loading parameters with changes in LV longitudinal (GLS) and circumferential (GCS) strains. Baseline and a 12-month follow-up 2D echocardiograms were performed in 191 Stage A heart failure patients with uncomplicated hypertension. These patients underwent simultaneous measurement of conventional and central blood pressures (BPs) and haemodynamic measurements by applanation tonometry. Significant, but weak correlations (r = 0.15-0.28) of LV strain parameters and their changes over the follow-up period were shown for the majority of LV afterload-associated variables, including central and brachial systolic, diastolic, and mean BPs 24-h systolic and diastolic BPs peak reservoir and excess pressures central augmented pressure (CAP) and pulse pressure augmentation index and arterial elastance index (EaI). Central mean BP, EaI, and changes in CAP and EaI over follow-up were independent contributors to LV deformation in multivariable analysis. No improvement in the Bland-Altman 95% limits of agreement and correlation coefficients was seen with LV afterload correction of GLS and GCS using central BP indices. LV longitudinal and circumferential strains in a population without apparent heart disease is relatively insusceptible to changes in LV afterload within physiological range, which, therefore, seem unlikely to be a significant confounder in repeated GLS or GCS observations.
Publisher: Elsevier BV
Date: 2003
Publisher: BMJ
Date: 09-02-2015
DOI: 10.1136/HEARTJNL-2014-306990
Abstract: Recent work has shown no difference in change of LVEF between RV apical (RVA) pacing and non-RVA pacing in patients with normal LV function. We hypothesised that a more sensitive marker (global longitudinal strain, GLS) could identify a detrimental effect of RVA and that assessment of deformation could identify whether dyssynchrony, contraction inefficiency and regional LV impairment were responsible for functional changes. In this substudy of Protect-PACE (The Protection of Left Ventricular Function During Right Ventricular Pacing. Does Right Ventricular High-septal Pacing Improve Outcome Compared With Right Ventricular Apical Pacing?), a randomised controlled trial of RVA and non-RVA pacing in pacemaker-dependent patients with preserved EF, 145 patients (76 with RVA) with echocardiograms of sufficient quality underwent measurement of LV longitudinal strain (GLS) from speckle tracking just after implantation and at 2 years. LV dyssynchrony, discoordination and regional apical longitudinal strain were also measured. Pacing was associated with reduced GLS after 2 years, although 2-year GLS was lower in RVA (-13.9 ± 4.1 vs -15.5 ± 4.6, p = 0.02). RVA was an independent correlate of ΔGLS, although there was a minor difference in ΔGLS between the RVA and non-RVA groups (-1.8 ± 3.6 vs -0.8 ± 3.4%, p= 0.07), reflecting impairment of GLS at baseline in RVA. Apical strain was significantly lower in RVA than those in non-RVA at baseline and 2 years (both p < 0.01). Dyssynchrony and discoordination parameters at 2 years also showed significant deterioration in RVA. Apical strain, dyssynchrony and discoordination parameters at 2 years were significantly associated with ΔGLS. Inefficient dyssynchronous contraction and the decrease in apical strain appear to be associated with global LV impairment in RVA. PROTECT-PACE ClinicalTrials.gov number NCT00461734.
Publisher: Elsevier BV
Date: 10-2009
DOI: 10.1016/J.AMJCARD.2009.05.028
Abstract: Myocardial deformation parameters are sensitive markers of global left ventricular (LV) systolic function, but their interaction with LV geometry is unknown. We sought to investigate the effect of LV geometry on myocardial deformation and its interaction with coronary artery disease (CAD). A total of 126 patients with normal resting LV function who underwent dobutamine stress echocardiography subsequently underwent coronary angiography within 6 months. Longitudinal myocardial deformation was calculated using tissue Doppler echocardiography. The extent of CAD was identified by quantitative coronary angiography. Patients with an increased relative wall thickness had a significantly lower peak strain rate (SR) and a smaller change in SR with stress, with no differences in the at rest values. Those with CAD, had significantly lower peak SR values and change in SR with no difference in resting measures. A linear regression model showed that the relative wall thickness and extent of CAD were the strongest predictors of change in SR. An increasing extent of CAD caused a steady degradation in the peak SR and change in peak SR. Markers of longitudinal myocardial deformation at peak stress reflect both myocardial and interstitial properties. In conclusion, a major determinant of subendocardial function is the wall thickness, as measured by the relative wall thickness, and not LV hypertrophy.
Publisher: Wiley
Date: 1990
Abstract: Dipyridamole thallium imaging has been proposed for cardiac risk stratification in patients undergoing peripheral vascular surgery. The purpose of this study was to define the benefit of this investigation in routine preoperative evaluation of these patients. The outcome of 86 patients undergoing vascular surgery procedures was examined in light of preoperative clinical assessment and dipyridamole SPECT thallium imaging (DST). Fifty-one patients (59%) were considered at high risk on clinical grounds, and 22 patients (26%) had perfusion defects. Ten patients suffered a perioperative coronary event, including unstable angina, myocardial infarction, or cardiac death. Seven of the patients with such events were among the 51 clinically high-risk subjects (14%). Three perioperative events occurred in the group of 19 patients with positive DST images who underwent surgery (16%), but the DST test failed to identify 7 patients who suffered coronary events. The frequency of abnormal thallium imaging was similar to the prevalence of angiographically significant coronary disease reported previously at this center, but considerably less than the rate of abnormal thallium imaging in past studies of vascular surgery patients. The application of the test to a low to moderate risk population is probably responsible for its lower predictive accuracy for coronary events. DST is not an ideal routine noninvasive technique for risk stratification in patients undergoing vascular surgery.
Publisher: Springer Science and Business Media LLC
Date: 24-03-2009
DOI: 10.1007/S12350-009-9076-Y
Abstract: We sought to assess and compare the diagnostic accuracy and prognostic value of dobutamine stress echocardiography (DSE), dobutamine SPECT, and adenosine SPECT myocardial perfusion imaging (MPI) in patients with end-stage renal disease (ESRD). The optimal stress imaging modality for patients with ESRD has not yet been determined. Forty-nine patients with ESRD underwent DSE, dobutamine SPECT MPI, and adenosine SPECT MPI. The primary endpoint of the trial was concordance between stress tests with respect to the presence or absence of ischemia. Agreement on the presence or absence of ischemia between adenosine SPECT MPI and DSE was 69% (kappa = .25, P = NS). Agreement on the presence or absence of ischemia between adenosine and dobutamine SPECT MPI was 77% (kappa = .37, P = <.009). Summed stress scores for adenosine and dobutamine SPECT MPI studies were highly correlated (r = .9, P = <.0001). DSE and SPECT MPI results provided incremental prognostic information when added to clinical variables. There is moderate concordance between DSE and adenosine SPECT MPI in ESRD patients referred for stress testing. Interobserver agreement was higher for SPECT MPI compared to DSE. Based on these observations, the optimal approach for diagnosing severe coronary artery disease and assessing risk in patients with ESRD has yet to be determined, but appears to warrant further investigation.
Publisher: Springer Science and Business Media LLC
Date: 2007
Publisher: Elsevier BV
Date: 07-2008
DOI: 10.1016/J.AMJCARD.2008.02.101
Abstract: Different patterns of abnormal left ventricular (LV) geometry are associated with variations in prognosis, but the mechanisms of these effects remain undefined. We investigated the association of myocardial deformation with these findings and their evolution. Two-dimensional echocardiography was performed in 85 hypertensive patients referred for serial evaluation (age 58 +/- 13 years, 48% male). LV mass index and regional wall thickness were used to assign patients into groups with normal geometry, concentric remodeling, concentric hypertrophy, and eccentric hypertrophy. Septal strain and strain rate were measured using velocity vector imaging. The evolution of morphological changes was followed over 2.7 +/- 1.3 years. Analysis of LV geometry revealed normal geometry in 13 patients (15%), concentric remodeling in 20 (24%), concentric hypertrophy in 42 (49%), and eccentric hypertrophy in 10 (12%). Overall strain was -13.6 +/- 4.5%, and strain rate was -0.65 +/- 0.24/second. Strain was significantly lower in patients with concentric remodeling (-12.8 +/- 4.2%) or concentric hypertrophy (-12.5 +/- 4.1%) compared with patients with normal geometry (-17.5 +/- 5.5%, p < or =0.05), and these associations were independent of blood pressure. Strain rate was also significantly reduced in patients with concentric hypertrophy (p < or =0.01). There were no significant differences in baseline strain, wall stress, blood pressure, or age between patients who changed LV geometric class and those who did not. In conclusion, baseline myocardial tissue deformation, but not evolution, is associated with LV geometry in treated hypertensive patients.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2011
DOI: 10.1161/CIRCHEARTFAILURE.110.959312
Abstract: Diastolic dysfunction (DD) is associated with adverse cardiovascular outcomes. We studied the impact of an exercise-based lifestyle intervention on the evolution of DD in patients with type 2 diabetes mellitus (T2DM) and prospectively investigated the clinical correlates of DD progression. A total of 223 outpatients with T2DM were randomized to supervised exercise-based lifestyle intervention (initial gym-based program and lifestyle and diet advice followed by telephone-guided supervision) or usual care. Patients underwent echocardiographic assessment of diastolic function and metabolic and clinical evaluation at baseline and 3 years. Changes in prevalence and evolution of DD were assessed and correlations sought with clinical and metabolic variables. DD was present in 50% of patients at baseline and 54% at 3 years, with no difference between the usual care and intervention groups (60% versus 48%, P =0.10). Abnormal DD at the final visit was independently associated with older age and a decrease in peak oxygen consumption over time ( P .05). There was no impact on glycemic control or exercise capacity. In a subanalysis restricted to patients who finished the full 3-year follow-up, control subjects were independently associated with DD at 3 years (β=0.90 odds ratio, 2.46 P =0.034), with the only other independent correlate being older age (β=0.05 odds ratio, 1.06 P =0.019). Despite being efficacious in the subgroup who completed 3 years of exercise-based lifestyle intervention, randomization to this program was not effective in reducing progression of subclinical DD in patients with T2DM, which may reflect the recognized difficulty of adherence to prolonged exercise intervention. URL: www.anzctr.org.au . Unique identifier: ACTRN12607000060448.
Publisher: Elsevier BV
Date: 09-2008
Publisher: Elsevier BV
Date: 08-1996
Publisher: Elsevier BV
Date: 10-2017
Publisher: Elsevier BV
Date: 10-2018
DOI: 10.1016/J.AHJ.2018.07.001
Abstract: The National Echocardiography Database Australia (NEDA) is a new echocardiography database collecting digital measurements on both a retrospective and prospective basis. To date, echocardiographic data from 435,133 in iduals (aged 61.6 ± 17.9 years) with linkage to 59,725 all-cause deaths during a median of 40 months follow-up have been collected. These data will inform a number of initial analyses focusing on pulmonary hypertension, aortic stenosis and the role of artificial intelligence to facilitate accurate diagnoses of cardiac abnormalities.
Publisher: Elsevier BV
Date: 2004
DOI: 10.1016/J.AMJCARD.2003.09.029
Abstract: The extent of abnormality in patients with positive dobutamine echocardiography (DE) is predictive of risk, but the wall motion score (WMS) has low concordance among observers. We sought whether quantifying the extent of abnormal wall motion using tissue Doppler (TD) could guide risk assessment in patients with abnormal DE in 576 patients with known or suspected coronary artery disease standard DE was combined with color TD imaging at peak dose. WMS was assessed by an expert observer and studies were identified as abnormal in the presence of >/=1 segments with resting or stress-induced wall motion abnormalities. Patients with abnormal DE had peak systolic velocity measured in each segment. Tissue tracking was used to measure myocardial displacement. Follow-up for death or infarction was performed after 16 +/- 12 months. Of 251 patients with abnormal DE, 22 patients died (20 from cardiac causes) and 7 had nonfatal myocardial infarctions. The average WMS in patients with events was 1.8 +/- 0.5, compared with 1.7 +/- 0.5 in patients without events (p = NS). The average systolic velocity in patients with events was 4.9 +/- 1.7 cm/s and 6.4 +/- 6.5 cm/s in the patients without events (p <0.001). The average tissue tracking in patients with events was 4.5 +/- 1.5 mm and was significant (5.7 +/- 3.1 mm) in those without events (p <0.001). Thus, TD is an alternative to WMS for quantifying the total extent of abnormal left ventricular function at DE, and appears to be superior for predicting adverse outcomes.
Publisher: Elsevier BV
Date: 07-2007
DOI: 10.1016/J.ECHO.2006.12.010
Abstract: The accuracy, reproducibility, and test-retest reliability of 3-dimensional (3D) echocardiography (3DE) with 3D reconstruction (3DR) and real-time (RT) imaging (RT 3DE) exceed that of 2-dimensional echocardiography (2DE). However, image quality with RT 3DE is inferior to 2DE and we sought to determine whether this justified ongoing use of 3DR. Unselected patients (n = 30, 22 men, age 66 +/- 7 years) presenting to the echocardiography laboratory for left ventricular (LV) evaluation were studied with 2DE and RT 3DE 3DR images were obtained using external localization. The 3D measurements and reconstructions were obtained offline. Magnetic resonance images (MRI) were obtained using true free induction, steady state precession during breath hold and 3D volumes and ejection fraction (EF) were measured using 3D software. A separate cohort of 20 patients (13 men, age 60 +/- 12 years) was measured for test-retest variation. All echocardiographic measures underestimated LV volumes and EF compared with MRI, but this was least with RT 3DE. End-diastolic volume by MRI (168 +/- 54 mL) was underestimated by RT 3DE (-15 +/- 31, P = .02), 3DR (-26 +/- 33, P < .01), and 2DE (-57 +/- 40, P < .01). Similarly, end-systolic volume by MRI (86 +/- 50 mL) was underestimated by RT 3DE (-15 +/- 31, P = .02), 3DR (-26 +/- 33, P < .01), and 2DE (-57 +/- 40, P < .01). However, EF measurements were similar with each method. Test-retest variation was less and interobserver and intraobserver correlations were better with RT 3DE for volumes and EF, compared with 3DR and 2DE. Despite limitations of image quality, RT 3DE is the most feasible and accurate approach for LV volume and EF measurements and follow-up LV assessment in daily practice.
Publisher: Wiley
Date: 03-1990
Abstract: This report describes the occurrence of chest pain and electrocardiographic features of acute myocardial infarction following intravenous dipyridamole-handgrip stress. Myocardial perfusion imaging (Rb-82 PET) demonstrated a stress-induced perfusion defect. Following failure to respond to medical therapy, urgent cardiac catheterization demonstrated total occlusion of the left anterior descending coronary artery. The vessel was revascularized, with limitation of myocardial damage evidenced by failure to develop anterior Q waves and only modest elevation of cardiac enzyme levels. Complications of intravenous dipyridamole stress are rare, this case constituting the first major problem in over 500 such procedures at this institution. However, this experience demonstrates the importance of vigilant observation during the performance of this technique.
Publisher: Elsevier BV
Date: 08-2022
DOI: 10.1016/J.JACC.2022.04.064
Abstract: Residual congestion detected using handheld ultrasound may be associated with increased risk of readmission and death after hospitalization for acute decompensated heart failure (ADHF). However, effective application necessitates routine use by nonexperts delivering clinical care. The objective of this study was to determine the ability of heart failure (HF) nurses to deliver a predischarge lung and inferior vena cava (IVC) assessment (LUICA) to predict 90-day outcomes. In this multisite, prospective, observational study, HF nurses scanned 240 patients with ADHF (median age: 77 years 56% men) using a 9-zone LUICA protocol. Obtained images were reviewed by independent nurses who were blinded to clinical characteristics and outcomes. Based on a B-line cut-off of 10, patients were dichotomized as congested (n = 115) or not congested (n = 125). Congested patients were more likely to have previous cardiac operations, long-standing HF (>6 months), and renal impairment. At 90 days, HF readmission or mortality occurred in 42 congested patients (37%) compared with 18 noncongested patients (14%). Pulmonary congestion increased at 30-day (OR: 3.86 95% CI: 1.65-8.99 P < 0.01) and 90-day (OR: 3.42 95% CI: 1.82-6.4 P < 0.01) HF readmission or mortality risk and 90-day mortality (OR: 5.18 95% CI: 1.44-18.69 P < 0.01). Pulmonary congestion increased the 90-day odds of HF readmission and/or death by 3.3- to 4.2-fold (P < 0.01), independent of demographics, HF characteristics, comorbidities, and event risk score. Over 90 days, days alive out of hospital were fewer (78.3 ± 21.4 days vs 85.5 ± 12.4 days P < 0.01) in congested patients. LUICA can be a powerful tool for detection of predischarge residual congestion. HF nurses can obtain images and provide diagnostic reports that are predictive of ADHF outcomes.
Publisher: Elsevier BV
Date: 11-2003
Publisher: American Medical Association (AMA)
Date: 06-2016
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2014
DOI: 10.1161/CIRCIMAGING.113.001177
Abstract: The decision-making role of exercise echocardiography in the surgical timing for aortic regurgitation remains a matter of debate because of limited data on its link with outcome. The aim of this study was to assess the role of echocardiographic measurements at rest and during exercise as predictors of valve surgery in asymptomatic aortic regurgitation. Comprehensive resting and exercise echocardiography was performed in 159 consecutive patients (50±15 years 80% male) with isolated moderately severe to severe aortic regurgitation and preserved left ventricular (LV) function (LV ejection fraction %, LV end-diastolic dimension ≤70 mm, LV end-systolic dimension ≤50 mm or ≤25 mm/m 2 ) in whom initial management was expectant. Echocardiographic measurements were performed at rest and during exercise. LV and right ventricular (RV) longitudinal strain was analyzed at rest using velocity vector imaging. Valve surgery was performed in 50 patients (31%) during 30±21 months. After adjustment for age and sex in a multivariable Cox proportional-hazards model, exercise tricuspid annular plane systolic excursion (TAPSE hazards ratio [HR], 0.48 P =0.001) was associated with valve surgery-free, independent of resting LV strain (HR, 1.63 P =0.005), exercise LV end-diastolic volume (HR, 1.38 P =0.048), and resting RV strain (HR, 1.69 P =0.002). In sequential Cox models, a model based on clinical data (χ 2 , 20.4) was improved by resting LV strain (χ 2 , 30.1 P =0.001), resting RV strain (χ 2 , 49.7 P .001), and further increased by exercise TAPSE (χ 2 , 64.4 P .001). In asymptomatic aortic regurgitation, resting LV strain, resting RV strain, and exercise TAPSE were independently associated with the need for earlier aortic surgery.
Publisher: Oxford University Press (OUP)
Date: 06-2008
DOI: 10.1038/AJH.2008.166
Abstract: A hypertensive response to exercise has prognostic significance. Patients with type 2 diabetes have vascular abnormalities which may predispose to exaggerated brachial and central blood pressure (BP) during exercise. This study aimed to test this hypothesis and to determine the clinical significance of high exercise BP by examining its relation to left ventricular (LV) mass. Brachial and central BP were recorded at rest and in response to maximal exercise in 73 diabetic patients (aged 54 +/- 10 years) and 73 controls (aged 53 +/- 12 years). Brachial BP was recorded using mercury sphygmomanometry and LV mass using 2D-echocardiography. Central BP was estimated by radial tonometry using an exercise-validated generalized transfer function. At rest there were no significant (P > 0.05) differences between groups in brachial or central BP. The diabetic patients had significantly increased exercise brachial systolic BP (SBP: 199 +/- 25 mm Hg vs. 185 +/- 21 mm Hg P = 0.002) and central SBP (158 +/- 17 mm Hg vs. 149 +/- 15 mm Hg P = 0.002). There was a significantly higher prevalence of an exaggerated exercise BP response (> or =210/105 mm Hg men and > or =190/105 mm Hg women) in the diabetic patients (51% vs. 22% P < 0.01). Compared with those with normal exercise BP, LV relative wall thickness (RWT) was significantly higher (0.41 +/- 0.09 vs. 0.36 +/- 0.08 P < 0.05) and LV hypertrophy was more prevalent (35% vs. 16% P < 0.05) in those with a hypertensive response. After accounting for other confounding variables, exercise central SBP remained independently associated with LV RWT (beta = 0.22 P = 0.006). Diabetic patients are more likely to exhibit exaggerated exercise BP. Regardless of disease status, high exercise central SBP may contribute to cardiovascular risk via adverse cardiac remodeling.
Publisher: Springer Science and Business Media LLC
Date: 03-07-2008
DOI: 10.1038/JHH.2008.71
Abstract: Central systolic blood pressure (SBP) may differ between in iduals with similar brachial SBP, which may have implications for risk assessment. This study aimed to determine the variation and potential clinical value of central SBP between patients with similar brachial SBP. Brachial SBP was measured by sphygmomanometer and central SBP by radial tonometry in 675 people (430 men), comprising healthy in iduals (n = 222), patients with known or suspected coronary artery disease (n = 229) and diabetes (n = 224). In iduals were stratified by brachial SBP in accordance with European Society of Hypertension guidelines (optimal, normal, high-normal, grades 1, 2 and 3 hypertension). The potential clinical value of central SBP was determined from the percentage of patients re-classified into different brachial SBP groups due to the difference between brachial and aortic SBP (defined as brachial SBP-central SBP). Central SBP increased with each brachial SBP level (optimal to grade 3 hypertension P < 0.001 for all). However, large variation in brachial-aortic SBP difference occurred within each brachial SBP group (range 2-33 mm Hg), resulting in sizeable overlap of central SBP between brachial SBP groups. For patients with normal brachial SBP, 96% had central SBP within the range of patients with high-normal brachial SBP, as well as 64% within the range of patients with grade 1 hypertension. We conclude that wide variation in brachial-aortic SBP difference occurs between patients with similar brachial SBP. This results in a significant overlap of central SBP scores between brachial SBP risk groups. This is likely to have treatment implications but remains to be tested.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 27-10-2015
Abstract: There has been an increasing interest in use of mineralocorticoid receptor antagonists ( MRA s) in patients with heart failure with preserved ejection fraction ( HFPEF ). However, a comprehensive evaluation of MRA effects on left ventricular ( LV ) structure and function in these patients is lacking. In this meta‐analysis, we evaluated the effects of MRA s on LV structure and function among patients with diastolic dysfunction or HFPEF . Randomized, controlled clinical trials evaluating the efficacy of MRA s in patients with diastolic dysfunction or HFPEF were included. The primary outcome was change in E/e’, a specific measure of diastolic function. Secondary outcomes included changes in other measures of diastolic function, LV structure, surrogate markers for myocardial fibrosis (carboxy‐terminal peptide of procollagen type I [ PICP ] and amino‐terminal peptide of pro‐collagen type‐ II [ PIIINP ]), blood pressure, and exercise tolerance. In the pooled analysis, MRA use was associated with significant reduction in E/e’ (weighted mean difference [ WMD ] [95% confidence interval { CI }]: −1.68 [−2.03 to −1.33] P .0001) and deceleration time ( WMD [95% CI ]: −12.0 ms [−23.3 to −0.7] P =0.04) as compared with control, suggesting and improvement in diastolic function. Furthermore, blood pressure and levels of PIIINP and PICP were also significantly reduced with MRA therapy with no significant change in LV mass or dimensions. MRA therapy in patients with asymptomatic diastolic dysfunction or HFPEF is associated with significant improvement in diastolic function and markers of cardiac fibrosis without a significant change in LV mass or dimensions.
Publisher: Elsevier BV
Date: 03-2008
DOI: 10.1016/J.AMJCARD.2007.10.037
Abstract: Echocardiography is frequently used for sequential evaluation of left ventricular (LV) function, although the reproducibility of such conventional measurements as LV ejection fraction (EF) have been questioned. The utility of such newer measurements as tissue Doppler imaging and left atrial (LA) size in serial clinical testing are undefined. The magnitude and clinical relevance of changes in conventional and new measurements of LV function were investigated and compared in 346 consecutive patients undergoing sequential echocardiography. Change in LA area, LVEF, tissue E velocity (Em), and transmitral E to Em ratio (E/Em) were compared over 304 +/- 239 days. Changes within and between parameters (after mean correction to make measurements comparable) were assessed in groups designated as stable (n = 144) or unstable (n = 202) according to clinical progress. A single observer remeasured these parameters in stable patients in idually and with paired studies side by side. Significant variability was seen in all measurements, with change in LVEF the only parameter differing between stable and unstable groups (6.4 +/- 8.9% vs 9.4 +/- 5.4% p <0.001). Tissue Em and E/Em ratio were more variable than LA area or LVEF. In stable patients, LVEF changed the least and E/Em changed the most over time (p <0.05). With a single blinded observer, Em had improved reproducibility (1.5 +/- 1.9 vs 2.3 +/- 2.6 cm/s p <0.001), as did visual EF. In conclusion, variability in all measurements was high irrespective of clinical status. Newer measurements were no better than LVEF in detecting changes in clinical status. Sequential LV assessment should be interpreted with caution, and more robust measurements are needed.
Publisher: Elsevier BV
Date: 04-2019
Publisher: Oxford University Press (OUP)
Date: 12-2000
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 20-12-2005
DOI: 10.1161/CIRCULATIONAHA.104.489310
Abstract: Background— Assessment of myocardial viability based on wall-motion scoring (WMS) during dobutamine echocardiography (DbE) is difficult and subjective. Strain-rate imaging (SRI) is quantitative, but its incremental value over WMS for prediction of functional recovery after revascularization is unclear. Methods and Results— DbE and SRI were performed in 55 stable patients (mean age, 64±10 years mean ejection fraction, 36±8%) with previous myocardial infarction. Viability was predicted by WMS if function augmented during low-dose DbE. SR, end-systolic strain (ESS), postsystolic strain (PSS), and timing parameters were analyzed at rest and with low-dose DbE in abnormal segments. Regional and global functional recovery was defined by side-by-side comparison of echocardiographic images before and 9 months after revascularization. Of 369 segments with abnormal resting function, 146 showed regional recovery. Compared with segments showing functional recovery, those that failed to recover had lower low-dose DbE SR, SR increment (ΔSR), ESS, and ESS increment (ΔESS) (each P .005). After optimal cutoffs for the strain parameters were defined, the sensitivity of low-dose DbE SR (78%, P =0.3), ΔSR (80%, P =0.1), ESS (75%, P =0.6), and ΔESS (74%, P =0.8) was better though not significantly different from WMS (73%). The specificity of WMS (77%) was similar to the SRI parameters. Combination of WMS and SRI parameters augmented the sensitivity for prediction of functional recovery above WMS alone (82% versus 73%, P =0.015 area under the curve=0.88 versus 0.73, P .001), although specificities were comparable (80% versus 77%, P =0.2). Conclusions— The measurement of low-dose DbE SR and ΔSR is feasible, and their combination with WMS assessment improves the sensitivity of viability assessment with DbE.
Publisher: Wiley
Date: 08-2011
Abstract: To describe the rationale and design of the Which Heart failure Intervention is most Cost-effective & consumer friendly in reducing Hospital care (WHICH?) trial. WHICH? is a pragmatic, multicentre, randomized controlled trial that seeks to determine if multidisciplinary management of chronic heart failure (CHF) patients post-acute hospitalization delivered in a patient's own home is superior to care delivered via a specialist CHF outpatient clinic. The composite primary endpoint is all-cause, unplanned recurrent hospitalization or death during 12-18 months of follow-up. Of 688 eligible patients, 280 patients (73% male and 66% principal diagnosis of CHF) with a mean age of 71 ± 14 years have been randomized to home- (n = 143) or clinic-based (n = 137) post-discharge management. This will provide 80% power (two-sided alpha of 0.05) to detect a 15% absolute difference in both the primary end-point and rate of all-cause hospital stay. Preliminary data suggest that the two groups are well matched in nearly all baseline socio-economic and clinical parameters. The majority of patients have significant co-morbidity, including hypertension (63%), coronary artery disease (55%), and atrial fibrillation (53%) with an accordingly high Charlson Index of Comorbidity Score (6.1 ± 2.4). Despite its relatively small size, the WHICH? trial is well placed to examine the relative impact of two of the most commonly applied forms of face-to-face management designed to reduce recurrent hospitalization and prolong survival in CHF patients.
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.ECHO.2019.07.003
Abstract: Although atrial fibrillation (AF) is a significant population health burden, and an avoidable cause of stroke, AF screening remains controversial. The aim of this study was to investigate whether coincidental echocardiography could provide information about patients at risk for AF. Asymptomatic participants ≥65 years of age with more than one AF risk factor (N = 445) undergoing echocardiography for risk evaluation were followed over a median of 15 months for incident AF. Left atrial volume index (LAVi), left ventricular (LV) global longitudinal strain (GLS absolute value), left atrial (LA) strain, and LV mass were measured. During the follow-up period, AF was diagnosed clinically by primary care physicians or by using a single-lead portable electrocardiographic monitoring device (five 60-sec recordings performed by participants over 1 week). AF was diagnosed in 45 patients (10% mean age, 70.5 ± 4.2 years 55% women). AF detection was higher in those with LV hypertrophy, GLS 34 mL/m Echocardiography is widely used in patients at risk for AF, and simple LV and LA measurements may be used to enrich the process of AF screening.
Publisher: BMJ
Date: 28-06-2010
Publisher: Elsevier BV
Date: 12-2006
DOI: 10.1016/J.AMJCARD.2006.07.026
Abstract: Intraventricular dyssynchrony has prognostic implications in patients who have severe functional limitation and decreased ejection fraction. Patients with less advanced cardiac disease often exhibit intraventricular dyssynchrony, but there is little available information about its prognostic relevance in such patients. We investigated the prognostic effect of intraventricular dyssynchrony on outcome in 318 patients with known or suspected coronary artery disease who were classified according to the presence or absence of left ventricular dysfunction and heart failure symptoms. Mortality was considered the primary end point over a median follow-up of 56 months, and a Cox proportional hazards model was used for survival analysis. Despite a low prevalence (8%) of left bundle branch block, there was a high prevalence of intraventricular dyssynchrony even in patients without symptomatic heart failure. The magnitude of intraventricular dyssynchrony correlated poorly with QRS duration (r = 0.25), end-systolic volume index (r = 0.27), and number of scar segments (r = 0.25). There were 58 deaths during follow-up. Ventricular volume, ischemic burden, and magnitude of intraventricular dyssynchrony predicted outcome, but magnitude of intraventricular dyssynchrony was an independent predictor of survival only in patients with asymptomatic left ventricular dysfunction. In conclusion, patients with known or suspected coronary artery disease have a high prevalence of intraventricular dyssynchrony. Although ventricular volume, ischemic burden, and intraventricular dyssynchrony are potentially important prognostic markers, the relative importance of intraventricular dyssynchrony changes with the clinical setting and may be greatest in patients with preclinical disease.
Publisher: Elsevier BV
Date: 06-2019
DOI: 10.1016/J.JACC.2019.03.482
Abstract: There is increasing evidence that current thresholds for diagnosing pulmonary hypertension (PHT) underestimate the prognostic impact of PHT. The aim of this study was to determine the prognostic impact of increasing pulmonary pressures within the National Echocardiography Database of Australia cohort (n = 313,492). The distribution of estimated right ventricular systolic pressure (eRVSP) was examined in 157,842 men and women. All had data linkage to long-term survival during median follow-up of 4.2 years (interquartile range: 2.2 to 7.5 years). The cohort comprised 74,405 men and 83,437 women 65.6 ± 17.7 years of age. Overall, 17,955 (11.4%), 7,016 (4.4%), and 4,515 (2.9%) subjects had eRVSP levels indicative of mild (40 to 49 mm Hg), moderate (50 to 59 mm Hg), or severe (≥60 mm Hg) PHT, respectively, assuming a right atrial pressure of 5 mm Hg. These subjects were more likely to die during long-term follow up (for severe PHT, adjusted hazard ratio: 9.73 95% confidence interval: 8.60 to 11.0 p < 0.001). After adjustment for age, sex, and evidence of left heart disease, those subjects with eRVSP levels within the third (28.05 to 32.0 mm Hg hazard ratio: 1.410 95% confidence interval: 1.310 to 1.517) and fourth (32.05 to 38.83 mm Hg hazard ratio: 1.979 95% confidence interval: 1.853 to 2.114) quintiles had significantly higher mortality (p 30.0 mm Hg) indicative of PHT was identified. (A Longitudinal Cohort Study of Echocardiograms From Public and Private Echocardiography Laboratories From Around Australia, Linked With the National Deaths Index ACTRN12617001387314).
Publisher: Elsevier BV
Date: 2015
DOI: 10.1016/J.JACC.2014.10.044
Abstract: Stage B heart failure (SBHF) describes asymptomatic ventricular disease that may presage the development of heart failure (HF) symptoms. This entity has been largely defined by structural changes the roles of sensitive indicators of nonischemic left ventricular (LV) dysfunction, such as LV strain, are undefined. This study sought to define the association of exercise capacity with left ventricular hypertrophy (LVH) and systolic/diastolic dysfunction in asymptomatic patients with HF risk factors. We used echocardiography to study 510 asymptomatic patients (age 58 ± 12 years) with type 2 diabetes mellitus, hypertension, or obesity. The results of cardiopulmonary exercise testing in patients with structural evidence of SBHF were compared with those in patients with subclinical dysfunction, defined by reduced LV strain (>-18%) or increased LV filling pressure (E/e' >13). Compared with healthy subjects, groups with LV abnormalities differed in terms of oxygen uptake (peak VO2): 25.5 ± 8.2 versus 21.0 ± 8.2 for strain >-18% (p 13 (p < 0.0001) and 26.0 ± 7.7 versus 15.9 ± 6.9 ml/kg/min for LVH (p < 0.0001). SBHF, defined as ≥1 imaging variable present, was associated with lower peak VO2 (beta = -0.20 p < 0.0001) and metabolic equivalents (beta = -0.21 p < 0.0001), independent of higher body mass index and insulin resistance, older age, male sex, and treatment with beta-blockers. LVH, elevated LV filling pressure, and abnormal myocardial deformation were independently associated with impaired exercise capacity. Including functional markers may improve identification of SBHF in nonischemic heart disease.
Publisher: American Medical Association (AMA)
Date: 10-2019
Publisher: Springer Science and Business Media LLC
Date: 09-12-2014
DOI: 10.1007/S40258-014-0141-6
Abstract: In the symptomatic patient, severe aortic stenosis (AS) has an extremely adverse prognosis in the absence of valve replacement, inevitably leading to deterioration of heart function, heart failure, and death. However, many patients with severe AS, advanced age, and comorbid disease may die with AS rather than from AS. While the results of surgical aortic valve replacement (SAVR) are extremely favorable, this technique is not always possible because of either local- or patient-level contraindications. Over the last decade, transcatheter aortic valve replacement (TAVR) has emerged as a new treatment strategy for selected patients with AS. It has now become the standard of care for extremely high-risk (inoperable) patients with AS, and is an appropriate alternative to surgery in high-risk but operable patients. However, whether this intervention is a cost-effective use of resources is open to question The aim of this review was to assess the results and quality of the economic evaluations in the current literature and to identify the drivers of cost effectiveness. We performed an electronic data search using four different electronic databases, selecting all studies that included cost-effectiveness data for TAVR compared with either medical management or surgery. Sixteen studies were evaluated for a qualitative and quantitative assessment. The quality of the cost-effectiveness analyses (CEAs) were generally sufficient. In contrast, we found an extreme heterogeneity of input assumptions with consequent difficulties to generalize the conclusions. However, in the population of patients with severe symptomatic AS and a prohibitive surgical risk, TAVR generally represents a good choice, with incremental costs that are well balanced by the great benefit in terms of quality of life and survival. Nevertheless, the cost effectiveness of this procedure in the real world, particularly in patients with high healthcare costs from other comorbid conditions, may be less favorable. In AS patients with high (but not prohibitive) surgical risk, the choice between TAVR and SAVR is still debatable. Both procedures are comparable in terms of efficacy and safety but the evidence is inconclusive from an economic point of view. On the basis of this review, it was ascertained that the details of risk evaluation and patient selection will be critical in understanding how improvements in survival can be used to target the use of TAVR to ensure the cost-effective and sustainable use of resources.
Publisher: Elsevier BV
Date: 11-1999
DOI: 10.1016/S0894-7317(99)70150-1
Abstract: The association of aortic regurgitation with left ventricular size, hypertrophy, and abnormal coronary flow may influence the accuracy of stress testing techniques for the diagnosis of coronary disease. We examined the diagnostic accuracy of treadmill exercise echocardiography to predict coronary artery disease in 76 patients with moderate to severe aortic regurgitation. Rest and poststress images were interpreted by 2 experienced observers, and accuracy was defined by comparison with stenoses >/=50% diameter at coronary angiography. Results were compared with accuracy in a control group of previously published studies in patients without valvular heart disease. After 6 patients were excluded because of a submaximal heart rate response (<85% age-predicted maximal heart rate), 70 patients were included in the final analysis. Patients with aortic regurgitation were of comparable age to the control group and exercised to similar workload. In 16 (23%) patients with significant coronary artery disease and significant aortic regurgitation, the sensitivity of exercise echocardiography was 56% compared with 83% in the control group (P =.03). The specificity in 54 patients with aortic regurgitation but no significant coronary artery disease was 67% compared with 83% in the control group (P =.02). Accuracy was 64% in aortic regurgitation compared with 83% in the control group (P =.02). In patients with aortic regurgitation, accuracy in the left anterior descending artery territory (76%) marginally exceeded that in the posterior (right + circumflex coronary artery) circulation (70%). Thus the presence of significant aortic regurgitation affects the regional wall motion of the left ventricle during exercise and adversely affects the accuracy of exercise echocardiography for the diagnosis of coronary artery disease.
Publisher: Elsevier BV
Date: 10-1991
DOI: 10.1016/0002-9149(91)90508-I
Abstract: Thioridazine, chlorpromazine and trifluoperazine were administered to six psychiatric patients. Each was used in four dosage levels (thioridazine and chlorpromazine: 200, 400, 800 and 1200 mg. daily trifluoperazine: 8, 16, 32, 64 mg. daily) and each increase in dosage was effected after four days of drug administration.Before the trial, twice during each drug period and before commencement of the next dose regimen, an electrocardiogram (ECG) was recorded. The findings indicated that thioridazine modifies the terminal portion (S-T segment, T and U waves) of the human ECG. A similar change occurred in three of six subjects while taking chlorpromazine and in one of six while taking trifluoperazine. Thioridazine induced changes in all six subjects studied, viz., blunting and notching of T waves with or without prolongation of QT interval. In some the notching produced a doublehump appearance in which a T wave of reduced voltage formed the proximal hump and a positive U wave of increased voltage formed the distal hump.Thioridazine-induced alterations in the ECG have been described as resembling those caused by quinidine they also resemble changes associated with hypokalemia.
Publisher: Elsevier BV
Date: 2020
DOI: 10.1016/J.JCMG.2019.01.035
Abstract: This study investigated the prognostic utility of left ventricular (LV) untwisting (UT) in the elderly patients at risk of heart failure (HF). LV UT mechanics represent a unique combination of LV filling linking ventricular relaxation and suction. The value of this parameter in the prediction of outcomes in patients at risk of HF is unclear. A group of 465 asymptomatic subjects ≥65 years of age with ≥1 HF risk factor (hypertension, diabetes, obesity), recruited from the community, underwent clinical evaluation and echocardiography including measurement of LV apical and basal peak UT velocities. Cox regression analysis was used to identify predictors of new-onset HF and cardiovascular death after a mean follow-up of 18.2 ± 7.5 months. A composite of both of the study endpoints occurred in 54 patients (11.6%). Adverse outcome was significantly associated with apical (hazard ratio [HR]: 0.98 95% confidence interval [CI]: 0.96 to 0.99 p = 0.006) UT but not with basal (p = 0.18) UT. The prognostic value of apical UT was independent of and incremental to clinical data, as expressed by the ARIC (Atherosclerosis Risk In Communities) study risk score, left atrial volume index (LAVI), and LV global longitudinal strain (GLS). The addition of apical UT to the model including ARIC risk score, LAVI, and GLS was associated with a 41% improvement in reclassification (p = 0.006). Echocardiographic assessment of apical UT provides incremental value in predicting adverse outcome in asymptomatic patients with HF risk factors. The inclusion of apical UT to the diagnostic algorithm may improve the prognostication process in this population.
Publisher: American Physiological Society
Date: 07-2018
DOI: 10.1152/AJPHEART.00157.2018
Abstract: Informal training in preclinical research may be a contributor to the poor reproducibility of preclinical cardiology research and low rates of translation into clinical research and practice. Mouse echocardiography is a widely used technique to assess cardiac structure and function in drug intervention studies using disease models. The interobserver variability of clinical echocardiographic measurements has been shown to improve with formalized training, but preclinical echocardiography lacks similarly critical standardization of training. The aims of this investigation were to assess the interobserver variability of echocardiographic measurements from studies in mice and address any technical impediments to reproducibility by implementing standardized guidelines through formalized training. In this prospective, single-site, observational cohort study, 13 scientists performing preclinical echocardiographic image analysis were assessed for measurement of short-axis M-mode-derived dimensions and calculated left ventricular (LV) mass. Ten M-mode images of mouse hearts acquired and analyzed by an expert researcher with a spectrum of LV mass were selected for assessment and validated by autopsy weight. After the initial observation, a structured formal training program was introduced, and accuracy and reproducibility were reevaluated. Mean absolute percentage error for expert-calculated LV mass was 6 ± 4% compared with autopsy LV mass and 25 ± 21% for participants before training. Standardized formal training improved participant mean absolute percentage error by ~30% relative to expert-calculated LV mass ( P 0.001). Participants initially categorized with high-range error (25–45%) improved to low-moderate error ranges ( –25%). This report reveals an ex le of technical skill training insufficiency likely endemic to preclinical research and provides validated guidelines for echocardiographic measurement for adaptation to formalized in-training programs. NEW & NOTEWORTHY The informal training common to academic/research institutions may be a contributor to the relatively poor reproducibility observed for preclinical cardiac research. In our observation of echocardiography analysis in murine models, we present evidence of moderate interobserver variability in standard preclinical research practice at an Australian heart research institute. These observations give rise to our recommendations for practical guidelines for echocardiography analysis in an adaptable approach to general preclinical research skill training. Listen to this article’s corresponding podcast at reclinical-echocardiography-training-and-guidelines/ .
Publisher: Common Ground Research Networks
Date: 2023
Publisher: Elsevier BV
Date: 11-2016
Publisher: Elsevier BV
Date: 05-1996
DOI: 10.1016/0735-1097(96)00022-8
Abstract: This study evaluated both the relation between dobutamine-induced wall motion abnormalities and the physiologic and morphologic features of epicardial coronary artery stenoses and the impact of the extent of the area at risk on the sensitivity of dobutamine echocardiography. The accuracy of dobutamine echocardiography has traditionally been assessed by comparing results with stenosis geometry. Myocardial fractional flow reserve is a functional index of coronary stenosis severity that takes into account both antero-grade and collateral flow and may therefore be a more appropriate standard for comparison. Seventy-five patients with normal left ventricular function, good echocardiographic images and an isolated coronary stenosis underwent, within 6 h, dobutamine echocardiography, quantitative coronary angiography and intracoronary pressure measurements. Myocardial fractional flow reserve was calculated as the ratio of mean hyperemic distal coronary to aortic pressure. The degree of dobutamine-induced dyssynergy correlated significantly with percent diameter stenosis (r = 0.68), area stenosis (r = 0.68) and minimal lumen diameter (r = -0.60) and markedly better with myocardial fractional flow reserve (r = -0.77). However, marked dispersion of the in idual data was observed. The sensitivity of dobutamine echocardiography in detecting lesions with a minimal lumen diameter or = 50% was 83% and 80%, respectively. All but one patient with a myocardial fractional flow reserve >0.75 had a normal stress test result. Among patients with a myocardial fractional flow reserve < or = 0.75, the sensitivity of dobutamine echocardiography was significantly lower for lesions in vessels with a reference diameter < or = 2.6 mm than for lesions in larger vessels (58% vs. 90%, p = 0.008). 1) The magnitude of wall motion abnormalities induced by dobutamine infusion correlates with angiographic and, more closely, with functional indexes of stenosis severity, even though a wide scatter is observed. 2) In patients with a functionally significant stenosis, the amount of myocardium at risk is a critical determinant of the accuracy of dobutamine echocardiography.
Publisher: Elsevier BV
Date: 06-2016
DOI: 10.1016/J.JCMG.2016.02.022
Abstract: In idual patient response to effective therapies for pulmonary hypertension (PAH) is variable and difficult to quantify. Consequently, management decisions regarding initiation and continuation of therapy are highly dependent on the results of investigations. Registry data show that changes in cardiac index, mean right atrial pressure, and mean pulmonary artery pressure have the greatest influence on survival. It is recognized that pulmonary artery pressure (PASP) responses to PAH-specific drugs are heterogeneous. However, follow-up testing is strongly focused on assessing changes in PASP and functional status (6-min walk). The goals of therapy, which should be highlighted in follow-up imaging, include not only reduction of PASP, decrease in pulmonary vascular resistance, and improvements in right ventricular function, cardiac output, and tricuspid regurgitation. This paper reviews the echocardiographic follow-up of pulmonary hypertension, and especially focuses on right ventricular function-a major determinant of outcome, for which reliable echocardiographic assessment has become more feasible.
Publisher: Wiley
Date: 22-01-2014
DOI: 10.1111/ECHO.12506
Abstract: The optimal method of cardiac resynchronization therapy (CRT) optimization is as yet unknown. We sought to investigate the responses of optimization at rest and on exercise. This 2 stage study involved 59 patients (age 65 ± 10, 75% male), who had all recently undergone successful CRT implantation. In the first stage, the 6-month response was compared between 30 in iduals who underwent resting echocardiographic optimization of CRT [atrioventricular (AV delay) plus ventriculo-ventricular delays (VV delay)], compared with the 29 who did not. In the second stage, a subset of 37 patients from the original cohort were randomized (double-blind) to either resting echocardiographic optimization (n = 20) or exercise echocardiographic optimization (n = 17) and followed for a further 6 months. Clinical and echocardiographic data were collected at each stage. Patients undergoing rest optimization demonstrated improvement in almost all variables and significantly in B-type natriuretic peptide (BNP) in contrast to those without optimization. In a linear regression model, the only significant predictor of BNP change was whether an in idual underwent resting optimization or not (β = 0.38, P = 0.04). In those undergoing resting optimization, the degree of change in AV delay was correlated with improvement in left ventricle (LV) end-diastolic volume (r(2) = 0.33, P < 0.01). Optimization on exercise was associated with a significant decrease in 6-minute walk test compared to those randomized to rest optimization possibly due to inducing nonoptimization at rest. In conclusion, echocardiographic optimization of CRT at rest is superior to no optimization or optimization on exercise. Patients with the greatest change in AV delay to reach optimal may undergo greater LV remodeling.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2010
DOI: 10.1161/CIRCIMAGING.109.908152
Abstract: Background— The estimation of left ventricular (LV) filling pressure from the ratio of transmitral and annular velocities (E/e′) after exercise echocardiography may identify diastolic dysfunction in patients who complain of exertional dyspnea. This study sought to determine the relative contributions of exercise E/e′ and ischemia to outcomes in patients referred for exercise echocardiography. Methods and Results— Rest and exercise E/e′ were obtained in 522 patients referred for exercise echocardiography, who were followed for cardiovascular death and hospitalization over a median of 13.2 months. Exercise E/e′ SD from normal was used to denote raised LV filling pressure with stress (n=75), and ischemia (n=250) was identified by inducible wall motion abnormalities. There were 65 cardiovascular hospitalizations during the follow-up period. Survival analysis showed patients without ischemia and with normal exercise E/e′ to have a better prognosis than those with ischemia, with or without raised exercise E/e′ ( P =0.003) and the outcomes of patients with isolated raised exercise E/e′ and isolated ischemia to be similar. Exercise E/e′ was most valuable in patients with normal resting E/e′ those with elevation with exercise had a worse outcome than those with normal exercise E/e′ ( P =0.014). Exercise capacity (hazard ratio, 0.893 P =0.008), exercise wall motion score index (hazard ratio, 1.507 P .001), and exercise E/e′ .5 (hazard ratio, 2.988 P =0.002) were independent predictors of outcome. The addition of exercise E/e′ to exercise capacity and wall motion score index resulted in an increment in model power to predict adverse outcome ( P =0.006). Conclusions— Exercise E/e′ is associated with cardiovascular hospitalization, independent of and incremental to inducible ischemia.
Publisher: Elsevier BV
Date: 11-1995
Publisher: Elsevier BV
Date: 2017
DOI: 10.1016/J.ECHO.2016.09.007
Abstract: Recent advances in the assessment of myocardial function have facilitated the direct measurement of atrial function using speckle-tracking echocardiography. Currently, normal reference ranges for atrial function using speckle-tracking echocardiography are based on a few initial studies, with variations among modestly sized (n = 100-350) studies. The authors searched the PubMed, Embase, and Scopus databases for the key terms "left atrial/atrial/atrium" and "strain/function/deformation/stiffness" and "speckle tracking/Velocity Vector Imaging/edge tracking." Studies of global left atrial function using speckle-tracking were selected if they involved >30 normal or healthy participants without any cardiac risk factors. Normal ranges for reservoir strain, conduit strain, and contractile strain were computed using a random-effects model. Meta-regression and subgroup analysis was performed to explore between-study heterogeneity. Forty studies (2,542 healthy subjects) satisfied the inclusion criteria. Meta-analysis revealed a normal reference range for reservoir strain of 39% (95% CI, 38%-41%, from 40 articles), for conduit strain of 23% (95% CI, 21%-25%, from 14 articles), and for contractile strain of 17% (95% CI, 16%-19%, from 18 articles). Meta-regression identified heart rate (P = .02) and body surface area (P = .003) as contributors to this heterogeneity. Subgroup analyses revealed heterogeneity due to s le size (n > 100 vs N < 100, P = .02). The normal reference ranges for the three components of left atrial function are demonstrated. The between-study heterogeneity is explained partly by heart rate, body surface area, and s le size.
Publisher: Elsevier BV
Date: 02-2016
DOI: 10.1016/J.AMJCARD.2015.11.048
Abstract: This investigation sought to quantify the risk factors for short-term readmission in patients with heart failure (HF). Electronic databases were systematically searched for studies reporting relative risk, odds ratio, and hazard ratio for the combined primary outcome of all-cause hospital readmission or all-cause mortality ≤90 days from discharge of patients with HF. Clinical characteristics, study design, type and incidence of outcome, univariable effect sizes for each risk factor, and their associated 95% confidence intervals were extracted. Each univariable effect size was pooled and computed in a separate meta-analysis using random-effects models weighted by inverse variance. The frequency of significance of each risk factor in multivariable models was also assessed to confirm their independence. Sixty-nine studies (2,038,524 patients) were included and 144 factors were reported, including 32 reported more than twice. The significant associations of the combined primary outcome were chronic lung disease, chronic kidney disease, atherosclerotic vascular disease (peripheral, coronary, and cerebrovascular), diabetes, anemia, lower systolic blood pressure, previous admission, multidisciplinary treatment, and use of beta-blockade and angiotensin-converting enzyme inhibition or angiotensin receptor blockade. In multivariable analyses, most of these variables remained independently associated with the combined primary outcome. However, age, male gender, black race, hypertension, dyslipidemia, smoking, atrial fibrillation, cancer, and uses of diuretics, aldosterone antagonists, and digoxin were not significant. In conclusion, noncardiovascular co-morbidities, poor physical condition, history of admission, and failure to use evidence-based medication are more strongly associated with 90-day readmission or death than standard risks in patients with HF.
Publisher: Oxford University Press (OUP)
Date: 06-10-2018
Abstract: Socioeconomic status (SES) is recognizably linked with incident heart failure (HF) risk and the association of SES with geography presents a potential target for geographical location of preventive health services. To better inform policy we sought to quantify the independent association between SES and incident HF and investigate differences by type of SES measure. MEDLINE and EMBASE were searched up to August 2018. Observational studies and randomized trials reporting adjusted HF incidence by stratified socioeconomic measures were included. Effect sizes reflected HF incidence in the lowest vs. highest SES stratum and were pooled using a random-effects model. Low SES referred to the lowest resource stratum, the definition of which varied across studies: meta-analysis was only performed where strata were comparable. Statistical heterogeneity was assessed using the I2 statistic. Eleven studies comprising 6 308 006 in iduals and 104 217 HF events found that low SES was associated with an increase in risk of incident HF ranging between 43% and 87% depending on SES measure, with an overall estimate of 62% [hazard ratio (HR) 1.62, 95% confidence interval (CI) 1.50-1.76]. By in idual measure, HRs of 1.66 (95% CI 1.3-2.11), 1.87 (95% CI 1.33-2.62), and 1.54 (95% CI 1.22-1.95) were observed for education, income, and occupation, respectively. For area-level indexes, HRs were 1.43 (95% CI 1.2-1.69) (Carstairs index) and 1.61 (95% CI 1.56-1.65) (index of multiple deprivation). Low SES assessed by all common measures confers independent risk for incident HF. These findings carry implications for the design and delivery of HF prevention programmes.
Publisher: Wiley
Date: 18-09-2014
DOI: 10.1111/ECHO.12740
Abstract: Longitudinal strain of right ventricle (RV) can be used to determine RV systolic function. This study compared RV longitudinal strain values of two different speckle tracking software technologies, velocity vector imaging (VVI) and two-dimensional speckle tracking echocardiography (2DSTE), and longitudinal strain by cardiac magnetic resonance (CMR). We studied 36 patients (28 men, 63 ± 11 years) with ischemic cardiomyopathy (ICM) who underwent echocardiography with GE machines and CMR. Longitudinal strain of RV analyzed with 2DSTE and VVI in same DICOM files. Longitudinal RV strain analyzed with 2DSTE and VVI in same raw data. These values were compared with RVEF and longitudinal strain by CMR. VVI strain showed significant correlations with RVEF by CMR (global RV: r = -0.56, P < 0.01, free wall: r = -0.52, P < 0.01, and septum: r = -0.49, P < 0.01). 2DSTE strain also revealed significant correlations (global RV: r = -0.40, P = 0.02, and septum: r = -0.35, P = 0.04). 2DSTE strain had significant bias with wide limits of agreement in global RV and septum compared with CMR strain. 2DSTE strain had significantly lower intra-observer variability than VVI (P = 0.03) or CMR strain (P = 0.04) in RV-free wall. RV longitudinal strains by VVI and 2SDTE demonstrated relatively good correlations with RVEF and longitudinal strain by CMR. However, when compared to CMR-derived strain, 2DSTE-derived strain underestimates longitudinal strain of RV septum and of global right ventricle. 2DSTE strain had significantly lower intra-observer variability compared with VVI or CMR strain analysis.
Publisher: Springer Science and Business Media LLC
Date: 14-06-2011
Abstract: Degenerative aortic stenosis (AS) has become the most common valvular heart disease and the definitive treatment of symptomatic, severe AS is surgical valve replacement. In the absence of symptoms, the presence of left ventricular (LV) systolic dysfunction is pivotal in making treatment decisions for patients with AS. However, the LV ejection fraction is not a sensitive marker of global LV systolic function in the presence of LV hypertrophy, implying that asymptomatic patients with AS can have myocardial dysfunction with preserved LV ejection fraction. Abnormal myocardial mechanics might explain the pathophysiological processes underlying chronic pressure overload in AS. In this article, we review how new echocardiographic deformation parameters--such as myocardial strain, strain rate, and twist measurements--offer the potential for clinicians to monitor the course of LV dysfunction in patients with AS. Quantifying disturbances in LV function might provide insight into the timing of aortic valve replacement and into the improvement of LV systolic and diastolic properties through regression of LV hypertrophy and fibrosis after valve implantation.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2011
Publisher: BMJ
Date: 04-2015
Publisher: SAGE Publications
Date: 2018
Abstract: This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2017
Publisher: Elsevier BV
Date: 11-2018
DOI: 10.1016/J.JACC.2018.08.2162
Abstract: Ejection fraction (EF) reflects both cardiac function and remodeling, and is widely recognized as a valuable diagnostic and prognostic tool. Its use in a variety of settings, ranging from heart failure and myocardial infarction to valvular heart disease, has made it a cornerstone of modern cardiology, pervading guidelines and practice. However, the development of the test was in another era, with younger patients and a lower prevalence of heart failure with preserved EF. The performance expectations of EF in the current era are also demanding-in relation to detection of subclinical LV dysfunction, and especially relating to recognition of changes in LV function on sequential testing-for ex le in patients taking cardiotoxic drugs. This review discusses whether the impressive evidence base for EF justifies its ongoing use in the context of newer markers of LV function, and the sophisticated questions posed by modern cardiology.
Publisher: Oxford University Press (OUP)
Date: 27-12-2013
DOI: 10.1093/AJH/HPS053
Abstract: The prognostic relevance of a hypertensive response to exercise (HRE) is ill-defined in in iduals undergoing exercise stress testing. The study described here was intended to provide a systematic review and meta-analysis of published literature to determine the value of exercise-related blood pressure (BP) (independent of office BP) for predicting cardiovascular (CV) events and mortality. Online databases were searched for published longitudinal studies reporting exercise-related BP and CV events and mortality rates. We identified for review 12 longitudinal studies with a total of 46,314 in iduals without significant coronary artery disease, with total CV event and mortality rates recorded over a mean follow-up of 15.2±4.0 years. After adjustment for age, office BP, and CV risk factors, an HRE at moderate exercise intensity carried a 36% greater rate of CV events and mortality (95% CI, 1.02-1.83, P = 0.039) than that of subjects without an HRE. Additionally, each 10mm Hg increase in systolic BP during exercise at moderate intensity was accompanied by a 4% increase in CV events and mortality, independent of office BP, age, or CV risk factors (95% CI, 1.01-1.07, P = 0.02). Systolic BP at maximal workload was not significantly associated with the outcome of an increased rate of CV, whether analyzed as a categorical (HR=1.49, 95% CI, 0.90-2.46, P = 0.12) or a continuous (HR=1.01, 95% CI, 0.98-1.04, P = 0.53) variable. An HRE at moderate exercise intensity during exercise stress testing is an independent risk factor for CV events and mortality. This highlights the need to determine underlying pathophysiological mechanisms of exercise-induced hypertension.
Publisher: Springer Science and Business Media LLC
Date: 03-10-2011
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2007
Publisher: Elsevier BV
Date: 09-2006
DOI: 10.1016/J.ECHO.2006.04.002
Abstract: The availability of automated online software may increase the feasibility of real-time 3-dimensional (3D) echocardiography (3DE) for left ventricular (LV) volume calculation in clinical practice. We sought to compare offline and online approaches with magnetic resonance imaging (MRI). Patients who presented to the clinical laboratory for evaluation of LV parameters (n = 110, 94 men, age 63 +/- 10 years) were studied with 2-dimensional echocardiography, online and offline 3DE, and MRI. The 3DE measurements were obtained by a semiautomated LV border detection based on tracing (online) and edge detection (offline). MRI images were obtained using true free induction steady-state precession during breath hold, with measurement of 3D volumes and ejection fraction (EF). All echocardiographic techniques underestimated LV volumes, but EF estimations were similar. The best correlation was between MRI versus offline 3DE. The correlation of online 3DE with MRI was significantly better than 2-dimensional echocardiography (end-diastolic volume (EDV) z = 4.2, end-systolic volume (ESV) z = 4.44, EF z = 4.32 all P < .01). However, correlation of offline 3DE with MRI was significantly better than online 3DE (EDV z = 2.57, P < .05 ESV z = 2.42, P < .05 EF z = 3.82, P < .01). Images were considered to be good quality (endocardium visualized in all walls) in 49 patients discrepancies between online and offline 3DE and MRI were similar in good- and poor-quality images. Wall-motion abnormalities were present in 98 patients discrepancies with MRI were similar in patients with and without abnormal wall motion. Online measurement of LV volumes is feasible and more accurate than with 2-dimensional echocardiography. Although the offline approach is more accurate, it is also more time-consuming.
Publisher: Elsevier BV
Date: 03-2006
DOI: 10.1016/J.CCA.2005.08.028
Abstract: Endothelial dysfunction plays an important role in the pathogenesis of coronary artery disease (CAD). Apart from traditional risk factors complement activation and inflammation may trigger and sustain endothelial dysfunction. We sought to assess the association between endothelial function, high sensitivity C-reactive protein (hs-CRP) and markers of complement activation in patients with either stable or unstable coronary artery disease. We prospectively recruited 78 patients, 35 patients with stable angina pectoris (SAP) and 43 patients with unstable angina pectoris (UAP). Endothelial function was assessed as brachial artery reactivity (BAR). Hs-CRP, C3a, C5a and C1-Inhibitor (C1 inh.) were measured enzymatically. Patients with UAP showed higher median levels of hs-CRP and C3a compared to patients with SAP, while BAR was not significantly different between patient groups. In UAP patients, hs-CRP was significantly correlated with cholesterol (r=0.27, p<0.02), C3a (r=0.32, p<0.001) and C1 INH.(r=0.41, p<0.003), but not with flow mediated dilatation (r=0.09, P=0.41). Hs-CRP and C1 INH.were found to be independent predictors of UAP in a backward stepwise logistic regression model. We conclude that both hs-CRP, a marker of inflammation and C3a, a marker of complement activation are elevated in patients with UAP, but not in patients with SAP.
Publisher: Elsevier BV
Date: 12-2021
DOI: 10.1016/J.YPMED.2021.106819
Abstract: Carotid intima-media thickness (cIMT), plaque quantification and coronary artery calcium (CAC) scoring have been suggested to improve risk prediction of cardiovascular disease (CVD), particularly for asymptomatic in iduals classified as low-to-intermediate risk. We aimed to compare the predictive value of cIMT, carotid plaque identification, and CAC scoring for identifying sub-clinical atherosclerosis and assessing future risk of CVD in asymptomatic, low-to-intermediate risk in iduals. We conducted a comprehensive search of Ovid (Embase and Medline), Cochrane Central Register of Controlled Trials (CENTRAL) and Medline complete (EBSCO health). A total of 30 papers were selected and data were extracted. Comparisons were made according to the cIMT measurement (mean, maximum), carotid plaque evaluation (presence or area), and CAC scoring. CVD event rates, hazard ratios (HR), net reclassification index (NRI), and c-statistic of the markers were compared. There were 27 studies that reported cIMT, 24 reported carotid plaque, and 6 reported CAC scoring. Inclusion of CAC scores yielded the highest HR ranging from 1.45 (95% CI, 1.11-1.88, p = 0.006) to 3.95 (95% CI, 2.97-5.27, p < 0.001), followed by maximum cIMT (HR 1.08 95% CI, 1.06-1.11, p < 0.001 to 2.58 95% CI, 1.83-3.62, p < 0.001) and carotid plaque presence (HR 1.21 95% CI, 0.5-1.2, p = 0.39 to 2.43 95% CI, 1.7-3.47, p < 0.001). The c-statistic enhanced predictive value by a minimum increase of 0.7. Finally, the NRI ranked higher with CAC (≥11.2%), followed by carotid plaque (≥2%) and cIMT (3%). CAC scoring was superior compared to carotid plaque and cIMT measurements in asymptomatic in iduals classified as being at low-to-intermediate risk.
Publisher: Elsevier BV
Date: 12-2022
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2019
DOI: 10.1161/CIRCHEARTFAILURE.119.006086
Abstract: Cognitive impairment is a prevalent, independent marker of readmission in heart failure (HF), but the screening is time-consuming. This study sought (1) to identify HF patients at low risk of cognitive impairment (obviating screening) and (2) to simplify a predictive model of HF outcomes by only using cognitive domains that are most predictive. The Montreal Cognitive Assessment was performed in 1152 Australian patients with HF who were followed for 12 months. One-third (376/1152) of the patients were enrolled into an HF disease management plan to reduce early readmission. Postdischarge outcomes in HF included 30- and 90-day readmission or death and days alive and out of hospital within 12 months of discharge. Cognitive impairment—present in 54% of patients—independently predicted HF outcomes. Normal cognition could be predicted with common clinical and sociodemographic factors with good discrimination (C statistic=0.74 [0.69–0.78]). The visuospatial/executive and orientation domains were most predictive of HF postdischarge outcomes. Using either Montreal Cognitive Assessment score or these 2 domains provided similar incremental values ( P =0.0004 and P =0.0008, respectively) in predicting HF outcomes (both C statistic=0.76) and could similarly identify a group of high-risk patients who benefited most from an HF disease management plan. Cognitive function independently predicts HF outcomes and may also contribute to how a patient responds to intervention. The time and resources spent on cognitive assessment for risk-stratification in HF may be minimized by (1) identifying patients with low risk of cognitive impairment and (2) simplifying the screening instrument to include only the domains that are most predictive of postdischarge outcomes in HF.
Publisher: Georg Thieme Verlag KG
Date: 10-2020
Abstract: Background This study aimed at risk-stratifying aortic dilatation using aortic wall thickness (AWT) and comparing methods of AWT assessment. Methods Demographic, epidemiological, and perioperative data on 72 consecutive aortic surgeries (age = 62 years[standard deviation (SD) = 12] years) performed by a single surgeon were collected from hospital database. Aortic thickness was measured on computed tomography scans, as well as intraoperatively in four quadrants, at the level of aortic sinuses, as well as midascending aorta, using calipers. Aortic wall stress was calculated using standard mathematical formulae. Results The ascending aorta was 48.2 (SD = 8) mm and the mean thickness at ascending aorta level was 1.9 (SD = 0.3) mm. There was congruence between imaging and intraoperative measurements of thickness, as well as between the radiologist and surgeon. Preoperatively, 16 patients had multiple imaging studies showing an average rate of growth of 1.2 mm per year without significant difference in thickness. The wider the aorta, the thinner was the lateral or convex wall. Aortic stenosis (p = 0.01), lateral to medial wall thickness ratio (p = 0.04), and history of hypertension (p = 0.00), all had protective effect on aortic root stress. The ascending aortic stress was directly affected by age (p = 0.03) and inversely related to lateral to medial wall thickness ratio (p = 0.03). Conclusion Aortic thickness can be measured preoperatively and easily confirmed intraoperatively. Risk stratification based on both aortic thickness and diameter (stress calculations) would better predict acute aortic events in dilated aortas and define aortic resection criteria more objectively.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2009
DOI: 10.1161/HYPERTENSIONAHA.109.135525
Abstract: Blood (or plasma) rheology is related to cardiovascular risk. Mechanisms of this association are unclear but may be partially related to impaired left ventricular (LV) function and increased central blood pressure (BP) during light activity. This study aimed to test these hypotheses. Twenty patients (14 men aged 61±12 years) with polycythemia rubra vera (n=16) or hemochromatosis (n=4) were studied at rest and during exercise at ≈50% of maximal heart rate before and after venesection (500 mL volume replaced with saline) to elicit an acute decrease in plasma viscosity at stable BP. Controls (n=20) underwent the same protocol with 25-mL venesection. Central BP and augmentation index were determined by tonometry. Resting LV systolic (peak longitudinal systolic strain rate and strain) and diastolic functions were determined by tissue-Doppler echocardiography. Venesection with blood volume replacement decreased viscosity (1.46±0.10 to 1.41±0.11 centipoise), protein, and hemoglobin ( P .05 for all) and increased strain rate and strain ( P .001 for both) in patients but not in controls ( P .10 for all). There was no change in LV diastolic function ( P .12 for all). Exercise augmentation index in patients was reduced after venesection (24±12% to 17±9% P =0.001) despite no significant change in other BP variables. Hemodynamics (resting or exercise) were not significantly changed in controls. Exercise central systolic BP correlated with triglycerides ( r =0.59 P .001). However, neither exercise hemodynamic changes nor LV functional changes correlated with any biochemical changes after venesection ( P .05). We conclude that an acute change in blood rheology improves ventricular-vascular interaction by enhanced LV systolic function and reduced light-exercise central BP.
Publisher: Elsevier BV
Date: 04-2008
DOI: 10.1016/J.IJCARD.2007.04.184
Abstract: The cardiovascular assessment of patients with suspected pulmonary arterial hypertension (PAH) involves Doppler echocardiography and often subsequent confirmation by right heart catheterization (RHC). However, there appears to be limited consensus on the appropriate technique(s) for assessing PAH, and thus no clear, comprehensive guidelines exist for assessment of PAH. The aim of this paper is to review the Doppler echocardiographic and RHC techniques for the diagnosis and/or assessment of PAH. We searched Medline (1966 to August 2006) and EMBASE (1980 to August 2006) bibliographic databases to allow identification of all potentially relevant studies and review articles. In addition, the reference lists of included articles were scanned to identify relevant references and unpublished reports missed by the search strategy. Our findings show that recommendations for the echocardiographic assessment of PAH at rest or with exercise are heterogeneous. Clinical practice guidelines provide limited details. Although more specific information regarding echocardiographic techniques can be obtained from in idual research articles, the techniques employed and the methods used to calculate specific hemodynamic variables do not appear to be consistent throughout the literature. RHC techniques for the confirmation of PAH are more consistent, albeit less frequently reported. The literature search identified several articles where indications and considerations for the catheterization of patients with PAH are discussed, together with safety considerations and principles for the accurate assessment of hemodynamic variables. Although clinical practice guidelines and numerous research studies provide details of echocardiographic measures in patients with PAH, greater consensus and standardisation of measurement techniques is required. A minimum dataset for the evaluation of PAH by these techniques is suggested.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2008
Publisher: Elsevier BV
Date: 08-2010
DOI: 10.1016/J.JCMG.2010.05.011
Abstract: The combination of high energy expenditure and the borderline adequacy of perfusion make the subendocardium uniquely vulnerable to injury. Selective subendocardial involvement is usually a marker of subclinical disease. Technical advances in new noninvasive imaging modalities, especially in spatial resolution, now permit qualitative and quantitative assessment of subendocardial structure, function, and perfusion. Many newer techniques have the potential to provide superior prognostic information to current standard assessment methods. This review describes the contemporary capabilities of multiple imaging modalities for assessment of the subendocardium, and seeks to guide the clinician regarding the information and technical deficiencies of each modality.
Publisher: Oxford University Press (OUP)
Date: 03-2000
Abstract: This review explores the balance between the incremental data supplied by stress echocardiography and its cost. This technique is now established as an accurate tool for the diagnosis of coronary artery disease and myocardial viability, but the current medical-economic environment mandates careful consideration of the impact of the results on patient outcomes. The tools for assessment of cost and efficiency are reviewed. Two considerations are explored for controlling costs avoidance of testing in those who will derive limited incremental data, and appropriate selection of stress echocardiography rather than other stress techniques. The balance between diagnostic accuracy and cost is explored in observational studies and computer models. Finally, the prognostic implications of testing are evaluated and data from the stress testing literature are explored to show that more effective patient selection for interventions may justify greater expenditure on testing. The appropriate selection of patients for testing has a significant evidence base. The cost of identifying coronary disease has been examined in a number of studies and facilitates the selection between testing modalities. Prognostic data are increasingly available, and further work is needed to combine this with cost analysis in order to show that stress echocardiography, like other stress modalities, may be used to guide therapy and thereby improve cost-effective outcomes.
Publisher: Elsevier BV
Date: 1990
DOI: 10.1016/0883-2897(90)90023-T
Abstract: The use of the 82Sr/82Rb generator in clinical positron emission tomography (PET) studies of myocardial perfusion has been described. An infusion pump is used to deliver the short-lived 82Rb from the generator to the patient. Various characteristics of the generator and the infusion system are described. The 82Rb yield was 69.8 +/- 13.3% and the 82Sr breakthrough was always less than the limit of 0.02 microCi/mCi 82Rb. The yield of 82Rb increased with the flow rate and the potency of the generator. Patients with coronary artery disease were studied for myocardial perfusion abnormalities by the 82Rb PET technique and images of excellent diagnostic quality were obtained.
Publisher: Elsevier BV
Date: 05-2019
Publisher: Elsevier BV
Date: 06-2022
DOI: 10.1016/J.AHJ.2022.02.007
Abstract: The traditional primary prevention paradigm for coronary artery disease (CAD) centers on population-based algorithms to classify in idual risk. However, this approach often misclassifies in iduals and leaves many in the 'intermediate' category, for whom there is no clear preferred prevention strategy. Coronary artery calcium (CAC) and polygenic risk scoring (PRS) are 2 contemporary tools for risk prediction to enhance the impact of effective management. To determine how these CAC and PRS impact adherence to pharmacotherapy and lifestyle measures in asymptomatic in iduals with subclinical atherosclerosis. The CAPAR-CAD study is a multicenter, open, randomized controlled trial in Victoria, Australia. Participants are self-selected in iduals aged 40 to 70 years with no prior history of cardiovascular disease (CVD), intermediate 10-year risk for CAD as determined by the pooled cohort equation (PCE), and CAC scores >0. All participants will have a health assessment, a full CT coronary angiogram (CTCA), and PRS calculation. They will then be randomized to receive their risk presented either as PCE and CAC, or PCE and PRS. The intervention includes e-Health coaching focused on risk factor management, health education and pharmacotherapy, and follow-up to augment adherence to a statin medication. The primary endpoint is a change in low-density lipoprotein cholesterol (LDL-C) from baseline to 12 months. The secondary endpoint is between-group differences in behavior modification and adherence to statin pharmacotherapy. As of July 31, 2021, we have screened 1,903 in iduals. We present the results of the 574 participants deemed eligible after baseline assessment.
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.ECHO.2019.06.002
Abstract: Left atrial (LA) enlargement is associated with atrial fibrillation (AF), but new-onset AF often occurs in the absence of LA enlargement. AF may be related to myocardial fibrosis, and even though left ventricular fibrosis is associated with mechanical dispersion, this phenomenon is not well studied in AF. We hypothesized that detection of LA dysfunction and mechanical dispersion using strain echocardiography is useful for predicting new-onset AF. Baseline echocardiography was performed at entry in 576 community-based participants at risk of heart failure or AF. In this case-control study, we compared 35 in iduals with new-onset AF (age 70 ± 4 years 57% men) over 2 years of follow-up with 35 age- and sex-matched in iduals who did not develop AF from the same cohort. Using speckle-tracking echocardiography, we measured the LA strain in each of 12 segments in the two- and four-chamber views. LA mechanical dispersion was defined as the SD of time to peak positive strain corrected by the R-R interval (SD-TPS, %). There was no significant difference in LA volume index (32.5 ± 9.2 mL/m LA dispersion obtained from strain echocardiography seems to provide incremental information about LA volume and function in the prediction of new-onset AF and warrants testing in a larger study.
Publisher: Elsevier BV
Date: 09-2017
DOI: 10.1016/J.CARDFAIL.2017.06.004
Abstract: Heart failure (HF) is associated with chronic sympathetic activation. Renal denervation (RDN) aims to reduce sympathetic activity by ablating the renal sympathetic nerves. We investigated the effect of RDN in patients with chronic HF and concurrent renal dysfunction in a prospective, multicenter, single-arm feasibility study. Thirty-nine patients with chronic systolic HF (left ventricular ejection fraction [LVEF] <40%, New York Heart Association class II-III,) and renal impairment (estimated glomerular filtration rate [eGFR assessed with the use of the Modification of Diet in Renal Disease equation] < 75 mL • min RDN was associated with reductions in NT-proBNP and 120-minute glucose tolerance test in HF patients 12 months after RDN treatment. There was no deterioration in other indices of cardiac and renal function in this small feasibility study.
Publisher: Elsevier BV
Date: 03-2023
Publisher: Springer Science and Business Media LLC
Date: 09-08-2018
DOI: 10.1007/S10554-018-1368-3
Abstract: Echocardiographic assessment of right atrial pressure (RAP) from inferior vena cava (RAP
Publisher: Elsevier BV
Date: 07-2010
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2010
DOI: 10.1161/CIRCIMAGING.109.934273
Abstract: Limitations in the predictive value of negative exercise echocardiography in type 2 diabetes mellitus has been linked to a reduced end-systolic pressure-volume response (ESPVR). We sought whether abnormal ESPVR reflected subclinical diabetic heart disease by examining the association between the ESPVR and markers of myocardial dysfunction and to establish if the change (Δ) or peak systolic blood pressure/end-systolic left ventricular volume ratio (SP/ESV) is a better marker of contractile reserve in type 2 diabetes mellitus. Resting and exercise echocardiography was performed in 167 apparently healthy patients with type 2 diabetes mellitus (97 men age, 55±10 years) without ischemia, other cardiac disease, or noncardiac complications of diabetes. Standard echocardiographic and color tissue Doppler measures (early diastolic tissue velocity, strain, and strain rate) were acquired at baseline and peak stress in apical long-axis views. Calibrated integrated backscatter was calculated from a resting parasternal long-axis view. ΔSP/ESV was calculated as [(peak stress SP/ESV)−(rest SP/ESV)]. The 83 subjects who demonstrated a ΔSP/ESV ≤12 mm Hg/mL/m 2 after exercise were older and had lower peak heart rate, resting diastolic and stress systolic tissue velocity, stress ejection fraction, and exercise capacity than the remainder. There was no significant association between ΔSP/ESV and metabolic derangement or echocardiographic measures of deformation or backscatter. Change in Sm and stress ejection fraction were independent correlates of ΔSP/ESV. ΔSP/ESV ratio is associated with established features of subclinical diabetic heart disease as well as determinants of contractile reserve (peak hemodynamic response and stress systolic function). Peak ESPVR is poorly associated with markers of myocardial dysfunction.
Publisher: Elsevier BV
Date: 02-2010
DOI: 10.1016/J.JCMG.2009.09.025
Abstract: Comparison of myocardial tissue-velocity imaging (TVI) and speckle-tracking echocardiography (STE) for prediction of viability at dobutamine echocardiography (DbE). Use of TVI-based strain imaging during DbE may facilitate the prediction of myocardial viability but has technical limitations. STE overcomes these but requires evaluation for prediction of viability. We studied 55 patients with ischemic heart disease and left ventricular systolic dysfunction (left ventricular ejection fraction <0.45) who were undergoing DbE for assessment of myocardial viability and who subsequently underwent myocardial revascularization. TVI was used to measure longitudinal end-systolic strain (longS) and peak systolic strain rate (SR) at rest and at low-dose dobutamine (LDD). Longitudinal, radial, and circumferential strain and strain rate were measured with STE. Segmental functional recovery was defined by improved wall-motion score on side-by-side comparison of echocardiographic images before and 9 months after revascularization and areas under the receiver operator characteristic curves were used to compare methods. Of the 375 segments with abnormal resting function, 154 (41%) showed functional recovery. Only circumferential resting and low-dose STE strain and low-dose longitudinal strain and SR predicted functional recovery independent of wall-motion analysis. Among different strain parameters, only TVI-based longitudinal end-systolic strain and peak systolic SR at LDD had incremental value over wall-motion analysis (areas under the receiver operator characteristic curves of 0.79, 0.79, and 0.74, respectively). STE measurements of strain and SR identified viability only in the anterior circulation, whereas TVI strain and SR accurately identified viability in both anterior and posterior circulations. Combination of TVI or STE methods with DbE can predict viability, with TVI strain and SR at LDD being the most accurate. TVI measures can predict viability in both anterior and posterior circulations, but STE measurements predict viability only in the anterior circulation.
Publisher: AME Publishing Company
Date: 08-2018
Publisher: Elsevier BV
Date: 09-2020
Publisher: Elsevier BV
Date: 05-2006
DOI: 10.1016/J.JACC.2006.02.042
Abstract: Our study attempted to validate a Doppler index of diastolic filling (E/E') during exercise with simultaneously measured left ventricular diastolic pressure (LVDP), investigate its association with exercise capacity, and understand which patients to select for testing. The ratio of early diastolic transmitral velocity to early diastolic tissue velocity approximates LVDP at rest, but there is limited validation of exercise E/E' with invasive hemodynamic measurement, and its clinical implications are unclear. The ratio of early diastolic transmitral velocity to early diastolic tissue velocity was measured at rest and during supine cycle ergometry in 37 patients undergoing left heart catheterization. In addition to correlation between invasive and estimated LVDP, the accuracy of different cutoffs for identification of elevated LVDP (>15 mm Hg) was determined at both rest and exercise. Doppler index of diastolic filling was also measured at rest and immediately after maximal treadmill exercise in 166 patients to investigate the association between exercise E/E' and exercise capacity ( 13 was highly specific (90%) for reduced exercise capacity, and even after classification of resting E/E', exercise E/E' permitted classification of patients with exercise capacity or =8 METs. The ratio of early diastolic transmitral velocity to early diastolic tissue velocity correlates with invasively measured LVDP during exercise. It can be used to reliably identify patients with elevated LVDP during exercise and reduced exercise capacity.
Publisher: Elsevier BV
Date: 09-1997
DOI: 10.1016/S0002-9149(97)00503-1
Abstract: This study evaluated the prediction of cardiac events (cardiac death, myocardial infarction, unstable angina, or late myocardial revascularization) in patients with submaximum responses to dobutamine stress, defined by attainment of <85% age-predicted heart rate. Of 1,772 patients undergoing dobutamine echocardiography over a 2-year period, 425 had a submaximum heart rate response. After exclusion of patients treated with beta-adrenoceptor blocking agents, 255 patients formed the study group. In these patients, the test was terminated after administration of the maximum dose of 40 microg/kg/min of dobutamine with atropine (end of protocol, n = 186), severe angina, ischemic ST-segment changes, or intolerable side effects (n = 69). Dobutamine-induced changes (ischemia, viability, or both) were detected in 46 patients, involving ischemia in 133 segments, viability in 23, and ischemia and viability in 16 segments. Patients were followed for an interval of 28 +/- 17 months 5 (1.2%) were lost to follow-up. Of the medically treated patients, cardiac events occurred in 73 of 228 (31%), including cardiac death in 25 (11%), nonfatal myocardial infarction in 11 (4.8%), severe unstable angina in 35 (15%), and late revascularization in 2 (0.9%). Cardiac events occurred in 11 of 30 (36%) with inducible abnormalities, and 62 of 198 without inducible abnormalities (31%, p = NS). Thus, cardiac event rates are high in patients with inadequate chronotropic responses to dobutamine stress, irrespective of whether stress-induced changes are detected. A negative dobutamine echocardiogram at submaximum heart rate should be considered nondiagnostic.
Publisher: Elsevier BV
Date: 05-2015
DOI: 10.1016/J.CARDFAIL.2015.02.002
Abstract: Selecting heart failure (HF) patients for intensive management to reduce readmissions requires effective targeting. However, available prediction scores are only modestly effective. We sought to develop a prediction score for 30-day all-cause rehospitalization or death in HF with the use of nonclinical and clinical data. This statewide data linkage included all patients who survived their 1st HF admission (with either reduced or preserved ejection fraction) to a Tasmanian public hospital during 2009-2012. Nonclinical data (n = 1,537 49.5% men, median age 80 y) included administrative, socioeconomic, and geomapping data. Clinical data before discharge were available from 977 patients. Prediction models were developed and internally and externally validated. Within 30 days of discharge, 390 patients (25.4%) died or were rehospitalized. The nonclinical model (length of hospital stay, age, living alone, discharge during winter, remoteness index, comorbidities, and sex) had fair discrimination (C-statistic 0.66 [95% confidence interval (CI) 0.63-0.69]). Clinical data (blood urea nitrogen, New York Heart Association functional class, albumin, heart rate, respiratory rate, diuretic use, angiotensin-converting enzyme inhibitor use, arrhythmia, and troponin) provided better discrimination (C-statistic 0.72 [95% CI 0.68-0.76]). Combining both data sources best predicted 30-day rehospitalization or death (C-statistic 0.76 [95% CI 0.72-0.80]). Clinical data are stronger predictors than nonclinical data, but combining both best predicts 30-day rehospitalization or death among HF patients.
Publisher: Oxford University Press (OUP)
Date: 20-09-2013
DOI: 10.1093/EHJCI/JET159
Abstract: The variability of ejection fraction (EF) poses a problem in the assessment of left ventricular (LV) function in patients receiving potentially cardiotoxic chemotherapy. We sought to use global longitudinal strain (GLS) to compare LV responses to various cardiotoxic chemotherapy regimens and to examine the response to cardioprotection with beta-blockers (BB) in patients showing subclinical myocardial damage. We studied 159 patients (49 ± 14 year, 127 women) receiving anthracycline (group A, n = 53, 46 ± 17 year), trastuzumab (group T, n = 61, 53 ± 12 year), or trastuzumab after anthracyclines (group AT, n = 45, 46 ± 9 year). LV indices [ejection fraction (EF), mitral annular systolic velocity, and GLS] were measured at baseline and follow-up (7 ± 7 months). Patients who decreased GLS by ≥11% were followed for another 6 months initiation of BB was at the discretion of the clinician. Anthracycline dose was similar between group A and group AT (213 ± 118 vs. 216 ± 47 mg/m(2), P = 0.85). Although ΔEF was similar among the groups, attenuation of GLS was the greatest in group AT (group A, 0.7 ± 2.8% shortening T, 1.1 ± 2.7% and AT, 2.0 ± 2.3% P = 0.003, after adjustment). Of 52 patients who decreased GLS by ≥-11%, 24 were treated with BB and 28 were not. GLS improved in BB groups (from -17.6 ± 2.3 to -19.8 ± 2.6%, P < 0.001) but not in non-BB groups (from -18.0 ± 2.0 to -19.0 ± 3.0%, P = 0.08). Effects of BB were similar with all regimens. GLS is an effective parameter for identifying systolic dysfunction (which appears worst with combined anthracycline and trastuzumab therapy) and responds to cardioprotection in patients administered beta-blockers.
Publisher: Oxford University Press (OUP)
Date: 09-2000
Abstract: Stress echocardiography is accepted as a routine test in patients with coronary artery disease for the identification of myocardial ischaemia, the diagnosis of viable myocardium and assessment of prognosis. This review addresses the application of the test to non-coronary heart diseases. Some caution should be applied to the use of stress echocardiography for the detection of ischaemia in patients with valvular heart disease. However, examination of haemodynamics and left ventricular function during exercise is worthwhile in the assessment of symptomatic patients with apparently mild or moderate valvular disease, as well as being useful for the detection of subclinical left ventricular dysfunction. In the future, this tool may be more widely applied to the identification of other 'subclinical' conditions, including pulmonary hypertension, anthracycline cardiotoxicity and valvular heart diseases, although the benefit of early diagnosis of these conditions remains to be established.
Publisher: Oxford University Press (OUP)
Date: 28-12-2015
DOI: 10.1093/EHJCI/JEV333
Abstract: Left atrial (LA) function helps to preserve cardiac output and to control pulmonary capillary wedge pressure in the setting of left ventricular (LV) impairment, but little is known about the contribution of the LA function to ventricular arrhythmia. We sought whether LA booster pump function was associated with arrhythmias in patients undergoing primary prevention implantable cardioverter-defibrillator (ICD) implantation for non-ischaemic dilated cardiomyopathy (NICM), independent of global longitudinal strain (GLS) and mechanical dispersion (MD). We identified 124 NICM patients (56 ± 13, 67 male) who underwent echocardiography pre-ICD implantation for primary prevention. The main outcome measure was appropriate ICD therapy (anti-tachycardia pacing or shock). The mitral A-wave was used as an LA functional marker. MD was defined as standard deviation of time to peak strain of each segment. Over a median follow-up of 3.8 ± 2.2 years, 36 patients had appropriate ICD therapy, including 23 shocks. Patients with appropriate ICD therapy had lower A-wave velocity (P < 0.001), larger LA volume (P < 0.001), and impaired circumferential MD (P = 0.006), but similar ejection fraction (EF) (P = 0.40) and GLS (P = 0.11). In sequential Cox proportional hazards models, A-wave, E/A ratio, and GLS were significantly associated with outcomes, independent of age, sex, and cardiac resynchronization therapy defibrillator or left bundle branch block. In nested Cox models, mitral A-wave had a prognostic value incremental to models with LV systolic (EF and GLS) and diastolic functional parameters (E/A, E/e', and LA volume) and MD. LA booster pump function was an independent and incremental predictor of arrhythmias in NICM over GLS and MD, and may aid better risk stratification in this population.
Publisher: Springer Science and Business Media LLC
Date: 12-04-2011
DOI: 10.1038/IJO.2011.79
Abstract: Body size is associated with increased brachial systolic blood pressure (SBP) and aortic stiffness. The aims of this study were to determine the relationships between central SBP and body size (determined by body mass index (BMI), waist circumference and waist/hip ratio) in health and disease. We also sought to determine if aortic stiffness was correlated with body size, independent of BP. BMI, brachial BP and estimated central SBP (by SphygmoCor and radial P2) were recorded in controls (n=228), patients with diabetes (n=211), coronary artery disease (n=184) and end-stage kidney disease (n=68). Additional measures of waist circumference and arterial stiffness (aortic and brachial pulse wave velocity (PWV)) were recorded in a subgroup of 75 controls (aged 51 ± 12 years) who were carefully screened for factors affecting vascular function. BMI was associated with brachial (r=0.30 P<0.001) and central SBP (r=0.29 P<0.001) in the 228 controls, but not the patient populations (r 0.15 for all comparisons). In the control subgroup, waist circumference was also significantly correlated with brachial SBP (r=0.29 P=0.01), but not central SBP (r=0.22 P=0.07). Independent predictors of aortic PWV in the control subgroup were brachial SBP (β=0.43 P<0.001), age (β=0.37 P<0.001), waist circumference (β=0.39 P=0.02) and female sex (β=-0.24 P=0.03), but not BMI. In health, there are parallel increases in central and brachial SBP as BMI increases, but these relationships are not observed in the presence of chronic disease. Moreover, BP is a stronger correlate of arterial stiffness than body size.
Publisher: Elsevier BV
Date: 02-2022
DOI: 10.1016/J.JSAMS.2021.09.008
Abstract: A hypertensive response to submaximal exercise is associated with cardiovascular disease but this relationship is influenced by functional capacity. Spironolactone improves functional capacity, which could mask treatment effects on exercise blood pressure. This study sought to examine this hypothesis. Retrospective analysis of a randomized clinical trial. 102 participants (54 ± 9 years 52% male) with a hypertensive response to maximal exercise (systolic BP ≥210 mm Hg men ≥190 mm Hg women) were randomized to 3-month spironolactone 25 mg daily (n = 53) or placebo (n = 49). Submaximal exercise blood pressure was measured during low-intensity cycling (50, 60 or 70% age-predicted maximal heart rate). Functional capacity was measured as maximal oxygen capacity obtained during a maximal treadmill exercise test, and (resting) aortic stiffness by carotid-to-femoral pulse wave velocity. Spironolactone improved submaximal exercise systolic blood pressure vs. placebo (-4 ± 16 vs. 2 ± 15 mm Hg, p = 0.045, Cohen's d = 0.42), and had a small (but non-statistically significant) improvement in functional capacity (0.64 ± 5.10 vs. -1.43 ± 5.04 ml/kg/min, p = 0.06, Cohen's d = 0.4). When treatment effects were expressed as the change in submaximal exercise systolic blood pressure relative to the change in functional capacity, a larger effect size was observed (-0.3 ± 1.1 vs. 0.3 ± 1.1 mm Hg/ml·kg·min Spironolactone reduces submaximal exercise blood pressure, but this treatment effect may be hidden by improved functional capacity and a non-fixed workload. This highlights the most clinically relevant exercise blood pressure is at a low intensity and fixed workload where the influence of fitness on exercise blood pressure is removed, and the effects of therapy can be appreciated.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-09-2005
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.JTCVS.2012.12.016
Abstract: We sought to understand the factors modulating left heart reverse remodeling after aortic valve replacement, the relationship between the preoperative symptoms and modulators of left heart remodeling, and their influence on long-term survival. From October 1991 to January 2008, 4264 patients underwent primary aortic valve replacement for aortic stenosis. Changes in the time course of left ventricular reverse remodeling were assessed using 5740 postoperative transthoracic echocardiograms from 3841 patients. Left ventricular hypertrophy rapidly declined after surgery, from 137 ± 42 g/m(2) preoperatively to 115 ± 27 by 2 years and remained relatively constant but greater than the upper limit of normal. The most important risk factor for residual left ventricular hypertrophy was greater preoperative left ventricular hypertrophy (P < .0001). Other factors included a greater left atrial diameter (reflecting diastolic dysfunction), a lower ejection fraction, and male gender. An increased postoperative transprosthesis gradient was associated with greater residual left ventricular hypertrophy however, its effect was minimal. Preoperative severe left ventricular hypertrophy and left atrial dilatation reduced long-term survival, independent of symptom status. Severe left ventricular hypertrophy with left atrial dilatation can develop from severe aortic stenosis, even without symptoms. These changes can persist, are associated with decreased long-term survival even after successful aortic valve replacement, and could be indications for early aortic valve replacement if supported by findings from an appropriate prospective study.
Publisher: Elsevier BV
Date: 04-1992
DOI: 10.1016/0167-5273(92)90052-5
Abstract: Current techniques for the detection of recurrent coronary stenoses following bypass grafting have shown disappointing diagnostic accuracy. This study used the same dipyridamole-handgrip stress to compare the accuracy of rubidium-82 positron emission tomography and thallium-201 single photon emission computed tomography, in 50 consecutive post-bypass patients undergoing coronary arteriography at a mean interval of 6.5 years after surgery. Significant stenoses in native coronary vessels (greater than 50% diameter) or grafts (greater than 70% diameter) were defined by quantitative angiography. Forty-six patients had recurrent or residual stenoses, 43 (93%) had a perfusion defect identified by positron emission tomography, and 35 (76%) were identified by single photon emission computed tomography (P = 0.04). Fourteen of the 17 patients (82%) without previous Q-wave myocardial infarction were identified by positron emission tomography 10 of the 17 (59%) were detected by single photon emission computed tomography (P = NS). Stress-induced perfusion defects were demonstrated by positron emission tomography in 19 patients of this group, thallium imaging identified reversible defects in 11, showed no perfusion defect in 1, and portrayed a persistent defect in 7 patients. Significant graft disease was present in 33 patients perfusion defects were identified by positron emission tomography in 30 (91%), and by single photon emission computed tomography in 24 (73%, P = NS). Four patients were fully revascularized, without significant recurrent coronary disease normal perfusion was present in 3 (75%) by positron emission tomography, and 4 (100%) by single photon emission computed tomography.(ABSTRACT TRUNCATED AT 250 WORDS)
Publisher: Wiley
Date: 08-1998
DOI: 10.1046/J.1365-2796.1998.00354.X
Abstract: This study sought to define the value of dobutamine echocardiography (DbE) for cardiac risk stratification in patients with chronic renal failure (CRF). Outcome study correlating results of DbE with late cardiac events in patients with CRF. Academic medical centre. All patients with CRF (serum creatinine > 2.5 mg dL-1) undergoing DbE were studied we analysed 193 consecutive patients (aged 63 +/- 13 years, 73 men). A standard dobutamine-atropine stress was administered until attainment of peak dose, or the development of severe ischaemia or side-effects. The electrocardiogram (ECG) and echocardiogram were obtained before, during and after stress. Ischaemia was identified by new or worsening wall-motion abnormalities with stress. Patients were followed up after 38 +/- 14 months for cardiac death, myocardial infarction or coronary disease progression requiring revascularization. DbE demonstrated ischaemia in 36 patients (19%), scar in 36 (19%) and a normal study in 121 patients. The heart-rate response to dobutamine was submaximal (< 85% age-predicted heart rate) in the absence of wall-motion abnormalities in 69 patients (36%), 54 of whom completed the protocol. Follow-up data were complete in 191 patients (99%) cardiac events occurred in 33 patients (17%), including 17 with cardiac death, 7 with infarction, and 9 requiring late revascularization. Spontaneous events occurred in 7 patients with ischaemia, 3 with scar (8%), 11 with a nondiagnostic study (16%) and 3 patients with a normal study (6%). Over the entire follow-up, the event-free survival in patients with ischaemia (66%) was markedly lower than those without ischaemia (84%, P = 0.006). However, the event rate in patients with nonischaemic responses increased from 8% to 16% between 24 and 40 months, and whilst ischaemia was an independent predictor of outcome at 24 months, it was not at 40 months. In patients with CRF, the identification of ischaemia at DbE is associated with a significant risk of adverse cardiac events. Patients with nonischaemic scans have a low frequency of events over short-term follow-up, but this increases at later follow-up. These later events may reflect progressive coronary disease, attributable to the atherogenic milieu of these patients, and imply that repeated testing may be required to maintain cardiac risk stratification in patients with CRF.
Publisher: Elsevier BV
Date: 12-2006
DOI: 10.1016/J.AMJCARD.2006.07.037
Abstract: Subclinical myocardial and vascular dysfunctions occur in subjects with obesity. We investigated whether these changes were reversible with weight loss due to lifestyle intervention. Quantitative assessment of myocardial and vascular functions was performed at baseline and after a minimum of 8 weeks of a lifestyle intervention program in 106 subjects with significant risk factors but no history of cardiovascular disease and normal ejection fractions. Myocardial function was assessed using strain rate, strain, regional myocardial systolic velocity, and diastolic velocity (e(m)). Myocardial reflectivity was assessed by calibrated integrated backscatter. Vascular function was assessed using brachial arterial reactivity and arterial compliance. Exercise capacity was measured by peak oxygen consumption per unit time (VO(2)). Weight loss (-4.5 +/- 2.0%) was achieved by 48 subjects, and 58 maintained or increased weight (+1 +/- 1.5%, p <0.001). Compared with the stable weight group, the weight loss group showed significant improvement in brachial arterial reactivity (8.6 +/- 4.9% vs 6.7 +/- 4.9%, p <0.05), e(m) (6.4 +/- 1.9 vs 5.5 +/- 1.9 cm/s, p <0.01), and reflectivity (calibrated integrated backscatter, 18.3 +/- 4.9 vs 16.2 +/- 5.2 dB, p <0.01). The magnitude of weight change correlated with changes in e(m) (r = 0.36) and calibrated integrated backscatter (r = 0.33). The change in e(m) correlated with peak VO(2) (r = 0.38, p <0.001) and was an independent predictor for peak VO(2) even after adjustment for age and body mass index in a multivariate model (R(2) = 0.45, p <0.001). Weight loss was not associated with a significant change in systolic parameters (regional myocardial systolic velocity, global strain, and strain rate) or arterial compliance.
Publisher: Elsevier
Date: 2017
Publisher: Elsevier BV
Date: 08-2018
Publisher: Elsevier BV
Date: 12-2012
Publisher: Elsevier BV
Date: 02-2013
DOI: 10.1016/J.ECHO.2012.10.008
Abstract: The definition of normal values of left ventricular global longitudinal strain (GLS), global circumferential strain, and global radial strain is of critical importance to the clinical application of this modality. The investigators performed a meta-analysis of normal ranges and sought to identify factors that contribute to reported variations. MEDLINE, Embase, and the Cochrane Library database were searched through August 2011 using the key terms "strain," "speckle tracking," "left ventricle," and "echocardiography" and related phrases. Studies were included if the articles reported left ventricular strain using two-dimensional speckle-tracking echocardiography in healthy normal subjects, either in the control group or as a primary objective of the study. Data were combined using a random-effects model, and effects of demographic, hemodynamic, and equipment variables were sought in a meta-regression. The search identified 2,597 subjects from 24 studies. Reported normal values of GLS varied from -15.9% to -22.1% (mean, -19.7% 95% CI, -20.4% to -18.9%). Normal global circumferential strain varied from -20.9% to -27.8% (mean, -23.3% 95% CI, -24.6% to -22.1%). Global radial strain ranged from 35.1% to 59.0% (mean, 47.3% 95% CI, 43.6% to 51.0%). There was significant between-study heterogeneity and inconsistency. The source of variation was sought between studies using meta-regression. Blood pressure, but not age, gender, frame rate, or equipment, was associated with variation in normal GLS values. The narrowest confidence intervals from this meta-analysis were for GLS and global circumferential strain, but in idual studies have shown a broad range of strain in apparently normal subjects. Variations between different normal ranges seem to be associated with differences in systolic blood pressure, emphasizing that this should be considered in the interpretation of strain.
Publisher: Springer Science and Business Media LLC
Date: 31-10-2018
DOI: 10.1038/S41371-018-0122-6
Abstract: Hypertension is the most significant modifiable risk factor for cardiovascular disease and contributes to the highest global burden of disease. Blood pressure (BP) measurement is among the most important of all medical tests, and it is critical for BP monitoring devices to be accurate. Comprehensive new evidence from meta-analyses clearly shows that many BP monitoring devices (including oscillometric machines and "gold standard" mercury auscultation) do not accurately represent the BP within the arteries at the upper arm (brachial) or central aorta. Particular variability in the accuracy of BP devices compared with intra-arterial BP has been demonstrated in the cuff BP range from prehypertension to grade I hypertension (systolic BP 120-159 to diastolic BP 80-99 mmHg). This is within the BP range that is most common among people worldwide and, thus almost certainly, feeding confusion around optimal hypertension guideline thresholds. At the in idual level, inaccurate BP devices have major potential consequences for best practice patient management, where underestimation of true BP is a missed opportunity to lower cardiovascular risk (with therapeutics or lifestyle) and overestimation of true BP could lead to overmedication. Each problem leads to increased cost from preventable cardiovascular events and unnecessary medications. Altogether, there is a critical need to improve the accuracy standards of BP monitoring devices. In the meantime, out-of-office BP (24 h of ambulatory BP and/or home BP monitoring) or automated, unobserved in-office BP monitoring that takes the average of multiple readings using validated devices are the best available options to determine BP control.
Publisher: Elsevier BV
Date: 04-1995
DOI: 10.1016/S0002-9149(99)80416-0
Abstract: Amyl nitrite may be used to provoke latent gradients in patients with hypertrophic cardiomyopathy (HC) without significant resting outflow tract gradients, but afterload reduction may not be comparable to a more physiologic stressor such as symptom-limited exercise testing. This study compared the ability of amyl nitrite and exercise testing to provoke outflow tract gradients in 57 patients (40 men and 17 women, mean age +/- SD 49 +/- 16 years) with HC (septal thickness 19 +/- 5 mm, average resting gradient 13 +/- 10 mm Hg) who underwent echocardiography at rest, after amyl nitrite inhalation, and after maximal exercise. No significant gradient (< 50 mm Hg) was induced after either provocation in 26 patients (46%) in 15 patients (26%), inducibility was achieved after both stressors, in 6 (11%) after exercise only, and in 10 (18%) after amyl only. Patients with amyl-induced gradients differed from those in whom gradients were noninducible on the basis of smaller outflow tract dimensions (p < 0.001), larger resting gradients (p < 0.001), and a greater prevalence of "septal bulge" morphology (p = 0.02). Those with exercise-induced gradients were able to attain a greater workload (p = 0.07), have larger resting gradients (p = 0.02), and also tended to have a septal bulge morphology (p < or = 0.01). Although outflow tract obstruction increased to similar levels after amyl nitrite (49 +/- 39 mm Hg) and symptom-limited exercise (47 +/- 39 mm Hg), gradients induced by exercise and amyl correlated poorly (r = 0.54).(ABSTRACT TRUNCATED AT 250 WORDS)
Publisher: Elsevier BV
Date: 11-1999
DOI: 10.1016/S0025-7125(05)70171-1
Abstract: Unidentified coronary artery disease remains a significant cause of premature death and morbidity during the prime of life. The availability of effective interventions for the management of ischemia has provoked new interest in screening for this condition in asymptomatic patients, in the hope of reducing the burden of this condition. Although widespread use of stress testing is ineffective, the use of imaging techniques may offer better accuracy for detection of ischemia. Other tests that identify evidence of atheroma in the peripheral or coronary circulation may be useful to identify patients at risk.
Publisher: Oxford University Press (OUP)
Date: 10-2002
Abstract: To determine the effects on homocysteine levels of two doses of folic acid compared to placebo, where the high dose is typical of that provided by pharmacological intervention and the low dose approximates that provided by dietary supplementation. The PACIFIC study was a double-blind, placebo-controlled, factorial randomized trial. Seven hundred and twenty-three in iduals with a history of myocardial infarction or unstable angina were recruited from 28 clinical cardiology centres in Australia and New Zealand and randomized to folic acid 2.0 mg daily, folic acid 0.2 mg daily or placebo. The primary outcome, homocysteine, was measured using a fluorescence polarization immunoassay. Compared to placebo, 2.0 mg folic acid reduced homo-cysteine by 1.8 micromol x 1(-1) [95% confidence interval (CI) 1.3-2.3] and 0.2 mg reduced homocysteine by 1.2 micromol x 1(-1) [95% CI 0.8-1.7). The higher dose reduced homocysteine significantly more than the lower dose (P=001). Both doses of folic acid reduced homocysteine, but the effects of the 2.0 mg dose were about one third greater than the 0.2 mg dose. Fortification of foods with folic acid should result in population-wide lower levels of homocysteine but high-dose pharmacological supplementation would produce greater reductions for high-risk in iduals.
Publisher: Elsevier BV
Date: 07-2017
DOI: 10.1016/J.ECHO.2017.03.014
Abstract: Left atrial (LA) strain imaging enables the quantitative assessment of LA function. The clinical relevance of these measurements is dependent on the provision of information incremental to the left ventricular (LV) evaluation. The aim of this study was to test the hypothesis that LA pump function but not reservoir function is independent of measurement of LV mechanics. Echocardiography was undertaken in a community-based study of 576 participants ≥65 years of age with one or more risk factors (e.g., hypertension, diabetes mellitus, obesity). Strain analysis was conducted using a dedicated software package, using R-R gating. LV function was classified as normal in the presence of global longitudinal strain (GLS) (≤-18%) or global circumferential strain (GCS) (≤-22%). The associations between GLS or GCS and LA reservoir, conduit, and pump strain were assessed using univariate and multivariate linear regression. Patients (mean age 71 ± 5 years, 54% women) with reduced GLS had higher blood pressure and rates of diabetes and obesity (P < .05). LA reservoir strain and conduit strain were lower in the group with impaired GLS (38.2 ± 7.3% vs 39.9 ± 6.4% [P = .004] and 18.7 ± 5.7% vs 20.5 ± 5.1% [P < .001], respectively), but there was no difference in LA pump strain (19.5 ± 5.5% vs 19.3 ± 4.6%, P = .72). GLS was independently associated with LA reservoir and conduit strain (P < .05) but not independently associated with LA pump strain (P = .91). Reduced GCS was associated with a larger body mass index, male sex, and diabetes (P .05). The application of LA strain is specific to the component measured. LA pump strain is independent of LV mechanics.
Publisher: IEEE
Date: 2001
Publisher: Springer Science and Business Media LLC
Date: 25-03-2014
Publisher: Oxford University Press (OUP)
Date: 21-03-2012
DOI: 10.1093/EHJCI/JES058
Publisher: Elsevier BV
Date: 04-2010
DOI: 10.1016/J.ATHEROSCLEROSIS.2009.10.018
Abstract: Total arterial compliance (TAC) reflects arterial function in the entire systemic circulation while distensibility coefficient (DC) is an estimate of local arterial compliance obtained from large elastic arteries. There are few studies relating TAC or DC to outcome. We sought whether DC or TAC predicted outcome in a primary prevention cohort with a spectrum of cardiovascular risk. Clinical data including blood pressure (BP) and diabetes mellitus (DM) were obtained and Framingham 10-year risk was calculated in 719 primary prevention patients (373 men age 55+/-11 years). TAC was calculated from applanation tonometry using the pulse-pressure method, 2D-echocardiography and Doppler, and DC was derived from 2D measurements of the common carotid artery and pulse pressure (PP). Cox regression analysis was performed to determine correlates of outcome. There were 42 deaths (5.8%) and 114 cardiovascular admissions (15.8%) over 57 months. The independent correlates of mortality were Framingham 10-year risk (HR=1.69 p<0.0001) and DC (HR=0.54 p=0.02) (model chi-square 24.52 p<0.0001) but not TAC. The independent predictors of the composite outcome of either death or admission for cardiovascular causes were Framingham 10-year risk (HR=1.28 p=0.001) and TAC (HR=0.75 p=0.006) (model chi-square 21.43 p<0.0001) but not DC. Measurement of arterial function is independently correlated with outcome in patients with varying degrees of cardiovascular risk, and different aspects identify fatal and non-fatal events. In addition, measurement of TAC and DC adds incremental benefit to Framingham risk scores alone in patients with intermediate cardiovascular risk.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-04-2013
DOI: 10.1161/CIRCULATIONAHA.113.001435
Abstract: Thoracic radiation results in radiation-associated heart disease (RAHD), often requiring cardiothoracic surgery (CTS). We sought to measure long-term survival in RAHD patients undergoing CTS, to compare them with a matched control population undergoing similar surgical procedures, and to identify potential predictors of long-term survival. In this retrospective observational cohort study of patients undergoing CTS, matched on the basis of age, sex, and type/time of CTS, 173 RAHD patients (75% women age, 63±14 years) and 305 comparison patients (74% women age, 63±4 years) were included. The vast majority of RAHD patients had prior breast cancer (53%) and Hodgkin lymphoma (27%), and the mean time from radiation was 18±12 years. Clinical and surgical parameters were recorded. The preoperative EuroSCORE and all-cause mortality were recorded. The mean EuroSCOREs were similar in the RAHD and comparison groups (7.8±3 versus 7.4±3, respectively P =0.1). Proximal coronary artery disease was higher in patients with RAHD versus the comparison patients (45% versus 38% P =0.09), whereas redo CTS was lower in the RACD versus the comparison group (20% versus 29% P =0.02). About two thirds of patients in either group had combination surgical procedures. During a mean follow-up of 7.6±3 years, a significantly higher proportion of patients died in the RAHD group than in the comparison group (55% versus 28% P .001). On multivariable Cox proportional hazard analysis, RAHD (2.47 95% confidence interval, 1.82–3.36), increasing EuroSCORE (1.22 95% confidence interval, 1.16–1.29), and lack of β-blockers (0.66 95% confidence interval, 0.47–0.93) were associated with increased mortality (all P .01). In patients undergoing CTS, RAHD portends increased long-term mortality. Alternative treatment strategies may be required in RAHD to improve long-term survival.
Publisher: Elsevier BV
Date: 11-2021
Publisher: Elsevier BV
Date: 02-2011
DOI: 10.1016/J.AMJCARD.2010.10.024
Abstract: Patients with type 2 diabetes mellitus (T2DM) might have subclinical myocardial dysfunction identified at rest or unmasked during exercise. We examined the correlates of the myocardial exercise response in patients with T2DM. Myocardial dysfunction was sought during at rest and exercise echocardiography in 167 healthy patients with T2DM (97 men, 55 ± 10 years). Myocardial ischemia was excluded using stress echocardiography. Standard echocardiography and color tissue Doppler imaging measures (early diastolic tissue velocity [Em], strain, and strain rate) were acquired at baseline and peak stress. The calibrated integrated backscatter was calculated from the at rest parasternal long-axis view. The longitudinal diastolic functional reserve index after exercise was defined as ΔEm [1 - (1/Em(base))]. The clinical, anthropometric, and metabolic data were collected at rest and stress. Subclinical myocardial dysfunction at baseline (n = 24) was independently associated with weight (odds ratio [OR] 1.02, p = 0.04) and hemoglobin A1c (OR 1.36, p = 0.03). This group displayed an impaired exercise response that was independently associated with a reduced exercise capacity (OR 0.84, p = 0.034) and longitudinal diastolic functional reserve index (OR 0.69, p = 0.001). Inducible myocardial dysfunction (stress Em <-9.9 cm/s) was identified after exercise in 70 of the remaining 143 subjects. This finding was associated with calibrated integrated backscatter (OR 1.08, p = 0.04) and lower peak heart rate (OR 0.97, p = 0.002) but not metabolic control. The intensity of the metabolic derangement in patients with T2DM was associated with subclinical at rest myocardial dysfunction, but not with the myocardial exercise response. In conclusion, the association of an abnormal stress response with nonmetabolic factors, including backscatter and blunted peak heart rate, suggests potential roles for myocardial fibrosis and cardiac autonomic neuropathy in patients with nonischemic diabetic heart disease.
Publisher: Elsevier BV
Date: 2003
DOI: 10.1016/S0002-9149(02)02999-5
Abstract: Abnormal left ventricular (LV) filling may occur with increasing age despite apparently normal LV size and function, and is usually attributed to LV hypertrophy and coronary artery disease. The purpose of this study was to determine whether myocardial abnormalities could be identified in 67 such patients (36 men, mean age 57 +/- 9 years) whose LV hypertrophy and coronary artery disease were excluded by dobutamine echocardiography. All patients underwent gray scale and color tissue Doppler imaging from 3 apical views, which were stored and analyzed off line. Disturbances in structure and function were assessed by averaging the cyclic variation of integrated backscatter, strain rate, and peak systolic strain from each myocardial segment. Calibrated integrated backscatter (corrected for pericardial backscatter intensity) was measured in the septum and posterior wall from the parasternal long-axis view. Abnormal LV filling was present in 36 subjects (54%). Subjects with and without abnormal LV filling had similar LV mass, but differed in age (p <0.01), cyclic variation (p = 0.001), strain rate (p <0.01), and peak systolic strain (p <0.001). Multivariate logistic regression analysis demonstrated that age (p = 0.016) and cyclic variation (p = 0.042) were the most important determinants of abnormal LV filling in these apparently normal subjects.
Publisher: Elsevier BV
Date: 07-2017
DOI: 10.1016/J.ECHO.2017.03.002
Abstract: Right ventricular (RV) free wall strain (RVFWS) is a feasible method for quantitation and follow-up of RV function and may have benefits over traditional markers such as fractional area change. However, like all ejection phase parameters, RVFWS is difficult to assess in the presence of changing afterload. The aim of this study was to compare RVFWS and traditional RV function parameters for tracking progress of RV function in patients with pulmonary arterial hypertension (PAH) over a range of pulmonary artery systolic pressure (PASPs). Sequential echocardiograms were collected retrospectively at two time points between 2005 and 2015 in 187 patients (71% women mean age, 63 ± 14 years) undergoing pulmonary vasodilator therapy for group 1 PAH. Patients were either studied during PAH therapy (n = 111) or before and after treatment initiation (n = 76). Standard measurements of RV and left ventricular function and PASP were performed, and speckle-tracking strain was used to calculate RVFWS. The linear response of RVFWS to afterload (PASP) was assessed using a standard regression equation. Because it is unclear if the response might be nonlinear, a quadratic association (PASP squared) was also used in the regression model. At visit 1, patients with PAH showed impaired functional capacity (mean 6-min walk distance, 371 ± 131 m), increased PASP (mean, 54 ± 26 mm Hg), and borderline RVFWS (mean, 18 ± 6%). Patients before PAH therapy showed more pronounced reduction in 6-min walk distance (mean, 302 ± 136 m) and RVFWS (mean, 16 ± 5%). RVFWS at baseline was associated with PASP (R Afterload changes should be taken into account in the evaluation of RVFWS during PAH follow-up, with the relationship to PASP likely to be linear.
Publisher: Elsevier BV
Date: 09-2013
DOI: 10.1016/J.EJCA.2013.04.030
Abstract: Cardiotoxicity is a well-recognised complication of chemotherapy with anthracycline and/or trastuzumab, and its prevention remains an important challenge in cancer survivorship. Several successful preventative strategies have been identified in animal trials. We sought to assemble the clinical evidence that prophylactic pharmacological interventions could prevent left ventricular (LV) dysfunction and heart failure in patients undergoing chemotherapy. We undertook a systemic review of the evidence from randomised trials and observational studies where a prophylactic intervention was compared with a control arm in patients with a normal ejection fraction and no past history of heart failure. The primary outcome was development of heart failure (HF), a drop in ejection fraction (EF) or both. A random-effects model was used to combine relative risks (RR) and 95% confidence intervals (CIs), and a meta-regression was undertaken to assess the impact of potential covariates. Data were collated from 14 published articles (n=2015 paediatric and adult patients) comprising 12 randomised controlled trials and two observational studies. The most studied chemotherapeutic agents were anthracyclines, and prophylactic agents included dexrazoxane, statins, beta-blocker and angiotensin antagonists. There were 304 cardiac events in the control arm compared to 83 in the prophylaxis arm (RR=0.31 [95% CI: 0.25-0.39], p<0.00001). Cardiac events were reduced with dexrazoxane (RR=0.35 [95% CI 0.27-0.45], p<0.00001), beta-blockade (RR=0.31 [95% CI 0.16-0.63], p=0.001), statin (RR=0.31 [95% CI 0.13-0.77], p=0.01) and angiotensin antagonists (RR=0.11 [95% CI 0.04-0.29], p<0.0001). Prophylactic treatment with dexrazoxane, beta-blocker, statin or angiotensin antagonists appear to have similar efficacy for reducing cardiotoxicity.
Publisher: Elsevier BV
Date: 08-2000
Abstract: The goals of this study were to examine peak systolic strain as an index of regional function in an animal model of inotropic stress and ischemia, and to compare these results with peak systolic myocardial tissue Doppler velocity (MDV). Myocardial tissue Doppler velocity is an objective measure of regional left ventricular responses to inotropic stimulation and ischemia, but it is affected by tethering from adjacent segments and translational movement. Myocardial Doppler strain (epsilon, relative change in length) is a more local measure of contractility, which can now be derived noninvasively from MDV. Eight dogs underwent graded dobutamine infusion followed by coronary occlusion. Epicardial 2-dimensional echocardiography and color MDV of the left ventricle were obtained and digitized from the short-axis view at baseline and with dobutamine doses of 2, 4, and 8 microg/kg per minute. These were repeated 0, 10, 20, 45, and 90 seconds after occlusion of the left anterior descending artery (LAD) (n = 3) or circumflex coronary artery (n = 5). Dobutamine was continued at 8 microg/kg per minute during coronary occlusion. The peak systolic radial MDV (cm/s) and systolic strain (epsilon(s), percent thickening) in the anterior and posterior walls were measured off-line at each stage. Dobutamine caused an increase in MDV (P =.0001) and epsilon(s) (P =.09) above baseline values. Coronary occlusion caused a reduction in wall motion after 45 seconds, all nonperfused segments were hypokinetic. There was a corresponding decrease in MDV and epsilon(s), but this occurred earlier for epsilon(s), and the difference between ischemic and nonischemic segments was greater for epsilon(s) than for MDV (P <. 03). Nonischemic regions trended to an increase in epsilon(s) (compensatory hyperkinesis), whereas MDV trended downward, probably reflecting the global decrease in left ventricular function. Both MDV and epsilon(s) increase with dobutamine and decrease during ischemia. epsilon(s) appears to respond to local ischemia earlier than MDV, perhaps because it is a more local measure. Thus epsilon(s) may prove to be an accurate parameter for the clinical recognition of regional ischemia.
Publisher: Oxford University Press (OUP)
Date: 06-2007
DOI: 10.1016/J.EUJE.2006.11.002
Abstract: The management of asymptomatic severe mitral regurgitation is showing an increasing trend towards early surgery. However, in situations where either the valve or the patient is not optimal for surgery, watchful waiting remains a reasonable policy. In this situation, the longstanding challenge of assessing left ventricular function in the setting of severe mitral regurgitation has been simplified by a number of investigations, including stress echocardiography and myocardial imaging. This paper reviews the evidence base for each of these techniques.
Publisher: Elsevier BV
Date: 02-2023
DOI: 10.1016/J.AHJ.2022.11.003
Abstract: Diabetic cardiomyopathy (DbCM) is a specific form of heart muscle disease that may result in substantial morbidity and mortality in in iduals with type 2 diabetes mellitus (T2DM). Hyperactivation of the polyol pathway is one of the primary mechanisms in the pathogenesis of diabetic complications, including development of DbCM. There is an unmet need for therapies targeting the underlying metabolic abnormalities that drive this form of Stage B heart failure (HF). Aldose reductase (AR) catalyzes the first and rate-limiting step in the polyol pathway, and AR inhibition has been shown to reduce diabetic complications, including DbCM in animal models and in patients with DbCM. Previous AR inhibitors (ARIs) were limited by poor specificity resulting in unacceptable tolerability and safety profile. AT-001 is a novel investigational highly specific ARI with higher binding affinity and greater selectivity than previously studied ARIs. ARISE-HF (NCT04083339) is an ongoing Phase 3 randomized, placebo-controlled, double blind, global clinical study to investigate the efficacy of AT-001 (1000 mg twice daily [BID] and 1500 mg BID) in 675 T2DM patients with DbCM at high risk of progression to overt HF. ARISE-HF assesses the ability of AT-001 to improve or prevent decline in exercise capacity as measured by functional capacity (changes in peak oxygen uptake [peak VO The ARISE-HF Trial is fully enrolled. This report describes the rationale and study design of ARISE-HF.
Publisher: Elsevier BV
Date: 12-2000
DOI: 10.1046/J.1444-2892.2000.009003098.X
Abstract: Conventional 2D echocardiography is an excellent qualitative imaging method, but its use for quantitation is limited by test-retest reproducibility of image planes. The increasing sophistication of medical treatments for left ventricular dysfunction, hypertension and valvular heart disease has created the need for accurate and reproducible measurements of chamber dimensions. Similarly, improvements in valve repair and catheter-based interventions for valve lesions and septal defects have created the need for better visualisation of cardiac structures. The use of 31) echocardiography may decrease variability both in the quality and interpretation of complex pathology among investigators. Three-dimensional echocardiography is achieved by using a 3D spatial registration device with a conventional 21) scanner, or by using a high-speed, phased-array real-time scanner. The latter are still developmental, so that the technique currently requires use of a 21) scanner, combined with a 31) spatial coordinate system, which may be external or internal to the scanning transducer. An external system permits data acquired from several cardiac windows to be integrated and reconstructed. Image reconstruction is performed using a wire-frame model or surface rendering. Wire-frame models are formed by manual or automatic connection of boundary data points this approach uses fewer data points than rendering, can be rapidly processed and is sufficient for quantitative analysis. Surface-rendering uses lighting and shading applied to a wire-frame model to produce a realistic 31) display, which may be useful for surgical planning and increasing understanding of anatomic relations. Three-dimensional echocardiography yields more accurate measurements of ventricular volume and function, as well as new measurements such as infarct area. With increased reproducibility and reliability, 3D echocardiography may well prove to be the essential tool required for the serial follow up of left ventricular mass and volume.
Publisher: Elsevier BV
Date: 08-2022
DOI: 10.1016/J.JCMG.2022.02.027
Abstract: Echocardiographic global longitudinal strain (GLS) is a useful measure for detection of cancer treatment-related cardiac dysfunction (CTRCD) but is influenced by blood pressure changes. This limitation may be overcome by assessment of myocardial work (MW), which incorporates blood pressure into the calculation. This work aims to determine whether myocardial work indices (MWIs) can help diagnose or prognosticate CTRCD. In this prospective cohort study, 136 women undergoing anthracycline and trastuzumab treatment for HER2+ breast cancer, underwent serial echocardiograms and cardiac magnetic resonance pre- and post-anthracycline and every 3 months during trastuzumab. GLS, global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency were measured. CTRCD was defined with cardiac magnetic resonance. Generalized estimating equations quantified the association between changes in GLS and MWIs and CTRCD at the current (diagnosis) and subsequent visit (prognosis). Regression tree analysis was used to explore the combined use of GLS and MW for the diagnostic rognostic assessment of CTRCD. Baseline left ventricular ejection fraction (LVEF) was 63.2 ± 4.0%. Thirty-seven (27.2%) patients developed CTRCD. An absolute change in GLS (standardized odds ratio [sOR]: 1.97 [95% CI: 1.07-3.66] P = 0.031) and GWI (sOR: 1.73 [95% CI: 1.04-2.85] P = 0.033) were associated with concurrent CTRCD. An absolute change in GLS (sOR: 1.79 [95% CI: 1.22-2.62] P = 0.003), GWI (sOR: 1.67 [95% CI: 1.20-2.32] P = 0.003), and GCW (sOR: 1.65 [95% CI: 1.17-2.34] P = 0.005) were associated with subsequent CTRCD. Change in GWI and GCW demonstrated incremental value over GLS and clinical factors for the diagnosis of concurrent CTRCD. In a small group with a GLS change 21 mm Hg reduction in systolic blood pressure, worsening of GWI identified patients with higher probability of concurrent CTRCD (24.0% vs 5.2%). MWIs did not improve identification of subsequent CTRCD beyond knowledge of GLS change. GLS can be used to diagnose and prognosticate cardiac magnetic resonance (CMR) defined CTRCD, with additional value from MWIs in selected cases. (Evaluation of Myocardial Changes During Breast Adenocarcinoma Therapy to Detect Cardiotoxicity Earlier With MRI [EMBRACE-MRI] NCT02306538).
Publisher: Cleveland Clinic Journal of Medicine
Date: 11-1995
Abstract: The cornerstones of the evaluation of cardiac risk in patients undergoing noncardiac surgery remain a thorough history and physical examination, and a resting electrocardiogram. However, new techniques to assess cardiac function allow more complete evaluation of high-risk patients.
Publisher: Elsevier BV
Date: 03-2021
Publisher: American Medical Association (AMA)
Date: 03-2022
Publisher: Oxford University Press (OUP)
Date: 2012
DOI: 10.1093/EHJCI/JER316
Publisher: Springer Science and Business Media LLC
Date: 07-11-2017
Publisher: BMJ
Date: 26-04-2009
Abstract: Strain (SI) and strain rate (SR) measure regional myocardial deformation and may be a new technique to assess phasic atrial function. To examine the feasibility of using SI and SR to evaluate phasic atrial function in patients with mild hypertension (HT). The study group comprised 54 patients with mild essential HT (29 women) and 80 age-matched normal controls (47 women). Standard two-dimensional and Doppler echocardiography was performed as well as Doppler tissue imaging. The following left atrial (LA) volumes were measured: (a) maximal LA volume or Vol(max) (b) minimal LA volume or Vol(min) (c) just before the "p" wave on ECG (Vol(p)). Phasic LA volumes were also calculated. Systolic (S-Sr), early diastolic (E-Sr), late diastolic (A-Sr) strain rate and SI were measured. Despite no differences in indexed maximal LA volume with only mild increases in left ventricular mass in the HT cohort compared with normal subjects (mean (SD) 86 (18) g/m(2) vs 67 (14) g/m(2) p = 0.001), E-Sr was significantly lower in the HT cohort. There was a corresponding reduction in indexed conduit volume in the HT cohort compared with normal subjects (10.5 (7.5) ml/m(2) vs 13.8 (6.1) ml/m(2) p = 0.006). Global E-Sr showed modest negative correlations with LA Vol(max) and LA ejection fraction. No significant difference was present in S-Sr, A-Sr or global atrial strain between the normal and HT cohorts. Mild HT results in a reduction in LA conduit volume, although maximal LA volume is unchanged. This is reflected by a reduction in E-Sr with preserved S-Sr and A-Sr.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2015
DOI: 10.1161/CIRCIMAGING.114.002942
Abstract: Better prediction of cardiac pacing patients at risk of atrial fibrillation (AF) would enable more effective prophylaxis. We sought whether left atrial (LA) electromechanical conduction time (EMT) and myocardial mechanics were associated with incident AF in patients undergoing dual chamber pacemaker implantation, independent of left atrial volume (LAV). Clinical data were obtained prospectively in 146 enrollees (73±10 years) undergoing dual chamber pacemaker implantation in the Protect-Pace study. Echocardiograms and 2-dimensional strain analysis were obtained post implantation and at 2 years. Complete ascertainment of AF during follow-up was identified from interrogation of permanent pacemakers. Cox regression was used to identify correlates of AF. Incident AF (n=29, 20%) was associated with higher systolic blood pressure ( P =0.01), lower left ventricular ejection fraction ( P =0.03), lower LA strain at atrial contraction (LASac P .001), higher LAV ( P .003), and longer septal electromechanical conduction time ( P .01). The associations of LAV and LASac with incident AF were independent of age, sex, systolic blood pressure, and left ventricular size and function. However, the combination of the 3 strongest predictors showed LASac ( P =0.02) and systolic blood pressure ( P =0.01) were independently associated with incident AF, but LAV was not ( P =0.07). Using the optimal cut points from receiver operator characteristic curves (62 mL for LAV and 8.6% for LASac), we demonstrated that a significantly greater rate of AF was associated with both lower LASac at higher LAV and with lower LASac at lower LAV. The risk of AF in patients receiving dual chamber pacing is independently associated with LA size and function, not left ventricular structural and functional characteristics or right ventricular lead location. URL: www.clinicaltrials.gov . Unique identifier: NCT00461734.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-02-2005
DOI: 10.1161/01.CIR.0000155233.67287.60
Abstract: Cardiovascular disease is the leading cause of mortality for women in the United States. Coronary heart disease, which includes coronary atherosclerotic disease, myocardial infarction, acute coronary syndromes, and angina, is the largest subset of this mortality, with 000 women dying annually from the disease. Atherosclerotic coronary artery disease (CAD) is the focus of this consensus statement. Research continues to report underrecognition and underdiagnosis of CAD as contributory to high mortality rates in women. Timely and accurate diagnosis can significantly reduce CAD mortality for women indeed, once the diagnosis is made, it does appear that current treatments are equally effective at reducing risk in both women and men. As such, noninvasive diagnostic and prognostic testing offers the potential to identify women at increased CAD risk as the basis for instituting preventive and therapeutic interventions. Nevertheless, the recent evidence-based practice program report from the Agency for Healthcare Research and Quality noted the paucity of women enrolled in diagnostic research studies. Consequently, much of the evidence supporting contemporary recommendations for noninvasive diagnostic studies in women is extrapolated from studies conducted predominantly in cohorts of middle-aged men. The majority of diagnostic and prognostic evidence in cardiac imaging in women and men has been derived from observational registries and referral populations that are affected by selection and other biases. Thus, a better understanding of the potential impact of sex differences on noninvasive cardiac testing in women may greatly improve clinical decision making. This consensus statement provides a synopsis of available evidence on the role of the exercise ECG and cardiac imaging modalities, both those in common use as well as developing technologies that may add clinical value to the diagnosis and risk assessment of the symptomatic and asymptomatic woman with suspected CAD.
Publisher: Elsevier BV
Date: 07-2022
DOI: 10.1016/J.JACC.2022.05.015
Abstract: Risk factor-based models fail to accurately estimate risk in select populations, in particular younger in iduals. A sizable number of people are also classified as being at intermediate risk, for whom the optimal preventive strategy could be more precise. Several personalized risk prediction tools, including coronary artery calcium scoring, polygenic risk scores, and metabolic risk scores may be able to improve risk assessment, pending supportive outcome data from clinical trials. Other tools may well emerge in the near future. A multidimensional approach to risk prediction holds the promise of precise risk prediction. This could allow for targeted prevention minimizing unnecessary costs and risks while maximizing benefits. High-risk in iduals could also be identified early in life, creating opportunities to arrest the development of nascent coronary atherosclerosis and prevent future clinical events.
Publisher: Springer Science and Business Media LLC
Date: 08-01-2005
DOI: 10.1007/S00125-004-1632-Z
Abstract: Subclinical left ventricular (LV) dysfunction has been shown by tissue Doppler and strain imaging in diabetic patients in the absence of coronary disease or LV hypertrophy, but the prevalence and aetiology of this finding remain unclear. This study sought to identify the prevalence and the determinants of subclinical diabetic heart disease. A group of 219 unselected patients with type 2 diabetes without known cardiac disease underwent resting and stress echocardiography. After exclusion of coronary artery disease or LV hypertrophy, the remaining 120 patients (age 57+/-10 years, 73 male) were studied with tissue Doppler imaging. Peak systolic strain of each wall and systolic (Sm) and diastolic (Em) velocity of each basal segment were measured from the three apical views and averaged for each patient. Significant subclinical LV dysfunction was identified according to Sm and Em normal ranges adjusted by age and sex. Strain and Em were correlated with clinical, therapeutic, echocardiographic and biochemical variables, and significant independent associations were sought using a multiple linear regression model. Significant subclinical LV dysfunction was present in 27% diabetic patients. Myocardial systolic dysfunction by peak strain was independently associated with glycosylated haemoglobin level (p<0.001) and lack of angiotensin-converting enzyme inhibitor treatment (p=0.003). Myocardial diastolic function (Em) was independently predicted by age (p=0.013), hypertension (p=0.001), insulin (p=0.008) and metformin (p=0.01) treatment. In patients with diabetes mellitus, subclinical LV dysfunction is common and associated with poor diabetic control, advancing age, hypertension and metformin treatment ACE inhibitor and insulin therapies appear to be protective.
Publisher: Elsevier BV
Date: 12-2013
DOI: 10.1016/J.JCMG.2013.10.005
Abstract: This systematic review seeks to present the outcomes of the natural history of aortopathy associated with bicuspid aortic valve (ABAV) and after interventions. Aortopathy is common in patients with ABAV, and early intervention has been proposed to reduce the risk of dissection. In asymptomatic patients, the timing of surgical management is based upon imaging of aortic size, but the actual threshold is based upon observational data and expert opinion. As evidence of high risk would justify early intervention, we sought to define the natural history of this condition and after interventions. We undertook a systemic review of the evidence from observational studies of ABAV published up to June 2013. The primary outcome was annualized all-cause mortality. Secondary outcomes included acute aortic events, rates of aneurysm enlargement, and peri-operative complications. A random-effects model was used to combine outcomes. A meta-regression was undertaken to assess the impact of potential covariates. The 32 eligible papers involved 11,045 patients (9,441 BAV and 1,604 control subjects, age 46 ± 14 years). There were 3 major groups, nonoperated bicuspid aortic valve (BAV) patients (ages from 30 to 40 years), patients after aortic surgery (generally 40 to 60 years of age) and after isolated valve replacement (>60 years of age). The respective annualized mortality of nonoperated BAV patients was 0.56% (95% confidence interval [CI]: 0.13 to 0.99), compared with 0.78% (95% CI: 0.20 to 1.36) in patients after aortic surgery and 2.39% (95% CI: 1.61 to 3.16) after isolated valve replacement. The annualized acute event rate in nonoperated BAV patients was 0.29% (95% CI: 0.23 to 0.35), this risk being no different from that of a tricuspid aortic valve (risk ratio: 0.68, 95% CI: 0.34 to 1.36). In the post-surgical series, 30-day mortality varied from 0% to 2.5%, and the risk of acute events was 0.16% (95% CI: 0.0 to 0.32) in patients after aortic surgery and 0.68% (95% CI: 0.42 to 0.94) after isolated valve replacement. Aortic dilation was at a rate of 0.16 mm/year over 6 decades in healthy BAV subjects and 1.1 ± 0.15 mm/year in older aortic valve replacement patients. The risk associated with ABAV varies according to age and clinical setting. Nonetheless, despite aortic dilatation, the acute aortic event risk of ABAV appears low in current practice. Decision-making regarding the timing of intervention needs to be made on the basis of the balance between this low risk and both the morbidity and mortality of surgery.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2004
DOI: 10.1097/01.HCO.0000131535.32657.87
Abstract: Heart failure and diabetes mellitus are frequently associated, and diabetes appears to potentiate the clinical presentation of heart failure related to other causes. The purpose of this review is to examine recent advances in the application of tissue Doppler imaging for the assessment of diabetic heart disease. Recent studies have documented that both myocardial systolic and diastolic abnormalities can be identified in apparently healthy patients with diabetes and no overt cardiac dysfunction. Interestingly, these are disturbances of longitudinal function, with compensatory increases of radial function-suggesting primary involvement of the subendocardium, which is a hallmark of myocardial ischemia. Despite this, there is limited evidence that diabetic microangiopathy is responsible-with reduced myocardial blood volume rather than reduced resting flow, and at least some evidence suggesting a normal increment of tissue velocity with stress. Finally, a few correlative studies have shown association of diabetic myocardial disease with poor glycemic control, while angiotensin converting enzyme inhibition may be protective. Tissue Doppler imaging (and the related technique of strain rate imaging) appears to be extremely effective for the identification of subclinical LV dysfunction in diabetic patients. It is hoped that the recognition of this condition will prompt specific therapy to prevent the development of overt LV dysfunction.
Publisher: Elsevier BV
Date: 11-2019
Publisher: BMJ
Date: 23-01-2013
DOI: 10.1136/HEARTJNL-2012-303329
Abstract: As myocardial fibrosis might be an important contributor to the association of obesity with left ventricular (LV) dysfunction and heart failure, we investigated the effects of spironolactone on LV function and serological fibrosis markers (procollagen type III N-terminal propeptide (PIIINP) and procollagen type I C-terminal propeptide (PICP)) in patients with obesity and abnormal LV performance. A prospective, randomised, double-blind, placebo-controlled study. A university hospital. 113 patients (mean±SD age 58±8 years) with body mass index≥30, without any comorbidities, with impaired early diastolic mitral annular velocity, randomised to spironolactone 25 mg/day or placebo for 6 months. Echocardiographically derived indices of LV systolic (strain and strain rate) and diastolic (E velocity, tissue e' and E/e' ratio) function, myocardial reflectivity (calibrated integrated backscatter (IB)), and serum PICP and PIIINP. In the spironolactone group, significant improvements in myocardial deformation, peak early diastolic velocity (Em), E/e' and IB were noted with a simultaneous decrease in PICP and PIIINP. No corresponding alterations were found with placebo. Improvement in LV systolic function (increase in strain) was independently associated with baseline strain (β=-0.43, p<0.001), change in IB (β=0.26, p<0.02) and baseline PICP (β=0.24, p<0.04). Among the independent determinants of LV diastolic improvement were for increase in Em - baseline Em (β=-0.44, p<0.001) and baseline PICP (β=0.35, p<0.002), and for decrease in E/e' - baseline E/e' (β=-0.35, p<0.005) and change in PICP (β=0.25, p<0.04). In patients with obesity without other comorbidities, aldosterone antagonism improves LV function and myocardial acoustic properties, and reduces circulating procollagen levels. Beneficial changes in cardiac performance are independently predicted by baseline LV dysfunction and baseline disturbances, as well as treatment-induced improvements in fibrosis markers. www.anzctr.org.au ACTRN12609000655246.
Publisher: Elsevier BV
Date: 11-2003
DOI: 10.1016/J.AMJCARD.2003.07.003
Abstract: The influence of complex plaque morphology on the extent of demand-induced ischemia in unselected patients is not well defined. We sought to investigate the functional significance of lesion morphology in patients who underwent coronary angiography and dobutamine stress echocardiography (DSE). Angiography and DSE were performed within a 6-month period (mean 1 +/- 1 month) in 196 patients. Angiographic assessments involved quantification of stenosis severity, assessment of the extent of jeopardized myocardium, and categorization of plaque morphology according to the Ambrose classification. DSE was interpreted by separate investigators with respect to wall motion score index (WMSI) and number of coronary territories involved. A general linear model was constructed to assess the independent contribution of patient characteristics and angiographic and DSE results with respect to extent of ischemic myocardium. Complex lesion morphology was seen in 62 patients (32%). Patients with complex lesions were more likely to have had prior myocardial infarction (p <0.001) and be current smokers (p = 0.03). During angiography, they exhibited a trend toward a greater number of diseased vessels, had a greater coronary jeopardy score (p <0.001) and more frequent collateral flow (p = 0.03). During echocardiography, patients had a higher stress WMSI (p <0.001) and were more likely to show ischemia in all 3 arterial territories (p <0.01). On multivariate regression, the coronary artery jeopardy score and the presence of complex plaque morphology were independent predictors of the extent of ischemic myocardium (R(2) = 34%, p <0.001). Thus, patients with complex plaque morphology are older, more likely to smoke, and more likely to have had prior myocardial infarction. They exhibit more extensive disease with higher coronary jeopardy scores and a higher resting and peak stress WMSI. Despite these differences, complex plaque morphology remains an independent predictor of the extent of ischemia during stress.
Publisher: Elsevier BV
Date: 09-2012
DOI: 10.1016/J.AMJCARD.2012.04.052
Abstract: Current guidelines recommend a multiparametric echocardiographic assessment of aortic regurgitation (AR). However, the absence of a hierarchical weighting of discordant parameters could cause interobserver variability. In the present study, we sought to define and improve the interobserver variability of AR assessment. Seventeen level 3 readers graded 20 randomly selected patients with AR. The readers also provided a usefulness score for each parameter, depending on its influence on their decision of the AR severity grade. A consensus strategy was subsequently formulated and validated against cardiac magnetic resonance imaging in a separate group of 80 patients. The readers were updated with the consensus document and recalibrated using the same cases. Agreement was statistically assessed using Randolph's free-marginal multirater kappa. At baseline, no uniform approach was used to combine the in idual parameters, contributing to the interobserver variability (overall kappa 0.5). A consensus strategy to categorize AR severity was developed in which the left ventricular volume took precedence over the other parameters and was used to differentiate chronic severe AR from less severe categories. Recalibration of the readers using this consensus strategy improved concordance (kappa increased to 0.7). The new strategy also improved the accuracy relative to cardiac magnetic resonance imaging, as evidenced by full agreement on severe AR between the consensus document-based grading and AR severity defined by cardiac magnetic resonance imaging in the separate validation group of 80 patients. In conclusion, grading of chronic AR using a multiparametric approach has suboptimal consistency between readers and a left ventricular volume-based consensus document improved concordance and accuracy.
Publisher: Elsevier BV
Date: 05-2008
DOI: 10.1016/J.AMJCARD.2007.12.034
Abstract: Obesity is associated with heart failure. Recognition of subclinical left ventricular (LV) dysfunction may permit the initiation of therapy to prevent the development of heart failure. In this study of anthropometric, biochemical, and echocardiographic measurements in 295 healthy overweight subjects, we sought to investigate the effect of insulin resistance and severity of obesity on LV function and to establish a strategy for detection of LV dysfunction using metabolic and echocardiographic measurements. Correlates of subclinical dysfunction (defined from myocardial deformation in a matched group of 98 slim controls) were sought, and receiver operator characteristic curves for clinical and laboratory parameters were performed to identify optimal cutoffs to permit an effective diagnostic strategy. Subclinical impairment of LV function (average strain 35 kg/m2). Independent correlates of strain were BMI (beta=-0.25, p<0.0001), fasting insulin (beta=-0.22, p<0.001), and age (beta=-0.18, p<0.003). In patients with a BMI<35 kg/m2, subclinical impairment was uncommon in the absence of hyperinsulinemia. Using a BMI<35 kg/m2 and an insulin level<13 mIU/L to select patients for further testing allowed echocardiography to be avoided in 35% of subjects in whom the prevalence of LV dysfunction was low. In conclusion, obesity and insulin resistance are important contributors to LV dysfunction, a deleterious effect of hyperinsulinemia on LV performance is particularly seen in overweight and moderately obese subjects, and the combination of BMI, fasting insulin, and echocardiography appears optimal for efficient identification of subclinical LV dysfunction in overweight and obese subjects.
Publisher: Elsevier BV
Date: 06-1992
Publisher: Society of Nuclear Medicine
Date: 06-2015
DOI: 10.2967/JNUMED.114.150433
Abstract: Data from echocardiography provide a cornerstone in the management of heart failure. All imaging techniques can provide an ejection fraction, but the versatility of echocardiography makes it unique in the provision of volumes, diastolic function, right ventricular function, hemodynamics, and valvular regurgitation. The early detection of heart failure has been facilitated by the assessment of global longitudinal strain, which is also useful in later heart failure for the assessment of left ventricular synchrony. The use of echocardiography has been associated with favorable outcomes, probably on the basis of facilitation of appropriate therapy. This review examines the evidence provided by echocardiography and its application in specific settings. Although the guidelines emphasize that no single test satisfies all imaging requirements in heart failure, and other modalities can provide additional information about specific questions (especially tissue characterization), echocardiography is indispensable in the management of heart failure.
Publisher: Elsevier BV
Date: 12-2012
Publisher: Elsevier BV
Date: 10-2017
Publisher: Elsevier BV
Date: 04-2020
DOI: 10.1016/J.JCMG.2019.10.016
Abstract: The purpose of this study was to investigate the effect of the temporal and observer variability of cardiac magnetic resonance (CMR)-measured native T Biomarkers and serial quantitative CMR tissue characterization may help identify early myocardial changes of CTRCD, but these parameters require both accuracy and reliability. A total of 50 participants (age 48.9 ± 12.1 years) underwent 3 CMR studies (1.5-T) and biomarker measurements (high-sensitivity troponin-I and B-type natriuretic peptide) at 3-month intervals: 20 with HER2-positive breast cancer (10 with and 10 without CTRCD), and 30 prospectively recruited healthy participants. T Compared with the patients without CTRCD, those with CTRCD had larger temporal change in native T The temporal changes in both biomarkers and tissue characterization measures in in idual patients overlap with the temporal variability in healthy participants and approach the minimal detectable temporal differences. While the accuracy of the parameters awaits further study, the temporal variability of these methods may pose challenges to routine clinical application in in idual patients receiving cancer therapy.
Publisher: Oxford University Press (OUP)
Date: 02-06-2009
DOI: 10.1093/EJECHOCARD/JEP056
Abstract: Echocardiography has become an integral part of modern cardiology, and parameters measured by echocardiography are enshrined in guidelines as components of clinical decision-making in the management of heart failure, valve disease and arrhythmias. This review will explore four modalities which will underpin the future of echocardiography - the hand-held machine, quantification, three-dimensional imaging, and contrast. Finally, we will explore the implications of the new financial milieu for the selection of cardiac imaging modalities.
Publisher: Elsevier BV
Date: 11-2013
Publisher: Wiley
Date: 05-2002
DOI: 10.1046/J.1540-8175.2002.00279.X
Abstract: The detection of viable myocardium has important implications for management, but use of stress echocardiography to detect this is subjective and requires exposure to dobutamine. We investigated whether cyclic variation (CV) of integrated backscatter (IB) from the apical views could provide a resting study for detection of contractile reserve (CR) and prediction of myocardial viability in 27 patients with chronic ischemic left ventricular (LV) dysfunction. Repeat echocardiography was performed after 6.7 +/- 3.8 months of follow-up 14 patients underwent revascularization and 13 were treated medically. Using a standardized dobutamine echocardiography (DbE) protocol, images from three apical views were acquired at 80-120 frames/sec at rest and during stress. CR was identified if improvement of wall motion was observed at low dose (5 or 10 microg/kg/min) DbE. Myocardial viability was characterized by improvement at follow-up echocardiography in patients with revascularization. CVIB at rest and low dose dobutamine were assessed in 194 segments with resting asynergy (severe hypokinesis or akinesis), of which 88 (45%) were in patients who underwent revascularization. Of these, CVIB could be measured in 190 (98%) segments at rest and 185 (95%) at low dose dobutamine. Sixty-two (33%) segments had CR during low dose DbE and 50 (57%) segments showed wall-motion recovery (myocardial viability) at follow-up echocardiography. Segments with CR had significantly higher CVIB at rest (P 8.2 dB) at rest, the accuracy of CVIB for detecting CR was 70%. Compared with nonviable segments, viable segments had significantly higher CVIB at rest (P < 0.001) and low dose dobutamine (P 5.3 dB) at rest, the accuracy of CVIB for detecting myocardial viability was 85%, which was higher than that in conventional DbE (62%, P < 0.01). Thus, assessment of CVIB from the apical views is a feasible and accurate tool for detecting CR and predicting myocardial viability in chronic LV dysfunction.
Publisher: Elsevier BV
Date: 03-1999
DOI: 10.1016/S0002-8703(99)70487-4
Abstract: Assessment of left ventricular (LV) contractility in mitral regurgitation is difficult, and latent systolic dysfunction may be present despite conventional indexes being in the "normal" range. We sought to demonstrate the presence of latent LV dysfunction in mitral regurgitation by showing diminished contractile reserve with the use of simplified pressure-volume loops from noninvasively derived parameters. We performed exercise echocardiography in 72 patients with isolated mitral regurgitation, minimal or no symptoms, normal resting LV function, and no coronary disease who subsequently underwent uncomplicated valve repair and in 15 healthy subjects. Simplified pressure-volume loops were constructed and LV stroke work was estimated at rest and immediately after exercise. As pressures were estimated, the findings were confirmed with a validated numerical model to estimate stroke work in patients and control subjects. Patients had a higher stroke work than did control subjects at rest (1.45 +/- 0.39 vs 0.92 +/- 0.21 J, P <.001). Eighteen patients had LV dysfunction develop after surgery. Patients with postrepair dysfunction had a significantly lower exercise stroke work (1.79 +/- 0.69) than did patients without (2.28 +/- 0.84 J, P =.02), but there was no difference in resting stroke work (1.48 +/- 0.39 vs 1.44 +/- 0.4, P = not significant). Change in stroke work with exercise was higher in patients with normal postoperative function (0.84 +/- 0.59 J) and control subjects (0.59 +/- 0.36 J) than patients with postoperative dysfunction (0.31 +/- 0.55 J, P =.001). The numerical model confirmed the lower exercise stroke work and change in stroke work in patients with postoperative dysfunction. The clinical study and numerical model confirmed diminished contractile reserve in patients who had LV dysfunction develop after uncomplicated mitral valve repair. Diminished contractile reserve may be a preoperative marker of latent contractile dysfunction.
Publisher: Elsevier BV
Date: 07-2014
DOI: 10.1016/J.JACC.2014.01.073
Abstract: The literature exploring the utility of advanced echocardiographic techniques (such as deformation imaging) in the diagnosis and prognostication of patients receiving potentially cardiotoxic cancer therapy has involved relatively small trials in the research setting. In this systematic review of the current literature, we describe echocardiographic myocardial deformation parameters in 1,504 patients during or after cancer chemotherapy for 3 clinically-relevant scenarios. The systematic review was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the EMBASE (1974 to November 2013) and MEDLINE (1946 to November 2013) databases. All studies of early myocardial changes with chemotherapy demonstrate that alterations of myocardial deformation precede significant change in left ventricular ejection fraction (LVEF). Using tissue Doppler-based strain imaging, peak systolic longitudinal strain rate has most consistently detected early myocardial changes during therapy, whereas with speckle tracking echocardiography (STE), peak systolic global longitudinal strain (GLS) appears to be the best measure. A 10% to 15% early reduction in GLS by STE during therapy appears to be the most useful parameter for the prediction of cardiotoxicity, defined as a drop in LVEF or heart failure. In late survivors of cancer, measures of global radial and circumferential strain are consistently abnormal, even in the context of normal LVEF, but their clinical value in predicting subsequent ventricular dysfunction or heart failure has not been explored. Thus, this systematic review confirms the value of echocardiographic myocardial deformation parameters for the early detection of myocardial changes and prediction of cardiotoxicity in patients receiving cancer therapy.
Publisher: Elsevier BV
Date: 06-2002
DOI: 10.1016/S0002-9149(02)02345-7
Abstract: Quantification of stress echocardiography may overcome the training requirements and subjective nature of visual wall motion score (WMS) assessment, but quantitative approaches may be difficult to apply and require significant time for image processing. The integral of long-axis myocardial velocity is displacement, which may be represented as a color map over the left ventricular myocardium. This study was designed to explore the feasibility and accuracy of measuring long-axis myocardial displacement, derived from tissue Doppler, for the detection of coronary artery disease (CAD) during dobutamine stress echocardiography (DBE). One hundred thirty patients underwent standard DBE, including 30 patients at low risk of CAD, 30 patients with normal coronary angiography (both groups studied to define normal ranges of displacement), and 70 patients who underwent coronary angiography in whom the accuracy of normal ranges was tested. Regional myocardial displacement was obtained by analysis of color tissue Doppler apical images acquired at peak stress. Displacement was compared with WMS, and with the presence of CAD by angiography. The analysis time was 3.2 +/- 1.5 minutes per patient. Segmental displacement was correlated with wall motion (normal 7.4 +/- 3.2 mm, ischemia 5.8 +/- 4.2 mm, viability 4.6 +/- 3.0 mm, scar 4.5 +/- 3.5 mm, p <0.001). Reversal of normal base-apex displacement was an insensitive (19%) but specific (90%) marker of CAD. The sum of displacements within each vascular territory had a sensitivity and specificity of 89% and 79%, respectively, for prediction of significant CAD, compared with 86% and 78%, respectively, for WMS (p = NS). The displacements in the basal segments had a sensitivity and specificity of 83% and 78%, respectively (p = NS). Regional myocardial displacement during DBE is feasible and offers a fast and accurate method for the diagnosis of CAD.
Publisher: Elsevier BV
Date: 02-2023
DOI: 10.1016/J.IJCARD.2022.11.045
Abstract: Valvular heart disease is becoming an increasingly prevalent with population ageing. We sought to define the current prevalence of valvular heart disease in Australia. The TasELF and VicELF studies prospectively recruited 962 asymptomatic participants ≥65 years, with at least one cardiovascular risk factor, from the Tasmanian and Victorian communities. People were excluded if they had a previous diagnosis of heart failure, or a life expectancy <1 year. All underwent baseline echocardiography. Those with moderate or severe valvular disease were identified. The current prevalence of clinically significant valve disease was applied to the Australian Bureau of Statistics population projections. Echocardiograms were interpretable in 943 participants (98%). Clinically significant valve disease was present in 5% of the population, and mitral regurgitation was the most common overall valvular lesion, present in 36% of the population. The projected numbers of people with clinically significant valvular disease is expected to increase significantly across all age groups by the year 2060. Clinically significant yet asymptomatic valvular disease was prevalent in a large community cohort of participants with at least one risk factor. The total burden of valvular heart disease is expected to increase dramatically over the coming decades.
Publisher: BMJ
Date: 03-07-2012
DOI: 10.1136/HEARTJNL-2012-302007
Abstract: Left atrial (LA) function is an important contributor to cardiac function in a variety of disease states and especially with exercise. The purpose of this study was to assess the role of LA function in the left ventricular (LV) filling pressure (E/e') response to exercise and exercise tolerance in patients with preserved LV ejection fraction (LVEF). LA contractile function (LA strain peak negative), conduit function (LA strain peak positive), and reservoir function (LA strain total) were measured from speckle tracking in 486 patients with preserved LVEF and negative exercise echocardiography for ischaemia. Maximal exercise tolerance was expressed as the estimated metabolic equivalents (METs). Per cent predicted METs was calculated in accordance with described nomograms. Features associated with exercise capacity were sought in a multiple linear regression, and compared using standardised β. Patients with increased stress E/e' had significantly lower LA strain profiles and larger LA volume than the remainder. LA strain total was strongly associated with exercise capacity in multivariate analysis (ß=0.21, p<0.001). E/e' rest was also associated with exercise capacity (ß=-0.11, p=0.001). Other independent correlates of exercise capacity were age (ß=-0.36, p<0.001), male gender (ß=0.34, p<0.001) and body mass index (ß=-0.23, p<0.001). The best predictor of per cent predicted METs was total LA strain in multivariate analysis. The association of reduced LA function with impaired exercise capacity was similar to that of elevated LVE/e', emphasising the role of ventriculo-atrial coupling to cardiac dysfunction with preserved LVEF.
Publisher: Springer Science and Business Media LLC
Date: 12-1999
DOI: 10.1016/S1071-3581(99)90091-0
Abstract: Seven clinical sites compiled data from 4638 women who were referred directly to coronary angiography (catheterization-first strategy n = 3375) or who underwent stress myocardial perfusion imaging (MPI) first (n = 1263) followed by coronary angiography if at least one reversible myocardial perfusion abnormality was detected. The study examines the cost minimization potential of these available invasive and noninvasive diagnostic strategies in women with chest pain. Women in both groups were subclassified by the core laboratory as being at low ( 0.60) pretest likelihood for coronary artery disease (CAD). Among the catheterization-first patients, at least one coronary stenosis >70% was present in 13% of low likelihood patients, 29% of intermediate likelihood patients, and 52% of patients with high CAD likelihood. Perfusion abnormality rates in the MPI-first group were 23% in low likelihood patients, 27% in intermediate likelihood patients, and 34% in high CAD likelihood patients. Of the MPI-first subset, 50%, 55%, and 76%, respectively, underwent catheterization in at least one coronary stenosis >70%. Cardiac death rates ranged from 0.5% to 2.2% in patients with CAD and did not differ from the 2 testing strategies (P = not significant). The composite cost per patient of diagnostic testing plus follow-up medical care over a period of 2.5 +/- 1.5 years (calculated for both strategies from inflation-corrected Medicare charges, adjusted for institutional cost-charge ratios) ranged from $2490 for patients with low likelihood to $3687 for patients with high likelihood with the catheterization-first strategy and from $1587 to $2585 for patients undergoing MPI first (P < .01 between risk subsets and strategies). In women referred for diagnostic evaluation of stable chest pain, MPI followed by selective coronary angiography in patients with at least 1 perfusion abnormality minimizes the near-term composite cost per patient compared with a direct catheterization-first strategy, regardless of pretest CAD likelihood.
Publisher: Elsevier BV
Date: 02-1996
DOI: 10.1016/0735-1097(95)00483-1
Abstract: This study sought to determine the degree of interinstitutional agreement in the interpretation of dobutamine stress echocardiograms. Dobutamine stress echocardiography involves subjective interpretation. Consistent methods for acquisition and interpretation are of critical importance for obtaining high interobserver agreement and for facilitating communication of test results. Five experienced centers were each asked to submit 30 dobutamine stress echocardiograms (dobutamine up to 40 micrograms/kg body weight per min and atropine up to 1 mg) obtained in patients undergoing coronary angiography. Thus, a total of 150 dobutamine stress echocardiograms were interpreted by each center without knowledge of any other patient data. Left ventricular wall motion was assessed using a 16-segment model but was otherwise not standardized. No patient was excluded because of poor image quality or inadequate stress level. Echocardiographic image quality was assessed using a five-point scale. Angiographically significant coronary artery disease (> or = 50% diameter stenosis) was present in 95 patients (63%). By a majority decision (three or more centers), the sensitivity, specificity and accuracy of dobutamine echocardiography were 76%, 87% and 80%, respectively. Abnormal or normal results of stress echocardiography were agreed on by four or all five of the centers in 73% of patients (mean kappa value 0.37, fair agreement only). Agreement on the left anterior descending artery territory (78%) was similar to that for the combined right coronary artery/left circumflex artery territory (74%), and for specific segments the agreement ranged from 84% to 97% and was highest for the basal anterior segment and lowest for the basal inferior segment. Agreement was higher in patients with no (82%) or three-vessel coronary artery disease (100%) and lower in patients with one- or two-vessel disease (61% and 68%, respectively). Agreement on positivity or negativity of stress test results was 100% for patients with the highest image quality but only 43% for those with the lowest image quality (p = 0.003). The current heterogeneity in data acquisition and assessment criteria among different centers results in low interinstitutional agreement in interpretation of stress echocardiograms. Agreement is higher in patients with no or advanced coronary artery disease and substantially lower in those with limited echocardiographic image quality. To increase interinstitutional agreement, better standardization of image acquisition and reading criteria of stress echocardiography is recommended.
Publisher: American Physiological Society
Date: 09-2019
DOI: 10.1152/AJPHEART.00327.2019
Abstract: The exercise consisted of: 1) a short survey to acquire baseline data on current practices regarding the conduct of animal studies, 2) a series of presentations for promoting awareness and providing advice and practical tools for improving experimental design, and 3) a follow-up survey 12 mo later to assess whether practices had changed. The surveys were compulsory for responsible investigators ( n = 16 paired data presented). Other investigators named on animal ethics applications were encouraged to participate (2017, total of 36 investigators 2018, 37 investigators). The major findings to come from the exercise included 1) a willingness of investigators to make changes when provided with knowledge/tools and solutions that were relatively simple to implement (e.g., proportion of responsible investigators showing improved practices using a structured method for randomization was 0.44, 95% CI (0.19 0.70), P = 0.003, and deidentifying drugs/interventions was 0.40, 95% CI (0.12 0.68), P = 0.010) 2) resistance to change if this involved more personnel and time (e.g., as required for allocation concealment) and 3) evidence that changes to long-term practices (“habits”) require time and follow-up. Improved practices could be verified based on changes in reporting within publications or documented evidence provided during laboratory visits. In summary, this exercise resulted in changed attitudes, practices, and reporting, but continued follow-up, monitoring, and incentives are required. Efforts to improve experimental rigor will reduce bias and will lead to findings with the greatest translational potential. NEW & NOTEWORTHY The goal of this exercise was to encourage preclinical researchers to improve the quality of their cardiac and metabolic animal studies by 1) increasing awareness of concerns, which can arise from suboptimal experimental designs 2) providing knowledge, tools, and templates to overcome bias and 3) conducting two short surveys over 12 mo to monitor change. Improved practices were identified for the uptake of structured methods for randomization, and de-identifying interventions/drugs. Listen to this article's corresponding podcast at /experimental-design-survey-training-practical-tools/ .
Publisher: Elsevier BV
Date: 07-2011
DOI: 10.1016/J.JCMG.2011.02.018
Abstract: The reservoir, conduit, and contractile functions of the left atrium are integral to overall cardiac performance. Recent advances in cardiac imaging offer the accurate assessment of LA phasic functions and structure, using techniques such as 3-dimensional echocardiography, color tissue Doppler imaging, and speckle tracking, as well as cardiac computed tomography and magnetic resonance imaging. These new developments are particularly important in view of the increasing use of intervention involving the left atrium. This review article highlights and contrasts the imaging of the size, mechanics, and structure of the left atrium using multiple modalities. The authors discuss recent studies on the clinical applications of the various techniques in disease conditions.
Publisher: Elsevier BV
Date: 10-1991
DOI: 10.1016/0300-9572(91)90003-H
Abstract: Despite advances in resuscitation, the ability to predict survival at cardiac arrests remains unsophisticated. We identified the factors determining outcome of all cardiopulmonary resuscitations performed at our institution over a 4-year period, and used a Cox multivariate regression model to design prognostic indices to assess the probability of successful resuscitation and hospital discharge. Cardiac arrests (710) were studied, and 193 (28%) were successfully resuscitated. The most influential variables, judged by the size and significance of their logistic regression coefficients, were rhythm, resuscitation delay, and age (for successful resuscitation), and rhythm, performance of intubation and defibrillation, defibrillation delay, and age (for survival until discharge). The combination of these in a prognostic index reliably predicted both outcome (area under the receiver operating curve of 0.78), and survival until discharge (area under the curve of 0.80).
Publisher: Wiley
Date: 19-06-2012
DOI: 10.1111/J.1464-5491.2011.03557.X
Abstract: Heart rate variability may be used to assess diabetic cardiac autonomic neuropathy. The aim of the present study was to determine the reliability of standard short-term clinical measurements of heart rate variability in patients with Type 2 diabetes. In 24 patients with Type 2 diabetes (11 male, age 61 ± 9 years), parameters of heart rate variability in the time domain (standard deviation of RR intervals, coefficient of variation of RR intervals and root mean square of successive RR interval differences) and frequency domain (very low frequency, low frequency, high frequency and total spectral power) were derived from a 5-min electrocardiograph recorded during two laboratory visits separated by 16 ± 8 days. Absolute and relative reliability were assessed by 95% limits of random variation and the intraclass correlation coefficient, respectively. Categorical agreement of classifications of heart rate variability and s le size estimates for clinical trials were calculated. Despite no significant difference in mean heart rate variability between tests, 95% limits of random variation indicated that repeated measurements were between 58% higher/37% lower (most reliable parameter coefficient of variation of RR intervals) and 443% higher/82% lower (least reliable parameter very low frequency power) than the first measure. The intraclass correlation coefficient ranged from 0.58 to 0.90 and s le size requirements from 20 to 93 patients per group. Agreement of categories of heart rate variability ranged from 79 to 96%. Short-term clinical measurements of heart rate variability in patients with Type 2 diabetes are characterized by poor absolute reliability, but substantial to good relative reliability, suggesting greater clinical utility in diagnosis than in sequential follow-up.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 24-09-2011
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2012
DOI: 10.1161/CIRCIMAGING.112.977348
Abstract: Current guidelines recommend intervention for symptomatic aortic stenosis, but the management of asymptomatic aortic stenosis remains controversial. As left ventricular global longitudinal strain (GLS) has been shown to predict cardiovascular outcome, we sought to find whether its use could guide the assessment of risk in these patients. We prospectively followed 79 patients with severe asymptomatic aortic stenosis (39 men mean age, 77 ± 12 years aortic valve [AV] area index, 0.36 cm 2 /m 2 ). In addition to standard echocardiography, speckle strain was measured to assess GLS. Patients were followed for cardiac death and AV replacement driven by symptom development. A multivariable Cox regression was performed to identify associations with events. During 23 ± 20 months, 3 patients had cardiac death and 49 underwent AV replacement. Event-free survival was 72 ± 5% at 1 year, 50 ± 5% at 2 years, and 24 ± 5% at 4 years. Death and AV replacement were predicted by GLS (hazard ratio [HR], 1.14 [95% CI, 1.01–1.28] P =0.037), as well as extent of AV calcification (HR, 2.44 [95% CI, 1.17–5.12] P =0.018), peak transaortic pressure gradient (HR, 1.03 [95% CI, 1.01–1.04] P .001), valvulo-arterial impedance (HR, 1.32 [95% CI, 1.04–1.67] P =0.045), and Society of Thoracic Surgeons Predicted Risk of Morbidity and Mortality (HR, 0.95 [95% CI, 0.90–1.00] P =0.052). A mean absolute GLS % was associated with a significant excess mortality, and this measurement added incremental prognostic value to the Society of Thoracic Surgeons Predicted Risk of Morbidity and Mortality, transaortic peak pressure gradient, AV calcification, and valvulo-arterial impedance. GLS is associated with outcomes in patients with severe asymptomatic aortic stenosis, incremental to other clinical and echocardiographic variables.
Publisher: Elsevier BV
Date: 11-1998
DOI: 10.1016/S0735-1097(98)00377-5
Abstract: This study sought to examine the prognostic importance of chronotropic incompetence among patients referred for stress echocardiography. Although chronotropic incompetence has been shown to be predictive of an adverse prognosis, it is not clear if this association is independent of exercise-induced myocardial ischemia. Consecutive patients (146 men and 85 women mean age 57 years) who were not taking beta-adrenergic blocking agents and were referred for symptom-limited exercise echocardiography were followed for a mean of 41 months. Chronotropic incompetence was assessed in two ways: (1) failure to achieve 85% of the age-predicted maximum heart rate and (2) a low chronotropic index, a heart rate response measure that accounts for effects of age, resting heart rate and physical fitness. The primary end point, a composite of death, nonfatal myocardial infarction, unstable angina and late (>3 months after the exercise test) myocardial revascularization, occurred in 41 patients. Failure to achieve 85% of the age-predicted maximum heart rate was predictive of events (relative risk [RR] 2.47, 95% confidence interval [CI] 1.28 to 4.79, p=0.007) similarly, a low chronotropic index was predictive (RR 2.44, 95% CI 1.31 to 4.55, p=0.005). Even after adjusting for myocardial ischemia and other possible confounders, failure to achieve 85% of age-predicted maximum heart rate was predictive (adjusted RR 2.20, 95% CI 1.11 to 4.37, p=0.02). A low chronotropic index also remained predictive (adjusted RR 1.85, 95% CI 0.98 to 3.47, p=0.06). Chronotropic incompetence is predictive of an adverse cardiovascular prognosis even after adjusting for echocardiographic myocardial ischemia.
Publisher: Elsevier BV
Date: 05-2004
Publisher: Elsevier BV
Date: 06-2014
Publisher: Elsevier BV
Date: 07-2003
Publisher: Elsevier BV
Date: 12-2003
DOI: 10.1016/J.AMJCARD.2003.08.053
Abstract: B-type natriuretic peptide (BNP) levels increase in systolic heart failure (HF). However, the value of BNP in hypertensive patients with suspected diastolic HF (symptoms suggestive of HF but normal ejection fraction) and its relation to myocardial function in these patients is unclear. We prospectively studied 72 ambulatory hypertensive subjects (40 women, mean age 58 +/- 8 years) with exertional dyspnea and ejection fraction > or =50%. Diastolic function was evaluated with transmitral and pulmonary venous Doppler, mitral annular velocities (pulsed-wave tissue Doppler), and flow propagation velocity (color M-mode). Systolic function was assessed with strain and strain rate derived from color tissue Doppler imaging. BNP was related to myocardial function and the presence or absence of global diastolic dysfunction. By conventional Doppler criteria, 34 patients had normal left ventricular diastolic function and 38 had isolated diastolic dysfunction. BNP values were higher in patients with diastolic dysfunction (46 +/- 48 vs 20 +/- 20 pg/ml, p=0.004) and were related independently to blood pressure, systolic strain rate, left atrial function (p<0.01 for all), and age (p=0.015). Patients with diastolic dysfunction and pseudonormal filling had higher BNP levels compared with impaired relaxation (89 +/- 47 vs 35 +/- 42 pg/ml, p=0.001). However, 79% of patients with diastolic dysfunction had BNP levels within the normal range. We conclude that in ambulatory hypertensive patients with symptoms suggestive of mild HF and normal ejection fraction, BNP is related to atrial and ventricular systolic parameters, blood pressure, and age. Although elevated in the presence of diastolic dysfunction, the BNP level mostly is in the normal range and, therefore, has limited diagnostic value in stable patients with suspected diastolic HF.
Publisher: Elsevier BV
Date: 2009
DOI: 10.1016/J.IJCARD.2008.03.049
Abstract: Patients with coronary slow flow (CSF) present with a syndrome (often recurrent) of resting angina with no significant coronary stenoses. The nature of myocardial blood flow (MBF), MBF reserve and systemic arterial characteristics may contribute to symptoms in these patients but this has not been examined previously. This study sought to measure MBF, arterial stiffness and wave reflection in patients with CSF and controls. Ten patients with angiographically proven CSF and 20 controls underwent dipyridamole-exercise stress myocardial contrast echocardiography and arterial waveform analysis. MBF was quantified off-line from 10 mid and apical segments with calculation of myocardial blood volume (A), red cell velocity (beta) and their product, MBF, at rest and post-stress. MBF reserve was calculated as the ratio of peak stress to resting MBF. Central arterial pressure waveforms were derived by radial tonometry, with arterial wave reflection expressed by augmentation index. Arterial stiffness was determined by aortic and brachial pulse wave velocities. There was no significant difference between CSF and control groups in mean resting beta (0.56+/-0.24 versus 0.59+/-0.26), A (7.9+/-1.4 versus 7.9+/-5.2), MBF (4.3+/-1.8 versus 4.4+/-3.6), MBF reserve (3.7+/-2.0 versus 4.0+/-2.0), augmentation index (26+/-12 versus 23+/-9%), aortic (7.4+/-1.8 versus 7.4+/-1.5 m/s) or brachial (8.0+/-0.8 versus 8.1+/-1.3) pulse wave velocity (p>0.4 for all). Similarly, there were no significant haemodynamic differences between groups after exercise (p>0.2 for all). MBF, large artery stiffness and arterial wave reflection characteristics are normal in CSF patients between their acute episodes.
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.ECHO.2013.09.012
Abstract: Left ventricular (LV) ejection fraction (EF) measured by two-dimensional echocardiographic (2DE) imaging is an important correlate of survival. Real-time three-dimensional echocardiographic (3DE) imaging has addressed some of the limitations of 2DE imaging. The aim of this study was to determine whether 3DE imaging is more predictive of outcomes than 2DE imaging. A total of 529 patients undergoing LV assessment with 2DE and 3DE imaging in 2003 and 2004 at a tertiary referral cardiac center were studied. Patients had a high frequency of cardiovascular risk factors. Images were gathered over four cardiac cycles using a matrix-array transducer, with measurements performed offline. Follow-up (all-cause mortality or cardiac hospitalization) was obtained over 6.6 ± 3.4 years in 455 of 486 patients with images suitable for measurement (94%). There were 194 events (43%), including 75 deaths (16.4%). Larger LV volumes and lower EF were associated with worse outcomes independent of age, heart failure, or end-stage renal disease. In stepwise Cox regression analyses, the associations of cardiac hospitalization and survival with clinical variables (age, chronic kidney disease, and heart failure) were augmented by 3DE EF and end-systolic volume more than by 2DE parameters. The incremental model χ(2) value with 3DE EF was 14.67 (P < .001), compared with 9.72 (P = .002) for 2DE EF. Similarly, in Cox regression analyses of mortality, the effects of clinical variables (age, advanced renal disease, and heart failure) were augmented more by 3DE EF (incremental χ(2) = 14.04, P < .0001) than 2DE EF (incremental χ(2) = 5.13, P = .024). In this outcome study, 3DE EF and volumes showed stronger associations with outcomes than those derived from 2DE imaging.
Publisher: Elsevier BV
Date: 12-1998
DOI: 10.1016/S0002-9149(98)00697-3
Abstract: Subjective interpretation of dobutamine echocardiograms provides only moderate interinstitutional observer agreement if nonunified data acquisition and assessment criteria are applied. The present study was undertaken to evaluate parameters associated with low interinstitutional observer agreement in the interpretation of dobutamine echocardiograms and to analyze whether standardized interpretation criteria improve interinstitutional observer agreement. One hundred fifty dobutamine echocardiograms (dobutamine up to 40 microg/kg/min body weight and atropine up to 1 mg) were evaluated at 5 centers. Clinical, procedural, and echocardiographic parameters were included in the analysis of variables with significant impact on interinstitutional agreement. Standardized interpretative criteria were established, and 90 dobutamine echocardiograms were reanalyzed by 3 observers using a standardized image display. Multivariate analysis demonstrated low image quality (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.08 to 0.45, p=0.0002), low severity of induced wall motion abnormality (OR 0.17, 95% CI 0.07 to 0.40, p <0.0001), and a low peak rate-pressure product (OR 0.93, 95% CI 0.43 to 2.27, p=0.0382) to result in a low interinstitutional agreement. Standardization of image display in cine loop format and of dobutamine stress echo interpretation criteria resulted in improvement in test result categorization as normal or abnormal, with a kappa value of 0.50, compared with 0.39 using the original subjective interpretation. In conclusion, image quality, the severity of induced wall motion abnormalities, and the obtained rate-pressure product have a significant impact on the interpretation homogeneity of dobutamine echocardiograms. Standardization of image display in cine loop format and of reading criteria results in improved interinstitutional agreement in interpretation of stress echocardiograms.
Publisher: Elsevier BV
Date: 2019
DOI: 10.1016/J.JCMG.2018.11.005
Abstract: In this in idual participant data meta-analysis on left ventricular global longitudinal strain (LVGLS), our objective was to: 1) describe its distribution 2) identify the most predictive cutoff values and 3) assess its impact on mortality in asymptomatic patients with significant aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF). The evidence supporting the prognostic role of LVGLS in asymptomatic patients with AS has been obtained from several relatively small studies. A literature search was performed for studies published between 2005 and 2017 without language restriction according to the following criteria: "aortic stenosis" AND "longitudinal strain." The corresponding authors of selected studies were contacted and invited to share their data that we computerized in a specific database. The primary endpoint was all-cause mortality. Among the 10 studies included, 1,067 asymptomatic patients with significant AS and LVEF >50% were analyzed. The median of LVGLS was 16.2% (from 5.6% to 30.1%). There were 91 deaths reported during follow-up with median of 1.8 (0.9 to 2.8) years, resulting in a pooled crude mortality rate of 8.5%. The LVGLS performed well in the prediction of death (area under the curve: 0.68). The best cutoff value identified was LVGLS of 14.7% (sensitivity, 60% specificity, 70%). Using random effects model, the risk of death for patients with LVGLS 2.5 (hazard ratio: 2.62 95% confidence interval: 1.66 to 4.13 p < 0.0001), without significant heterogeneity between studies (I This in idual participant data meta-analysis demonstrates that in asymptomatic patients with significant AS and normal LVEF, impaired LVGLS is associated with reduced survival. These data emphasize the potential usefulness of LVGLS for risk stratification and management of these patients.
Publisher: Elsevier BV
Date: 11-1992
DOI: 10.1016/0735-1097(92)90251-H
Abstract: The purpose of this report was to study the protective effects of passive and active distal coronary perfusion during prolonged balloon inflation. Prolonged balloon inflation has been proposed to improve immediate and long-term results of percutaneous transluminal coronary angioplasty, but it requires protection against myocardial ischemia. A 30-min balloon occlusion of the left anterior descending artery was performed in three groups of closed chest anesthetized dogs: 1) control (no distal coronary perfusion, n = 13), 2) passive distal coronary perfusion (autoperfusion catheter, n = 10), and 3) active distal coronary perfusion (infusion of the perfluorochemical Fluosol at 30 ml/min, n = 11). At 10 min of balloon inflation, echocardiographic wall motion indexes (scored from 1 [normal] to 5 [dyskinesia]) in the autoperfusion catheter and Fluosol groups (2.4 +/- 1.2 and 2.0 +/- 0.9, respectively) were significantly better than in the control group (3.6 +/- 0.4, p = 0.001), but at 25 min this improvement in wall motion had attenuated and became statistically insignificant when compared with values in the control group. Left ventricular end-diastolic pressure at peak inflation in the Fluosol group (19.5 +/- 5.5 mm Hg) was higher than in the control (7.6 +/- 3.6) and autoperfusion catheter (5.3 +/- 1.4, p < or = 0.01) groups. Pathologic evidence of infarction by tetrazolium staining was seen in three control dogs and in none of the other groups (p = 0.07). Ventricular tachycardia and fibrillation were less frequent in the autoperfusion catheter group (p = 0.02). Three deaths were observed in the control dogs, two in the Fluosol group and none in the dogs with an autoperfusion catheter (p = NS). Passive (the autoperfusion balloon catheter) and active (Fluosol) distal coronary perfusion methods are comparable and better than no perfusion in protecting the myocardium against ischemia produced by prolonged coronary balloon inflation in an experimental canine model. This protection is transient, attenuating after 10 to 25 min, and partial because there was no significant difference in the incidence of myocardial infarction and death among groups, although the latter observations may be related to small s le size.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2002
Publisher: Elsevier BV
Date: 08-1995
DOI: 10.1016/0735-1097(95)80004-Z
Abstract: This study compared the accuracy and cost implications of using exercise echocardiography and exercise electrocardiography for detection of coronary artery disease in women. The specificity of exercise electrocardiography in women is lower than in men. Exercise echocardiography accurately identifies coronary artery disease in women, but its utility in place of exercise electrocardiography is unclear. One hundred sixty-one women without a previous Q wave infarction underwent exercise echocardiography and coronary angiography. Positive findings were a new or worsening wall motion abnormality on the exercise echocardiogram and ST segment depression > 0.1 mV at 0.08 s after the J point on the exercise electrocardiogram (ECG). Coronary artery stenosis > 50% diameter narrowing was present in 59 patients the sensitivity (mean +/- SD) of exercise echocardiography was 80 +/- 3%. In 48 patients with an interpretable ECG, the sensitivity of exercise echocardiography was 81 +/- 4%, and that of the exercise ECG was 77 +/- 3% (p = 0.50). In 102 patients without coronary artery disease, the overall specificity of exercise echocardiography was 81 +/- 4%. In 70 patients with an interpretable ECG, the specificity of exercise echocardiography (80 +/- 3%) exceeded that of the exercise ECG (56 +/- 4%, p < 0.0004). The accuracy of exercise echocardiography was also greater than exercise electrocardiography (81 +/- 5% vs. 64 +/- 6%, p 80%) or low (< 20%) posttest probability group. In women without a previous exercise ECG, the specificity of exercise echocardiography continued to exceed that of exercise electrocardiography (80 +/- 3% vs. 64 +/- 3%, p = 0.05). Exercise echocardiography had the best balance between accuracy and cost for the diagnosis of coronary artery disease in women. Exercise echocardiography is more specific than exercise electrocardiography for diagnosis of coronary artery disease in women and is a cost-effective approach to the diagnosis of coronary artery disease because of the avoidance of inappropriate angiography.
Publisher: Elsevier BV
Date: 06-2019
Publisher: Springer Science and Business Media LLC
Date: 09-12-2022
DOI: 10.1186/S12933-022-01711-5
Abstract: Subclinical LV dysfunction (LVD) identifies heart failure (HF) risk in type 2 diabetes mellitus (T2DM). We sought the extent to which clinical scores (ARIC-HF, WATCH-DM), natriuretic peptides (NTpBNP) and troponin (hs-TnT) were associated with subclinical LV dysfunction (LVD). These associations could inform the ability of these tests to identify which patients should undergo echocardiography. Participants with T2DM were prospectively recruited from three community-based populations. ARIC-HF risk at 4 years and WATCH-DM scores were calculated from clinical data. NTpBNP and hs-TnT were measured using an electro-chemiluminescence assay. All underwent a comprehensive echocardiogram. We calculated the sensitivity and specificity of clinical scores and biomarkers to identify abnormal global longitudinal strain (GLS ≥ −16%)), diastolic function (E/e’ ≥ 14 or e’ 8 cm/s), left atrial volume index (LAV 34 ml/m 2 ) and LV hypertrophy (LV mass index 88 g/m 2 (F) 102 g/m 2 (M)). Of 804 participants (median age 69 years [inter-quartile range (IQR) 65–73], 36% female), clinical scores suggested significant HF risk (median ARIC-HF 8% [IQR 4–12] WATCH-DM 10 points [IQR 8–12]), and the median NTpBNP was 50 pg/mL [IQR 25–101] and hs-TnT 9.6 pg/mL [IQR 6.8–13.6]. Abnormal GLS was present in 126 (17%), elevated E/e’ in 114 (15%), impaired e’ in 629 (78%), increased LAV in 351 (44%) and LV hypertrophy in 113 (14%). After adjustments for age, body-mass index, and renal function, each standard deviation increase in NTpBNP was associated with a GLS increase of 0.32 ( p 0.001) and hs-TnT increase by 0.26 ( p 0.001). Similar trends were observed with ARIC-HF (standardised β = 0.22, p 0.001) and WATCH-DM (standardised β = 0.22, p 0.001) in univariable analyses. However, none of the risk assessment tools provided satisfactory discrimination for abnormal GLS (AUC 63%), diastolic indices (e’ AUC 54–61%) or LV mass (AUC 59–67%). At a sensitivity of 90%, there was an unacceptably low ( 50%) specificity. Although risk assessment based on clinical scores or biomarkers would be desirable to stratify HF risk in people with T2DM, they show a weak relationship with subclinical LVD.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 31-08-2004
DOI: 10.1161/01.CIR.0000139905.47128.9F
Abstract: Background— Although assessment of myocardial perfusion by myocardial contrast echocardiography (MCE) is feasible, its incremental benefit to stress echocardiography is not well defined. We examined whether the addition of MCE to combined dipyridamole-exercise echocardiography (DExE) provides incremental benefit for evaluation of coronary artery disease (CAD). Methods and Results— MCE was combined with DExE in 85 patients, 70 of whom were undergoing quantitative coronary angiography and 15 patients with a low probability of CAD. MCE was acquired by low-mechanical-index imaging in 3 apical views after acquisition of standard resting and poststress images. Wall motion, left ventricular opacification, and MCE components of the study were interpreted sequentially, blinded to other data. Significant ( %) stenoses were present in 43 patients and involved 69 coronary territories. The addition of qualitative MCE improved sensitivity for the detection of CAD (91% versus 74%, P =0.02) and accurate recognition of disease extent (87% versus 65% of territories, P =0.003), with a nonsignificant reduction in specificity. Conclusions— The addition of low-mechanical-index MCE to standard imaging during DExE improves detection of CAD and enables a more accurate determination of disease extent.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-1986
DOI: 10.1097/00004836-198608000-00004
Abstract: Over a 3-year period, arteriovenous malformations (angiodysplasia) were identified at upper gastrointestinal endoscopy in 41 patients. The lesions were multiple in one-third of patients and were predominantly situated in the proximal stomach. We considered angiodysplasia to be the cause of upper gastrointestinal bleeding in 11 (27%) patients and of anemia in nine (22%) patients. In these two groups other mucosal lesions were not seen at upper gastrointestinal endoscopy and there had been prior undiagnosed episodes of overt or occult bleeding in almost half. In 21 (51%) patients the lesions were judged to be incidental findings. Other medical conditions noted were the presence of an aortic systolic murmur (24%) and renal impairment (12%). Only three patients had mucocutaneous telangiectasia (two had Osler-Rendu-Weber syndrome, and one had scleroderma with CRST syndrome). Specific treatment in 14 symptomatic patients included endoscopic electrocoagulation or injection sclerotherapy. In eight patients with adequate post-treatment surveillance, endoscopy demonstrated obliteration of the vascular lesions.
Publisher: Elsevier BV
Date: 10-2013
DOI: 10.1016/J.JACC.2013.06.043
Abstract: The aim of this study was to test the effects of treatment with ivabradine on exercise capacity and left ventricular filling in patients with heart failure with preserved ejection fraction (HFpEF). Because symptoms of HFpEF are typically exertional, optimization of diastolic filling time by controlling heart rate may delay the onset of symptoms. Sixty-one patients with HFpEF were randomly assigned to ivabradine 5 mg twice daily (n = 30) or placebo (n = 31) for 7 days in this double-blind trial. Cardiopulmonary exercise testing with echocardiographic assessment of myocardial function and left ventricular filling were undertaken at rest and after exercise. The ivabradine group demonstrated significant improvement between baseline and follow-up exercise capacity (4.2 ± 1.8 METs vs. 5.7 ± 1.9 METs, p = 0.001) and peak oxygen uptake (14.0 ± 6.1 ml/min/kg vs. 17.0 ± 3.3 ml/min/kg, p = 0.001), with simultaneous reduction in exercise-induced increase in the ratio of peak early diastolic mitral flow velocity to peak early diastolic mitral annular velocity (3.1 ± 2.7 vs. 1.3 ± 2.0, p = 0.004). Work load-corrected chronotropic response (the difference in heart rate at the same exercise time at the baseline and follow-up tests) showed a slower increase in heart rate during exercise than in the placebo-treated group. Therapy with ivabradine (β = 0.34, p = 0.04) and change with treatment in exertional increase in the ratio of peak early diastolic mitral flow velocity to peak early diastolic mitral annular velocity (β = -0.30, p = 0.02) were independent correlates of increase in exercise capacity, and therapy with ivabradine (β = 0.32, p = 0.007) was independently correlated with increase in peak oxygen uptake. In patients with HFpEF, short-term treatment with ivabradine increased exercise capacity, with a contribution from improved left ventricular filling pressure response to exercise as reflected by the ratio of peak early diastolic mitral flow velocity to peak early diastolic mitral annular velocity. Because this patient population is symptomatic on exertion, therapeutic treatments targeting abnormal exercise hemodynamic status may prove useful. (Use of Exercise and Medical Therapies to Improve Cardiac Function Among Patients With Exertional Shortness of Breath Due to Lung Congestion ACTRN12610001087044).
Publisher: Oxford University Press (OUP)
Date: 03-2011
DOI: 10.1093/EJECHOCARD/JER021
Abstract: Echocardiographic imaging is ideally suited for the evaluation of cardiac mechanics because of its intrinsically dynamic nature. Because for decades, echocardiography has been the only imaging modality that allows dynamic imaging of the heart, it is only natural that new, increasingly automated techniques for sophisticated analysis of cardiac mechanics have been driven by researchers and manufacturers of ultrasound imaging equipment. Several such techniques have emerged over the past decades to address the issue of reader's experience and inter-measurement variability in interpretation. Some were widely embraced by echocardiographers around the world and became part of the clinical routine, whereas others remained limited to research and exploration of new clinical applications. Two such techniques have dominated the research arena of echocardiography: (1) Doppler-based tissue velocity measurements, frequently referred to as tissue Doppler or myocardial Doppler, and (2) speckle tracking on the basis of displacement measurements. Both types of measurements lend themselves to the derivation of multiple parameters of myocardial function. The goal of this document is to focus on the currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardial dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated back- scatter analysis. This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses, briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use.
Publisher: Elsevier BV
Date: 05-2004
Publisher: Oxford University Press (OUP)
Date: 15-01-2000
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2012
Publisher: Elsevier BV
Date: 10-2008
Publisher: Wiley
Date: 07-2005
DOI: 10.1111/J.1365-2362.2005.01513.X
Abstract: Brachial pulse pressure (BPP) is a predictor of outcome in epidemiologic studies, but brachial and aortic pulse pressure (AoPP) may not correspond and both are influenced by multiple parameters including arterial properties and cardiac output. We sought to what extent pulse pressure (PP) measurements reflected direct measurement of arterial properties, assessed as total arterial compliance (TAC). We studied 123 patients (76 men age 55 +/- 11) 31 normal controls, 46 patients with coronary artery disease and 46 patients with hypertension. PP was determined from brachial cuff pressure and TAC was measured by simultaneous radial applanation tonometry and pulsed wave Doppler of the LV outflow. AoPP was calculated using a transfer function from the radial waveform. There was a significant difference between BPP and AoPP (57 +/- 16 vs. 45 +/- 14 P < 0.0001), although TAC correlated with BPP (r = -0.72 P = 0.01) and AoPP (r = -0.66 P = 0.01). In a multiple linear regression, the difference between BPP and AoPP was predicted by cardiac output (CO) (P = 0.002) and gender (P = 0.03). Bland-Altman analysis showed the best correspondence between BPP and AoPP in the middle tertile (CO 4.7 to 5.7 L min(-1)) with less correlation in the low and high tertiles. The same analysis by gender showed a higher difference in women than men (14 +/- 6 vs. 10 +/- 5 P < 0.0001). The difference between BPP and AoPP showed the best correlation in the control group and the worst in the hypertension group. BPP correlates with TAC in men with normal cardiac function. However, in women, in patients at the low and high extremes of function, and in patients with preclinical and overt cardiovascular disease, there appears to be incremental value in measuring TAC.
Publisher: Elsevier BV
Date: 09-2021
Publisher: Elsevier BV
Date: 03-2016
Publisher: Elsevier BV
Date: 03-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 03-2013
DOI: 10.1161/CIRCIMAGING.112.000162
Abstract: The role of exercise-induced pulmonary hypertension in decision making regarding surgical timing for asymptomatic chronic mitral regurgitation is controversial. We reasoned that the exercise-induced pulmonary hypertension response could not be interpreted without knowledge of right ventricular (RV) function. The aim of this study was to assess the role of RV measures at rest and during exercise as predictors of prognosis in asymptomatic mitral regurgitation. Comprehensive resting and exercise echocardiography was performed in 196 consecutive patients (56±13 years 64% male) with isolated moderate to severe mitral regurgitation (effective regurgitant orifice area, 38±18 mm 2 ) and preserved left ventricular function in whom initial management was expectant. Left ventricular and RV longitudinal strain were analyzed at rest using velocity vector imaging. Tricuspid annular plane systolic excursion and systolic pulmonary arterial pressure were measured at rest and during exercise. Valve surgery was performed in 88 patients (45%) over 27±15 months. After adjustment for age and sex in a Cox proportional-hazards model, exercise tricuspid annular plane systolic excursion (hazard ratio, 0.26 P .001), was associated with valve surgery-free survival, independent of resting left ventricular strain (hazard ratio, 1.09 P =0.027), exercise systolic pulmonary arterial pressure (hazard ratio, 1.03 P .001), and resting RV strain (hazard ratio, 1.10 P =0.004). In sequential Cox models, a model based on clinical data and left ventricular strain (χ 2 , 15.9) was improved by RV strain and RV chamber size (χ 2 , 28.8 P =0.003) and exercise systolic pulmonary arterial pressure (χ 2 , 40.1 P =0.002) and further increased by exercise tricuspid annular plane systolic excursion (χ 2 , 52.2 P =0.002). Exercise-induced RV dysfunction provides important incremental prognostic value in the management of asymptomatic mitral regurgitation.
Publisher: Elsevier BV
Date: 08-2018
DOI: 10.1016/J.JCMG.2018.03.019
Abstract: This study sought to evaluate the hypothesis that global longitudinal strain (GLS) guidance of cardioprotective therapy would improve cardiac function of at-risk patients undergoing potentially cardiotoxic chemotherapy, compared with usual care. The conventional criteria for diagnosis of chemotherapy-related cardiac dysfunction (CTRCD) are dependent on the recognition of heart failure symptoms and/or changes in left ventricular ejection fraction. However, the measurement variability of left ventricular ejection fraction necessitates broad diagnostic ranges, with the consequence of low sensitivity for CTRCD. Observational data have shown GLS to be a robust and sensitive marker to predict CTRCD and thereby guide the initiation of cardioprotective therapy, but these data are insufficient to justify changing the diagnostic criteria for CTRCD. The SUCCOUR (Strain sUrveillance of Chemotherapy for improving Cardiovascular Outcomes) trial is an international multicenter prospective randomized controlled trial. Patients who are taking cardiotoxic chemotherapy (n = 320) with at least 1 risk factor will be randomly allocated into GLS- and ejection fraction-guided strategies. All participants will be followed over 3 years for the primary endpoint (change in 3-dimensional ejection fraction) and other secondary endpoints. Among the first 185 patients (age 54 ± 13 years 93% women) from 23 international sites, 88% had breast cancer, 9% had lymphoma, and 3% had other cancers. Heart failure risk factors were prevalent: 34% had hypertension and 10% had diabetes mellitus. The most common chemotherapy regimen during this study was the combination of anthracycline and trastuzumab. The baseline 3-dimensional left ventricular ejection fraction was 61 ± 4%, and GLS was 20.3 ± 2.5%. Of 93 patients followed up in the first year of the study, 10 had to withdraw for noncardiac reasons. Of 40 patients randomized to the GLS-guided arm, 15 have been started on cardioprotective therapy, whereas 4 of 46 patients in the ejection fraction-guided arm have been started on therapy. The SUCCOUR trial will be the first randomized controlled trial of GLS and will provide evidence to inform guidelines regarding the place of GLS for surveillance for CTRCD. (Strain sUrveillance of Chemotherapy for improving Cardiovascular Outcomes [SUCCOUR] ANZ Clinical Trials ACTRN12614000341628).
Publisher: Elsevier BV
Date: 08-2016
DOI: 10.1016/J.JCMG.2015.09.027
Abstract: This study sought to investigate the associations of left ventricular (LV) strain and its serial change with major adverse cardiac events (MACE) in hypertensive heart disease, independent of and incremental to clinical and LV geometric parameters. In patients with hypertensive heart disease, MACE are associated with abnormal LV morphology, but their association with subclinical LV dysfunction is unclear. We retrospectively studied 388 asymptomatic nonischemic patients with hypertension who had abnormal LV geometry at a baseline echocardiogram between 2005 and 2014. Global longitudinal strain (GLS) was measured using speckle tracking. Patients were followed for MACE (death and admission because of heart failure, myocardial infarction, and strokes) over median of 4 years. A Cox proportional hazards model was used to assess the association of parameters with MACE. MACE (n = 72 19%) were associated with higher prevalence of concentric hypertrophy and impaired GLS (both, p 70, atrial fibrillation, concentric hypertrophy, and baseline GLS >-16% from the derivation cohort (C statistic, 0.71), and a separate validation cohort showed it to have good discrimination for MACE (C statistic, 0.71). GLS and its deterioration are associated with MACE in asymptomatic hypertensive heart disease. A risk score incorporating strain was useful for predicting risk of MACE.
Publisher: Elsevier BV
Date: 04-2016
Publisher: Elsevier BV
Date: 07-2020
DOI: 10.1016/J.HLC.2019.08.010
Abstract: Acute decompensated heart failure (ADHF) carries a high event rate following discharge. The complex interplay between age, frailty and decongestion may lend itself to a functional test. In the doorbell test the patient simulates answering the doorbell. They are timed rising from a recumbent position, bending over twice and walking 10 metres, this time is added to the change in respiratory rate. We aimed to determine if the doorbell test was associated with post ADHF events (death or readmission). The test was performed at hospital discharge, with follow up at 30-days and 1-year. In 74 patients at 30-days there was a 14% event rate. At 1-year there were 40 (54%) events (9 deaths and 31 readmissions, 28 were cardiovascular of which 14 were [heart failure] HF). Amongst those who had an event at 30-days only doorbell test scores were different (58 [36,72] vs 32 [26,53] p < 0.05). One-year (1-year) events were associated with doorbell test scores (47 [29,62] vs 30 [26,42] p < 0.05), body weight (78 kg [68,94] vs 95 [76,105] (p < 0.05), creatinine (134 mmol/L [114, 173] vs 99 [82, 133] p < 0.01) and age (76 years [61,86] vs 67 [53, 73] p < 0.01). Heart failure readmissions were associated with doorbell test scores (56 [46,68] vs 30 [26,47] p < 0.001). Death was associated with body weight (74 kg [69,81] vs 88 [72,101] p < 0.05) and age (83 years [78,86] vs 69 [55,77] p < 0.01). After age stratification, the hazard ratio for heart failure readmission associated with a high doorbell test score was 11.08 (95%C.I. 2.01-61.17 p = 0.006), while the hazard ratio for 1-year cardiovascular readmission was 4.62 (95%C.I. 1.71-12.51 p = 0.003). There was no association with 1-year mortality. The doorbell test represents a novel test of multiple domains of the ADHF pre-discharge state and demonstrates an association with 30-day and 1-year rehospitalisation.
Publisher: Elsevier BV
Date: 10-2018
DOI: 10.1016/J.JCMG.2018.03.015
Abstract: This study sought to identify whether impaired global longitudinal strain (GLS), diastolic dysfunction (DD), or left atrial enlargement (LAE) should be added to stage B heart failure (SBHF) criteria in asymptomatic patients with type 2 diabetes mellitus. SBHF is a precursor to clinical heart failure (HF), and its recognition justifies initiation of cardioprotective therapy. However, original definitions of SBHF were based on LV hypertrophy and impaired ejection fraction. Patients with asymptomatic type 2 diabetes mellitus ≥65 years of age (age 71 ± 4 years 55% men) with preserved ejection fraction and no ischemic heart disease were recruited from a community-based population. All underwent a standard clinical evaluation, and a comprehensive echocardiogram, including assessment of left ventricular hypertrophy (LVH), LAE, DD (abnormal E/e'), and GLS (<16%). Over a median follow-up of 1.5 years (range 0.5 to 3), 20 patients were lost to follow-up, and 290 in iduals were entered into the final analyses. In this asymptomatic group, LV dysfunction was identified in 30 (10%) by DD, 68 (23%) by LVH, 102 (35%) by LAE, and 68 (23%) by impaired GLS. New-onset HF developed in 45 patients and 4 died, giving an event rate of 112/1,000 person-years. Survival free of the composite endpoint (HF and death) was about 1.5-fold higher in patients without a normal, compared with an abnormal echocardiogram. LVH, LAE, and GLS <16% were associated with increased risk of the composite endpoint, independent of ARIC risk score and glycosylated hemoglobin, but abnormal E/e' was not. The addition of left atrial volume and GLS provided incremental value to the current standard of clinical risk (ARIC score) and LVH. In a competing-risks regression analysis, LVH (hazard ratio: 2.90 p < 0.001) and GLS <16% (hazard ratio: 2.26 p = 0.008), but not DD and LAE were associated with incident HF. Subclinical left ventricular systolic dysfunction is prevalent in asymptomatic elderly patients with type 2 diabetes mellitus, and impaired GLS is independent and incremental to LVH in the prediction of incident HF.
Publisher: Springer Science and Business Media LLC
Date: 15-05-2020
DOI: 10.1007/S10198-020-01198-5
Abstract: This study uses longitudinal cohort data to estimate the impacts of air pollution on health outcomes among people first hospitalised with heart diseases. Despite the generally low level of pollution in Australia, we find that acute exposure to pollution increases readmissions to hospitals within 3-12 months after discharge and is more evident among those suffering from heart failure. We further show that chronic exposure to air pollution increases the risk of death within 72 months, hospital admissions and general practitioner (GP) visits. Patients with coronary heart disease or cerebrovascular disease are the most affected groups. Finally, a cost saving of $1.3 billion will be generated to the health sector, if the monthly concentration of PM
Publisher: Elsevier BV
Date: 12-2013
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.AHJ.2013.07.035
Abstract: Risk assessment may be important in patients being considered for repeat revascularization after prior coronary intervention or surgery. We sought the prognostic value of radionuclide stress myocardial perfusion imaging or echocardiography among patients with previous revascularization. Studies on the outcomes of stress imaging tests after revascularization were selected from an electronic search if they reported the odds or hazard ratio (HR) of an abnormal stress test in the prediction of mortality (cardiac or total), hard cardiac events (cardiac death and myocardial infarction [MI]), total hard events (total mortality and MI]), or overall events (cardiac death, MI, and repeat revascularization). In 29 studies (12,874 patients, 63 ± 3 years, 80% men), an abnormal test result was associated with hard cardiac events (HR 1.2, 95% CI 1.1-1.3), cardiac mortality (HR 5.8, 95% CI 0.8-10.8), total mortality (HR 2.2, 95% CI 1.3-3.1), total hard events(HR 2.4, 95% CI 1.4-3.3), and overall events (HR 1.2, 95% CI 1.1-1.3). The nature of the end point was not associated with differences in the prediction of events, but the type of revascularization showed a significant association with outcome, with percutaneous intervention portending a worse outcome. Age and the timing of the stress imaging postrevascularization were inversely associated with survival. Gender, length of follow-up after testing, symptom status, past infarction, and risk factor status did not explain interstudy heterogeneity. In patients with previous revascularization, abnormal results at stress echocardiography or radionuclide myocardial perfusion imaging are predictive of subsequent events, with age, type of revascularization, and the timing of the stress imaging after revascularization being important sources of heterogeneity between studies.
Publisher: Elsevier BV
Date: 2008
DOI: 10.1016/J.HFC.2007.10.003
Abstract: The natriuretic peptides are a family of compounds secreted from the atria and ventricles in response to a variety of stimuli, including increased wall stress, tachycardia, and myocardial ischemia. Increases in the levels of these compounds correlate with increased left-ventricular filling pressure in patients with systolic dysfunction, although the production of the compounds from severely impaired ventricles may be reduced, leading to lower than anticipated levels in severe heart failure. The association of increased natriuretic peptides with diastolic dysfunction has been variable, with no elevation reported in many patients with mild dysfunction. These patients with mild diastolic dysfunction become symptomatic with exercise, in association with increased filling pressure with stress, which may be documented using echocardiography or possibly the natriuretic peptide response. However, the variability of peptide levels within in iduals may pose a problem to the interpretation of sequential data in response to exercise or therapies.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 09-2011
DOI: 10.1161/CIRCOUTCOMES.111.961839
Abstract: Traditional management of severe aortic stenosis (AS) is based on delay in aortic valve replacement (AVR) until the development of symptoms. Surgery for asymptomatic AS has been proposed to reduce the small risk of sudden death before AVR and avoid heart failure (HF) after AVR. Because a trial to compare these options is unlikely, we developed a Markov model to inform the choice between immediate surgery and watchful waiting in asymptomatic AS. We defined health states as preoperative, postoperative, postcomplication, and death. We calculated the implications of watchful waiting, tissue and mechanical AVR-based on risks, transitions, utilities, and cost derived from literature review. Further analyses evaluated situations thought to favor immediate surgery and watchful waiting. Sensitivity analyses were based on the likelihood of preoperative death and HF in follow-up. In the reference case (age, 65 years post-AVR utility, 0.9 annualized pre-AVR mortality, 1% and post-AVR HF, 11.3%), the utility of watchful waiting was superior to that of immediate mechanical or tissue AVR (quality-adjusted life-years, 7.4 versus 5.3 versus 5.3, respectively), and the cost was less than immediate surgery. Sensitivity analyses showed immediate surgery was not likely to be more effective regardless of the yearly probability of post-AVR HF in the watchful waiting group (range, 0% to 80%). Immediate surgery was likely to be effective when pre-AVR annual mortality reached 13%. Immediate surgery in asymptomatic severe AS does not improve outcomes unless risk of sudden death pre-AVR and HF after AVR are higher than currently reported.
Publisher: Elsevier BV
Date: 12-2010
DOI: 10.1016/J.JCMG.2010.09.014
Abstract: The purpose of this study was to investigate the independent association between global cardiac autonomic neuropathy (CAN) and left ventricular (LV) dysfunction in addition to regional associations of LV dysinnervation and function, in patients with type 2 diabetes mellitus (T2DM). CAN represents a potential mechanism in the etiology of nonischemic diabetic cardiomyopathy. Clinical measures of CAN based on total spectral power of heart rate variability and cardiac reflex testing and echocardiographic assessment of LV function were performed in 118 patients with type 2 diabetes mellitus. Systolic and diastolic function were defined at rest and peak exercise using peak systolic and peak early diastolic (Em) tissue velocities, calculated in 6 basal- and mid-segments using color tissue Doppler. Iodine 123-metaiodobenzylguanidine imaging was performed in 33 patients to directly quantify global (heart/mediastinum ratio) and regional LV sympathetic integrity. Patients with CAN demonstrated higher resting heart rate, systolic and mean blood pressures, aortic stiffness, hemoglobin A(1c), and urine albumin/creatinine ratio, in addition to lower peak heart rate, chronotropic index, and exercise capacity. Diastolic function (Em) was associated with CAN, evidenced by total spectral power (r = 0.42, p < 0.001) and heart/mediastinum ratio (r = 0.41, p = 0.017). Diastolic function (Em) at rest and systolic function (peak systolic tissue velocity) at rest and exercise were significantly reduced in patients with CAN. Furthermore, total spectral power was associated with Em independent of age, hypertension, metabolic factors, and other relevant contributors to LV dysfunction (β = 0.20, p = 0.035). Relative regional tracer deficits indicative of local denervation were predominant in the anterior and lateral walls (p < 0.001). Associations with regional Em, independent of global iodine 123-metaiodobenzylguanidine uptake, were identified exclusively in mid-anterior (β = 0.45, p = 0.01) and mid-lateral walls (β = 0.34, p = 0.03). However, no association was found between regional denervation and systolic or diastolic dyssynchrony. The diastolic dysfunction of type 2 diabetes mellitus shows associations with both regional markers of sympathetic integrity and clinical markers of autonomic neuropathy.
Publisher: Oxford University Press (OUP)
Date: 04-2008
Abstract: Diabetes mellitus is responsible for a spectrum of cardiovascular disease. The best known complications arise from endothelial dysfunction, oxidation, inflammation, and vascular remodelling and contribute to atherogenesis. However, the effects on the heart also relate to concurrent hypertensive heart disease, as well as direct effects of diabetes on the myocardium. Diabetic heart disease, defined as myocardial disease in patients with diabetes that cannot be ascribed to hypertension, coronary artery disease, or other known cardiac disease, is reviewed.
Publisher: Elsevier BV
Date: 06-1999
Publisher: Elsevier BV
Date: 10-2016
Publisher: Elsevier BV
Date: 09-2013
DOI: 10.1016/J.AHJ.2013.06.003
Abstract: Appropriate use criteria (AUC) for stress single-photon emission computed tomography (SPECT) are only one step in appropriate use of imaging. Other steps include pretest clinical risk evaluation and optimal management responses. We sought to understand the link between AUC, risk evaluation, management, and outcome. We used AUC to classify 1,199 consecutive patients (63.8 ± 12.5 years, 56% male) undergoing SPECT as inappropriate, uncertain, and appropriate. Framingham score for asymptomatic patients and Bethesda angina score for symptomatic patients were used to classify patients into high (≥5%/y), intermediate, and low (≤1%/y) risk. Subsequent patient management was defined as appropriate or inappropriate based on the concordance between management decisions and the SPECT result. Patients were followed up for a median of 4.8 years, and cause of death was obtained from the social security death registry. Overall, 62% of SPECTs were appropriate, 18% inappropriate, and 20% uncertain (only 5 were unclassified). Of 324 low-risk studies, 108 (33%) were inappropriate, compared with 94 (15%) of 621 intermediate-risk and 1 (1%) of 160 high-risk studies (P < .001). There were 79 events, with outcomes of inappropriate patients better than uncertain and appropriate patients. Management was appropriate in 986 (89%), and appropriateness of patient management was unrelated to AUC (P = .65). Pretest clinical risk evaluation may be helpful in appropriateness assessment because very few high-risk patients are inappropriate, but almost half of low-risk patients are inappropriate or uncertain. Appropriate patient management is independent of appropriateness of testing.
Publisher: Elsevier BV
Date: 06-2009
Publisher: Elsevier BV
Date: 05-1991
DOI: 10.1016/0167-5273(91)90217-D
Abstract: The prognostic significance of right ventricular ejection fraction, measured by radionuclide ventriculography, was assessed in 168 consecutive patients with inferior myocardial infarction. Right ventricular ejection fraction was 0.40 or less in 35 patients. Over a follow-up period of 40 months, there were 15 deaths in the total group of 168 patients, eight (23%) in the 35 with right ventricular ejection fraction of 0.40 or less, and seven (5%) in the remainder of the group. The one year survival of patients with right ventricular impairment (84 +/- 6%) was significantly worse (P less than 0.01) than those with a right ventricular ejection fraction over 0.40 (95 +/- 2%). A multivariate Cox model analysis showed age (P less than 0.001), left ventricular ejection fraction (P less than 0.01), and right ventricular ejection fraction (P less than 0.03) to be independent predictors of survival. Impaired right ventricular function is an adverse prognostic factor in patients with inferior infarction, particularly in those with impaired left ventricular function.
Publisher: Elsevier BV
Date: 06-2023
Publisher: Elsevier BV
Date: 08-2018
DOI: 10.1016/J.JCMG.2018.03.003
Abstract: The goal of this study was to compare echocardiographic measurements of global longitudinal strain (GLS) (using 3 apical views) with single-view longitudinal strain (LS, 4- or 2-chamber [4CV_LS and 2CV_LS, respectively]) for detection of cancer-therapy related cardiotoxicity. GLS is useful for the detection of cardiotoxicity, but the need for repeated measurements poses a significant burden on busy echocardiography laboratories. A single-view LS measurement, possibly at point of care, could improve efficiency. Seventeen international centers prospectively recruited 108 patients (mean age 54 ± 13 years) at high risk for cardiotoxicity as part of the ongoing SUCCOUR (Strain Surveillance for Improving Cardiovascular Outcomes During Chemotherapy) randomized controlled trial. Echocardiography performed at baseline and follow-up were analyzed in a core laboratory setting blinded to clinical information. Peak systolic GLS and LS were measured from raw data. Cardiotoxicity was defined by reduction in left ventricular ejection fraction >0.10 to <0.55 or a relative drop in GLS by ≥12%. Cardiotoxicity developed in 46 patients by either criteria. Baseline and follow-up 2-dimensional left ventricular ejection fraction were 61 ± 4% and 58 ± 5%, respectively (p < 0.001). The baseline GLS (-20.9 ± 2.4%) was not different from 4CV_LS (-20.7 ± 2.5% p = 0.09) or 2CV_LS (-21.1 ± 3.1% p = 0.25). The follow-up GLS (-19.5 ± 2.4%) was also similar to 4CV_LS (-19.5 ± 2.6% p = 0.80) and 2CV_LS (-19.7 ± 3.1% p = 0.19). There was good correlation between GLS and 4CV_LS at baseline (r = 0.86 p < 0.001) and follow-up (r = 0.89 p < 0.001) and with 2CV_LS at baseline (r = 0.87 p < 0.001) and follow-up (r = 0.88 p < 0.001). However, there was 15% to 22% disagreement between GLS and 4CV_LS or 2CV_LS for the detection of cardiotoxicity. The interobserver and intraobserver reproducibility was higher for GLS (intraclass correlation: 0.93 to 0.95 coefficient of variance: 2.9% to 3.7%) compared with either single-chamber-based LS measurement (intraclass correlation: 0.85 to 0.91 coefficient of variance: 4.1% to 4.8%). Although there was good correlation between GLS and single-view LS measurements, single-view LS measurement led to disagreement in the diagnosis of cardiotoxicity in up to 22% of patients. GLS measurements were more reproducible than single-view LS. GLS based on 3 apical views should remain the preferred technique for detection of cardiotoxicity. (Strain Surveillance for Improving Cardiovascular Outcomes During Chemotherapy [SUCCOUR] ACTRN12614000341628).
Publisher: Oxford University Press (OUP)
Date: 26-08-2021
Publisher: Elsevier BV
Date: 09-2018
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-1994
Abstract: The uptake of F-18 deoxyglucose into dysfunction segments after myocardial infarction identifies metabolically active (FDG+) or inactive (FDG-) myocardium. Although patients with FDG+ segments have been found to be at risk for adverse events, the prognostic significance of viable myocardium in relation to other influences on postinfarction prognosis, including revascularization, remain ill defined. The purpose of this study was to investigate the relative prognostic significance of FDG+ tissue and to establish whether myocardial revascularization in patients with viable tissue attenuates the risk of adverse outcome. One hundred thirty-seven patients with left ventricular dysfunction and resting perfusion defects after myocardial infarction underwent positron emission tomography with both dipyridamole stress Rb-82 perfusion imaging and FDG imaging. After the exclusion of 4 patients proceeding to transplantation, 2 with uninterpretable scans and 2 lost to follow-up, 129 patients were followed clinically for 17 +/- 9 months. Four groups were defined: patients with FDG+ dysfunctional myocardium who were revascularized (n = 49) or treated medically (n = 21) and those with FDG- segments who were revascularized (n = 19) or treated medically (n = 40). The groups of patients with FDG+ or FDG- findings, with and without revascularization, did not differ with respect to known determinants of postinfarction prognosis: age, left ventricular ejection fraction, or the prevalence of multivessel disease. Nonfatal ischemic events occurred in 48% of medically treated FDG+ patients compared with 8% of revascularized patients with FDG+ tissue (P .001) and 5% of patients with FDG- myocardium (P .001). Thirteen patients died from cardiac causes 11 (85%) had a left ventricular ejection fraction of 30%, and these patients were evenly distributed between FDG+ and FDG- groups. Using Cox's proportional hazards model, only the presence of FDG+ myocardium (odds ratio, 12.9 P .001) and the absence of revascularization (odds ratio, 5.8 P = .002) independently predicted ischemic events, while only age (P = .02) and ejection fraction (P .001) but not the presence of viable myocardium were predictive of death. Residual viable myocardium after myocardial infarction may act as an unstable substrate for further events unless it is revascularized. Despite this association, age and left ventricular dysfunction remained the strongest predictors of cardiac death after myocardial infarction in these patients with a spectrum of left ventricular dysfunction.
Publisher: Elsevier BV
Date: 12-2008
DOI: 10.1016/J.ECHO.2008.09.021
Abstract: Different 2-dimensional speckle-based strain techniques have been developed to overcome the problem of angle dependency with Doppler-based strain. However, their relative accuracy has not been assessed. The aim of this study was to determine the feasibility and accuracy of 2 such techniques (velocity vector imaging [VVI] and automated function imaging [AFI]), using tagged harmonic phase (HARP) magnetic resonance imaging (MRI) as a reference standard. Thirty patients with known or suspected ischemic heart disease underwent measurement of peak systolic longitudinal, radial, and circumferential Lagrangian strain with all 3 techniques using a 16-segment model. The extent of scar tissue in each segment was determined using contrast-enhanced MRI. The measurement of myocardial strain in all 3 directions was highly feasible with both VVI and AFI. Longitudinal strain was underestimated by both VVI (-11 +/- 8% P < .01) and AFI (-12 +/- 6% P < .01) in comparison with HARP MRI (-14 +/- 5%), and radial strain was underestimated by VVI (14 +/- 18% vs 23 +/- 7% P < .01). All strain measurements with AFI showed better correlation and agreement with HARP MRI compared with VVI. Circumferential strain with AFI had the greatest accuracy (area under the receiver operating characteristic curve = 0.74, P < .001) for the prediction of scar tissue on MRI. Two-dimensional strain measured with AFI has significantly better accuracy than VVI. Circumferential strain with AFI has the best discriminative ability for the detection of regional myocardial dysfunction.
Publisher: Elsevier BV
Date: 10-2016
DOI: 10.1016/J.IJCARD.2016.07.074
Abstract: Cognitive impairment is highly prevalent in heart failure (HF), and may be associated with short-term readmission. This study investigated the role of cognition, incremental to other clinical and non-clinical factors, independent of depression and anxiety, in predicting 30-day readmission or death in HF. This study followed 565 patients from an Australia-wide HF longitudinal study. Cognitive function (MoCA score) together with standard clinical and non-clinical factors, mental health and 2D echocardiograms were collected before hospital discharge. The study outcomes were death and readmission within 30days of discharge. Logistic regression, Harrell's C-statistic, integrated discrimination improvement (IDI) and net reclassification index were used for analysis. Among 565 patients, 255 (45%) had at least mild cognitive impairment (MoCA≤22). Death (n=43, 8%) and readmission (n=122, 21%) within 30days of discharge were more likely to occur among patients with mild cognitive impairment (OR=2.00, p=0.001). MoCA score was also negatively associated with 30-day readmission or death (OR=0.91, p<0.001) independent of other risk factors. Adding MoCA score to an existing prediction model of 30-day readmission significantly improved discrimination (C-statistic=0.715 vs. 0.617, IDI estimate 0.077, p<0.001). From prediction models developed from our study, adding MoCA score (C-statistic=0.83) provided incremental value to that of standard clinical and non-clinical factors (C-statistic=0.76) and echocardiogram parameters (C-statistic=0.81) in predicting 30-day readmission or death. Reclassification analysis suggests that addition of MoCA score improved classification for a net of 12% of patients with 30-day readmission or death and of 6% of patients without (p=0.002). Mild cognitive impairment predicts short-term outcomes in HF, independent of clinical and non-clinical factors.
Publisher: Elsevier BV
Date: 05-2020
Publisher: Springer Science and Business Media LLC
Date: 21-07-2016
DOI: 10.1007/S11886-016-0759-0
Abstract: Type 2 diabetes mellitus (T2DM) is a well-recognized risk factor for cardiovascular diseases and cardiac death. While the increased mortality of patients with DM has traditionally been attributed to coronary artery disease, approximately half of the mortality has other causes, including non-ischemic heart failure (HF). In this context, effective screening and diagnosis of cardiac structural and functional abnormalities are crucial for preventive strategies and for predicting prognosis. This review discusses various echocardiographic diagnostic modalities, including tissue Doppler imaging (TDI) and two-dimensional (2D) speckle-tracking echocardiography (STE) for screening, risk stratification, and guidance of management of patients with T2DM.
Publisher: BMJ
Date: 17-02-2011
Abstract: To link ischaemia, left ventricular (LV) untwisting and changes in filling pressure during dobutamine stress echocardiography (DSE). Cross-sectional study at rest and at peak dobutamine stress. Academic medical centre. Patients who had undergone routine DSE between January and September 2009. Routine DSE was combined with measurement of transmitral pulsed-wave Doppler, myocardial tissue Doppler and speckle-tracking echocardiography at baseline and peak dose in 110 patients (51 women, 62±12 years). Untwisting rates (proto-diastolic and during isovolumic relaxation time (IVRT)) were measured by speckle tracking. Raised filling pressure was defined as E/e'>15. DSE studies were classified into normal, ischaemic or scar responses, independent of E/e'. Echocardiographic outcomes. Patients were categorised in three groups: group 1 (n=44), normal resting and peak E/e' group 2 (n=33), normal resting E/e' but raised peak E/e' group 3 (n=33), abnormal resting E/e'. Risk factors and resting ejection fraction were similar in each group. Proto-diastolic untwisting rate was an independent predictor of raised filling pressure at peak stress (r(2)=0.3, p=0.03). An abnormal filling response during DSE was independently predicted by resting untwisting rate (UTR)-IVRT (p=0.003), and resting E/a (p=0.0001) (model pseudo-r(2)=0.76). Proto-diastolic UTR was lower in the ischaemic and scar groups at peak. Patients with abnormal filling pressure response have an impaired LV untwisting rate during isovolumic relaxation. This phenomenon supports the role of impaired LV suction as the mediator of the effect of myocardial ischaemia during DSE on filling pressure response to stress.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 10-2022
DOI: 10.1161/HYPERTENSIONAHA.122.19420
Abstract: Exaggerated exercise blood pressure (EEBP) during clinical exercise testing is associated with poor blood pressure (BP) control and cardiovascular disease (CVD). Type-2 diabetes (T2DM) is thought to be associated with increased prevalence of EEBP, but this has never been definitively determined and was the aim of this study. Clinical exercise test records were analyzed from 13 268 people (aged 53±13 years, 59% male) who completed the Bruce treadmill protocol (stages 1–4, and peak) at 4 Australian public hospitals. Records (including BP) were linked to administrative health datasets (hospital and emergency admissions) to define clinical characteristics and classify T2DM (n=1199) versus no T2DM (n=12 069). EEBP was defined as systolic BP ≥90th percentile at each test stage. Exercise BP was regressed on T2DM history and adjusted for CVD and risk factors. Prevalence of EEBP (age, sex, preexercise BP, hypertension history, CVD history and aerobic capacity adjusted) was 12% to 51% greater in T2DM versus no T2DM (prevalence ratio [95% CI], stage 1, 1.12 [1.02–1.24] stage 2, 1.51 [1.41–1.61] stage 3, 1.25 [1.10–1.42] peak, 1.18 [1.09–1.29]). At stages 1 to 3, 8.6% to 15.8% (4.8%–9.7% T2DM versus 3.5% to 6.1% no-T2DM) of people with ‘normal’ preexercise BP ( /90 mm Hg) were identified with EEBP. Exercise systolic BP relative to aerobic capacity (stages 1–4 and peak) was higher in T2DM with adjustment for all CVD risk factors. People with T2DM have higher prevalence of EEBP and exercise systolic BP independent of CVD and many of its known risk factors. Clinicians supervising exercise testing should be alerted to increased likelihood of EEBP and thus poor BP control warranting follow-up care in people with T2DM.
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.IJCARD.2016.12.043
Abstract: The appropriateness of repeat transthoracic echocardiography (TTE) for stable heart failure (HF) is based on timing of the follow-up examination, but this lacks scientific support. We sought the association of routine follow-up TTE on survival and readmission in stable HF. Patients with HF were selected from consecutive HF admissions from 2008 to 2012. Groups were ided into: no follow-up TTE routine <1year with no change in status ("rarely appropriate"), ≥1year follow-up with no change in status ("maybe appropriate") and TTE due to change in clinical status ("appropriate"). Survival analysis was performed for the combined endpoint of HF readmission and death, and a separate analysis was performed for HF readmission, with death as a competing risk. Of 550 HF patients, 141 had a follow-up TTE, including 41 (29%) within 1year. The event-free time in years was similar between no TTE (1.10years [95%CI: 0.69, 1.49], routine TTE 1year (2.45years [95% CI: 1.37, 5.78]) all were greater than symptomatic patients (0.09years [95% CI: 0.02, 1.80]). HF readmission was independently associated with statins, renal disease, coronary angiography and NYHA class, but not follow-up TTE timing. There were no differences in the cumulative incidence for death between groups. There were no differences in change in management in routine TTE <1year and ≥1year. The distinction of appropriateness of routine repeat TTE in stable HF patients, based on testing <1 or ≥1year after index admission appears unjustified.
Publisher: Oxford University Press (OUP)
Date: 20-12-2011
DOI: 10.1093/EJECHOCARD/JER291
Abstract: Myocardial fibrosis is an important contributor to heterogeneity of left ventricular (LV) dysfunction in the metabolic syndrome (MS). Comparison of strain with calibrated integrated backscatter (cIB) and serological fibrosis markers could provide a means to understand the association of cardiac function with markers of fibrosis. We studied 172 patients with MS (age 50 ± 13 years) and 61 healthy controls in a prospective, cross-sectional study. Echocardiographic evaluation included myocardial velocities and deformation, and calibrated cIB. Procollagen type III amino-terminal propeptide (PIIINP) and procollagen type I carboxy-terminal propeptide (PICP) were measured from serum. MS patients demonstrated LV systolic and diastolic function, and myocardial echodensity disturbances, as well as elevated serum PIIINP and PICP levels. For most functional variables, calibrated cIB in the basal septum was the strongest determinant of impaired LV performance, independent of higher procollagen levels, LV mass index, age, body mass index, creatinine level, and C-reactive protein. Patients with increased abdominal fat deposit (assessed by the waist-to-hip ratio) presented higher levels of procollagen peptides and septal calibrated cIB, and with more profound LV dysfunction as indicated by lower myocardial deformation and early diastolic velocity, and higher E/e'. Myocardial echodensity is a stronger correlate of LV systolic and diastolic dysfunction in MS, than circulating procollagen peptides. Both fibrosis and LV function abnormalities are increased at a higher waist-to-hip ratio, which might provide a rationale for the implementation of intensified therapy in this subset of patients.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-1997
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 07-2013
Publisher: Elsevier BV
Date: 03-2013
DOI: 10.1016/J.AMJCARD.2012.11.028
Abstract: Diabetic autonomic neuropathy is a possible link between abnormal metabolism in type 2 diabetes mellitus (T2DM) and risk for atrial fibrillation (AF) and heart failure (HF). The aim of this study was to elucidate the association between attenuated heart rate recovery (HRR) and these manifestations of myocardial dysfunction in T2DM. Nine hundred fourteen consecutive patients with T2DM (mean age 56 ± 11 years, 508 men) without diabetes mellitus complications, with negative results on stress echocardiography, were enrolled. Patients with known cardiac disease were excluded. Demographics, clinical assessment, co-morbidities, and insulin use were collected prospectively. The association of HRR with new-onset HF and AF was sought using a Cox proportional-hazards model. There were 47 events (22 HF and 25 AF) during a median follow-up period of 7.8 years. Events were associated with age, exercise capacity, HRR, and left atrial volume index but not with baseline glycosylated hemoglobin, left ventricular mass index, or standard markers of diastolic function. In sequential Cox models for the combined outcomes, the model based on clinical data (age and gender overall chi-square = 5.5) was not significantly improved by left atrial volume index (chi-square = 8.6, p = 0.10) or maximum METs (chi-square = 8.7, p = 0.07) but was significantly improved by adding HRR (chi-square = 19.7, p = 0.004). In addition, HRR provided significant incremental prognostic value regarding the composite end point (net reclassification improvement 19.2%, p = 0.04 integrated discrimination improvement 1.58%, p = 0.004). In conclusion, the association of HRR with subsequent HF and AF, independent of and incremental to left atrial volume index and other markers of abnormal cardiac structure and function, indicates a role for autonomic neuropathy as the link between metabolic and cardiac risk in patients with T2DM.
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.ECHO.2015.02.007
Abstract: Heart failure (HF) readmissions are a common and serious problem of heterogeneous etiology. Left ventricular (LV) ejection fraction has not been found to be a consistent risk marker. However, LV strain has been shown to predict outcomes in other settings, so the aim of this study was to determine the association of LV strain with 30-day HF readmission, independent of and incremental to clinical and basic echocardiographic parameters. A total of 468 patients who underwent echocardiography at the time of the first admission for HF from July 2009 to June 2012 were retrospectively studied. Clinical parameters were comprehensively assessed, and standard echocardiographic parameters and two strain parameters (global longitudinal strain [GLS] and global circumferential strain) were measured using speckle-tracking. Patients were followed for all-cause 30-day hospital readmission or death after discharge, and the associations of parameters with outcome were assessed using Cox proportional hazards models. Readmission within 30 days (n = 92 patients [20%]) was associated with greater impairment of LV GLS (-8.6% [interquartile range, -10.9% to -5.9%] vs -11.1% [interquartile range, -14.6% to -7.7%], P < .01). The association of GLS with readmission (hazard ratio, 1.13 95% confidence interval, 1.07-1.19 P 50%. GLS is associated with HF readmission, independent of and incremental to clinical and basic echocardiographic parameters.
Publisher: Elsevier BV
Date: 06-1990
DOI: 10.1016/S0002-8703(05)80173-5
Abstract: We developed a new angiographic score of the extent of coronary disease (extent score), which we compared with conventional stenosis and vessel scores that emphasize the severity of stenosis. Scores were determined in 132 patients (29 women, 103 men with a mean age of 55 +/- 10 years) who underwent elective coronary angiography. Risk factors were more closely related to the extent score than to either the stenosis or vessel scores (Total R2 = 0.35 versus 0.28 (p less than 0.001) and 0.25 (p less than 0.001), respectively). The extent score was more closely related to age (r = 0.30, p less than 0.05), than was either stenosis (r = 0.21 ns) or vessel score (r = 0.26, p less than 0.05). Apolipoprotein B was the strongest predictor of both extent and stenosis scores but was more closely related to the extent score (r = 0.36, p less than 0.05), even after correction for age and gender. This new angiographic score that assesses the extent of coronary disease is simple to perform and correlates better with age and lipoprotein risk factors than conventional scores do.
Publisher: Elsevier BV
Date: 04-2022
Publisher: Elsevier BV
Date: 08-1999
DOI: 10.1016/S0167-5273(99)00070-4
Abstract: Contrast echocardiography may be used to assess myocardial perfusion. However, gray scale assessment of myocardial contrast echocardiography (MCE) is difficult because of variations in regional backscatter intensity, difficulties in distinguishing varying shades of gray, and artifacts or attenuation. We sought to determine whether the assessment of rest myocardial perfusion by MCE could be improved with subtraction and color coding. MCE was performed in 31 patients with previous myocardial infarction with a 2nd generation agent (NC100100, Nycomed AS), using harmonic triggered or continuous imaging and gain settings were kept constant throughout the study. Digitized images were post processed by subtraction of baseline from contrast data and colorized to reflect the intensity of myocardial contrast. Gray scale MCE alone, MCE images combined with baseline and subtracted colorized images were scored independently using a 16 segment model. The presence and severity of myocardial contrast abnormalities were compared with perfusion defined by rest MIBI-SPECT. Segments that were not visualized by continuous (17%) or triggered imaging (14%) after color processing were excluded from further analysis. The specificity of gray scale MCE alone (56%) or MCE combined with baseline 2D (47%) was significantly enhanced by subtraction and color coding (76%, p<0.001) of triggered images. The accuracy of the gray scale approaches (respectively 52% and 47%) was increased to 70% (p<0.001). Similarly, for continuous images, the specificity of gray scale MCE with and without baseline comparison was 23% and 42% respectively, compared with 60% after post processing (p<0.001). The accuracy of colorized images (59%) was also significantly greater than gray scale MCE (43% and 29%, p<0.001). The sensitivity of MCE for both acquisitions was not altered by subtraction. Post-processing with subtraction and color coding significantly improves the accuracy and specificity of MCE for detection of perfusion defects.
Publisher: BMJ
Date: 05-2005
Publisher: Elsevier BV
Date: 05-2011
DOI: 10.1016/J.JCMG.2011.01.016
Abstract: We sought the impact of recent recommendations on observer concordance on interpretation of diastolic stage and assessment of filling pressure. Worsening stages of diastolic dysfunction are associated with worsening outcome. However, the echocardiographic classification of diastolic function is complex, and parameters may be discordant. The interobserver agreement of diastolic assessment is undefined. A complete diastolic evaluation (transmitral flow, left atrial volume, tissue Doppler, pulmonary venous flow, mitral flow propagation, and left ventricular images) was obtained in 20 patients and interpreted by 14 experts in 8 countries (280 case reads). Each investigator was asked to interpret diastolic class and left ventricular filling pressure. Brain natriuretic peptide level was drawn on the same day of the echocardiogram to corroborate filling pressures obtained by the echocardiogram. Concordance was assessed as kappa, and accuracy was compared with specific application of the recommendations by 2 investigators. For recognition of raised filling pressure, the sensitivity and specificity of readers for raised filling pressure defined by the reference read were 66 ± 37% and 88 ± 26%, respectively. Complete agreement among all readers was obtained in 10 of 20 cases. Diagnosis of normal and categories of abnormal filling was correct in 71% to 95%, with the lowest values obtained for normal and pseudonormal filling. There was no difference between U.S. and international readers. Not all patients in each diastolic stage showed all of the changes that are typical of that stage, and variations appeared to be attributable to differences in weighting of conflicting observations. Overall, kappa values for filling pressure and diastolic class were 0.71 (range 0.60 to 0.80) and 0.68 (range 0.54 to 0.86). Correct results for estimation of filling pressure were obtained by a high proportion of readers. Classification of diastolic stages continues to be variable and might be addressed by provision of a uniform hierarchy of observations.
Publisher: Elsevier BV
Date: 04-2013
DOI: 10.1016/J.AMJCARD.2012.12.053
Abstract: Sleep disordered breathing (SDB) is associated with type 2 diabetes mellitus (T2DM) and cardiovascular disease however, the contribution of SDB to incident heart failure (HF), coronary artery disease (CAD), and atrial fibrillation (AF) in patients with T2DM is unknown. We followed up 834 consecutive asymptomatic patients with T2DM (age 56 ± 11 years, 369 women) with normal exercise echocardiographic findings for ≤8 years using electronic health records. The demographics, cardiac risk factors, symptoms, diagnoses, and medications were collected at the echocardiography and validated from the electronic health records. SDB was confirmed by a comprehensive sleep evaluation and/or polysomnography before echocardiography. SDB was diagnosed in 188 patients (21%) at baseline 116 were untreated. During a median follow-up of 4.9 years (interquartile range 3.9 to 6.1), 22 congestive HF, 72 CAD, and 40 AF incident events were observed. In the Cox proportional hazards models, SDB was associated with incident CAD (hazard ratio 1.8, 95% confidence interval 1.1 to 3.0, p = 0.01 adjusted hazard ratio 1.9, 95% confidence interval 1.2 to 3.2, p <0.01) and AF (hazard ratio 2.6, 95% confidence interval 1.4 to 4.7, p = 0.01 adjusted hazard ratio 2.9, 95% confidence interval 1.5 to 5.9, p <0.01). Limiting SDB to only those patients diagnosed using polysomnography (n = 132), SDB was associated with incident CAD (hazard ratio 1.9, 95% confidence interval 1.1 to 3.3, p = 0.03 adjusted hazard ratio 2.2, 95% confidence interval 1.2 to 3.9, p = 0.01) and HF (hazard ratio 2.7, 95% confidence interval 1.1 to 7.0, p = 0.03 adjusted hazard ratio 3.5, 95% confidence interval 1.4 to 9.0, p <0.01). Female gender, age, elevated blood pressure, and left ventricular mass were additional correlates of CAD in those with asymptomatic T2DM. In conclusion, the association of SDB with incident CAD, AF, and HF in patients with T2DM justifies more liberal screening for SDB in patients with T2DM, realizing that SDB is a potentially modifiable risk factor.
Publisher: Elsevier BV
Date: 07-1991
DOI: 10.1016/S0894-7317(14)80454-9
Abstract: A 60-year-old white man became hypotensive and dyspneic 3 days after right pneumonectomy for bronchogenic carcinoma. Transthoracic echocardiography was nondiagnostic because of technical difficulty. Transesophageal echocardiography demonstrated a loculated posterior pericardial effusion with isolated diastolic left atrial collapse. The hemodynamic disturbance resolved after drainage of the effusion. Transesophageal echocardiography plays a valuable role in the diagnosis of postoperative cardiac t onade.
Publisher: BMJ
Date: 11-08-2012
DOI: 10.1136/HEARTJNL-2012-302229
Abstract: Limited strategies have been developed to evaluate and address the alarming discrepancy in early mortality between Indigenous and non-Indigenous populations. To assess heart failure (HF), HF risk factors and document cardiac characteristics in an Australian Aboriginal population. Adults were enrolled across six Aboriginal communities in Central Australia. They undertook comprehensive cardiovascular assessments, including echocardiography, to determine HF status, asymptomatic ventricular dysfunction and underlying risk factor profile. Of 436 participants (mean age 44±14 years 64% women) enrolled, 5.3% (95% CI 3.2% to 7.5%) were diagnosed with HF, only 35% of whom had a pre-existing HF diagnosis. Asymptomatic left ventricular dysfunction (ALVD) was seen in 13% (95% CI 9.4% to 15.7%) of the population. Estimates of HF risk factor prevalence were as follows: body mass index (BMI) ≥30 kg/m(2) 42%, hypertension 41%, diabetes mellitus 40%, coronary artery disease (CAD) 7% and history of acute rheumatic fever or rheumatic heart disease 7%. In logistic regression analysis (after adjustment for age and gender), HF was associated with CAD (OR=9.6, p<0.001), diabetes (OR=5.4, p=0.002), hypertension (OR=4.8, p=0.006), BMI ≥30 kg/m(2) (OR=2.9, p=0.02), acute rheumatic fever or rheumatic heart disease (OR=5.6, p=0.001) and B-type natriuretic peptide (OR=1.02, p<0.001). The burden of HF, ALVD and risk factors in this population was extremely high. This study highlights potentially modifiable targets on which to focus resources and screening strategies to prevent HF in this high-risk Indigenous population.
Publisher: Elsevier BV
Date: 05-2018
DOI: 10.1016/J.AHJ.2017.09.011
Abstract: The lifetime risk of coronary artery disease (CAD) is doubled in people with a family history of premature disease, yet this risk is not captured in most 5- or 10-year risk assessment algorithms. Coronary artery calcium scoring (CCS) is a marker of subclinical CAD risk, which has been shown in observational studies to provide prognostic information that is incremental to clinical assessment is relatively inexpensive and is performed with a small radiation dose. However, the use of CCS in guiding prevention is not strongly supported by guidelines. Showing definitive evidence of the efficacy and cost-effectiveness of CCS is therefore of importance. The proposed randomized controlled trial of the use of CCS will be targeted to 40- to 70-year-old first-degree relatives of patients with CAD onset <60 years old or second-degree relatives of patients with onset <50 years old. Control patients will undergo standard risk scoring and be blinded to CCS results. In the intervention group, primary prevention in patients undergoing CCS will be informed by this score. At 3 years, effectiveness will be assessed on change in plaque volume at computed tomography coronary angiography, the extent of which has been strongly linked to outcome. The CAUGHT-CAD trial will provide evidence to inform the guidelines regarding the place of CCS in decision making regarding primary prevention of patients with a family history of premature disease.
Publisher: Elsevier BV
Date: 05-2004
Publisher: Elsevier BV
Date: 03-1999
DOI: 10.1016/S0002-8703(99)70494-1
Abstract: Coronary disease is an important cause of long-term morbidity in patients needing major vascular surgery. We sought to assess the efficacy of preoperative clinical evaluation and the detection of inducible ischemia for prediction of immediate and long-term cardiac outcomes of patients undergoing vascular surgery. In 233 patients undergoing vascular procedures, we assessed risk clinically on the basis of Eagle's criteria. Dobutamine echocardiography was performed with a standard protocol and results were classified as showing ischemia, scar, or a normal response. Patients were observed perioperatively, and late follow-up (28 +/- 13 months) was completed in all surgical survivors. A composite end point of cardiac death, myocardial infarction, and unstable and progressive angina requiring late revascularization was used to judge event-free survival. Of 233 patients undergoing preoperative dobutamine echocardiography, 39 (17%) had inducible ischemia and 36 (15%) had scar. Perioperative events occurred in 8 patients (3%). None of the patients with ischemia had perioperative events, reflecting the effect of revascularization in 9 patients. Late events occurred in 36 patients ischemia on preoperative stress testing was a predictor of these events even after adjusting for clinical variables and left ventricular dysfunction (relative risk = 3.3 95% confidence interval 1.6 to 6.8 P =.001). The association of ischemia with clinical predictors was associated with incrementally worse outcome. In addition to perioperative assessment, the combined use of clinical and dobutamine echocardiographic evaluation may stratify the risk of late cardiac events.
Publisher: Elsevier BV
Date: 11-1997
DOI: 10.1016/S0002-8703(97)80003-8
Abstract: Controversy exists as to whether a sex bias exists that affects the diagnostic approach to suspected coronary artery disease: previous studies have used coronary angiography, but not other noninvasive testing, as a primary end point. This investigation examined posttest sex differences in diagnostic evaluation after exercise treadmill testing according to a broader end point than just coronary angiography alone. The design was a cohort analytic study with a 90-day follow-up. The study was done at the Cleveland Clinic Foundation, an academic group practice. Patients included consecutive adults (1023 men and 579 women) with chest pain but no documented coronary disease who were referred for symptom-limited exercise treadmill testing without adjunctive imaging none had undergone prior invasive cardiac procedures. Main outcome measures included (1) performance of any subsequent diagnostic study (invasive or noninvasive) and (2) performance of coronary angiography as the next diagnostic study. During follow-up, 89 (8.7%) men and 48 (8.3%) women underwent a second diagnostic study (odds ratio 0.95 95% confidence interval 0.66 to 1.37 p > 0.8), whereas 64 (6.3%) men and 21 (3.6%) women went straight to coronary angiography (odds ratio 0.56 95% confidence interval 0.34 to 0.93 p = 0.02). In multivariable logistic regression analyses, which considered baseline clinical characteristics, the ST-segment response, and other prognostically important exercise responses, women tended to be less likely than men to be referred to any second test (adjusted odds ratio 0.70 95% confidence interval 0.42 to 1.19 p > 0.1) but were markedly and significantly less likely to be referred straight to coronary angiography (adjusted odds ratio 0.33 95% confidence interval 0.17 to 0.65). After exercise treadmill testing, women were only slightly less likely than men to be referred for subsequent diagnostic testing they were, however, much less likely to be referred straight to coronary angiography as opposed to another noninvasive study.
Publisher: Elsevier BV
Date: 03-2018
Publisher: Elsevier BV
Date: 04-2010
DOI: 10.1016/J.JCMG.2010.02.002
Abstract: Despite the central role of echocardiography in its primary assessment, heart failure is a condition in which access to multiple cardiovascular imaging modalities is important. A number of important observations relative to this topic have been made in the last year, including the assessment of left ventricular synchrony, myocardial mechanics, heart failure with preserved ejection fraction, metabolic imaging, assessment of myocardial viability, and fusion imaging.
Publisher: Elsevier BV
Date: 07-2004
Publisher: Elsevier BV
Date: 11-2013
DOI: 10.1016/J.ECHO.2013.07.017
Abstract: Although not recommended in isolation, visual estimation of echocardiographic ejection fraction (EF) is widely applied to confirm quantitative EF. However, interobserver variability for EF estimation has been reported to be as high as 14%. The aim of this study was to determine whether self-directed education could improve the accuracy and interobserver variability of visual estimation of EF and whether a multireader estimate improves measurement precision. Thirty-one participants provided single-point EF estimates for 30 echocardiograms with a spectrum of EFs, image quality, and clinical contexts in patients undergoing cardiac magnetic resonance (CMR) within 48 hours. Participants received their own case-by-case variance from CMR EF, and the 10 cases with the largest reader variability were discussed along with corresponding CMR images. Self-directed learning was undertaken by side-by-side review of echocardiographic and CMR images. Two months later, 20 new cases were shown to the same 31 participants, using the same methodology. The baseline interobserver variability of ±0.120 improved to ±0.097 after the intervention. EF misclassification (defined as ±0.05 of CMR EF) was reduced from 56% to 47% (P < .001), and the intervention also resulted in a decrease in the absolute difference between CMR and echocardiography for all cases and all readers (from 0.07 ± 0.01 to 0.06 ± 0.01, P = .0001). This improvement was most prominent for the readers with lower baseline accuracy. A combined physician-sonographer EF estimate improved the precision of EF determination by 25% compared with in idual reads. In readers with varying levels of experience, a simple, mostly self-directed intervention modestly decreased interobserver variability and improved the accuracy of EF measurements. Combined physician-sonographer EF reporting improved the precision of EF estimates.
Publisher: Elsevier BV
Date: 10-2016
DOI: 10.1016/J.JACC.2016.07.763
Abstract: Impaired functional capacity is a hallmark of patients with heart failure with preserved ejection fraction (HFpEF). Despite the association of HFpEF with reduced myocardial compliance attributed to fibrosis, spironolactone has not been shown to alter outcomes-perhaps reflecting the heterogeneity of underlying pathological mechanisms. The authors sought to identify improvement in exercise capacity with spironolactone in the subset of patients with HFpEF with exercise-induced increase in ratio between early mitral inflow velocity and mitral annular early diastolic velocity (E/e') reflecting elevation of left ventricular (LV) filling pressure. In this randomized, blinded, parallel-group, placebo-controlled trial, 150 subjects (age 67 ± 9 years) with exertional dyspnea (New York Heart Association functional class II to III, left ventricular ejection fraction >50%, diastolic dysfunction, and exertional E/e' >13), excluding those with ischemic heart disease, were recruited in a tertiary cardiology center. Patients were randomized to 6 months of oral spironolactone 25 mg/day or matching placebo. Primary outcomes were improvements in peak oxygen uptake (VO At follow-up, 131 patients completed therapy-64 taking spironolactone and 67 placebo. At baseline, subjects had substantial exercise limitation (peak VO In patients with HFpEF and abnormal diastolic response to exertion, improvement in exercise E/e' mediates the beneficial effect of spironolactone on exercise capacity. Identification of exercise-induced increase in LV filling pressure in patients with HFpEF may define a subgroup with warranting trial of spironolactone.
Publisher: Elsevier BV
Date: 12-2005
DOI: 10.1016/J.AHJ.2005.01.035
Abstract: Exercise training (ExT) improves exercise capacity in chronic heart failure, but the results of home-based training have been variable. We sought the predictors of favorable outcome using a telemonitoring approach. Exercise capacity and quality of life (QOL) were assessed in 30 patients (28 men, age 64 +/- 8 years) with symptomatic chronic heart failure and left ventricular ejection fraction 60% maximum heart rate, observed during heart-rate monitoring. Peak V*O2 increased by 26% (P < .001) after 4 months of hospital ExT, but this increase had fallen to 8% (P = .07) at 12 months only adherent patients (n = 15) showed persistent improvement of peak V*O2 at 12 months (P = .02). Improvement in peak V*O2 at 12 months was associated with baseline peak V*O2 (r = -0.61, P < .001) and hours logged on the heart rate monitor (r = 0.47, P = .01). Quality of life improvements were sustained at 12 months for the Minnesota Living with Heart Failure Questionnaire and Hare-Davis Depression Questionnaire. Nevertheless, QOL improvements achieved during the outpatient program were lost or attenuated at 12 months in nonadherent patients but were maintained in adherent patients. Telemonitoring is feasible for following adherence to home ExT. Ongoing adherence is critical in obtaining sustained benefit from ExT in heart failure.
Publisher: Elsevier BV
Date: 04-1992
DOI: 10.1016/0002-9149(92)90782-T
Abstract: The extent of ischemic and hibernating myocardium, which may be detected by increased postexercise uptake of fluoro-18 deoxyglucose (FDG) using positron emission tomography, may determine the degree of functional benefit after revascularization. This study examined the influence of the amount of this FDG-avid myocardium on changes in left ventricular function and exercise parameters after revascularization. Echocardiography and exercise testing were performed before and after intervention in 23 patients who had undergone positron emission tomography for the evaluation of myocardial perfusion (using rubidium-82), and postexercise FDG imaging in the fasting state. Follow-up echocardiography (22 +/- 14 weeks after revascularization) was compared with preoperative FDG activity in 7 myocardial regions per patient. Systolic function improved after intervention in 19 of 26 malperfused, dysfunctional FDG-avid regions (73%), and did not improve in 35 of 47 dysfunctional regions without increased FDG uptake (74%). The influence of the amount of FDG-avid tissue on changes in functional state was examined by comparing 9 patients with multiple (greater than or equal to 2) FDG-avid regions with the remainder. Those with multiple FDG-avid regions demonstrated improvement in peak rate-pressure product (20 +/- 4 to 26 +/- 4 x 10(3), p less than 0.02), and percentage of maximal heart rate achieved at peak (84 +/- 10% to 93 +/- 6%, p = 0.04), neither of which changed significantly in the remaining patients. Exercise capacity increased from 5.6 +/- 2.7 to 7.5 +/- 1.7 METS in the group with multiple FDG-avid regions this increase of 55 +/- 18% exceeded the increase of 13 +/- 10% in the remainder (p = 0.04).(ABSTRACT TRUNCATED AT 250 WORDS)
Publisher: Elsevier BV
Date: 2005
DOI: 10.1016/J.AHJ.2004.06.017
Abstract: Previous work suggesting a better correlation of diastolic than systolic function with exercise capacity in heart failure may reflect the relative insensitivity and load-dependence of ejection fraction (EF). We sought the correlation of new and more sensitive methods of quantifying systolic and diastolic function and filling pressure with functional capacity. We studied 155 consecutive exercise tests on 95 patients with congestive heart failure (81 male, aged 62 +/- 10 years), who underwent resting 2-dimensional echocardiography and tissue Doppler imaging before and after measurement of maximum oxygen uptake (peak VO2). The resting EF was 31% +/- 10% and a peak VO2 was 13 +/- 5 mL/kg.min the majority of these patients (80%) had an ischemic cardiomyopathy. Resting EF (r = 0.14, P = .09) correlated poorly with peak VO2 and mean systolic (r = 0.23, P = .004) and diastolic tissue velocities (r = 0.18, P = .02). Peak EF was weakly correlated with the mean systolic (r = 0.18, P = .02) and diastolic velocities (r = 0.16, P < .04). The mean sum of systolic and diastolic velocities in both annuli (r = 0.30, P < .001) and E/Ea ratio (r = -0.31, P < .001) were better correlated with peak VO2 . Prediction of peak VO2 was similar with models based on models of filling pressure (R = 0.61), systolic factors (R = 0.63), and diastolic factors (R = 0.59), although a composite model of filling pressure, systolic and diastolic function was a superior predictor of peak VO2 (R = 0.69 all P < .001). The reported association of diastolic rather than systolic function with functional capacity may have reflected the limitations of EF. Functional capacity appears related not only to diastolic function, but also to systolic function and filling pressure, and is most closely associated with a combination of these factors.
Publisher: Elsevier BV
Date: 11-2014
Publisher: Oxford University Press (OUP)
Date: 09-2005
Publisher: Elsevier BV
Date: 08-2003
DOI: 10.1016/S0735-1097(03)00654-5
Abstract: We sought to use quantitative markers of the regional left ventricular (LV) response to stress to infer whether diabetic cardiomyopathy is associated with ischemia. Diabetic cardiomyopathy has been identified in clinical and experimental studies, but its cause remains unclear. We studied 41 diabetic patients with normal resting LV function and a normal dobutamine echo and 41 control subjects with a low probability of coronary disease. Peak myocardial systolic velocity (Sm) and early diastolic velocity (Em) in each segment were averaged, and mean Sm and Em were compared between diabetic patients and controls and among different stages of dobutamine stress. Both Sm and Em progressively increased from rest to peak dobutamine stress. In the diabetic group, Sm was significantly lower than in control subjects at baseline (4.2 +/- 0.9 cm/s vs. 4.7 +/- 0.9 cm/s, p = 0.012). However, Sm at a low dose (6.0 +/- 1.3), before peak (8.4 +/- 1.8), and at peak stress (8.9 +/- 1.8) in diabetic patients was not significantly different from that of controls (6.3 +/- 1.4, 8.9 +/- 1.6, and 9.6 +/- 2.1 cm/s, respectively). The Em (cm/s) in the diabetic group (rest: 4.2 +/- 1.2 low dose: 5.0 +/- 1.4 pre-peak: 5.3 +/- 1.1 peak: 5.9 +/- 1.5) was significantly lower than that of controls (rest: 5.8 +/- 1.5 low dose: 6.6 +/- 1.5 pre-peak: 6.9 +/- 1.3 peak: 7.3 +/- 1.7 all p < 0.001). However, the absolute and relative increases in Sm or Em from rest to peak stress were similar in diabetic and control groups. Subtle LV dysfunction is present in diabetic patients without overt cardiac disease. The normal response to stress suggests that ischemia due to small-vessel disease may not be important in early diabetic heart muscle disease.
Publisher: Springer Science and Business Media LLC
Date: 02-09-2009
DOI: 10.1007/S00125-009-1507-4
Abstract: Weight excess and insulin resistance mediate the link between obesity and left ventricular dysfunction. We investigated the effect and mechanisms of lifestyle modification on left ventricular function changes in obese patients. Reduction of body weight and insulin resistance was sought using a behavioural intervention programme including dietary restrictions and exercise training in 261 patients (age 45 +/- 13 years) with BMI >or=30 kg/m(2), no history of cardiac disease and a normal stress echocardiogram. Each patient underwent echocardiographic measurement of myocardial deformation and velocity at baseline and at 6 month follow-up. Improvements in left ventricular systolic and diastolic function were demonstrated only in patients with significant reduction of weight and/or insulin resistance. Left ventricular improvement was less frequent in patients with diabetes than in those without (52% vs 82% for strain, 50% vs 81% for strain rate and 59% vs 80% for peak early diastolic myocardial velocity). The independent predictors of improved left ventricular systolic function (increase in strain) were: weight reduction (beta = 0.14, p < 0.05), decrease in the HOMA insulin resistance index (beta = 0.20, p < 0.005) and absence of diabetes (beta = 0.18, p < 0.02). A decrease in HbA(1c) also predicted improvement of left ventricular diastolic function (beta = 0.26, p < 0.001). There was a parallel increment in exercise capacity with intervention and increase in strain was independently correlated with increase in VO(2) (beta = 0.13, p < 0.04). Effective lifestyle modifications in obese patients improve left ventricular systolic and diastolic function, but appear less effective with co-existing diabetes. The reversal of left ventricular function abnormalities is associated with reduction of both weight and insulin resistance, and is accompanied by an increase in cardiorespiratory fitness.
Publisher: Oxford University Press (OUP)
Date: 17-12-2019
DOI: 10.1093/EHJCI/JEZ303
Abstract: Left atrial (LA) strain is a prognostic biomarker with utility across a spectrum of acute and chronic cardiovascular pathologies. There are limited data on intervendor differences and no data on intermodality differences for LA strain. We sought to compare the intervendor and intermodality differences between transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) derived LA strain. We hypothesized that various components of atrial strain would show good intervendor and intermodality correlation but that there would be systematic differences between vendors and modalities. We evaluated 54 subjects (43 patients with a clinical indication for CMR and 11 healthy volunteers) in a study comparing TTE- and CMR-derived LA reservoir strain (ƐR), conduit strain (ƐCD), and contractile strain (ƐCT). The LA strain components were evaluated using four dedicated types of post-processing software. We evaluated the correlation and systematic bias between modalities and within each modality. Intervendor and intermodality correlation was: ƐR [intraclass correlation coefficient (ICC 0.64–0.90)], ƐCD (ICC 0.62–0.89), and ƐCT (ICC 0.58–0.77). There was evidence of systematic bias between vendors and modalities with mean differences ranging from (3.1–12.2%) for ƐR, ƐCD (1.6–8.6%), and ƐCT (0.3–3.6%). Reproducibility analysis revealed intraobserver coefficient of variance (COV) of 6.5–14.6% and interobserver COV of 9.9–18.7%. Vendor derived ƐR, ƐCD, and ƐCT demonstrates modest to excellent intervendor and intermodality correlation depending on strain component examined. There are systematic differences in measurements depending on modality and vendor. These differences may be addressed by future studies, which, examine calibration of LA geometry/higher frame rate imaging, semi-quantitative approaches, and improvements in reproducibility.
Publisher: Elsevier BV
Date: 02-2021
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 20-11-2018
Abstract: The prognostic impact of jeopardized myocardium ( JM ) in patients with advanced ischemic cardiomyopathy ( ICM ) is unclear. We hypothesized that JM is an independent predictor of mortality in patients with advanced ICM . Patients with ICM who underwent cardiac magnetic resonance imaging between January 2002 and January 2013 were included in our study. JM was identified as a vascular territory with % myocardial scarring on cardiac magnetic resonance imaging and with % stenosis in a major coronary vessel that was not subsequently revascularized. A propensity score was developed for revascularization. A multivariable Cox proportional hazards model was used to evaluate the association of JM with all‐cause mortality. We evaluated 631 patients over a mean follow‐up of 5.1 years. Overall, 336 patients underwent subsequent revascularization during the follow‐up period, among whom 23% had remaining JM , while 295 patients were medically treated (57% with JM ). There were 204 deaths (32%). On multivariable analysis, JM (hazard ratio, 1.88 95% confidence interval, 1.38–2.55 [ P .001]) was independently associated with all‐cause mortality after adjusting for multiple other factors. The risk associated with the presence of JM increased by 5% for every 10‐unit increase in left ventricular end‐systolic volume index. JM is an independent and incremental predictor of mortality in patients with advanced ICM . Patients undergoing revascularization with residual JM had similar risk of mortality compared with medically treated patients with JM . The risk associated with JM significantly increased in the presence of worsening adverse left ventricular remodeling. Cardiac magnetic resonance viability assessment may provide important risk stratification in patients with ICM .
Publisher: Oxford University Press (OUP)
Date: 04-09-2014
Abstract: Chronic right ventricle (RV) apical (RVA) pacing is standard treatment for an atrioventricular (AV) block but may be deleterious to left ventricle (LV) systolic function. Previous clinical studies of non-apical pacing have produced conflicting results. The aim of this randomized, prospective, international, multicentre trial was to compare change in LV ejection fraction (LVEF) between right ventricular apical and high septal (RVHS) pacing over a 2-year study period. We randomized 240 patients (age 74 ± 11 years, 67% male) with a high-grade AV block requiring >90% ventricular pacing and preserved baseline LVEF >50%, to receive pacing at the RVA (n = 120) or RVHS (n = 120). At 2 years, LVEF decreased in both the RVA (57 ± 9 to 55 ± 9%, P = 0.047) and the RVHS groups (56 ± 10 to 54 ± 10%, P = 0.0003). However, there was no significant difference in intra-patient change in LVEF between confirmed RVA (n = 85) and RVHS (n = 83) lead position (P = 0.43). There were no significant differences in heart failure hospitalization, mortality, the burden of atrial fibrillation, or plasma brain natriutetic peptide levels between the two groups. A significantly greater time was required to place the lead in the RVHS position (70 ± 25 vs. 56 ± 24 min, P < 0.0001) with longer fluoroscopy times (11 ± 7 vs. 5 ± 4 min, P < 0.0001). In patients with a high-grade AV block and preserved LV function requiring a high percentage of ventricular pacing, RVHS pacing does not provide a protective effect on left ventricular function over RVA pacing in the first 2 years. ClinicalTrials.gov number NCT00461734.
Publisher: Elsevier BV
Date: 2012
Publisher: Elsevier BV
Date: 11-2004
DOI: 10.1016/J.JACC.2004.08.016
Abstract: This study was designed to predict the response and prognosis after cardiac resynchronization therapy (CRT) in patients with end-stage heart failure (HF). Cardiac resynchronization therapy improves HF symptoms, exercise capacity, and left ventricular (LV) function. Because not all patients respond, preimplantation identification of responders is needed. In the present study, response to CRT was predicted by the presence of LV dyssynchrony assessed by tissue Doppler imaging. Moreover, the prognostic value of LV dyssynchrony in patients undergoing CRT was assessed. Eighty-five patients with end-stage HF, QRS duration >120 ms, and left bundle-branch block were evaluated by tissue Doppler imaging before CRT. At baseline and six months follow-up, New York Heart Association functional class, quality of life and 6-min walking distance, LV volumes, and LV ejection fraction were determined. Events (death, hospitalization for decompensated HF) were obtained during one-year follow-up. Responders (74%) and nonresponders (26%) had comparable baseline characteristics, except for a larger dyssynchrony in responders (87 +/- 49 ms vs. 35 +/- 20 ms, p /=65 ms had an excellent prognosis (6% event rate) after CRT as compared with a 50% event rate in patients with dyssynchrony <65 ms (p /=65 ms respond to CRT and have an excellent prognosis after CRT.
Publisher: Elsevier BV
Date: 02-2013
Publisher: Korean Society of Echocardiography
Date: 2013
Publisher: BMJ
Date: 05-2022
DOI: 10.1136/BMJOPEN-2021-057856
Abstract: This study sought whether higher risk patients with coronary heart disease (CHD) benefit more from intensive disease management. Longitudinal cohort study. State-wide public hospitals (Queensland, Australia). This longitudinal study included 20 426 patients hospitalised in 2010 with CHD as the principal diagnosis. Patients were followed-up for 5 years. The primary outcome was days alive and out of hospital (DAOH) within 5 years of hospital discharge. Secondary outcomes included all-cause readmission and all-cause mortality. A previously developed and validated risk score (PEGASUS-TIMI54) was used to estimate the risk of secondary events. Data on sociodemography, comorbidity, interventions and medications were also collected. High-risk patients (n=6573, risk score ≥6) had fewer DAOH (∆=−142 days (95% CI: −152 to –131)), and were more likely to readmit or die (all p .001) than their low-risk counterparts (n=13 367, risk score ). Compared with patients who were never prescribed a medication, those who consumed maximal dose of betablockers (∆=39 days (95% CI: 11 to 67)), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (∆=74 days (95% CI: 49 to 99)) or statins (∆=109 days (95% CI: 90 to 128)) had significantly greater DAOH. Patients who received percutaneous coronary intervention (∆=99 days (95% CI: 81 to 116)) or coronary artery bypass grafting (∆=120 days (95% CI: 92 to 148)) also had significantly greater DAOH than those who did not. The effect sizes of these therapies were significantly greater in high-risk patients, compared with low-risk patients (interaction p .001). Analysis of secondary outcomes also found significant interaction between both medical and interventional therapies with readmission and death, implicating greater benefits for high-risk patients. CHD patients can be effectively risk-stratified, and use of this information for a risk-guided strategy to prioritise high-risk patients may maximise benefits from additional resources spent on intensive disease management.
Publisher: BMJ
Date: 11-2005
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2013
DOI: 10.1161/CIRCIMAGING.112.000026
Abstract: Studies of echocardiographic predictors of response after cardiac resynchronization therapy (CRT) have largely involved single parameters. We hypothesized that combining parameters would be more robust and sought to develop a multiparametric echocardiographic score for predicting CRT response. Global longitudinal strain of left ventricle was added to standard echocardiographic measurements in 334 consecutive patients (224 men mean, 65±12 years) who underwent baseline echocardiography before CRT and underwent follow-up echocardiograms at 1 year. Regression analysis was performed to create an echocardiographic score for prediction of LV reverse remodeling (defined as ≥15% reduction in the LV end-systolic volume). Cox proportional hazards models were used to identify the association of the score with death, transplantation or LV assist device implantation, and heart failure hospitalization during 57±22 months of follow-up. LV reverse remodeling (n=161 48%) was associated with pre-CRT LV end-diastolic dimension index .1 cm/m 2 , global longitudinal strain of left ventricle –7%, left atrial area cm 2 , right ventricular end-diastolic area index .0 cm 2 /m 2 , right atrial area cm 2 , and right ventricular fractional area change ≥35%. Combination of these into an echocardiographic score allowed prediction of LV reverse remodeling with a sensitivity of 84% and a specificity of 79%. During follow-up, there were 134 deaths, 18 heart transplantations/LV assist device implantations, and 93 heart failure admissions. The score was associated with heart failure admission, heart transplantation/LV assist device, or death (hazard ratio, 0.97 95% confidence interval, 0.95–0.98 P .001) and all-cause death (hazard ratio, 0.97 95% confidence interval, 0.96–0.98 P .001), independent of age, sex, ischemic cause, and initial functional class. A multiparametric echocardiographic score is helpful in selecting patients likely to undergo reverse remodeling after CRT and predicts clinical outcomes.
Publisher: Elsevier BV
Date: 12-1995
DOI: 10.1016/S0002-9149(99)80347-6
Abstract: Inappropriate chronotropic response to exercise has been observed to correlate with poor prognosis in patients with coronary disease, but the mechanism for this association is not well defined. We attempted to examine the association between chronotropic response to exercise and angiographic severity of coronary disease in patients with suspected or stable coronary artery disease. The chronotropic response, expressed as peak heart rate, chronotropic index (ratio of heart rate reserve and metabolic reserve utilized), or percent maximal heart rate achieved, was correlated with angiographic findings obtained within 180 days of the test. Significant coronary disease was defined as > or = 1 stenosis of > or = 50% in a major epicardial artery or its main branches severe coronary disease was defined as > or = 50% stenosis in all 3 epicardial arteries, or in the left main coronary trunk, or 2-vessel disease with > or = 70% proximal left anterior descending artery stenosis. We observed that peak heart rate and percent maximal heart rate achieved were independent negative predictors of both significant and severe coronary disease by logistic regression. The chronotropic index predicted severe coronary disease only. All 3 parameters of chronotropic response exhibited a significant gradient of abnormality across the spectrum of coronary disease (p < 0.01 for all), expressed by the number of vessels involved and correlated with left anterior descending artery involvement (p < 0.05 for all). We conclude that chronotropic response to exercise predicts the presence and angiographic severity of coronary disease. This association is likely related to the proportion of left ventricular myocardium rendered ischemic during stress.
Publisher: Wiley
Date: 23-10-2021
DOI: 10.5694/MJA2.51321
Publisher: Elsevier BV
Date: 2013
DOI: 10.1016/J.JACC.2012.09.035
Abstract: The aim of this study was to identify the best echocardiographic method for sequential quantification of left ventricular (LV) ejection fraction (EF) and volumes in patients undergoing cancer chemotherapy. Decisions regarding cancer therapy are based on temporal changes of EF. However the method for EF measurement with the lowest temporal variability is unknown. We selected patients in whom stable function in the face of chemotherapy for breast cancer was defined by stability of global longitudinal strain (GLS) at up to 5 time points (baseline, 3, 6, 9, and 12 months). In this way, changes in EF were considered to reflect temporal variability of measurements rather than cardiotoxicity. A comprehensive echocardiogram consisting of 2-dimensional (2D) and 3-dimensional (3D) acquisitions with and without contrast administration was performed at each time point. Stable LV function was defined as normal GLS (≤-16.0%) at each examination. The EF and volumes were measured with 2D-biplane Simpson's method, 2D-triplane, and 3-dimensional echocardiography (3DE) by 2 investigators blinded to any clinical data. Inter-, intra-, and test-retest variability were assessed in a subgroup. Variability was assessed by analysis of variance and compared with Levene's or t test. Among 56 patients (all female, 54 ± 13 years of age), noncontrast 3D EF, end-diastolic volume, and end-systolic volume had significantly lower temporal variability than all other methods. Contrast only decreased the temporal variability of LV end-diastolic volume measurements by the 2D biplane method. Our data suggest that a temporal variability in EF of 0.06 might occur with noncontrast 3DE due to physiological differences and measurement variability, whereas this might be >0.10 with 2D methods. Overall, 3DE also had the best intra- and inter-observer as well as test-retest variability. Noncontrast 3DE was the most reproducible technique for LVEF and LV volume measurements over 1 year of follow-up.
Publisher: Elsevier BV
Date: 02-2018
DOI: 10.1016/J.JCHF.2017.11.016
Abstract: This study sought to measure the impact on all-cause death or readmission of adding center-based exercise training (ET) to disease management programs for patients with a recent acute heart failure (HF) hospitalization. ET is recommended for patients with HF, but evidence is based mainly on ET as a single intervention in stable outpatients. A randomized, controlled trial with blinded outcome assessor, enrolling adult participants with HF discharged from 5 hospitals in Queensland, Australia. All participants received HF-disease management program plus supported home exercise program intervention participants were offered 24 weeks of supervised center-based ET. Primary outcome was all-cause 12-month death or readmission. Pre-planned subgroups included age ( 40%), and exercise adherence. Between May 2008 and July 2013, 278 participants (140 intervention, 138 control) were enrolled: 98 (35.3%) age ≥70 years, 71 (25.5%) females, and 62 (23.3%) with a left ventricular ejection fraction of >40%. There were no adverse events associated with ET. There was no difference in primary outcome between groups (84 of 140 [60.0%] intervention vs. 90 of 138 [65.2%] control p = 0.37), but a trend toward greater benefit in participants age <70 years (OR: 0.56 [95% CI: 0.30 to 1.02] vs. OR: 1.56 [95% CI: 0.67 to 3.64] p for interaction = 0.05). Participants who exercised to guidelines (72 of 101 control and 92 of 117 intervention at 3 months) had a significantly lower rate of death and readmission (91 of 164 [55.5%] vs. 41 of 54 [75.9%] p = 0.008). Supervised center-based ET was a safe, feasible addition to disease management programs with supported home exercise in patients recently hospitalized with acute HF, but did not reduce combined end-point of death or readmission. (A supervised exercise programme following hospitalisation for heart failure: does it add to disease management? ACTRN12608000263392).
Publisher: Elsevier BV
Date: 02-2023
Publisher: Elsevier BV
Date: 02-2004
Publisher: Elsevier BV
Date: 02-2004
Publisher: Elsevier BV
Date: 05-2019
Publisher: Elsevier BV
Date: 11-1998
DOI: 10.1016/S0735-1097(98)00373-8
Abstract: We sought to assess the feasibility and accuracy of myocardial contrast echocardiography (MCE) using standard imaging approaches for the detection of perfusion defects in patients who had a myocardial infarction (MI). Myocardial contrast echocardiography may be more versatile than perfusion scintigraphy for identifying the presence and extent of perfusion defects after MI. However, its reliability in routine practice is unclear. Fundamental or harmonic MCE was performed with continuous or triggered imaging in 203 patients with a previous MI using bolus doses of a perfluorocarbon-filled contrast agent (NC100100). All patients underwent single-photon emission computed tomography (SPECT) after the injection of technetium-99m (Tc-99m) sestamibi at rest. Quantitative and semiquantitative SPECT, wall motion and digitized echocardiographic data were interpreted independently. The accuracy of MCE was assessed for detection of segments and patients with moderate and severe sestamibi-SPECT defects, as well as for detection of patients with extensive perfusion defects (>12% of left ventricle). In segments with diagnostic MCE, the segmental sensitivity ranged from 14% to 65%, and the specificity varied from 78% to 95%, depending on the dose of contrast agent. Using both segment- and patient-based analysis, the greatest accuracy and proportion of interpretable images were obtained using harmonic imaging in the triggered mode. For the detection of extensive defects, the sensitivity varied from 13% to 48%, with specificity from 63% to 100%. Harmonic imaging remained the most accurate approach. Time since MI and SPECT defect location and intensity were all determinants of the MCE response. The extent of defects on MCE was less than the extent of either abnormal wall motion or SPECT abnormalities. The combination of wall motion and MCE assessment gave the best balance of sensitivity (46% to 55%) and specificity (82% to 83%). Although MCE is specific, it has limited sensitivity for detection of moderate or severe perfusion defects, and it underestimates the extent of SPECT defects. The best results are obtained by integration with wall motion. More sophisticated methods of acquisition and interpretation are needed to enhance the feasibility of this technique in routine practice.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2013
DOI: 10.1161/CIRCHEARTFAILURE.112.000055
Abstract: Chemotherapy with trastuzumab and anthracycline is associated with incident heart failure (HF) in patients with breast cancer. We hypothesized that continuous incidental use of β-blocker agents (BB) was protective against HF in patients without established structural heart disease who were receiving trastuzumab and anthracycline. We identified 920 consecutive patients with breast cancer (age 52.3±11.0 years) with normal ejection fraction before receiving trastuzumab and anthracycline therapy at our institution between 2005 and 2010. Using a propensity score and a greedy 5 to 1 digit-matching algorithm, 106 of these patients on continuous BB during cancer treatment were matched with 212 patients from the same pool with similar characteristics but not on continuous BB. During a median follow-up of 3.2±2.0 years, 32 incident HF admissions were identified in these 318 patients with breast cancer, whereas 28 cancer-related (noncardiac) deaths occurred before any incident HF. Cumulative incidence regression models and cause-specific hazards of new HF events were estimated from competing risk Cox models of time-dependent covariates. Although trastuzumab therapy showed significant association with incident HF, independent of anthracycline-related cardiotoxicity (hazard ratio, 9.0 95% confidence interval, 3.0–27.0 P .0001), continuous use of BB was associated with lower risk of new HF events (hazard ratio, 0.2 95% confidence interval, 0.1–0.5 P =0.003). Coincidental, continuous use of BB is associated with lower incidence of HF in patients with breast cancer and normal baseline ejection fraction in a competing risk framework, and after matching for demographics, clinical, and cancer-related treatment characteristics. Prospective randomized clinical trials to validate these findings are warranted.
Publisher: Public Library of Science (PLoS)
Date: 29-06-2012
Publisher: Springer Science and Business Media LLC
Date: 07-02-2014
Abstract: Appropriate disposition of emergency department (ED) patients with chest pain is dependent on clinical evaluation of risk. A number of chest pain risk stratification tools have been proposed. The aim of this study was to compare the predictive performance for major adverse cardiac events (MACE) using risk assessment tools from the National Heart Foundation of Australia (HFA), the Goldman risk score and the Thrombolysis in Myocardial Infarction risk score (TIMI RS). This prospective observational study evaluated ED patients aged ≥30 years with non-traumatic chest pain for which no definitive non-ischemic cause was found. Data collected included demographic and clinical information, investigation findings and occurrence of MACE by 30 days. The outcome of interest was the comparative predictive performance of the risk tools for MACE at 30 days, as analyzed by receiver operator curves (ROC). Two hundred eighty-one patients were studied the rate of MACE was 14.1%. Area under the curve (AUC) of the HFA, TIMI RS and Goldman tools for the endpoint of MACE was 0.54, 0.71 and 0.67, respectively, with the difference between the tools in predictive ability for MACE being highly significant [chi 2 (3) = 67.21, N = 276, p 0.0001]. The TIMI RS and Goldman tools performed better than the HFA in this undifferentiated ED chest pain population, but selection of cutoffs balancing sensitivity and specificity was problematic. There is an urgent need for validated risk stratification tools specific for the ED chest pain population.
Publisher: Oxford University Press (OUP)
Date: 08-0033
DOI: 10.1093/EHJCI/JEX147
Abstract: Impairment of myocardial function is an important potential complication of systemic sclerosis (SSc) and associated with poor prognosis. The detection of left (LV) and right ventricular (RV) dysfunction may prompt specific therapeutic interventions. We sought to investigate the prognostic value of both LV and RV deformation in patients with SSc. Speckle tracking LV strain parameters [global longitudinal strain (GLS) and global circumferential strain (GCS)] and tricuspid annular peak systolic velocity (Ts') were measured in 103 patients with SSc and 103 age- and gender-matched controls. Subjects were followed for a median of 3.4 years for heart failure-specific admission or death, and the association of the study parameters with outcome was assessed using Cox proportional hazards models. GLS, GCS, and Ts' were significantly impaired in patients with SSc, even without pulmonary hypertension, compared with controls. GCS (r2 = 0.07, P = 0.03) but not GLS (r2 = 0.04, P = 0.11) was associated with systolic pulmonary artery pressure. During follow-up, SSc patients (n = 17, 17%) had more events than controls (n = 7, 7%, P = 0.04). In SSc patients, GCS (but not GLS), Ts', and 6-minute walk distance (6MWD) were significantly associated with outcome. 6MWD and Ts' (but not GCS) were independently associated with outcome. A model based on age, gender, 6MWD, and GCS was significantly improved by adding by adding Ts' (P = 0.02). RV dysfunction was associated with adverse outcome, independent of and incremental to clinical and LV deformation parameters in SSc. LV dysfunction appears to have less prognostic relevance than RV dysfunction.
Publisher: Elsevier BV
Date: 02-1998
DOI: 10.1016/S0140-6736(97)07062-1
Abstract: Chronic inflammation is associated with various chronic diseases, including cardiovascular disease, neurodegenerative disease, and cancer, which severely affect the health and quality of life of people. Oxidative stress induced by unbalanced production and elimination of reactive oxygen species (ROS) is one of the essential risk factors for chronic inflammation. Recent studies, including the studies of mushrooms, which have received considerable attention, report that the antioxidant effects of natural compounds have more advantages than synthetic antioxidants. Mushrooms have been consumed by humans as precious nourishment for 3,000 years, and so far, more than 350 types have been identified in China. Mushrooms are rich in polysaccharides, peptides, polyphenols, alkaloids, and terpenoids and are associated with several healthy biological functions, especially antioxidant properties. As such, the extracts purified from mushrooms could activate the expression of antioxidant enzymes through the Keap1/Nrf2/ARE pathway to neutralize excessive ROS and inhibit ROS-induced chronic inflammation through the NF-κB pathway. Recently, the antioxidant properties of mushrooms have been successfully applied to treating cardiovascular disease (CAD), neurodegenerative diseases, diabetes mellitus, and cancer. The present review summarizes the antioxidant properties and the mechanism of compounds purified from mushrooms, emphasizing the oxidative stress regulation of mushrooms to fight against chronic inflammation.
Publisher: Wiley
Date: 24-03-2022
DOI: 10.1002/EJHF.2150
Publisher: Elsevier BV
Date: 1996
DOI: 10.1016/0735-1097(95)00393-2
Abstract: This study sought to establish the prognostic implications of ischemic and viable myocardium identified by dobutamine echocardiography in patients with left ventricular dysfunction. Recent studies have suggested that in patients with viable myocardium identified by positron emission tomography, medical treatment is associated with recurrent cardiac events. Dobutamine echocardiography has been used to identify viable myocardium in patients with left ventricular dysfunction, but the prognostic significance of this test is undefined. One hundred thirty-six consecutive patients (mean [+/- SD] age 67 +/- 7.9 years 104 men) with moderate or severe left ventricular dysfunction (left ventricular ejection fraction 30 +/- 5%) undergoing dobutamine echocardiography were included in the study. Dobutamine was administered using a standard incremental protocol (5 to 40 micrograms/kg body weight per min intravenously in 3-min stages) with additional atropine (1 mg intravenously) as required. Standard body weight echocardiographic views were digitized on-line and compared using a side-by-side display. Viable myocardium was identified by enhancement of regional function at low dose (< 10 micrograms) scar was diagnosed by akinesia at rest or dyskinesia without change and ischemia as new or worsening dysfunction. One hundred thirty patients (95%) were followed up for 16 +/- 8 months after the original study for major cardiac events (cardiac death, myocardial infarction or severe unstable angina requiring late myocardial revascularization). No significant complications occurred during dobutamine echocardiography. Viable myocardium was detected in 26 patients (19%), ischemia in 23 (17%), both viability and ischemia in 13 (10%) and scar in 74 (54%). Of 108 patients treated medically, 46 had viable or ischemic myocardium, and 62 had scar only. There were no significant differences in age or other clinical characteristics, stress response, left ventricular dimensions and ejection fraction between the two groups. Cardiac events occurred in 26 medically treated patients (24%): 18 died of cardiac-related causes 4 had a nonfatal myocardial infarction and 4 had late revascularization because of unstable angina. The event rate was greater in patients with viable or ischemic myocardium than those with scar (43% vs. 8%, p = 0.01 by log-rank test). In a Cox regression model, the presence of viable or ischemic myocardium was found to predict subsequent events (relative risk 3.51, p = 0.02) independently of ejection fraction and age. Viable or ischemic myocardium detected at dobutamine echocardiography in patients with left ventricular dysfunction is associated with an adverse prognosis, independent of age and ejection fraction.
Publisher: Elsevier BV
Date: 08-2010
Publisher: Springer New York
Date: 2007
Publisher: Massachusetts Medical Society
Date: 03-11-2005
DOI: 10.1056/NEJME058192
Publisher: Elsevier BV
Date: 09-1998
DOI: 10.1016/S0002-9149(98)00462-7
Abstract: Functional testing is recommended for risk stratification of medically treated patients with unstable angina. Exercise echocardiography is used in this situation, but its safety and prognostic value are not well defined. The objective of this study was to assess the incremental prognostic value of exercise echocardiography in 226 consecutive patients (128 men, age 59+/-13 years) with medically treated unstable angina, who underwent exercise echocardiography from 1991 to 1996. Clinical risk was designated as low in 108 patients, intermediate in 116, and high in 2 patients according to the unstable angina practice guidelines. There were no major complications from the stress tests. The exercise electrocardiogram was nondiagnostic in 57 patients (25%). Ischemia was identified by exercise electrocardiography in 33 patients and exercise echocardiography in 55 patients. Patients were followed for 29+/-18 months. After exclusion of 38 patients who underwent early revascularization, 28 patients had cardiac death, nonfatal infarction, and late (>3 months) revascularization. Ischemia at exercise echocardiography was associated with a 24-month event-free survival of 81%, compared to 95% with negative exercise echocardiography (p=0.02). A positive exercise electrocardiogram was associated with a 24-month event-free survival of 84%, compared to 93% with negative exercise electrocardiograms (p=0.08). In a Cox regression model, event-free survival was predicted by ischemia at exercise echocardiography (relative risk 2.8, confidence interval: 1.3 to 6.3, p=0.05), but not at exercise electrocardiography (relative risk 2.1, confidence interval 0.7 to 5.8, p=0.16).
Publisher: Korean Society of Echocardiography
Date: 2014
Publisher: Elsevier BV
Date: 04-2012
DOI: 10.1016/J.ECHO.2011.12.020
Abstract: Two-dimensional (2D) speckle tracking-derived left atrial (LA) strain (ε) facilitates comprehensive evaluation of LA contractile, reservoir, and conduit function however, its dependence on the in idual software used for assessment has not been evaluated. The aim of this study was to compare LA ε derived from two different speckle-tracking software technologies, Velocity Vector Imaging (VVI) and 2D speckle-tracking echocardiography (STE). VVI-derived and 2D STE-derived global longitudinal LA ε and ε rate (SR) were directly compared in 127 patients (mean age, 62 ± 10 years) with atrial fibrillation. Peak negative, peak positive, and total ε (corresponding to LA contractile, conduit, and reservoir function) were measured during sinus rhythm. Late negative (LA contraction), peak positive (left ventricular systole), and early negative (left ventricular early diastole) SR were also measured. The measurement of LA ε and SR by both software was feasible in high proportions of patients (93% with VVI and 93% with 2D STE). The average analysis of ε(negative) was -7.24 ± 3.87% by VVI and -7.30 ± 3.37% by 2D STE (P = .84). The average analysis of ε(positive) was 14.52 ± 5.82% by VVI and 10.74 ± 4.51% by 2D STE (P < .01). The average analysis of ε(total) was 21.76 ± 7.39% by VVI and 18.04 ± 5.98% by 2D STE (P < .01). VVI-derived and 2D STE-derived ε(positive), ε(negative), and ε(total) had good correlations with one another (R = 0.79, R = 0.75, and R = 0.80), with low mean differences. Late negative, peak positive, and early negative SR were correlated less well (R = 0.78, R = 0.71, and R = 0.67). LA ε measurement using both VVI and 2D STE is feasible in a large proportion of patients in clinical practice. VVI and 2D STE provide comparable LA ε and SR measurements for LA contractile function.
Publisher: Elsevier BV
Date: 09-1994
DOI: 10.1016/0002-9149(94)90898-2
Abstract: This study compares the accuracy of the routine exercise electrocardiogram, exercise score, and exercise echocardiography for the diagnosis of coronary artery disease (CAD) in women. Seventy women with a pretest probability of 53 +/- 30% for CAD were stressed using a maximal symptom-limited bicycle exercise protocol. Significant ST-segment change was defined by a depression of > 0.1 mV 0.06 second after the J point. The exercise score was calculated from ST response, heart rate, and workload using an equation derived from a multivariate model. A positive stress echocardiogram was defined by development of a new or worsening wall motion abnormality. The results were compared with the presence or absence of significant (> 50% diameter) stenoses at angiography. Exercise echocardiography identified 29 of the 33 patients (88%) with CAD, compared with 22 (67%) using ST analysis alone, and 20 (61%) using the exercise score (both p < 0.05 vs exercise echocardiography). The specificity of exercise echocardiography (84%) and the multivariate score (73%) were comparable, and exceeded that of the ST analysis (51%) in 37 patients without CAD (p < 0.01). The accuracy of exercise echocardiography (86%) exceeded that of the exercise score (67%, p = 0.01) and ST analysis (59%, p < 0.01). Among all 70 patients, an intermediate (20% to 80%) probability of coronary disease was identified in 21 patients on the basis of exercise echocardiography, in 38 based on the multivariate score, and in 38 based on the ST analysis alone. Exercise echocardiography is more sensitive than the exercise score, and more sensitive and specific than ST-segment analysis for the diagnosis of CAD in women.(ABSTRACT TRUNCATED AT 250 WORDS)
Publisher: Elsevier BV
Date: 04-2006
DOI: 10.1016/J.JACC.2005.11.063
Abstract: Strain and strain rate (SR) are measures of deformation that are basic descriptors of both the nature and the function of cardiac tissue. These properties may now be measured using either Doppler or two-dimensional ultrasound techniques. Although these measurements are feasible in routine clinical echocardiography, their acquisition and analysis nonetheless presents a number of technical challenges and complexities. Echocardiographic strain and SR imaging has been applied to the assessment of resting ventricular function, the assessment of myocardial viability using low-dose dobutamine infusion, and stress testing for ischemia. Resting function assessment has been applied in both the left and the right ventricles, and may prove particularly valuable for identifying myocardial diseases and following up the treatment response. Although the evidence base is limited, SR imaging seems to be feasible and effective for the assessment of myocardial viability. The use of the technique for the detection of ischemia during stress echocardiography is technically challenging and likely to evolve further. The clinical availability of strain and SR measurement may offer a solution to the ongoing need for quantification of regional and global cardiac function. Nonetheless, these techniques are susceptible to artifact, and further technical development is necessary.
Publisher: Cleveland Clinic Journal of Medicine
Date: 07-1995
Abstract: Stress echocardiography is a cost-effective and reliable diagnostic test for patients with suspected coronary artery disease. Stress echocardiography should be used in preference to exercise electrocardiography as the primary test in patients with uninterpretable ST segments. It is attractive for use as the primary test in patients with coexisting valvular disease. It probably is the optimal test for women. Stress echocardiography should be used as a secondary test when the result of exercise electrocardiography is inconsistent with the clinical status. In patients requiring nonexercise stress testing, an imaging test is mandatory. The ability of stress echocardiography to identify the location and extent of myocardial ischemia makes it appropriate in situations where decisions regarding revascularization will be made on these grounds. The overall accuracy of stress echocardiography and perfusion scintigraphy is comparable in expert hands. but one must always consider the expertise of the operator and the quality of each test in the environment in which it is performed.
Publisher: Elsevier BV
Date: 09-1991
Abstract: A 46-year-old woman with isolated tricuspid stenosis complained of increasing fatigue and dyspnea on exertion. Exercise Doppler echocardiography reproduced her symptoms and revealed a marked increase in trans-tricuspid gradient. Successful percutaneous balloon tricuspid valvotomy was performed, with resolution of her symptoms.
Publisher: Elsevier BV
Date: 08-2012
DOI: 10.1016/J.JCMG.2012.05.011
Abstract: We studied in a multicenter setting the accuracy and reproducibility of 3-dimensional echocardiography (3DE)-derived measurements of left atrial volume (LAV) using new, dedicated volumetric software, side by side with 2-dimensional echocardiography (2DE), using cardiac magnetic resonance (CMR) imaging as a reference. Increased LAV is associated with adverse cardiovascular outcomes. Although LAV measurements are routinely performed using 2DE, this methodology is limited because it is view dependent and relies on geometric assumptions regarding left atrial shape. Real-time 3DE is free of these limitations and accordingly is an attractive alternative for the evaluation of LAV. However, few studies have validated 3DE-derived LAV measurements against an accepted independent reference standard, such as CMR imaging. We studied 92 patients with a wide range of LAV who underwent CMR (1.5-T) and echocardiographic imaging on the same day. Images were analyzed to obtain maximal and minimal LAV: CMR images using standard commercial tools, 2DE images using a biplane area-length technique, and 3DE images using Tomtec LA Function software. Intertechnique comparisons included linear regression and Bland-Altman analyses. Reproducibility of all 3 techniques was assessed by calculating the percentage of absolute differences in blinded repeated measurements. Kappa statistics were used to compare 2DE and 3DE classification of normal/enlarged against the CMR reference. 3DE-derived LAV values showed higher correlation with CMR than 2DE measurements (r = 0.93 vs. r = 0.74 for maximal LAV r = 0.88 vs. r = 0.82 for minimal LAV). Although 2DE underestimated maximal LAV by 31 ± 25 ml and minimal LAV by 16 ± 32 ml, 3DE resulted in a minimal bias of -1 ± 14 ml for maximal LAV and 0 ± 21 ml for minimal LAV. Interobserver and intraobserver variability of 2DE and 3DE measurements of maximal LAV were similar (7% to 12%) and approximately 2 times higher than CMR (4% to 5%). 3DE classified enlarged atria more accurately than 2DE (kappa: 0.88 vs. 0.71). Compared with CMR reference, 3DE-derived LAV measurements are more accurate than 2DE-based analysis, resulting in fewer patients with undetected atrial enlargement.
Publisher: Elsevier BV
Date: 06-2021
Publisher: Elsevier BV
Date: 10-2013
DOI: 10.1016/J.ECHO.2013.06.003
Abstract: The ratio of tricuspid regurgitation velocity (TRV) to the time-velocity integral of the right ventricular outflow tract (TVIRVOT) has been studied as a reliable measure to distinguish elevated from normal pulmonary vascular resistance (PVR). The equation TRV/TVIRVOT × 10 + 0.16 (PVRecho) has been shown to provide a good noninvasive estimate of PVR. However, its role in patients with significantly elevated PVR (> 6 Wood units [WU]) has not been conclusively evaluated. The aim of this study was to establish the validity of the TRV/TVIRVOT ratio as a correlate of PVR. The role of TRV/TVIRVOT was also compared with that of a new ratio, TRV(2)/TVIRVOT, in patients with markedly elevated PVR (>6 WU). Data from five validation studies using TRV/TVIRVOT as an estimate of PVR were compared with invasive PVR measurements (PVRcath). Multiple linear regression analyses were generated between PVRcath and both TRV/TVIRVOT and TRV(2)/TVIRVOT. Both PVRecho and a new derived regression equation based on TRV(2)/TVIRVOT: 5.19 × TRV(2)/TVIRVOT - 0.4 (PVRecho2) were compared with PVRcath using Bland-Altman analysis. Logistic models were generated, and cutoff values for both TRV/TVIRVOT and TRV(2)/TVIRVOT were obtained to predict PVR > 6 WU. One hundred fifty patients remained in the final analysis. Linear regression analysis between PVRcath and TRV/TVIRVOT revealed a good correlation (r = 0.76, P < .0001, Z = 0.92). There was a better correlation between PVRcath and TRV(2)/TVIRVOT (r = 0.79, P 6 WU. Moreover, PVRecho2 compared better with PVRcath than PVRecho using Bland-Altman analysis in the entire cohort and in patients with PVR > 6 WU. TRV(2)/TVIRVOT and TRV/TVIRVOT both predicted PVR > 6 WU with good sensitivity and specificity. TRV/TVIRVOT is a reliable method to identify patients with elevated PVR. In patients with TRV/TVIRVOT > 0.275, PVR is likely > 6 WU, and PVRecho2 derived from TRV(2)/TVIRVOT provides an improved noninvasive estimate of PVR compared with PVRecho.
Publisher: Portland Press Ltd.
Date: 2004
DOI: 10.1042/CS20030153
Abstract: Subclinical left ventricular (LV) dysfunction may be identified by reduced longitudinal contraction. We sought to define the effects of subclinical LV dysfunction on radial contractility in 53 patients with diabetes mellitus with no LV hypertrophy, normal ejection fraction and no ischaemia as assessed by dobutamine echocardiography, in comparison with age-matched controls. Radial peak myocardial systolic velocity (Sm) and early diastolic velocity (Em), strain and strain rate were measured in the mid-posterior and mid-anteroseptal walls in parasternal views and each variable was averaged for in idual patients (radial contractility). These variables were also measured in the mid-posterior and mid-anteroseptal walls in the apical long-axis view and each variable was averaged for in idual patients (longitudinal contractility). Mean radial Sm, strain and strain rate were significantly increased in diabetic patients (2.9±0.6 cm/s, 28±5% and 1.8±0.4 s-1 respectively) compared with controls (2.4±0.7 cm/s, 23±4% and 1.6±0.3 s-1 respectively all P& .001), but there was no difference in Em (3.3±1.2 compared with 3.1±1.1 cm/s, P=not significant). In contrast, longitudinal Sm, Em, strain and strain rate were significantly lower in diabetic patients (3.6±1.1 cm/s, 4.3±1.6 cm/s, 21±4% and 1.6±0.3 s-1 respectively) than in controls (4.3±1.0 cm/s, 5.7±2.3 cm/s, 26±4% and 1.9±0.3 s-1 respectively all P ⩽ 0.001). Thus radial contractility appears to compensate for reduced longitudinal contractility in subclinical LV dysfunction occurring in the absence of ischaemia or LV hypertrophy.
Publisher: Elsevier BV
Date: 11-2003
DOI: 10.1016/J.AMJCARD.2003.06.016
Abstract: We evaluated patients with end-stage heart failure who have a high likelihood of response to cardiac resynchronization therapy (biventricular pacing). It appears that 20% of patients do not respond to this expensive therapy despite the use of selection criteria (dilated cardiomyopathy, heart failure, New York Heart Association class II or IV, left ventricular ejection fraction 120 ms). The presence of left ventricular dyssynchrony is needed to result in improvement after cardiac resynchronization therapy.
Publisher: Elsevier BV
Date: 05-2017
DOI: 10.1016/J.AMJCARD.2017.02.010
Abstract: In independent studies, abnormal global longitudinal strain (GLS) and myocardial inflammation or scar detected by 18F-fludeoxyglucose positron emission tomography (FDG-PET) are associated with poor prognosis among patients with high likelihood for cardiac sarcoidosis. However, commonly used imaging modalities have not been evaluated in the same population. Our goals were to examine the relation between GLS and FDG-PET, and to evaluate the incremental prognostic value of these imaging techniques for predicting major adverse cardiac events (MACE) in patients suspected to have cardiac sarcoidosis. We identified patients with systemic sarcoidosis who underwent an echocardiogram and FDG-PET within 60 days. Regional strain (average of base, mid, and apical segmental strains from each of 6 wall regions) was calculated and compared with regional FDG-PET findings. The associations among GLS, FDG-PET findings, and MACE (defined as death, ventricular tachycardia, heart failure hospitalization, or transplantation) were evaluated using a Cox model. Of 84 patients, 51 had abnormal FDG-PET. GLS was impaired in patients with abnormal versus normal FDG-PET (-14.2 ± 4.7% vs -17.9 ± 3.5%, p <0.01). After adjusting for clinical risk factors, both GLS and the number of segments with abnormal perfusion and metabolism on FDG-PET were associated with adverse cardiac events (p <0.01 for both). In conclusion, GLS and regional LS are impaired in patients with abnormal perfusion and metabolism detected using FDG-PET. Additionally, both GLS and abnormal FDG-PET have incremental prognostic value for predicting MACE in patients with systemic sarcoidosis.
Publisher: Elsevier BV
Date: 02-2022
DOI: 10.1016/J.ECHO.2021.09.003
Abstract: Heart failure (HF) remains a common complication for patients with coronary artery disease (CAD), especially after acute myocardial infarction. Although left ventricular ejection fraction (LVEF) is conventionally used to assess cardiac function for risk stratification, it has been shown in other settings to underestimate the risk of HF compared with global longitudinal strain (GLS). Moreover, most evidence pertains to early-onset HF. We sought the clinical and myocardial predictors for late-onset HF in patients with CAD. We analyzed echocardiograms (including GLS) in 334 patients with CAD (ages 65 ± 11 years, 77% male) who were enrolled in the Nurse-Led Intervention for Less Chronic Heart Failure trial, a prospective, randomized controlled trial that compared standard care with nurse-led intervention to prevent HF in in iduals at risk of incident HF. Long-term (9 years) follow-up was obtained via data linkage. Analysis was performed using a competing-risk model. Baseline LVEF values were normal or mildly impaired (LVEF ≥ 40%) in all subjects. After a median of 9 years of follow-up, 50 (15%) of the 334 patients had new HF admissions, and 68 (20%) died. In a competing-risk model, HF was associated with GLS (hazard ratio = 1.15 [1.05-1.25], P = .001), independent of estimated glomerular filtration rate (hazard ratio = 0.98 [0.97-0.99], P = .045), Charlson comorbidity score (hazard ratio = 1.64 [1.25-2.15], P < .001), or E/e' (hazard ratio = 1.08 [1.02-1.14], P = .01). Global longitudinal strain-but not conventional echocardiographic measures-added incremental value to a clinical model based on age, gender, and Charlson score (area under the curve, 0.78-0.83, P = .01). Global longitudinal strain was still associated with HF development in patients taking baseline angiotensin convertase enzyme inhibitors (hazard ratio = 1.21 [1.11-1.31], P < .01) and baseline beta-blockers (1.17 [1.09, 1.26] P < .01). Mortality was associated with older men, risk factors (hypertension or diabetes), and comorbidities (AF and chronic kidney disease). Global longitudinal strain is independently associated with risk of incident HF in patients admitted with CAD and provides incremental prognostic value to standard markers. Identifying an at-risk subgroup using GLS may be the focus of future randomized controlled trails to enable targeted therapeutic intervention.
Publisher: Elsevier BV
Date: 08-2009
DOI: 10.1016/J.JACC.2009.04.061
Abstract: We sought to evaluate whether global 2-dimensional (2D) strain offers additional benefit over left ventricular ejection fraction (LVEF) to predict clinical events in heart failure. Although 2D strain based on speckle tracking has been proposed as a simple and reproducible tool to detect systolic dysfunction, the relationship of 2D strain and prognosis has not been studied. Two hundred one patients (age 63 +/- 11 years, 34% female, LVEF 34 +/- 13%) hospitalized for acute heart failure underwent clinical evaluation and conventional and tissue Doppler echocardiography. Using dedicated software, we measured the global longitudinal strain (GLS) in apical 4- and 2-chamber views and the global circumferential strain (GCS) in a parasternal short-axis view. Cardiac events were defined as readmission for heart failure or cardiac death. There were 23.4% clinical events during 39 +/- 17 months of follow-up. In univariate analysis, age, left atrial volume, left ventricular volume, LVEF, ratio of early transmitral flow to early diastolic annular velocity (E/e'), and both GLS and GCS were predictive of cardiac events. In multivariate Cox models, age (hazard ratio [HR]: 1.06, 95% confidence interval [CI]: 1.01 to 1.10, p = 0.017) and GCS (HR: 1.15, 95% CI: 1.04 to 1.28 p = 0.006) were independently associated with cardiac events. By Cox proportional hazards model, the addition of GCS markedly improved the prognostic utility of a model containing ejection fraction, E/e', and GLS. GCS is a powerful predictor of cardiac events and appears to be a better parameter than ejection fraction in patients with acute heart failure.
Publisher: Elsevier BV
Date: 02-2006
DOI: 10.1016/J.JACC.2005.11.015
Abstract: The purpose of this research was to identify the determinants of right ventricular (RV) dysfunction in overweight and obese subjects. Right ventricular dysfunction in obese subjects is usually ascribed to comorbid diseases, especially obstructive sleep apnea. We used tissue Doppler imaging to identify the determinants of RV dysfunction in overweight and obese subjects. Standard and tissue Doppler echocardiography was performed in 112 overweight (body mass index [BMI] 25 to 29.9 kg/m2) or obese (BMI >30 kg/m2) subjects and 36 referents (BMI 35 kg/m2 had reduced RV function compared with referent subjects, evidenced by reduced s(m) (6.5 +/- 2.4 cm/s vs. 10.2 +/- 1.5 cm/s, p < 0.001), peak strain (-21 +/- 4% vs. -28 +/- 4%, p < 0.001), peak strain rate (-1.4 +/- 0.4 s(-1) vs. -2.0 +/- 0.5 s(-1), p < 0.001), and e(m) (-6.8 +/- 2.4 cm/s vs. -10.3 +/- 2.5 cm/s, p < 0.001), irrespective of the presence of sleep apnea. Similar but lesser degrees of reduced systolic function (p < 0.05) were present in overweight (BMI 25 to 29.9 kg/m2) and mildly obese (BMI 30 to 35 kg/m2) groups. Differences in RV e(m), s(m), and strain indexes were demonstrated between the severely versus overweight and mildly obese groups (p < 0.05). Body mass index remained independently related to RV changes after adjusting for age, log insulin, and mean arterial pressures. In obese patients, these changes were associated with reduced exercise capacity but not the duration of obesity and presence of sleep apnea or its severity. Increasing BMI is associated with increasing severity of RV dysfunction in overweight and obese subjects without overt heart disease, independent of sleep apnea.
Publisher: Elsevier BV
Date: 09-2007
DOI: 10.1016/J.AHJ.2007.04.046
Abstract: Left ventricular opacification (LVO) improves image quality at stress echocardiography (SE). We examined whether routine use of LVO adds incremental benefit and is cost-effective for diagnosis of coronary artery disease (CAD). Contrast pharmacologic and/or exercise SE was performed in 135 patients (81 men 56 +/- 10 years) undergoing coronary angiography. Observers sequentially interpreted first standard, then LVO images a positive SE was defined by resting or inducible wall motion abnormality in > or = 2 segments. Coronary artery disease (75 patients, 119 territories) was defined as > 50% stenosis. Three cost-effectiveness models were studied, and a sensitivity analysis was performed. Left ventricular opacification increased the sensitivity of SE (80%-91% P = .03), including single-vessel CAD (65%-87% P = .04), with no significant change in specificity (72%-77% P = NS). Left ventricular opacification was of benefit to 14% of patients, unrelated to resting image quality. Use of LVO in all patients added 59% to the cost of the procedure (P < .001), at a cost of $1069 per additional correct diagnosis. In a cost-effectiveness model based on cardiac outcomes after SE, LVO resulted in an increase in total cost of $1069. A 3.7% improvement in sensitivity resulted in a negative cost to identify CAD, but even 15% to 20% improvements in specificity failed to balance the cost of contrast for exclusion of CAD. Left ventricular opacification adds significant incremental diagnostic benefit to standard SE, especially single-vessel CAD. Despite improved sensitivity, the use of contrast in all patients was not cost-effective when analyzed with a model based on previously published patient outcomes.
Publisher: Wiley
Date: 05-10-2021
DOI: 10.1002/EHF2.13632
Abstract: This study aimed to determine the relationship of low birth weight (LBW) with adult cardiac structure and function and investigate potential causal pathways. A population‐based s le of 925 Australians (41.3% male) were followed from childhood (aged 7–15 years) to young adulthood (aged 26–36 years) and mid‐adulthood (aged 36–50 years). Left ventricular (LV) global longitudinal strain (GLS, %), LV mass index (LVMi, g/m 2.7 ), LV filling pressure (E/e′), and left atrial volume index (g/m 2 ) were measured by transthoracic echocardiography in mid‐adulthood. Birth weight category was self‐reported in young adulthood and classified as low (≤5 lb or ≤2270 g), normal (5–8 lb or 2271–3630 g), and high ( lb or g). Of the 925 participants, 7.5% ( n = 69) were classified as LBW. Compared with participants with normal birth weight, those with LBW had 2.01‐fold (95% confidence interval: 1.19, 3.41, P = 0.009) higher risks of impaired GLS (GLS −18%) and 2.63‐fold (95% confidence interval: 0.89, 7.81, P = 0.08) higher risks of LV hypertrophy (LVMi 48 g/m 2.7 in men or g/m 2.7 in women) in adulthood, independent of age, sex, and any socio‐economic factors. Participants with LBW significantly increased body fat from childhood to adulthood relative to their peers and had greater levels of triglycerides, fasting glucose, and arterial stiffness in adulthood. These risk factors were the strongest mediators and explained 54% of the LBW effect size on adult GLS and 33% of the LBW effect size on LVMi. The remaining of these associations was independent of any of the measured risk factors. Low birth weight was associated with impaired cardiac structure and function in mid‐adulthood. This association was only partially explained by known risk factors.
Publisher: Elsevier BV
Date: 02-2013
Publisher: Elsevier BV
Date: 06-2012
Publisher: Massachusetts Medical Society
Date: 04-08-2005
DOI: 10.1056/NEJMOA044154
Publisher: AMPCo
Date: 11-2006
DOI: 10.5694/J.1326-5377.2006.TB00690.X
Abstract: Chronic heart failure (CHF) is found in 1.5%-2.0% of Australians. Considered rare in people aged less than 45 years, its prevalence increases to over 10% in people aged >/= 65 years. CHF is one of the most common reasons for hospital admission and general practitioner consultation in the elderly (>/= 70 years). Common causes of CHF are ischaemic heart disease (present in > 50% of new cases), hypertension (about two-thirds of cases) and idiopathic dilated cardiomyopathy (around 5%-10% of cases). Diagnosis is based on clinical features, chest x-ray and objective measurement of ventricular function (eg, echocardiography). Plasma levels of B-type natriuretic peptide (BNP) may have a role in diagnosis, primarily as a test for exclusion. Diagnosis may be strengthened by a beneficial clinical response to treatment(s) directed towards amelioration of symptoms. Management involves prevention, early detection, amelioration of disease progression, relief of symptoms, minimisation of exacerbations, and prolongation of survival.
Publisher: Elsevier BV
Date: 11-1995
DOI: 10.1016/0735-1097(96)81472-0
Abstract: This study examined the influence of left ventricular hypertrophy on the accuracy of exercise electrocardiography and echocardiography for detection of coronary artery disease. Electrocardiographic repolarization abnormalities caused by left ventricular hypertrophy compromise the diagnostic accuracy of exercise electrocardiography but not of exercise echocardiography. The relative merits of these investigations are less well defined in patients with hypertrophy but without electrocardiographic (ECG) changes. We prospectively evaluated 147 consecutive patients without prior myocardial infarction undergoing both exercise echocardiography and coronary arteriography. Coronary stenoses > 50% diameter were present in 62 patients (42%). Positive test results were defined by a new or worsening wall motion abnormality or > 0.1 mV of ST depression. Echocardiographic left ventricular hypertrophy (mass > 131 g/m2 in men, > 100 g/m2 in women) was identified in 68 patients. A subgroup with clinically suspected hypertrophy was defined according to the presence of ECG evidence of hypertrophy, hypertension or aortic stenosis. The overall sensitivity of exercise echocardiography exceeded that of exercise electrocardiography (71% vs. 54%, p = 0.06). Echocardiographic hypertrophy had no significant effect on the sensitivity of either test. The specificity of exercise echocardiography exceeded that of exercise electrocardiography (91 vs. 74%, p = 0.01). In patients with hypertrophy, the specificity of exercise echocardiography exceeded that of exercise electrocardiography (95% vs. 69%, p < 0.01), whereas among patients without hypertrophy, the specificities (respectively, 87% and 78%) were more comparable. The accuracy of exercise echocardiography exceeded that of the exercise ECG in the overall group (82% vs. 65%, p = 0.002) and in patients with hypertrophy (85% vs. 60%, p = 0.004), but this difference was less prominent in patients without hypertrophy (80% vs. 69%, p = NS). In patients with clinically suspected hypertrophy, exercise echocardiography demonstrated a higher sensitivity, specificity and accuracy than exercise electrocardiography. The cost incurred in the identification of coronary disease was least with a strategy involving use of the exercise echocardiogram instead of routine exercise testing in patients with known or clinically suspected left ventricular hypertrophy. Exercise echocardiography is more accurate than exercise electrocardiography for the detection of coronary artery disease in patients with known or clinically suspected left ventricular hypertrophy.
Publisher: Wiley
Date: 19-04-2021
DOI: 10.1002/EJHF.2177
Abstract: Cognitive impairment (CI) is highly prevalent in heart failure (HF), and increases patients' risks of readmission. This study sought to determine whether the presence and degree of CI could identify patients most likely to benefit from a HF disease management programme (DMP) to reduce readmissions. A total of 1152 consecutive Australian patients admitted with HF (2014–2017) were prospectively followed up for 12 months. Of these, 324 patients who received DMP (1‐month duration, including post‐discharge home visits, medication reconciliation, exercise guidance and early clinical review) were matched (1:2 ratio) with 648 usual care patients. Cognitive function was assessed either on the day of or one day before discharge using the Montreal Cognitive Assessment (MoCA). Outcomes included readmission or death at 1, 3 and 12 months, and days at home within 12 months of discharge. Poorer cognitive function was associated with all adverse outcomes. Compared with usual care, DMP was associated with lower odds of 30‐day [odds ratio (OR) 0.60, 95% confidence interval 0.40, 0.91] and 90‐day (OR 0.53, 95% confidence interval 0.36, 0.77) readmission or death, and with 19 more days at home within 12 months, independent of HF therapy. The effect sizes of these associations were greater for patients with diminished cognition than those with normal cognition (interaction P = 0.036), and might have been more pronounced among those with mild CI compared with those with more severe CI (MoCA score 17–22 OR 0.42, 95% confidence interval 0.21, 0.87) at 30 days (OR 0.31, 95% confidence interval 0.16, 0.60 at 90 days). Patients with normal cognition had fewer events, irrespective of DMP. Cognitive function may determine how HF patients respond to a DMP. Cognitive screening before implementation of a DMP may allow personalized plans for patients with different levels of cognitive function.
Publisher: Wiley
Date: 11-2016
DOI: 10.1002/EJHF.643
Abstract: Incident heart failure (HF) continues to pose a common and serious problem. We sought to examine the value of echocardiographic predictors of new HF in a community-based elderly population at risk for HF, independent of and incremental to clinical evaluation. Asymptomatic patients ≥65 years old, with ≥1 HF risk factor (hypertension, type 2 diabetes, or obesity) were recruited from the community patients with valve disease, reduced ejection fraction (EF), and atrial fibrillation (AF) were excluded. Patients underwent standard clinical evaluation including calculation of the Charlson co-morbidity score and a comprehensive echocardiography including global longitudinal strain (GLS). Functional capacity was assessed by 6 min walk test. New HF and cardiovascular death were assessed after a mean follow-up of 14 ± 4 months by three independent cardiologists using Framingham criteria. Of 410 subjects (median age 70 years 48% men), the prevalence of stage B HF was 13% [by LV hypertrophy (LVH)], 12% (by abnormal E/e'), 33% (by impaired GLS), and 31% [by left atrial enlargement (LAE)]. New HF symptoms developed in 49, and 2 died of cardiovascular causes, giving an event rate of 104/1000 person-years. These patients were older (P = 0.012), had a higher Charlson co-morbidity score (P < 0.001), larger LV mass and left atrium, higher E/e', and lower GLS (P < 0.05). LAE, LVH, abnormal GLS, and E/e' were independent predictors of new HF. In sequential models, LV mass and GLS added incremental information to clinical parameters. GLS significantly reclassified in iduals (P = 0.002), but no reclassification improvement was identified using LV mass index, E/e', and left atrial volume index. Echocardiographic assessment (especially GLS and LV mass) provides incremental value in predicting incident HF.
Publisher: Elsevier BV
Date: 03-2021
Publisher: Elsevier BV
Date: 05-2007
DOI: 10.1016/J.JACC.2007.01.078
Abstract: Tissue Doppler imaging (TDI) is evolving as a useful echocardiographic tool for quantitative assessment of left ventricular (LV) systolic and diastolic function. Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as heart failure, acute myocardial infarction, and hypertension. In these conditions, myocardial mitral annular or basal segmental (Sm) systolic and early diastolic (Ea or Em) velocities have been shown to predict mortality or cardiovascular events. In particular, those with reduced Sm or Em values of or =15. In addition, systolic intraventricular dyssynchrony measured by segmental analysis of myocardial velocities is another independent predictor of adverse clinical outcome in heart failure subjects, even when the QRS duration is normal. In heart failure patients who received cardiac resynchronization therapy, the presence of systolic dyssynchrony at baseline is associated with favorable LV remodeling, which in turn predicts a favorable long-term clinical outcome. Finally, TDI and derived deformation parameters improve prognostic assessment during dobutamine stress echocardiography. A high mean Sm value in the basal segments of patients with suspected coronary artery disease is associated with lower mortality rate or myocardial infarction and is superior to the wall motion score.
Publisher: Oxford University Press (OUP)
Date: 16-04-2016
DOI: 10.1093/AJH/HPW039
Abstract: Central blood pressure (CBP) independently predicts cardiovascular risk, but calibration methods may affect accuracy of central systolic blood pressure (CSBP). Standard central systolic blood pressure (Stan-CSBP) from peripheral waveforms is usually derived with calibration using brachial SBP and diastolic BP (DBP). However, calibration using oscillometric mean arterial pressure (MAP) and DBP (MAP-CSBP) is purported to provide more accurate representation of true invasive CSBP. This study sought to determine which derived CSBP could more accurately discriminate cardiac structural abnormalities. A total of 349 community-based patients with risk factors (71±5years, 161 males) had CSBP measured by brachial oscillometry (Mobil-O-Graph, IEM GmbH, Stolberg, Germany) using 2 calibration methods: MAP-CSBP and Stan-CSBP. Left ventricular hypertrophy (LVH) and left atrial dilatation (LAD) were measured based on standard guidelines. MAP-CSBP was higher than Stan-CSBP (149±20 vs. 128±15mm Hg, P < 0.0001). Although they were modestly correlated (rho = 0.74, P < 0.001), the Bland-Altman plot demonstrated a large bias (21mm Hg) and limits of agreement (24mm Hg). In receiver operating characteristic (ROC) curve analyses, MAP-CSBP significantly better discriminated LVH compared with Stan-CSBP (area under the curve (AUC) 0.66 vs. 0.59, P = 0.0063) and brachial SBP (0.62, P = 0.027). Continuous net reclassification improvement (NRI) (P < 0.001) and integrated discrimination improvement (IDI) (P < 0.001) corroborated superior discrimination of LVH by MAP-CSBP. Similarly, MAP-CSBP better distinguished LAD than Stan-CSBP (AUC 0.63 vs. 0.56, P = 0.005) and conventional brachial SBP (0.58, P = 0.006), whereas Stan-CSBP provided no better discrimination than conventional brachial BP (P = 0.09). CSBP is calibration dependent and when oscillometric MAP and DBP are used, the derived CSBP is a better discriminator for cardiac structural abnormalities.
Publisher: Elsevier BV
Date: 05-2021
Publisher: Elsevier BV
Date: 02-2021
Publisher: Elsevier BV
Date: 10-2002
DOI: 10.1016/S0735-1097(02)02105-8
Abstract: The goal of this study was to determine whether wall stress at rest and during stress could explain the influence of left ventricular (LV) morphology on the accuracy of dobutamine stress echocardiography (DSE). The sensitivity of DSE appears to be reduced in patients with concentric remodeling, but the cause of this finding is unclear. We studied 161 patients without resting wall motion abnormalities who underwent DSE and coronary angiography. Patients were classified into four groups according to relative wall thickness (normal <0.45) and LV mass (normal </=131 g/m(2) in men and /=50% stenosis. Circumferential (cESS) and meridional end-systolic wall stress (mESS) were calculated at rest and peak DSE. Both false-negative and false-positive results for DSE were present in 35 patients (22%). The accuracy of DSE in patients with concentric remodeling (61%) was lower than that in patients with normal geometry (85%, p < 0.05) or concentric hypertrophy (86%, p < 0.05), but the accuracy with eccentric hypertrophy (64%, p < 0.05) was lower than with concentric hypertrophy. Patients in lowest quartile of cESS and mESS at peak had significantly lower sensitivity and accuracy than those in the highest quartile. A reduced cESS at peak (p = 0.012), presence of concentric remodeling (p = 0.044), and eccentric hypertrophy (p = 0.012) were significant predictors of both false-negative and false-positive results for DSE. The accuracy of DSE is influenced by the LV geometric pattern and peak wall stress.
Publisher: Springer Science and Business Media LLC
Date: 2007
DOI: 10.1186/AR2323
Publisher: Elsevier BV
Date: 03-2001
DOI: 10.1016/S0002-9149(00)01425-9
Abstract: The main limitation of dobutamine echocardiography (DE) is its subjective interpretation. We sought to reduce the need for expert interpretation by developing a quantitative approach to DE using myocardial Doppler velocity (MDV) in 242 patients undergoing DE. In 128 patients with a normal dobutamine echocardiogram, the normal range was designed to give a specificity of 80%. The accuracy of this range was investigated in 114 consecutive patients who underwent coronary angiography within 2 months of DE. A standard dobutamine echocardiographic protocol was used, with MDV gathered from color tissue Doppler at rest and peak stress. Wall motion at these stages was scored by experienced observers using a 16-segment model and MDV was measured off-line. Sensitivity and specificity of wall motion scoring and MDV were obtained by comparison with angiographic evidence of disease, defined as stenosis > 50% of the coronary artery diameter. The normal range in tethered segments (septum, anteroseptum, and inferior) was > or = 7 cm/s in the basal segments and > or = 5 cm/s in the midsegments. In the free wall (anterior, lateral, and posterior), the cutoff was > or = 6 cm/s in the base and > or = 4 cm/s in the midventricle. Of 114 patients undergoing angiography, 84 (75%) had significant stenoses, and the sensitivity of wall motion scoring and MDV were 88% and 83%, respectively, with specificities of 81% and 72% (p = NS). The accuracy was similar overall (86% vs 80%), as well as in each vascular territory. These data suggest that a fully quantitative interpretation of DE using site-specific normal ranges of tissue Doppler, which account for regional variations of base-apex function, is feasible and equivalent in accuracy to expert wall motion scoring.
Publisher: Elsevier BV
Date: 12-1991
DOI: 10.1016/0002-9149(91)90285-S
Abstract: Transesophageal contrast echocardiography is an effective but semiinvasive technique for the detection of interatrial right-to-left shunts. Transcranial Doppler ultrasound is an alternative noninvasive method, but may be limited by false-positive diagnoses due to intrapulmonary shunting. This study examined the accuracy of transcranial Doppler for the detection of shunt lesions. Transcranial Doppler of the right middle cerebral artery was performed simultaneously with transesophageal and transthoracic contrast echocardiography in 32 patients using agitated saline contrast during normal respiration and Valsalva. Transesophageal contrast echocardiography diagnosed an interatrial right-to-left shunt in 13 patients and intrapulmonary shunting in 6 patients. Transcranial Doppler identified all 13 interatrial right-to-left shunts and an intrapulmonary shunt in 3 of 6 patients. Absence of a shunt was confirmed by transcranial Doppler in 12 of 12 patients. Transcranial Doppler had a sensitivity of 100% (13 of 13), specificity of 100% (18 of 18) and accuracy of 100% (31 of 31) for prediction of an interatrial right-to-left shunt by transesophageal contrast echocardiography. In comparison, transthoracic contrast echocardiography had a sensitivity of 54% (7 of 13), specificity of 94% (17 of 18) and accuracy of 77% (24 of 31). Thus, transcranial Doppler is highly accurate for detection of an interatrial right-to-left shunt and not compromised by physiologic intrapulmonary shunts, whereas transthoracic contrast echocardiography lacks sensitivity. Transcranial Doppler may be useful as an alternative to transesophageal study, where the primary indication for transesophageal echocardiography is exclusion of an interatrial right-to-left shunt.
Publisher: Elsevier BV
Date: 08-1997
DOI: 10.1016/S0735-1097(97)00167-8
Abstract: The purpose of this study was to define the value of exercise echocardiography as an independent predictor of cardiac events in women with known or suspected coronary artery disease (CAD), incremental to the data provided by clinical evaluation and exercise testing. Exercise echocardiography is more accurate than exercise electrocardiography for the identification of CAD in women. However, the prognostic implications of exercise echocardiography, especially relative to exercise electrocardiography, are undefined. Symptom-limited exercise echocardiography was performed in 549 consecutive women between 1989 and 1993. Echocardiography and electrocardiography were performed before and after treadmill exercise an abnormal result on exercise electrocardiography was defined by ST segment depression > 0.1 mV, ischemia by exercise echocardiography as a new or worse wall motion abnormality after exercise and scar by akinesia or dyskinesia at rest. After exclusion of six patients with uninterpretable studies (1%) and 35 (6%) lost to follow-up, 508 women (mean [+/-SD] age 55 +/- 11 years) were followed up for 41 +/- 10 months for cardiac-related death, infarction or late revascularization. The group attained 92 +/- 10% of age-predicted maximal heart rate, with an exercise capacity of 7 +/- 2 metabolic equivalents. Of 420 women with an interpretable electrocardiogram, significant ST segment changes were present in 68 (16%). Results of exercise echocardiography were normal in 413 (81%) women, positive for ischemia in 66 (13%) and scar only in 29 (6%). No events occurred in 444 patients (89%), and 19 underwent primary revascularization (within 3 months of exercise test). Cardiac events occurred in 36 women (7%), including 17 who died of cardia causes and 19 who had a myocardial infarction or required late revascularization for progressive symptoms. On univariate analysis, the variables associated with cardiac mortality and total cardiac events were a history of CAD, diabetes, left ventricular hypertrophy, exercise capacity and echocardiographic evidence of myocardial ischemia and infarction. A Cox proportional hazards model showed the independent predictors of outcome to be known CAD (odds ratio [OR] 6.6, 95% confidence interval [CI] 3.2 to 13.7, p < 0.00001) and echocardiographic ischemia (OR 4.3, 95% CI 2.1 to 8.7, p < 0.0001). The prognostic value of exercise echocardiography incremental to clinical and exercise variables was demonstrated using sequential Cox models. In this large cohort of women, exercise echocardiography provided key prognostic information incremental to clinical and exercise testing data.
Publisher: Elsevier BV
Date: 05-2021
DOI: 10.1016/J.JDIACOMP.2021.107907
Abstract: Although microvascular disease (mVD) has been linked to poor cardiovascular outcomes in diabetes mellitus, the contribution of mVD to diabetic cardiomyopathy (DC) is unexplored. We investigated whether LV systolic and diastolic dysfunction is associated with mVD in T2DM. We recruited 32 asymptomatic patients with T2DM (age 71 ± 4 years, 31% females) from a community-based population. All underwent a comprehensive echocardiogram at baseline including assessment of global longitudinal strain (GLS) and diastolic function. Adenosine stress perfusion on cardiac magnetic resonance imaging (CMR) was performed in all patients. Coronary sinus flow (CSF) was measured offline at rest and peak stress with coronary flow reserve (CFR) calculated as the ratio of global stress and rest CSF. Resting CSF was reduced in 15 (47%) compared to 4 (13%) with adenosine-stress (p = 0.023). Overall, CFR was observed to be reduced in the cohort (2.38 [IQR 2.20]). Abnormal CFR was not associated with diabetes duration of ≥10 years or poor glycaemic control. CFR was not associated with abnormal GLS (OR 1.04 [95% CI 0.49, 2.20], p = 0.93). However, a modest negative correlation was observed with e' and CFR (r = -0.49, p = 0.004). This pilot study did not show correlation between subclinical systolic dysfunction and a novel MRI biomarker of microvascular disease. However, there was a weak correlation with myocardial relaxation. Confirmation of these findings in larger studies is indicated.
Publisher: Elsevier BV
Date: 2014
DOI: 10.1016/J.AMJCARD.2013.09.025
Abstract: It is unknown whether echocardiographic morphologic and hemodynamic parameters have incremental value in predicting 30-day heart failure (HF)-specific readmission risk among patients admitted with HF. We performed a prospective cohort study of adult patients entering a transitional care program after HF hospitalization to assess the role of echocardiographic parameters in predicting 30-day HF-specific readmission risk. Patients were followed for at least 30 days postdischarge, and readmission outcomes were ascertained prospectively. A previously validated 30-day HF readmission score (Yale Center for Outcome Research and Evaluation [CORE]) was calculated using 20 clinical and pathology parameters. Atrial and ventricular morphologic and hemodynamic variables were obtained from the index hospitalization echocardiogram. A Cox proportional hazards model was used to identify variables associated with 30-day HF specific readmission risk. Among 283 patients (mean age 72 ± 14 years, 57% men, 54% ischemic HF, ejection fraction 35% ± 17%) who underwent echocardiography during index admission there were 46 HF specific readmissions. After risk adjustment, elevated echocardiographic right atrial pressure (RAP hazard ratio [HR] 3.70, 95% confidence interval [CI] 1.82 to 7.52, p <0.001), left ventricular filling pressures (HR 7.46, 95% CI 2.31 to 24.14, p = 0.001), and weight change during admission (HR 0.93, 95% CI 0.87 to 0.99, p = 0.02) were independently associated with 30-day HF-specific readmission risk. However, only elevated RAP and left ventricular filling pressure added incremental prognostic value to the Yale-CORE HF readmission score. An E/e' threshold of 23 identified a subgroup at highest risk of readmission and provided a net 29% reclassification improvement over the Yale-CORE HF readmission score (p = 0.005).
Publisher: Elsevier BV
Date: 12-1999
Publisher: Wiley
Date: 09-12-2012
DOI: 10.1111/J.1540-8175.2011.01586.X
Abstract: To assess the effects of frame and volume rate on the concordance between two-dimensional speckle tracking strain (2DS) and three-dimensional speckle tracking strain (3DS), and between 2DS and triplane imaging of speckle tracking (Tri-P). Global longitudinal strains (GLSs) derived from 2DS, 3DS, and Tri-P were compared among 142 prospectively recruited patients who underwent evaluation of subclinical left ventricle (LV) function. Feasibility to obtain GLS of 3DS was significantly higher than that of Tri-P (76% vs. 47%, P 20 per second. Likewise, there was a better correlation between 2DS and 3DS when the difference between 2D frame rate and 3D volume rate was ≤40 per second, compared to when it was >40 per second. These associations differed from segment to segment and the apical segments had the highest correlation and the basal the lowest. The feasibility of each means of strain calculation showed important differences, with 2DS being the most attainable. Strain values were not interchangeable among 2DS, Tri-P, and 3DS. Importantly, poor correlations seemed to be driven by differences in acquisition rate. Currently, 2DS offers the most robust measurement of subclinical myocardial dysfunction.
Publisher: Elsevier BV
Date: 10-2004
Publisher: BMJ
Date: 12-2000
Abstract: To assess resting and exercise echocardiography for prediction of left ventricular dysfunction in patients with significant asymptomatic aortic regurgitation. Cohort study of patients with aortic regurgitation. Tertiary referral centre specialising in valvar surgery. 61 patients (38 men, 23 women mean (SD) age 53 (14) years) with asymptomatic or minimally symptomatic aortic regurgitation and no known coronary artery disease 35 were treated medically and 26 had aortic valve replacement. Exercise echocardiography was used to evaluate ejection fraction, which was measured on the resting and post-stress images using the modified Simpson method. Patients with an increment of ejection fraction after exercise were denoted as having contractile reserve (CR+) those without an increment were labelled CR-. Standard univariate and multivariate methods and receiver operating characteristic analyses were used to assess the ability of contractile reserve to predict follow up ejection fraction. In the 35 medically treated patients, 13 of 21 (62%) with CR+ (mean (SD) ejection fraction increment 7 (3)%) had preserved ejection fraction on follow up. In the 14 patients with CR- (ejection fraction decrement 8 (4)%), 13 (93%) had a decrement of ejection fraction on follow up from 60 (5)% at baseline to 54 (3)% on follow up (p = 0.005). Age, resting left ventricular dimensions, medical treatment, aortic regurgitation severity, exercise capacity, and rate-pressure product were similar in both CR+ and CR- groups. Among the 26 surgical patients, 13 showed CR+ (ejection fraction increase 9 (5)%), all of whom had an increase in ejection fraction on follow up (from 49% to 59%). Of 13 surgical patients with CR- (ejection fraction decrease 7 (5)%), 10 (77%) showed the same or worse ejection fraction on postoperative follow up. Contractile reserve on exercise echocardiography is a better predictor of left ventricular decompensation than resting indices in asymptomatic patients with aortic regurgitation. In patients undergoing aortic valve replacement, contractile reserve had a better correlation with resting ejection fraction on postoperative follow up. Measurement of contractile reserve may be useful to monitor the early development of myocardial dysfunction in asymptomatic patients with aortic regurgitation, and may help to optimise the timing of surgery.
Publisher: Elsevier BV
Date: 11-2019
Publisher: Springer Science and Business Media LLC
Date: 16-07-2008
Abstract: The high frequency of premature death from cardiovascular disease in indigenous Australians is often attributed to the high prevalence of risk factors, especially type II diabetes mellitus (DM). We evaluated the relationship of ethnicity to atherosclerotic burden, as evidenced by carotid intima-media thickness (IMT), independent of risk factor status. We studied 227 subjects (147 men 50 ± 13 y): 119 indigenous subjects with (IDM, n = 54), and without DM (InDM, n = 65), 108 Caucasian subjects with (CDM, n = 52), and without DM (CnDM, n = 56). IMT was measured according to standard methods and compared with clinical data and cardiovascular risk factors. In subjects both with and without DM, IMT was significantly greater in indigenous subjects. There were no significant differences in gender, body mass index (BMI), systolic blood pressure (SBP), or diastolic blood pressure (DBP) between any of the groups, and subjects with DM showed no difference in plasma HbA1c. Cardiovascular risk factors were significantly more prevalent in indigenous subjects. Nonetheless, ethnicity (β = -0.34 p 0.0001), age (β = 0.48 p 0.0001), and smoking (β = 0.13 p 0.007) were independent predictors of IMT in multiple linear regression models. Ethnicity appears to be an independent correlate of preclinical cardiovascular disease, even after correction for the high prevalence of cardiovascular risk factors in indigenous Australians. Standard approaches to control currently known risk factors are vital to reduce the burden of cardiovascular disease, but in themselves may be insufficient to fully address the high prevalence in this population.
Publisher: Springer Science and Business Media LLC
Date: 03-2021
DOI: 10.1530/ERP-21-0001
Publisher: Elsevier BV
Date: 11-2004
DOI: 10.1016/J.AMJCARD.2004.07.129
Abstract: This study sought the ability of strain rate imaging to detect subclinical left ventricular dysfunction, as evidenced by reduced contractile reserve (CR) in 32 asymptomatic patients with isolated severe mitral regurgitation. Compared with CR- patients (n = 10), CR+ patients (n = 22) had significantly higher end-systolic strain and peak systolic strain rate, but these parameters were not significantly different between CR+ patients and matched normal controls.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-09-2012
DOI: 10.1161/CIRCULATIONAHA.111.084434
Abstract: The value of assessment of viability as a predictor of surgical revascularization benefit in ischemic cardiomyopathy has recently been questioned in a large trial. We sought to determine whether the contribution of viability as myocardial scar burden (SB) to predict revascularization outcomes could be modulated by end-systolic volume index (ESVi). Delayed hyperenhancement–MRI was obtained in 450 patients with ≥70% stenosis in ≥1 epicardial coronary artery (75% men median age, 62.8±10.7 years mean left ventricular ejection fraction, 23±9% mean ESVi, 115±50 mL) from 2002 to 2006. SB was quantified as scar percentage (infarcted mass/total left ventricular mass). Subsequent surgical revascularization was performed in 245 (54%) patients and subsequent percutaneous coronary interventions were performed in 28 (6%) patients. A propensity score was developed for revascularization. Cox proportional hazards models of all-cause mortality were used for risk adjustment. Over a mean follow-up of 5.8±2.7 years, 186 (41%) deaths occurred. After adjusting for prior revascularization, sex, diabetes, age, use of cardiac resynchronization therapy, implantable cardioverter defibrillator, mitral regurgitation, and mitral valve procedures an interaction between scar percentage and ESVi ( P =0.016) and an interaction between post-MRI revascularization and ESVi ( P =0.0017) were independently associated with mortality. ESVi demonstrated a significant interaction with revascularization and female sex, such that enhanced survival was associated with ESVi. ESVi also showed an interaction with SB better survival was associated with lower volumes and less scar. ESVi and SB provide independent, incremental prognostic value in patients with severe ischemic cardiomyopathy. The risk associated with SB should not be assessed in isolation.
Publisher: Elsevier BV
Date: 10-2019
DOI: 10.1016/J.JACC.2019.08.1017
Abstract: Chronic kidney disease (CKD) is a major risk factor for coronary artery disease (CAD). As well as their high prevalence of traditional CAD risk factors, such as diabetes and hypertension, persons with CKD are also exposed to other nontraditional, uremia-related cardiovascular disease risk factors, including inflammation, oxidative stress, and abnormal calcium-phosphorus metabolism. CKD and end-stage kidney disease not only increase the risk of CAD, but they also modify its clinical presentation and cardinal symptoms. Management of CAD is complicated in CKD patients, due to their likelihood of comorbid conditions and potential for side effects during interventions. This summary of the Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference on CAD and CKD (including end-stage kidney disease and transplant recipients) seeks to improve understanding of the epidemiology, pathophysiology, diagnosis, and treatment of CAD in CKD and to identify knowledge gaps, areas of controversy, and priorities for research.
Publisher: Oxford University Press (OUP)
Date: 05-2007
Publisher: Elsevier BV
Date: 2009
DOI: 10.1016/J.JCMG.2007.12.007
Abstract: The interpretation of wall motion is an important component of echocardiography but remains a source of variation between observers. It has been believed that automated quantification of left ventricular (LV) systolic function by measurement of LV systolic strain from speckle-tracking echocardiography might be helpful. This multicenter study of nearly 250 volunteers without evidence of cardiovascular disease showed an average LV peak systolic strain of -18.6 +/- 0.1%. Although strain was influenced by weight, blood pressure, and heart rate, these features accounted for only 16% of variance. However, there was significant segmental variation of regional strain to necessitate the use of site-specific normal ranges.
Publisher: Elsevier BV
Date: 09-1991
DOI: 10.1016/0002-8703(91)90531-L
Abstract: The identification of LA enlargement may have important clinical implications. Previous correlations of ECG P wave morphologies associated with LA enlargement and echocardiography have been limited by the use of small numbers of patients and by the employment of M-mode echocardiography without the benefit of two-dimensional guidance. The purpose of this study was to further examine the sensitivity and specificity of various P wave morphologies (P wave greater than or equal to 110 msec, notched P greater than or equal to 40 msec, and PTFV1 greater than or equal to 40 msec.mm) for the diagnosis of LA enlargement and to determine if these waveforms may be predictive of LA size. ECGs and surface echocardiograms obtained within 1 week of each other were evaluated in 551 patients (140 normal and 411 study subjects). The various P wave morphologies were found to be poorly sensitive (30% to 60%) but very specific (90%) for LA enlargement. Combinations of P wave morphologies did not improve sensitivity or specificity. ECG features did give an estimate of the degree of LA enlargement. When PTFV1 is greater than or equal to 40 msec.mm, 95% of patients had LA size greater than or equal to 40 mm and when this parameter was greater than or equal to 60 msec.mm, 75% had LA size greater than or equal to 60 mm. These criteria for LA enlargement on the ECG are specific and predictive of the degree of LA enlargement measured by echocardiography.
Publisher: Oxford University Press (OUP)
Date: 02-01-1990
DOI: 10.1093/EURHEARTJ/11.SUPPL_G.72
Abstract: To evaluate the effects of left ventricular hypertrophy in the development of myocardial ischaemia as detected by thallium-201 exercise scintigraphy, we studied 150 patients by two-dimensional echocardiography, SPECT thallium-201 scintigraphy, and coronary arteriography. Patients were ided into four groups according to the presence or absence of left ventricular hypertrophy and coronary artery disease. There were 62 patients with coronary artery disease and 28 with left ventricular hypertrophy. Left ventricular mass index ranged from a mean of 91.2 g m-2 in the no LVH no CAD group, to a mean of 150.6 g m-2 in the LVH CAD group. For the whole group, the sensitivity of thallium for the detection of coronary artery disease was 82%, specificity 75%, positive predictive value 70%, and negative predictive value 86%. The proportion of patients with abnormal thallium was highest (100%) in the group with left ventricular hypertrophy and coronary artery disease. The second largest group with abnormal perfusion by thallium imaging comprised patients with coronary artery disease and no left ventricular hypertrophy (78%). Both coronary artery disease and left ventricular mass index were demonstrated to be independent predictors of myocardial ischaemia in a multivariate regression model (P = 0.01). We conclude that left ventricular hypertrophy sensitizes the myocardium for the development of ischaemia.
Publisher: Elsevier BV
Date: 07-1998
DOI: 10.1016/S0002-8703(98)70182-6
Abstract: In patients with left ventricular dysfunction one of the aims of therapy may be to improve functional capacity. This study compared the improvement of functional capacity in response to medical therapy with that caused by revascularization. Fifty-two patients with severe left ventricular dysfunction were ided into groups with ischemic cardiomyopathy undergoing revascularization (group A, n = 20) or incremental medical treatment (group B, n = 16) and a control group receiving maximal medical therapy at the start of the study (group C, n = 16). All patients underwent a baseline metabolic exercise test with evaluation of peak oxygen consumption and derived exercise capacity in metabolic equivalents (METS) with standard electrocardiographic and hemodynamic monitoring. Therapy was then optimized in the medical treatment group, whereas the revascularization group underwent coronary bypass grafting. All patients subsequently underwent follow-up metabolic exercise testing. In groups A, B, and C resting left ventricular ejection fractions were comparable (26%+/-5%, 25%+/-7%, and 23%+/-8%, respectively), as were results of initial metabolic exercise tests (4.7+/-0.9 METS, 4.7+/-1.4 METS, and 5.2+/-1.4 METS). At follow-up group A improved exercise capacity from 4.7 to 5.6 METS (p = 0.01). Groups B (4.7 to 5.0 METS) and C (5.2 to 5.6 METS) had no significant improvement. The mean respiratory exchange ratio improved significantly in group A (1.14 to 1.20, p = 0.02), as did left ventricular ejection fraction (26% to 31%, p = 0.02). However, neither parameter changed significantly in groups B or C. In patients with severe left ventricular dysfunction improvements of exercise capacity are more marked after coronary revascularization than may be obtained after maximization of medical therapy.
Publisher: Elsevier BV
Date: 07-2020
Publisher: AMPCo
Date: 11-2002
Publisher: Elsevier BV
Date: 11-2005
DOI: 10.1016/J.AHJ.2005.01.029
Abstract: Screening for coronary artery disease is constrained by its low prevalence in unselected patients. We compared the ability of clinical scores to identify a high-risk group with diabetes mellitus and investigated a Bayesian strategy by combination with exercise echocardiography (ExE). The Framingham risk score (FRS), a score based on the American Diabetes Association (ADA) screening guidelines, the United Kingdom Prospective Diabetes Study (UKPDS) risk engine, and a disease-specific diabetic cardiac risk score (DCRS) were calculated in 199 asymptomatic patients with type 2 diabetes mellitus undergoing ExE. The frequency of abnormal ExE and the proportion of these with coronary stenoses were sought in groups designated as high risk on the basis of optimal cutoffs for each score. All patients were followed up for 1 year. High risk was identified in fewer patients with the DCRS (27%) than FRS (38%, P = .02), ADA (41%, P = .004), and UKPDS (43%, P = .001). Exercise echocardiography was positive in 27 (14%) 11 of 23 proceeding to angiography showed significant stenoses. Areas under the receiver operator characteristic curves for prediction of a positive ExE were similar for DCRS, UKPDS, and FRS but less for ADA (P = .04). Positive ExE was uncommon in low-risk patients (8%-11%) and most were false positives (58%-80%). Cardiovascular events (n = 9) were more likely in the high-risk compared with the low-risk UKPDS (9% vs 2%, P = .03) and DCRS (12% vs 2%, P = .01). Combination of the UKPDS or DCRS with ExE may optimize detection of coronary artery disease and cardiac events in asymptomatic patients, while minimizing the numbers of ExE and false-positive rate.
Publisher: Elsevier BV
Date: 02-2021
Publisher: Oxford University Press (OUP)
Date: 27-03-2018
DOI: 10.1093/EHJCI/JEY042
Abstract: The EACVI/ASE/Industry Task Force to standardize deformation imaging prepared this consensus document to standardize definitions and techniques for using two-dimensional (2D) speckle tracking echocardiography (STE) to assess left atrial, right ventricular, and right atrial myocardial deformation. This document is intended for both the technical engineering community and the clinical community at large to provide guidance on selecting the functional parameters to measure and how to measure them using 2D STE.This document aims to represent a significant step forward in the collaboration between the scientific societies and the industry since technical specifications of the software packages designed to post-process echocardiographic datasets have been agreed and shared before their actual development. Hopefully, this will lead to more clinically oriented software packages which will be better tailored to clinical needs and will allow industry to save time and resources in their development.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-1993
Abstract: The mechanisms of action of exercise-simulating and vasodilator stressors support their combination with imaging techniques that evaluate left ventricular function and perfusion, respectively. However, reported accuracies of either pharmacological stress together with two-dimensional echocardiography (2DE) or single photon emission computed tomography (SPECT) of myocardial perfusion are similar. The purpose of this study was to establish the optimal stress for each imaging technique by comparing the results of digitized 2DE and 99mTc-methoxyisobutyl isonitrile (MIBI) SPECT using both dobutamine and adenosine stresses in the same patients and conditions. Ninety-seven consecutive patients without evidence of previous infarction undergoing coronary angiography for clinical indications were studied prospectively. Dobutamine was infused during clinical, ECG, and echocardiographic monitoring in dose increments from 5 to 40 micrograms.kg-1.min-1. Adenosine was infused under the same conditions in doses of 0.10, 0.14, and 0.18 mg.kg-1.min-1. For each protocol, the end points were achievement of peak dose, development of severe ischemia, or intolerable side effects. At peak stress, 20 mCi of MIBI was injected, and SPECT imaging was performed 2 hours later abnormal poststress images were compared with resting SPECT: Digitized 2DE images were compared qualitatively before, during, and after stress in a cine-loop display. Significant coronary disease (n = 59 patients) was defined by the quantification of 50% stenosis in a major epicardial vessel. The sensitivity of adenosine 2DE was 58%, less than those of adenosine MIBI (86%, p = 0.001), dobutamine 2DE (85%, p = 0.001), and dobutamine MIBI (80%, p = 0.01). Their respective specificities were 87%, 71%, 82%, and 74% (p = NS). The accuracy of adenosine 2DE was 69%, compared with 80% for adenosine MIBI (p 0.001), 84% for dobutamine 2DE (p = 0.001), and 77% for dobutamine MIBI (p = 0.005) the latter three did not differ significantly in either sensitivity or accuracy. This prospective, direct comparison of alternative pharmacological stresses in patients without myocardial infarction shows vasodilator stress scintigraphy and dobutamine stress echocardiography and scintigraphy to share equivalent levels of sensitivity. All three are significantly more sensitive than adenosine stress echocardiography. Dobutamine stress may be used for wall motion or perfusion imaging, but adenosine stress is best combined with perfusion scintigraphy.
Publisher: Elsevier BV
Date: 07-2015
DOI: 10.1016/J.ECHO.2015.05.002
Abstract: Hypertension remains a major contributor to the global burden of disease. The measurement of blood pressure continues to have pitfalls related to both physiological aspects and acute variation. As the left ventricle (LV) remains one of the main target organs of hypertension, and echocardiographic measures of structure and function carry prognostic information in this setting, the development of a consensus position on the use of echocardiography in this setting is important. Recent developments in the assessment of LV hypertrophy and LV systolic and diastolic function have prompted the preparation of this document. The focus of this work is on the cardiovascular responses to hypertension rather than the diagnosis of secondary hypertension. Sections address the pathophysiology of the cardiac and vascular responses to hypertension, measurement of LV mass, geometry, and function, as well as effects of treatment.
Publisher: Georg Thieme Verlag KG
Date: 2016
DOI: 10.1160/TH15-11-0869
Abstract: The prognostic significance of patients presenting with pulmonary embolism (PE) and elevated International Normalised Ratio (INR) not on anticoagulant therapy has not been described. We investigated whether these patients had higher mortality compared to patients with normal INR. A retrospective study of patients admitted to a tertiary hospital with acute PE from 2000 to 2012 was undertaken, with study outcomes tracked using a state-wide death registry. Patients were excluded if they were taking anticoagulants or had inadequate documentation of their INR and medication status. Of the 1,039 patients identified, 94 (9 %) had an elevated INR ( 1.2) in the absence of anticoagulant use. These patients had higher mortality at six months follow-up (26 % vs 6 %, p 0.001) compared to controls (INR ≤ 1.2). An INR 1.2 at diagnosis was an independent predictor of death at six months post-PE (hazard ratio [HR] 2.9, 95 % confidence interval [CI] 1.8–4.7, p 0.001). The addition of INR to a multivariable model that included the simplified pulmonary embolism severity index (sPESI), chest pain, and serum sodium led to a significant net reclassification improvement estimated at 8.1 %. The final model’s C statistic increased significantly by 0.04 (95 % CI 0.01–0.08, p=0.03) to 0.83 compared to sPESI alone (0.79). In summary, patients presenting with acute PE and elevated INR while not on anticoagulant therapy appear to be at high risk of death. Future validation studies in independent cohorts will clarify if this novel finding can be usefully incorporated into clinical decision making in patients with acute PE.
Publisher: BMJ
Date: 09-2018
DOI: 10.1136/BMJOPEN-2018-024178
Abstract: Recent technology advances have allowed for heart rhythm monitoring using single-lead ECG monitoring devices, which can be used for early diagnosis of atrial fibrillation (AF). We sought to investigate the AF detection rate using portable ECG devices compared with Holter monitoring. We searched the Medline, Embase and Scopus databases (conducted on 8 May 2017) using search terms related to AF screening and included studies with adults aged years using portable ECG devices or Holter monitoring for AF detection. We excluded studies using implantable loop recorders and pacemakers. Using a random-effects model we calculated the overall AF detection rate. Meta-regression analysis was performed to explore potential sources for heterogeneity. Quality of reporting was assessed using the tool developed by Downs and Black. Portable ECG monitoring was used in 18 studies (n=117 436) and Holter monitoring was used in 36 studies (n=8498). The AF detection rate using portable ECG monitoring was 1.7% (95% CI 1.4 to 2.1), with significant heterogeneity between studies (p .001). There was a moderate linear relationship between total monitoring time and AF detection rate (r=0.65, p=0.003), and meta-regression identified total monitoring time (p=0.005) and body mass index (p=0.01) as potential contributors to heterogeneity. The detection rate (4.8%, 95% CI 3.6% to 6.0%) in eight studies (n=10 199), which performed multiple ECG recordings was comparable to that with 24 hours Holter (4.6%, 95% CI 3.5% to 5.7%). Intermittent recordings for 19 min total produced similar AF detection to 24 hours Holter monitoring. Portable ECG devices may offer an efficient screening option for AF compared with 24 hours Holter monitoring. CRD42017061021.
Publisher: Wiley
Date: 13-08-2012
DOI: 10.1111/J.1464-5491.2012.03719.X
Abstract: Poor prognosis associated with blunted post-exercise heart-rate recovery may reflect autonomic dysfunction. This study sought the accuracy of post-exercise heart-rate recovery in the diagnosis of cardiac autonomic neuropathy, which represents a serious, but often unrecognized complication of Type 2 diabetes. Clinical assessment of cardiac autonomic neuropathy and maximal treadmill exercise testing for heart-rate recovery were performed in 135 patients with Type 2 diabetes and negative exercise echocardiograms. Cardiac autonomic neuropathy was defined by abnormalities in ≥ 2 of 7 autonomic function markers, including four cardiac reflex tests and three indices of short-term (5-min) heart-rate variability. Heart-rate recovery was defined at 1-, 2- and 3-min post-exercise. Patients with cardiac autonomic neuropathy (n = 27 20%) had lower heart-rate recovery at 1-, 2- and 3-min post-exercise (P < 0.01). Heart-rate recovery demonstrated univariate associations with autonomic function markers (r-values 0.20-0.46, P < 0.05). Area under the receiver-operating characteristic curve revealed good diagnostic performance of all heart-rate recovery parameters (range 0.80-0.83, P < 0.001). Optimal cut-offs for heart-rate recovery at 1-, 2- and 3-min post-exercise were ≤ 28 beats/min (sensitivity 93%, specificity 69%), ≤ 50 beats/min (sensitivity 96%, specificity 63%) and ≤ 52 beats/min (sensitivity 70%, specificity 84%), respectively. These criteria predicted cardiac autonomic neuropathy independently of relevant clinical and exercise test information (adjusted odds ratios 7-28, P < 0.05). Post-exercise heart-rate recovery provides an accurate diagnostic test for cardiac autonomic neuropathy in Type 2 diabetes. The high sensitivity and modest specificity suggests heart-rate recovery may be useful to screen for patients requiring clinical autonomic evaluation.
Publisher: Elsevier BV
Date: 06-2010
Publisher: American College of Physicians
Date: 18-11-2014
DOI: 10.7326/M13-1505
Publisher: Magnolia Press
Date: 16-05-2013
Publisher: Oxford University Press (OUP)
Date: 22-06-2012
DOI: 10.1093/EHJCI/JES078
Abstract: The diastolic stress test (DST) may facilitate the attribution of exertional dyspnoea to cardiac and non-cardiac diseases. However, there is currently no consensus as to the optimal marker of exertional diastolic dysfunction (DD)-the main alternatives being estimated left ventricular (LV) filling pressure (exercise E/e') and diastolic functional reserve (DFRI). We sought to compare the correlates of these parameters. DST was performed by adding the measurement of the transmitral (E) and annular (e') velocities to standard exercise echo in 559 consecutive patients without significant rest or exercise mitral regurgitation. Exertional DD was separately defined by post-stress E/e' >13 or DFRI <13.5. Logistic regression was used to identify the correlates of abnormal responses and linear regression was used to identify the contribution of both to exercise capacity. Abnormal exercise E/e' (n = 112, 20%) and DFRI (n = 317, 57%) were modestly associated (κ 0.35, P < 0.0001). In a linear regression, abnormal exercise E/e' (β = -0.19, P < 0.001) and DFRI (β = -0.15, P = 0.001) were associated with exercise capacity, independent of age, body mass index, wall thickness, haemodynamics or abnormal stress results. Logistic regression revealed abnormal exercise E/e' (R(2)= 0.34) to be independently associated with female gender (β = 0.26, 95% CI: 0.11-0.60, P = 0.002), age (β = 1.04, 95% CI: 1.01-1.07, P = 0.01), hypertension (β = 0.35, 95% CI: 0.15-0.80, P = 0.01) and wall thickness (β = 4.3, 95% CI: 1.3-14.1, P = 0.02). The closest association of abnormal DFRI was exercise capacity (β = 0.89, 95% CI: 0.79-1.02, P = 0.09) no other clinical or stress variable was independently associated. Exercise E/e' and DFRI are both associated with exercise capacity, but E/e' is more closely associated with the expected parameters of DD.
Publisher: Elsevier BV
Date: 03-2023
DOI: 10.1016/J.JCMG.2022.10.010
Abstract: Global longitudinal strain (GLS) can predict cancer therapeutics-related cardiac dysfunction and guide initiation of cardioprotection (CPT). In this study, the authors sought to determine whether echocardiography GLS-guided CPT provides less cardiac dysfunction in survivors of potentially cardiotoxic chemotherapy, compared with usual care at 3 years. In this international multicenter prospective randomized controlled trial, patients were enrolled from 28 international sites. All patients treated with anthracyclines with another risk factor for heart failure were randomly allocated to GLS-guided (>12% relative reduction in GLS) or ejection fraction (EF)-guided (>10% absolute reduction of EF to <55%) CPT. The primary end point was the change in 3-dimensional (3D) EF (ΔEF) from baseline to 3 years. Among 331 patients enrolled, 255 (77%, age 54 ± 12 years, 95% women) completed 3-year follow-up (123 in the EF-guided group and 132 in the GLS-guided group). Most had breast cancer (n = 236 93%), and anthracycline followed by trastuzumab was the most common chemotherapy regimen (84%). Although 67 (26%) had hypertension and 32 (13%) had diabetes mellitus, left ventricular function was normal at baseline (EF 59% ± 6%, GLS 20.7% ± 2.3%). CPT was administered in 18 patients (14.6%) in the EF-guided group and 41 (31%) in the GLS-guided group (P = 0.03). Most patients showed recovery in EF and GLS after chemotherapy 3-year ΔEF was -0.03% ± 7.9% in the EF-guided group and -0.02% ± 6.5% in the GLS-guided (P = 0.99) group respective 3-year EFs were 58% ± 6% and 59% ± 5% (P = 0.06). At 3 years, 17 patients (5%) had cancer therapeutics-related cardiac dysfunction (11 in the EF-guided group and 6 in the GLS guided group P = 0.16) 1 patient in each group was admitted for heart failure. Among patients taking potentially cardiotoxic chemotherapy for cancer, the 3-year data showed improvement of LV dysfunction compared with 1 year, with no difference in ΔEF between GLS- and EF-guided CPT. (Strain Surveillance of Chemotherapy for Improving Cardiovascular Outcomes [SUCCOUR] ACTRN12614000341628).
Publisher: Oxford University Press (OUP)
Date: 28-01-2014
DOI: 10.1093/EHJCI/JEU013
Abstract: Subclinical diabetic cardiomyopathy (DCM) is frequent in asymptomatic subjects with type 2 diabetes (T2DM). We sought the response of functional and fibrosis markers to therapy in a trial of aldosterone antagonism for treatment of DCM. Biochemical, anthropometric, and echocardiographic data were measured in 225 subjects with T2DM. Myocardial function was evaluated with standard echocardiography and myocardial deformation ischaemia was excluded by exercise echocardiography. Calibrated integrated backscatter and post-contrast T1 mapping from cardiac magnetic resonance imaging were used to assess myocardial structure. Amino-terminal propeptides of pro-collagen type I (PINP) and III (PIIINP), the carboxy-terminal propeptide of pro-collagen type I (PICP) and transforming growth factor beta-1 were measured from peripheral blood or urine to assess myocardial collagen turnover. Diastolic dysfunction was identified in 81 in iduals, of whom 49 (25 male, age 60 ± 10 years) were randomized to spironolactone 25 mg/day or placebo therapy for 6 months. Groups were well-matched at baseline. Spironolactone therapy was associated with improvements in diastolic filling profile (Δpeak E wave velocity -4 ± 15 vs. 9 ± 10 ms, P = 0.001 ΔE/A ratio -0.1 ± 0.3 vs. 0.2 ± 0.2, P < 0.001) and cIB values (-21.2 ± 4.5 dB vs. -18.0 ± 5.2 dB, P = 0.026 ΔcIB -5.1 ± 6.8 vs. -1.3 ± 5.2, P = 0.030). ΔcIB was independently associated with spironolactone therapy (β = 0.320, P = 0.026) but not Δblood pressure. With intervention, pro-collagen biomarkers (ΔPINP P = 0.92, ΔPICP P = 0.25, ΔPIIINP P = 0.52, and ΔTGF-β1 P = 0.71) and T1 values (P = 0.54) remained similar between groups. Spironolactone-induced changes in myocardial structure and diastolic properties in DCM are small, and are unassociated with changes in collagen biomarkers or T1 values.
Publisher: Elsevier BV
Date: 05-2001
Abstract: Early atherosclerosis involves the endothelium of many arteries. Information about peripheral arterial anatomy and function derived from vascular imaging studies such as brachial artery reactivity (BAR) and carotid intima media thickness (IMT) may be pertinent to the coronary circulation. The prevention and early treatment of atherosclerosis is gaining more attention, and these tests might be used as indications or perhaps guides to the effectiveness of therapy, but their application in clinical practice has been limited. This review seeks to define the anatomy and pathophysiology underlying these investigations, their methodology, the significance of their findings, and the issues that must be resolved before their application. The literature on BAR and IMT is extensively reviewed, especially in relation to clinical use. Abnormal flow-mediated dilation is present in atherosclerotic vessels, is associated with cardiovascular risk factors, and may be a marker of preclinical disease. Treatment of known atherosclerotic risk factors has been shown to improve flow-mediated dilation, and some data suggest that vascular responsiveness is related to outcome. Carotid IMT is associated with cardiovascular risk factors, and increased levels can predict myocardial infarction and stroke. Aggressive risk factor management can decrease IMT. BAR and IMT are functional and structural markers of the atherosclerotic process. The clinical use of BAR has been limited by varying reproducibility and the influence by exogenous factors, but IMT exhibits less variability. A desirable next step in the development of BAR and IMT as useful clinical tools would be to show an association of improvement in response to treatment with improvement in prognosis.
Publisher: Elsevier BV
Date: 06-2009
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 1990
DOI: 10.1097/00007890-199001000-00022
Abstract: The efficacy of dipyridamole single photon emission computed tomography (SPECT) thallium as a screening test for coronary artery disease (CAD), was studied in 45 patients with end-stage renal failure undergoing evaluation for renal transplantation. Coronary arteriography, dipyridamole SPECT thallium imaging and clinical follow-up were performed in all patients. Nineteen patients (42%) had an obstruction of 50% or more in at least one coronary artery. Fourteen patients had a positive thallium scan, but 7 of these were false-positives (sensitivity 37%, specificity 73%). The sensitivity was considerably lower than that quoted for non-ESRF patients in the literature, and significantly lower than a control group of 19 patients without ESRF having comparable severity and distribution of CAD. Five of the 6 patients who died of cardiac causes over a mean follow-up period of 25 months had normal thallium imaging, but all had significant coronary artery disease at cardiac catheterization. Dipyridamole SPECT thallium imaging has not proved a useful screening test for angiographically significant CAD, and does not predict cardiac prognosis in this population.
Publisher: Elsevier BV
Date: 07-2000
DOI: 10.1016/S0002-9149(00)00819-5
Abstract: Effective allocation of medical resources in stable chest pain patients requires the accurate diagnosis of coronary artery disease and the stratification of future cardiac risk. We studied the relative predictive value for cardiac death of 3 commonly applied noninvasive strategies, clinical assessment, stress electrocardiography, and myocardial perfusion tomography, in a large, multicenter population of stable angina patients. The multicenter observational series comprised 7 community and academic medical centers and 8,411 stable chest pain patients. All patients underwent pretest clinical screening followed by stress (exercise 84% or pharmacologic 16%) electrocardiography and myocardial perfusion tomography. Risk-adjusted multivariable Cox proportional hazards models were developed to predict cardiac death. Kaplan-Meier rates of time to cardiac catheterization were also computed. Cardiac mortality was 3% during the 2.5 +/- 1.5 years of follow-up. The number of infarcted vascular territories and pretest clinical risk factors were strong predictors of cardiac mortality, whereas the number of ischemic vascular territories gained increasing importance when determining post-test resource use requirements (i.e., the decision to perform cardiac catheterization). Exertional ST-segment depression in a population with a high frequency of electrocardiographic abnormalities at rest was not a significant differentiator of cardiac death risk. Stable chest pain patients are accurately identified as being at high risk for near-term cardiac events by both physicians' screening clinical evaluation and by the results of stress myocardial perfusion imaging. Disease management strategies for stable chest pain patients aimed at risk reduction should incorporate knowledge of relevant end points in treatment and guideline development.
Publisher: Wiley
Date: 25-07-2023
DOI: 10.1111/IMJ.16185
Abstract: Post‐acute sequelae of COVID‐19 (PASC or ‘long COVID’) reflect ongoing symptoms, but these are non‐specific and common in the wider community. Few reports of PASC have been compared with a control group. To compare symptoms and objective impairment of functional capacity in patients with previous COVID‐19 infection with uninfected community controls. In this community‐based, cross‐sectional study of functional capacity, 562 patients from Western Melbourne who had recovered from COVID‐19 infections in 2021 and 2022 were compared with controls from the same community and tested for functional capacity pre‐COVID‐19. Functional impairment ( % of the predicted response) was assessed using the Duke Activity Status Index (DASI) and 6‐min walk distance (6MWD) test. A subgroup underwent cardiopulmonary exercise testing before and after exercise training. Of 562 respondents (age 54 ± 12 years, 69% women), 389 were symptomatic. Functional impairment ( % predicted metabolic equivalent of tasks) was documented by DASI in 149 participants (27%), and abnormal 6MWD ( % predicted) was observed in 14% of the symptomatic participants. Despite fewer risk factors and younger age, patients with COVID‐19 had lower functional capacity by 6MWD ( P 0.001) and more depression ( P 0.001) than controls. In a pilot group of seven participants (age 58 ± 12 years, two women, VO 2 18.9 ± 5.7 mL/kg/min), repeat testing after exercise training showed a 20% increase in peak workload. Although most participants (69%) had symptoms consistent with long COVID, significant subjective functional impairment was documented in 27% and objective functional impairment in 14%. An exercise training programme might be beneficial for appropriately selected patients.
Publisher: Wiley
Date: 02-1991
Abstract: The identification of ischemic and hibernating myocardium facilitates the selection of patients most likely to benefit from revascularization. This study examined the feasibility of metabolic imaging, using post-exercise F-18 deoxyglucose positron emission tomography (FDG-PET) for the diagnosis of both ischemia and hibernation in 27 patients with known coronary anatomy. Normal post-exercise FDG uptake was defined in each patient by reference to normal resting perfusion and normal coronary supply. Abnormal elevation of FDG (ischemia or hibernation) was compared in 13 myocardial segments in each patient, with the results of dipyridamole stress perfusion imaging performed by rubidium-82 positron emission tomography (Rb-PET). Myocardial ischemia was diagnosed by either FDG-PET or Rb-PET in 34 segments subtended by significant local coronary stenoses. Increased FDG uptake was present in 32/34 (94%) and a reversible perfusion defect was identified by Rb-PET in 22/34 (65%, p less than .01). In 3 patients, ischemia was identified by metabolic imaging alone. In 16 patients with previous myocardial infarction, perfusion defects were present at rest in 89 regions, 30 of which (34%) demonstrated increased FDG uptake, consistent with the presence of hibernation. Increased post-exercise FDG uptake appears to be a sensitive indicator of ischemia and myocardial hibernation. This test may be useful in selecting post-infarction patients for revascularization.
Publisher: Elsevier BV
Date: 05-2010
Publisher: Elsevier BV
Date: 11-2004
DOI: 10.1016/J.ECHO.2004.06.012
Abstract: The development of therapeutic interventions to prevent progressive valve damage is more likely to limit the progression of structural damage to the aortic valve with normal function (aortic sclerosis [ASC]) than clinically apparent aortic stenosis. Currently, the ability to appreciate the progression of ASC is compromised by the subjective and qualitative evaluation of sclerosis severity. We sought to reveal whether the intensity of ultrasonic backscatter could be used to quantify sclerosis severity in 26 patients with ASC and 23 healthy young adults. Images of the aortic valve were obtained in the parasternal long-axis view and saved in raw data format. Six square-shaped 11 x 11 pixel regions of interest were placed on the anterior and posterior leaflets, and calibrated backscatter values were obtained by subtracting the regions of interest in the blood pool from the averaged backscatter values obtained from the leaflets. Mean ultrasonic backscatter values for sclerotic valves exceeded the results in normal valve tissue (16.3 +/- 4.4 dB vs 9.8 +/- 3.3 dB, P < .0001). Backscatter values were greater (22.0 +/- 3.5 dB) in a group of 6 patients with aortic stenosis. Within the sclerosis group, the magnitude of backscatter was directly correlated (P < .05) with a subjective sclerosis score, and with transvalvular pressure gradient. Mean reproducibility was 2.4 +/- 1.8 dB (SD) between observers, and 2.3 +/- 1.7 dB (SD) between examinations. Measurement of backscatter from the valve leaflets of patients with ASC may be a feasible means of following the progression and treatment response of aortic sclerosis.
Publisher: Elsevier BV
Date: 02-2018
DOI: 10.1016/J.JCMG.2016.12.025
Abstract: The aim of this study was to perform a systematic review and meta-analysis to estimate the normal ranges of magnetic resonance imaging (MRI)-based feature tracking (FT) and to identify sources of variations. Similar analyses were also performed for strain encoding, displacement encoding with stimulated echoes, and myocardial tagging. MRI-FT is a novel technique for quantification of myocardial deformation using MRI cine images. However, the reported 95% confidence intervals (CIs) from the 2 largest studies have no overlaps. Four databases (EMBASE, SCOPUS, PUBMED, and Web of Science) were systematically searched for MRI strains of the left (LV) and right (RV) ventricles. The key terms for MRI-FT were "tissue tracking," "feature tracking," "cardiac magnetic resonance," "cardiac MRI," "CMR," and "strain." A random effects model was used to pool LV global longitudinal strain (GLS), global circumferential strain (GCS), global radial strain (GRS), and RVGLS. Meta-regressions were used to identify the sources of variations. 659 healthy subjects were included from 18 papers for MRI-FT. Pooled mean of LVGLS was -20.1% (95% CI: -20.9% to -19.3%), LVGCS -23% (95% CI: -24.3% to -21.7%), LVGRS 34.1% (95% CI: 28.5% to 39.7%), and RVGLS -21.8% (95% CI: -23.3% to -20.2%). Although there were no publication biases except for LVGCS, significant heterogeneities were found. Meta-regression showed that variation of LVGCS was associated with field strength (β = 3.2 p = 0.041). Variations of LVGLS, LVGRS, and RVGLS were not associated with any of age, sex, software, field strength, sequence, LV ejection fraction, or LV size. LVGCS seems the most robust in MRI-FT. Among the MRI-derived strain techniques, the normal ranges were mostly concordant in LVGLS and LVGCS but varied substantially in LVGRS and RVGLS. The pooled means of 4 MRI-derived myocardial strain methods in normal subjects are demonstrated. Differences in field strength were attributed to variations of LVGCS.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 1998
Publisher: Elsevier BV
Date: 10-2017
Publisher: Springer London
Date: 2009
Publisher: Oxford University Press (OUP)
Date: 27-04-2012
DOI: 10.1093/EHJCI/JES084
Abstract: To evaluate left atrial (LA) volume and function as assessed by strain and strain rate derived from 2D speckle tracking and their association with diastolic dysfunction (DD) in patients with diabetes mellitus (DM). Seventy three patients with DM were compared with age- and gender-matched normal controls 30 patients with DM alone were compared to those with hypertension (HT) alone. The maximum LA volume, traditional measures of atrial function, 2D strain and strain rate were analysed. The LA indexed volume (LAVI) was larger in DM group than that in normal controls (38.2 ± 9.9 vs. 20.5 ± 4.8 ml/m(2), P< 0.0001), as well as in DM alone compared with hypertensive patients (33.9 ± 10 vs. 25.7 ± 8 ml/m(2), P< 0.0001). Global strain was significantly reduced in the DM group compared with that in normal controls (22.5 ± 8.67 vs. 30.6 ± 8.27% P< 0.0001) but was similar with HT. There was a weak correlation between LAVI and global strain with increasing grades of DD (r= 0.439, P< 0.0001 and r= - 0.316, P< 0.0001, respectively) in the diabetic group. However, there was no significant difference in LAVI between these groups. A logistic regression analysis for predictors of LAVI demonstrated that only diabetes was a determinant of LAVI. Patients with diabetes showed a significant reduction in global strain compared with normal controls but no difference with increasing grades of diastolic function. LA enlargement in DM is independent of associated HT and diastolic function. LA enlargement is associated with LA dysfunction as evaluated by 2D strain. It is likely that a combination of DD and a diabetic atrial myopathy contribute to LA enlargement in patients with DM.
Publisher: Elsevier BV
Date: 06-2011
DOI: 10.1016/J.NIOX.2011.04.009
Abstract: Nitric oxide (NO) is a modulator of left ventricular hypertrophy (LVH) and myocardial relaxation. The impact of NO availability on development of LVH has never been demonstrated in humans. We tested the hypotheses that elevation of asymmetric dimethylarginine (ADMA) concentrations (biochemical marker of decreased NO generation), and impairment of vascular responsiveness to NO donor GTN, would each predict the presence of LVH and associated LV diastolic dysfunction in a normal aging population. In 74 subjects aged 68±6 years, LV volumes and mass indexed to height(2.7) (LVMI) were calculated from cardiac MRI. Despite the absence of clinically-defined LVH, there was a relationship (r=0.29 p=0.01) between systolic BP and LVMI. Both elevation of ADMA levels to the highest quartile or impairment of GTN responsiveness (determined by applanation tonometry) to the lowest quartile were determinants of LVMI independent of systolic BP (p=0.01 and p=0.03, respectively). Filling pressure (E/E' ratio from echocardiography) was increased in patients with impaired vascular NO responsiveness (p<0.05) irrespective of LVMI. ADMA remained a significant determinant of LVMI on multivariate analysis. These data imply that NO bioavailability within the myocardium modulates earliest stages of LVH development and facilitates development of diastolic dysfunction at a given LV mass.
Publisher: Elsevier BV
Date: 02-2020
Publisher: Springer Science and Business Media LLC
Date: 27-09-2018
DOI: 10.1007/S11936-018-0689-9
Abstract: The prevalence of heart failure with preserved ejection fraction (HFpEF) is rising and in some places, it is already the most prevalent form of heart failure. The usual treatments of HF do not improve mortality or outcomes in HFpEF, suggesting a distinct pathophysiology that remains poorly characterized. The neutrality of clinical trial results is also attributable to the heterogeneity of patient profiles, and by poor characterization offered by classical echocardiography parameters. Emerging imaging modalities may overcome this problem. We therefore aimed to summarize recent advances offered by cardiovascular imaging in disease characterization, and the implication of findings to new phenotype-specific treatment options. Novel cardiovascular imaging techniques such as LV global longitudinal strain, left atrial strain, tissue characterization by magnetic resonance T1 time, as well as incorporation of systolic and diastolic stress testing offer greatly improved characterization, diagnosis, and stratification of disease pathogenesis. These techniques offer insight into identification of HFpEF sub-phenotypes that are resistant to, or responsive to therapies. There is a growing body of evidence that novel cardiovascular imaging modalities are able to characterize HFpEF patients with much greater accuracy than current guideline-driven parameters. Whether this information can be synthesized to adequately stratify patients into sub-phenotypes with clearer disease pathogenesis amenable to targeted intervention will be of particular future interest.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2011
DOI: 10.1161/CIRCIMAGING.111.963587
Abstract: Metabolic and vascular disturbances contribute to diabetic cardiomyopathy, but the role of interstitial fibrosis in early disease is unproven. We sought to assess the relationship between imaging markers of diffuse fibrosis and myocardial dysfunction and to link this to possible causes of early diabetic cardiomyopathy. Hemodynamic and metabolic data were measured in 67 subjects with type 2 diabetes mellitus (age 60±10 years) with no cardiac symptoms. Myocardial function was evaluated with standard echocardiography and myocardial deformation ischemia was excluded by exercise echocardiography. Calibrated integrated backscatter was calculated from parasternal long-axis views. T1 mapping was performed after contrast with a modified Look-Locker technique using saturation recovery images. Amino-terminal propeptides of procollagens type I and III, as well as the carboxy-terminal propeptide of procollagen type I, were assayed to determine collagen turnover. Subjects with abnormal early diastolic tissue velocity (E m ) had shorter postcontrast T1 values ( P =0.042) and higher calibrated integrated backscatter ( P =0.007). They were heavier ( P =0.003) and had worse exercise capacity ( P .001), lower insulin sensitivity ( P =0.003), and blunted systolic tissue velocity ( P =0.05). Postcontrast T1 was associated with diastolic dysfunction (E m r =0.28, P =0.020 E/E m r =−0.24, P =0.049), impaired exercise capacity ( r =0.30, P =0.016), central adiposity ( r =−0.26, P =0.046), blood pressure (systolic r =−0.30, P =0.012 diastolic r =−0.49, P .001), and insulin sensitivity ( r =0.30, P =0.037). The association of T1 with E/E m (β=−0.31, P =0.017) was independent of blood pressure and metabolic disturbance. Amino-terminal propeptide of procollagens type III was linked to diastolic dysfunction (E m r =−0.32, P =0.008) and calibrated integrated backscatter ( r =0.30, P =0.015) but not T1 values. The association between myocardial diastolic dysfunction, postcontrast T1 values, and metabolic disturbance supports that diffuse myocardial fibrosis is an underlying contributor to early diabetic cardiomyopathy.
Publisher: Oxford University Press (OUP)
Date: 09-1991
DOI: 10.1093/OXFORDJOURNALS.EURHEARTJ.A059838
Abstract: The purpose of this study was to compare rubidium-82 PET with thallium-201 SPECT imaging in 150 patients. Both techniques followed a single dipyridamole-handgrip stress, and images were displayed using the same 3-dimensional format and quantitative colour scale. Coronary arteriography was employed to assign the correct diagnosis in situations of disparity. Results of PET and SPECT were at least partially concordant in 110 patients (73%), although 22 had more than one defect. A reversible perfusion defect was identified in 60 patients, but the scans were concordant in only 20 (33%). These disparities were chiefly due to false-negative SPECT imaging (22 patients, 55%), and probable delayed thallium redistribution (13 patients, 33%). No patients had ischaemia correctly identified by SPECT in the presence of normal PET imaging. Persistent defects were identified in 91 patients, some of whom also had reversible defects, and the results were consistent in 54 (59%). Other than the delayed thallium redistribution group, the major categories causing disparities were false-positive (6 patients, 16%), and false negative SPECT (8 patients, 22%), attributable to attenuation and scatter. PET appears able to identify smaller, less ischaemic areas subtended by milder coronary stenoses. The availability of a true resting scan with Rb-PET enhances the discrimination between ischaemia and infarction. Attenuation correction, and the high energy photons of positron annihilation, yield more accurate evaluation of inferior wall defects and greater specificity in the presence of soft tissue attenuation.
Publisher: Elsevier BV
Date: 02-2008
DOI: 10.1016/J.ECHO.2007.05.043
Abstract: Reduced total arterial compliance (TAC) may be a marker of preclinical vascular disease. Irreversible risk factors such as age and body habitus are determinants of TAC, the importance of which may have been hidden by reports in selected subgroups, such as the elderly and those with diabetes mellitus or hypertension. We sought the comparative influence of reversible and irreversible risk factors on TAC in a large primary prevention group. We studied 720 consecutive patients with and without cardiovascular risk factors but with no overt cardiovascular disease. TAC was calculated by the pulse-pressure method from simultaneous applanation tonometry and left ventricular outflow tract Doppler. Central pressure was derived using a transfer function from the radial tonometric waveform and calibrated using mean and diastolic brachial cuff pressure. There were 192 patients with no cardiovascular risk factors, 180 patients with one cardiovascular risk factor, 173 patients with two cardiovascular risk factors, and 175 patients with three or more risk factors. Although age, gender, height, weight, hypertension, diabetes mellitus, hyperlipidemia, and number of risk factors were all significantly associated with TAC, age accounted for approximately 13% of the variance, and the only other independent predictors were height and weight. TAC was not significantly different in age-matched subgroups with single risk factors. TAC is associated with multiple risk factors, but age is a major determinant. The influence of age and other correlates may dwarf the contribution of in idual risk factors and therefore their alteration with therapy.
Publisher: Elsevier BV
Date: 10-2012
Publisher: Elsevier BV
Date: 2013
DOI: 10.1016/J.JCMG.2012.08.009
Abstract: This study sought to determine whether the increasing difficulty of assessing wall motion (WM), Doppler coronary flow reserve on the left anterior descending coronary artery (CFR-LAD), and myocardial perfusion (MP) during stress echocardiography (SE) was justified by increasing prognostic information in patients with known or suspected coronary artery disease. The use of echocardiographic contrast agents during SE permits the assessment of both CFR-LAD and MP, but their relative incremental prognostic value is undefined. This study followed a multicenter cohort of 718 patients for 16 months after high-dose dipyridamole contrast SE for evaluation of known or suspected coronary artery disease. The ability of WM, CFR-LAD, and MP to predict cardiac events was studied by multivariable models and risk reclassification. Abnormal SE was detected as a reversible WM abnormality in 18%, reversible MP defect in 27%, and CFR-LAD <2 in 38% of subjects. Fifty cardiac events occurred (annualized event rate 6.0%). A normal MP stress test had a 1-year hard event rate of 1.2%. The C-index of outcomes prediction based on clinical data was improved with MP (p < 0.001) and WM/CFR-LAD (p = 0.037), and MP (p = 0.003) added to clinical and WM data. Net risk reclassification was improved by adding MP (p < 0.001) or CFR-LAD (net reclassification improvement p = 0.001) in addition to clinical and WM data. The model including clinical data, WM/CFR-LAD, and MP performed better than that without MP did (p = 0.012). The multiparametric assessment of WM, CFR-LAD and MP during stress testing in patients with known or suspected coronary artery disease is feasible. Contrast SE allowed better prognostication, irrespective of the use of CFR-LAD or MP. The addition of either CFR-LAD or MP assessment to standard WM analysis and clinical parameters yielded progressively higher values for the prediction of cardiac events and may be required in today's intensively treated patients undergoing SE, because their average low risk of future cardiac events requires methods with higher predictive sensitivity than that available with standalone WM assessment.
Publisher: Elsevier BV
Date: 05-2013
DOI: 10.1016/J.ECHO.2013.02.008
Abstract: Assessment of left ventricular systolic function is necessary during trastuzumab-based chemotherapy because of potential cardiotoxicity. Deformation indices have been proposed as an adjunct to clinical risk factors and ejection fraction (EF), but the optimal parameter and optimal cutoffs are undefined. The aim of this study was to determine the best means of early detection of subsequent reduction of EF in patients with breast cancer treated with trastuzumab. Eighty-one consecutive women (mean age, 50 ± 11 years) receiving trastuzumab were prospectively studied, 37 of whom received concurrent anthracyclines. Conventional echocardiographic indices (mitral annular systolic [s'] and diastolic [e'] velocities) and myocardial deformation indices (global longitudinal peak systolic strain [GLS], global longitudinal peak systolic strain rate [GLSR-S], and global longitudinal early diastolic strain rate [GLSR-E]) were measured at baseline and at 6 and 12 months. Cardiotoxicity was defined as a >10% decline as a percentage of baseline EF in 12 months. In the 24 patients (30%) who later developed cardiotoxicity, myocardial deformation indices decreased at 6 months (GLS, P 0) of 0.77 (95% confidence interval, 0.33-1.22 P = .036). GLS is an independent early predictor of later reductions in EF, incremental to usual predictors in patients at risk for trastuzumab-induced cardiotoxicity.
Publisher: Elsevier BV
Date: 04-1997
DOI: 10.1016/S0002-9149(97)00014-3
Abstract: Impaired functional capacity is common in patients with mitral regurgitation (MR), but the determinants of functional capacity in patients with normal left ventricular (LV) function are unclear. Forty patients with chronic, isolated, nonrheumatic MR with no coronary artery disease underwent exercise echocardiography with continuous expired gas analysis. Cardiac output and regurgitant stroke volume were measured at rest and immediately after exercise by pulsed-wave Doppler echocardiography. For controls, 17 healthy volunteers without MR were also studied. Patients achieved a significantly lower VO2max compared with controls (25.6 +/- 7.7 vs 31.7 +/- 7.7 ml/kg/min, p = 0.008). VO2max showed better correlations with exercise cardiac output than with cardiac output at rest in both patients and controls. Multiple linear regression identified exercise cardiac output (partial r = 0.65), patient age (partial r = -0.56), and gender as independent determinants of VO2max (multiple R = 0.85, p <0.001). Cardiac output at rest, LV ejection fraction, regurgitant stroke volume, and fraction were not significant determinants. With exercise, the regurgitant stroke volume increased in 13 patients and decreased in 27 patients. The former 13 patients had a significantly lower exercise cardiac output (7.4 +/- 2.5 vs 9.4 +/- 2.6 L/min, p = 0.026). Patients who stopped exercise due to dyspnea (n = 7) had a significantly lower exercise cardiac output and VO2max compared with those who stopped due to fatigue (n = 33), with no differences in resting or exercise regurgitant volume. Patients with an increase in LV end-systolic volume with exercise (n = 8) also had a significantly lower exercise cardiac output (6.9 +/- 1.9 vs 9.2 +/- 2.7 L/min, p = 0.037) and showed a trend toward a lower VO2max (21 +/- 7.5 vs 26 +/- 6.4 ml/kg/min, p = 0.07). In patients with chronic MR, exercise cardiac output is the major determinant of VO2max. Regurgitant volume and fraction are not related to functional capacity. Limitations in functional capacity in these patients may be more related to a diminished cardiac reserve than to a large regurgitant volume.
Publisher: Polskie Towarzystwo Kardiologiczne
Date: 25-01-2021
DOI: 10.33963/KP.15720
Publisher: Elsevier BV
Date: 12-2020
Publisher: Elsevier BV
Date: 04-2009
DOI: 10.1016/J.JCMG.2009.01.005
Abstract: Although a prognostic benefit has been shown from cardiac resynchronization therapy, questions are often directed toward the prediction of symptomatic or functional benefit. Recent multicenter trials have shown the pitfalls of current mechanical markers of left ventricular synchrony, but these negative trial results have not marked the conclusion of efforts to predict outcome. Potential new contributors to the assessment of mechanical synchrony include echocardiographic and magnetic resonance techniques for the assessment of myocardial deformation. Nonsynchrony markers that seem promising include assessment of the location and extent of myocardial scar and imaging of the coronary venous and phrenic nerve anatomy.
Publisher: Elsevier BV
Date: 03-2011
DOI: 10.1016/J.ECHO.2011.01.015
Abstract: Echocardiographic imaging is ideally suited for the evaluation of cardiac mechanics because of its intrinsically dynamic nature. Because for decades, echocardiography has been the only imaging modality that allows dynamic imaging of the heart, it is only natural that new, increasingly automated techniques for sophisticated analysis of cardiac mechanics have been driven by researchers and manufacturers of ultrasound imaging equipment.Several such technique shave emerged over the past decades to address the issue of reader's experience and inter measurement variability in interpretation.Some were widely embraced by echocardiographers around the world and became part of the clinical routine,whereas others remained limited to research and exploration of new clinical applications.Two such techniques have dominated the research arena of echocardiography: (1) Doppler based tissue velocity measurements,frequently referred to as tissue Doppler or myocardial Doppler, and (2) speckle tracking on the basis of displacement measurements.Both types of measurements lend themselves to the derivation of multiple parameters of myocardial function. The goal of this document is to focus on the currently available techniques that allow quantitative assessment of myocardial function via image-based analysis of local myocardial dynamics, including Doppler tissue imaging and speckle-tracking echocardiography, as well as integrated backscatter analysis. This document describes the current and potential clinical applications of these techniques and their strengths and weaknesses,briefly surveys a selection of the relevant published literature while highlighting normal and abnormal findings in the context of different cardiovascular pathologies, and summarizes the unresolved issues, future research priorities, and recommended indications for clinical use.
Publisher: Elsevier BV
Date: 04-2007
DOI: 10.1016/J.JACC.2007.01.059
Abstract: We investigated the accuracy of automated analysis of myocardial deformation during dobutamine stress echocardiography (DSE). The time required for segmental measurement of strain rate imaging (SRI) limits its feasibility for quantification of DSE. Myocardial deformation was assessed at DSE in 197 patients, 76 with and 61 without coronary artery disease (CAD) at angiography, and 60 at low risk of CAD. Automated deformation analysis was based on velocity gradient and segment length methods of measuring longitudinal motion within a region of interest tracked through the cardiac cycle. Results were compared with independent wall motion scoring (WMS). Patients were randomly ided group A (n = 69) established optimal cutoffs for the parameters and group B (n = 68) tested their accuracy. The feasibility of WMS exceeded that of both SRI methods at rest and at peak stress. In group A, the area under the receiver-operating characteristics curve of the peak systolic strain rate was 0.90 by both methods, and the optimal cutoffs for detection of CAD were -1.3 (velocity gradient) and -1.2 s(-1) (segment length). The areas under the receiver-operating characteristics curves for end-systolic strain were less (0.87) by both methods, with respective cutoffs of 9% and 8%. In group B, the velocity and segment length methods had respective sensitivities of 87% and 84% for SR, and 87% and 88% for end-systolic strain. Both significantly exceeded that of WMS in the same group (75%). Automated analysis of myocardial deformation at DSE is feasible and accurate, and may increase the sensitivity of expert conventional reading.
Publisher: Wiley
Date: 05-2006
DOI: 10.1111/J.1540-8175.2006.00224.X
Abstract: The improvement of exercise capacity due to exercise training in heart failure has been associated with peripheral adaptation, but the contribution of cardiac responses is less clear. We sought the extent to which the improvement of functional capacity in patients undergoing exercise training for heart failure was related to myocardial performance. Thirty-seven patients (35 men, age 64 +/- 11) with symptomatic heart failure and left ventricular ejection fraction < or = 35% (29 +/- 9%) were studied during a 16-week exercise training program. LV function was assessed by resting and exercise 2D-echocardiography, tissue Doppler derived myocardial strain, and strain rate. Peak oxygen consumption (VO2) and LV function were measured at baseline and follow-up, and the contribution of LV function at baseline and its response to training to the change of each parameter was sought. Baseline peak VO2 (12.4 +/- 4.6) increased by 9% at 8 weeks (13.5 +/- 4.2, P = 0.26), and by 21% at 16 weeks (15.0 +/- 4.9, P < 0.001). Although there were no overall changes in myocardial parameters in this study, change in peak VO2 at 16 weeks was significantly correlated with baseline strain (r = 0.51, P = 0.003) and the improvement of strain at 8 weeks (r = 0.44, P = 0.01), independent of baseline functional capacity and clinical variables. Thus, change in peak VO2 following 16 weeks exercise training is related to myocardial function at baseline.
Publisher: Wiley
Date: 19-06-2007
DOI: 10.1111/J.1540-8175.2007.00539.X
Abstract: Doppler estimation of pulmonary artery systolic pressure (PASP) from tricuspid regurgitation velocity is a simple approach to the detection of pulmonary hypertension but may be influenced by right ventricular stroke volume. We sought the clinical utility of incorporating Doppler calculation of pulmonary vascular resistance (PVR) into determination of pulmonary hypertension in 578 consecutive patients with tricuspid regurgitation. Right atrial pressure was estimated from vena caval dimensions and collapsibility. Pulmonary hypertension was classified on the basis of a) PASP >35 mmHg, b) age-/gender normalized PASP, c) PVR >2 Wood units. The mean PASP was 40 +/- 13 mmHg and PVR was 1.9 +/- 0.8 Wood units. Standard PASP identified pulmonary hypertension in 58%, compared with 36% by age-/gender normalized PASP (P < 0.0001), and 31% by PVR (P < 0.0001). Of patients who had pulmonary hypertension by PASP, 33% were reclassified as normal on the basis of PVR and 6% were reclassified from normal to pulmonary hypertension. PVR is easy to incorporate into a standard echo exam, and identifies a small group with normal PASP as having PAH, and a larger group of apparently increased PASP as normal.
Publisher: Elsevier BV
Date: 06-2015
DOI: 10.1016/J.ECHO.2014.12.009
Abstract: Disagreement of strain measurements among different vendors has provided an obstacle to the clinical use of strain. A joint standardization task force between professional societies and industry was initiated to reduce intervendor variability of strain. Although feedback from this process has been used in software upgrades, little is known about the effects of efforts to improve conformity. The aim of this study was to assess whether intervendor agreement for global longitudinal strain (GLS) has improved after standardization initiatives. Eighty-two subjects (mean age, 52 ± 21 years 55% men) prospectively underwent two sequential examinations using two most common ultrasound systems (Vivid E9 and iE33). GLS was calculated using proprietary software (EchoPAC-PC BT12 [E12] and BT13 [E13] vs QLAB version 8.0 [Q8], QLAB version 9.0 [Q9], and QLAB version 10.0 [Q10]). Agreements in GLS were evaluated with Bland-Altman plots. Coefficients of variation (CVs) were compared using the Friedman test and compared with CVs of left ventricular volumes and ejection fraction (LVEF). Median GLS using E12 was -19.2% (interquartile range [IQR], -15.2% to -23.2%), compared with -19.3% (IQR, -14.9% to -23.7%) for E13, -15.7% (IQR, -11.4% to -20%) for Q8, -19% (IQR, -15.7% to -22.3%) for Q9, and -18.7% (IQR, -15.7% to -21.7%) for Q10. The CVs of prestandardization GLS (12 ± 8% [E12/Q8] and 14 ± 8 [E13/Q8]) were significantly larger than that of LVEF (5 ± 5) (P < .001). Since standardization, the CVs of GLS have shown improvement (6 ± 4 [E12/Q9], 7 ± 4 [E12/Q10], 6 ± 4 [E13/Q9], and 7 ± 4 [E13/Q10]) and are similar to those of LVEF. Subsequent to the joint standardization task force, there has been improvement in between-vendor concordance in GLS between two leading ultrasound manufactures, the variability of which is now analogous to that of LVEF. The removal of concerns about measurement variability should allow wider use of GLS.
Publisher: Elsevier BV
Date: 05-2019
DOI: 10.1016/J.CARDFAIL.2019.01.015
Abstract: Disease management programs (DMPs) may reduce short-term readmission or death after heart failure (HF) hospitalization. We sought to determine if targeting of DMP to the highest-risk patients could improve efficiency. Patients (n = 412) admitted with HF were randomized to usual care or an intensive DMP including optimizing intravascular volume status at discharge, increased self-care education, exercise guidance, closer home surveillance, and increased intensity of HF nurse follow-up. Both treatment groups were similar in demographics, medication use, Charlson comorbidity index, ejection fraction, and left ventricular and atrial volumes. Readmission or death occurred in 74/197 (37%) usual care and 50/215 (23%) DMP patients within 30 days (relative risk [RR] 0.62, 95% confidence interval [CI] 0.46-0.84), and 113/197 (57%) usual care and 78/215 (36%) DMP patients within 90 days, (RR 0.63, 9%% CI 0.51-0.78). The predicted risk of death and readmission (estimated from our previously developed risk score) was similar between treatment groups (mean predicted risk 38.6 ± 22.2% vs 39.4 ± 21.9% P = .73) and similar across categories of predicted risk between the treatment groups. For 30-day readmission or death, patients from the 2 highest risk quintiles showed a benefit from intervention, and there was an interaction between intervention and predicted risk (P = .02). For 90-day readmission or death, most patients-other than those in the lowest-risk quintile-benefited from the intervention. Use of a risk score may permit targeting of DMP to reduce HF admission. Intensive DMP may reduce short-term readmission or death, particularly in high-risk patients.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 30-06-2009
Publisher: Springer Science and Business Media LLC
Date: 18-10-2011
DOI: 10.1007/S10554-011-9963-6
Abstract: Measurement of left ventricular (LV) mechanical dyssynchrony from single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) allows optimization of cardiac resynchronization therapy in heart failure patients. We compared the discriminatory ability and reproducibility of a new software method, Corridor 4DM (4DM) to the established method, Emory Cardiac Toolbox (ECTb) in normals and heart failure patients. LV dyssynchrony was measured in 100 control (Group 1) and 100 patients with LVEF <35% (Group 2) using time to peak thickening with first harmonic, fourth harmonic, and volume curve methods with the 4DM software, and compared to ECTb. Of the 3 4DM methods, first harmonic had the best correlation with the ECTb (R = 0.88, slope = 1.00, P < 0.0001, bias = -0.18° [95% CI: -20° 16°] for phase standard deviation and similarly for histogram bandwidth, while volume curve analysis had the greatest variation. The intra and inter-observer reproducibility for 4DM time to peak thickening with first harmonic was very good (R = 0.99, P < 0.0001 and coefficient of variability 10% [95% CI 9.2-12%] for intra-observer, and R = 0.97, P < 0.0001, coefficient of variability 16% [15-17%] for inter-observer, respectively). Finally, in patients with LVEF <35%, the area under the curve on receiver operator characteristic analysis was 0.93 [95% CI: 0.89-0.97] to detect significant mechanical dyssynchrony (i.e. standard deviation ≥43°) using 4DM versus ECTb. The 4DM-software provides an accurate and reproducible alternative method of dyssynchrony analysis of SPECT MPI for evaluation and management of heart failure.
Publisher: Elsevier BV
Date: 06-2007
Abstract: The nongeometric nature of the right ventricle (RV) makes it difficult to measure. We sought to determine whether real-time three-dimensional echocardiography (RT3DE) is superior to two-dimensional echocardiography (2DE) for the follow-up of RV function by validation vs cardiac MRI. RV volumes and ejection fraction (EF) were studied with 2DE (including area-length [A-L], the modified two-dimensional subtraction [2DS] method, and the Simpson method of discs), RT3DE, and MRI in 50 patients with left ventricular wall motion abnormalities, the results of which suggested possible RV infarction. Test-retest variation was performed by a complete restudy using a separate sonographer within 24 h without the alteration of hemodynamics or therapy. Interobserver and intraobserver variations were noted in a subgroup of 20 patients. EF estimations were similar using each technique. The mean (+/- SD) MRI end-diastolic volume (87 +/- 22 mL) was only slightly underestimated by RT3DE (mean difference, -3 +/- 10 p < 0.05), with a greater mean difference for 2DE A-L (-29 +/- 10 p < 0.05), and the Simpson method of discs (-29 +/- 23 p < 0.05), and was greatly overestimated by 2DS (mean difference, 26 +/- 23 p < 0.05). Similarly, the mean MRI end-systolic volume (46 +/- 17 mL) was only slightly underestimated by RT3DE (-4 +/- 7 p < 0.05), compared with 2DE A-L (-16 +/- 8 p < 0.05) and the Simpson method of discs (-16 +/- 8 p < 0.05), and was overestimated by 2DS (14 +/- 13 p < 0.05). RT3DE findings had a higher correlation with each parameter than any 2DE technique. There was also good intraobserver and interobserver correlation between RT3DE by two sonographers. RT3DE had less test-retest variation of RV volumes and EF than any 2DE measure. RT3DE is more accurate than two-dimensional approaches and reduces the test-retest variation of RV volumes and EF measurements in follow-up RV assessment.
Publisher: Wiley
Date: 11-2004
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 20-05-2008
Publisher: Elsevier BV
Date: 06-2013
DOI: 10.1016/J.ECHO.2013.02.014
Abstract: Although impaired left ventricular (LV) filling in constrictive pericarditis (CP) is attributable to external constraints by a tethered pericardium, impaired left atrial (LA) function can further impair LV filling. Previous studies focused on the impact of a tethered pericardium on LV diastolic behavior, but its impact on LA function has been largely overlooked. The objectives of this study were to evaluate LA mechanics in CP and to assess the impact of pericardiectomy on LA mechanics. A total of 52 patients with CP (mean age, 57 ± 12 years) and 19 control subjects were studied retrospectively. All patients with CP underwent echocardiography before (median, 12 days interquartile range, 5-34 days) and after pericardiectomy (median, 20 days interquartile range, 5-64 days). Global LA longitudinal strain (ε) was calculated, which included peak negative ε (εnegative), peak positive ε (εpositive), and the sum of those values, total LA ε (εtotal), using speckle-tracking echocardiography with Velocity Vector Imaging. The regional difference of LA ε between the septal and lateral walls was assessed before and after the procedure. Patients with CP showed depressed global LA εnegative, LA εtotal, and LA εpositive compared with controls. LA contractile (global LA εnegative) and reservoir functions (global LA εtotal) showed significant increases after pericardiectomy. Regional analysis revealed that the improvement in LA function after surgery was more apparent in lateral segments, while the regional function of septal walls was depressed after surgery. Patients with CP have impaired LA mechanics, presumably because of the constrictive tethering process involving the left atrium. Speckle-tracking echocardiography showed consistent results of changes in LA mechanics with conventional echocardiographic parameters early after the procedure. Regional ε analysis aided in recognition of the impact of constrictive tethering and pericardiectomy on LA function.
Publisher: BMJ
Date: 12-2008
Publisher: Elsevier BV
Date: 03-2018
Publisher: Elsevier BV
Date: 03-2010
DOI: 10.1016/J.IJCARD.2009.08.007
Abstract: Perhexiline improves functional capacity in heart failure, but the mechanisms are undefined. We sought its effects on myocardial deformation in patients with viable myocardium. Thirty-six medically-treated patients, stable at least 6 months post-infarction with LV dysfunction and myocardial viability shown by dobutamine echo (DbE) were randomised to receive perhexiline or matching placebo for 1 year. Cardiopulmonary exercise testing and DbE were performed at baseline and follow-up. Peak-systolic strain (S) and strain rate (SR) were measured offline in 111 dysfunctional segments in the placebo and 88 in the treatment group at rest, low-dose (LDD) and peak-dose dobutamine (PDD). The serum perhexiline level was 0.27+/-0.7 microg/l. There was no difference in the wall motion response to dobutamine at baseline and follow-up. Resting strain and SR were similar in the two groups at baseline and follow-up. However, SR at LDD and PDD increased in the placebo group and worsened during the same period in the perhexiline group. Patients on perhexiline and placebo had a similar rate-pressure product and exercise duration at baseline (7.9+/-2.7 vs 8.7+/-3.3 min, p=NS) and follow-up (9.6+/-4.6 vs 10.1+/-3.03 min, p=NS). Perhexiline does not improve the deformation of abnormal myocardial segments in patients with ischaemic LV dysfunction.
Publisher: Elsevier BV
Date: 12-2020
Publisher: BMJ
Date: 13-05-2009
Abstract: In patients with ischaemic cardiomyopathy and viable myocardium, left ventricular ejection fraction (LVEF) does not always improve after revascularisation. Whether this may affect prognosis is unclear. To evaluate the prognosis of viable patients with and without improvement of LVEF after coronary revascularisation. Before revascularisation, radionuclide ventriculography (RNV) and dobutamine stress echocardiography were performed to assess LVEF and myocardial viability, respectively. Nine to 12 months after revascularisation, LVEF improvement was assessed by RNV. Patients were ided into three groups: group 1, viable patients with LVEF improvement (n = 27) group 2, viable patients without LVEF improvement (n = 15), group 3, non-viable patients (n = 48). Cardiac events were evaluated during a 4-year follow-up. After revascularisation, the mean (SD) LVEF improved from 32 (9)% to 42 (10)% in group 1, but did not change significantly in group 2 and in group 3, p<0.001 by analysis of variance (ANOVA). Heart failure symptoms improved in both groups 1 (mean (SD) NYHA class from 3.1 (0.9) to 1.7 (0.7)) and 2 (from 3.2 (0.7) to 1.7 (0.9)), but not in group 3 (from 2.8 (1.0) to 2.7 (0.5)), p<0.001 by ANOVA. During follow-up, the cardiac event rate was low (4%) in group 1, intermediate (21%) in group 2 and high (33%) in group 3 (p = 0.01). The best prognosis after revascularisation may be expected in those viable patients whose LVEF improves. Conversely, viable patients without functional improvement have an intermediate prognosis.
Publisher: Springer London
Date: 2008
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-2009
Publisher: Oxford University Press (OUP)
Date: 02-11-1995
DOI: 10.1093/EURHEARTJ/16.SUPPL_M.3
Abstract: Previous reports have suggested that dobutamine stress echocardiography compares favourably with other stress agent-imaging modality combinations for the detection of coronary artery disease. However, in daily clinical practice the value of a test is defined on a probability basis. To study the relative diagnostic contribution of clinical and dobutamine stress test variables, Bayesian analysis was performed in 223 patients with suspected coronary artery disease, who underwent coronary angiography and a high-dose dobutamine stress test in conjunction with electrocardiography, echocardiography and Technetium-99m sestamibi SPECT myocardial perfusion scintigraphy. According to the pre-test (clinical) probabilities, patients were ided into low-, intermediate- and high-risk groups 155 patients were in the intermediate-risk group. After dobutamine stress echocardiography the number of patients in this intermediate-risk group was reduced to 102 (P < 0.0001). This reduction of patients in the intermediate-risk group by echocardiography was better than perfusion scintigraphy (102 vs 126 patients, P < 0.05) or classic markers of ischaemia such as angina and/or ST-segment changes (102 vs 150, P < 0.0001). Moreover, there was a good correlation between the echocardiographic post-test probabilities and the true distribution of coronary artery disease.
Publisher: American Physiological Society
Date: 07-2011
DOI: 10.1152/AJPHEART.00102.2011
Abstract: Acute elevation of circulating lipids, such as the postprandial state, contributes to increased cardiovascular risk. However, the effect of acutely elevated triglycerides on arterial and left ventricular function is not completely understood. We aimed to assess whether an acute increase in triglycerides affects ventricular-vascular interaction. Fifteen healthy men (age, 49 ± 8 yr) underwent blinded, randomized infusion of saline and intravenous fat emulsion to acutely raise plasma triglycerides. All subjects underwent both randomization trials, in random order on two separate days. Ventricular-vascular interaction measures were recorded by tonometry (central blood pressure) and echocardiography (left ventricular volumes, strain, and strain rate) at baseline and after 1 h infusion. Net ventricular-vascular interaction was defined by the effective arterial elastance ( E A )-to-left ventricular end-systolic elastance ( E LV ) ratio ( E A / E LV ). When compared with saline, the infusion of intravenous fat emulsion increased triglycerides and free fatty acids (Δ P 0.001 for both) and improved left ventricular contractility (Δ E LV , end-systolic volume and strain rate P 0.05 for all). However, arterial function was unchanged (Δ E A , brachial and central blood pressure P 0.05 for all). Overall, E A / E LV was decreased by an infusion of intravenous fat emulsion ( P = 0.004) but not saline ( P 0.05, P = 0.001 for Δ between trials). We conclude that intravenous fat emulsion and acute elevation of blood lipids (including triglycerides and free fatty acids) alter ventricular-vascular interaction by increasing left ventricular contractility without affecting arterial load. These findings may have implications for cardiovascular responses to parenteral nutrition.
Publisher: BMJ
Date: 21-09-2019
DOI: 10.1136/HEARTJNL-2017-312932
Abstract: Mitral valve prolapse (MVP) is commonly observed as a benign finding. However, the literature suggests that it may be associated with sudden cardiac death (SCD). We performed a meta-analysis and systematic review to determine the: (1) prevalence of MVP in the general population (2) prevalence of MVP in all SCD and unexplained SCD (3) incidence of SCD in MVP and (4) risk factors for SCD. The English medical literature was searched for: (1) MVP community prevalence (2) MVP prevalence in SCD cohorts (3) incidence SCD in MVP and (4) SCD risk factors in MVP. Thirty-four studies were identified for inclusion. This study was registered with PROSPERO (CRD42018089502). The prevalence of MVP was 1.2% (95% CI 0.5 to 2.0) in community populations. Among SCD victims, the cause of death remained undetermined in 22.1% (95% CI 13.4 to 30.7) of these, MVP was observed in 11.7% (95% CI 5.8 to 19.1). The incidence of SCD in the MVP population was 0.14% (95% CI 0.1 to 0.3) per year. Potential risk factors for SCD include bileaflet prolapse, ventricular fibrosis complex ventricular ectopy and ST-T wave abnormalities. The high prevalence of MVP in cohorts of unexplained SCD despite low population prevalence provides indirect evidence of an association of MVP with SCD. The absolute number of people exposed to the risk of SCD is significant, although the incidence of life-threatening arrhythmic events in the general MVP population remains low. High-risk features include bileaflet prolapse, ventricular fibrosis, ST-T wave abnormalities and frequent complex ventricular ectopy. PROSPERO (CRD42018089502).
Publisher: Wiley
Date: 17-10-2019
DOI: 10.1111/ECHO.14502
Abstract: The availability of a true 3D dataset provides an opportunity for automation of left ventricular (LV) and left atrial (LA) measurements. Although manual and automated measurements of 3D volumes are known to correlate, the variance is an important parameter for the in idual patient. The reasons for discrepancies remain unexplained. We hence aim to explain the disagreement between automated and manual LV and LA volumes. A total of 355 patients underwent standard clinical echo, with offline analysis in both fully- (Heart Model, Philips) and semiautomated (3DQ-Adv, Philips) assessment of routine indices of LV and LA function and shape. Each image was classified according to quality using a 4-point scale as well as the American Society for Echocardiography guidelines for appropriate use of contrast. Bland-Altman plots were used to assess agreement, and t tests were used to assess differences in agreement. Predictors of volume discrepancy were sought with linear regression. Measures of LV and LA volumes were greater with automatic than semiautomatic assessment. The difference in left ventricular end-diastolic volume was dependent on the number of regional wall-motion abnormalities (RWMA) (β = 0.59, P < .04) and image quality (β = 19.71, P = .02). RWMA predicted the difference in left ventricular end-systolic volume (β = 0.83, P < .01) and left atrial end-systolic volume (β = -1.01 P < .01). LV and LA volumes were higher with automatic than semiautomatic assessment. Image quality and RWMA may contribute to this discrepancy. These limitations need to be addressed before fully automatic assessment of 3D echocardiograms can be used in the clinic.
Publisher: Elsevier BV
Date: 02-1999
DOI: 10.1016/S0002-9343(98)00388-X
Abstract: The association between myocardial perfusion imaging defects and cardiac mortality in women is undefined. We examined whether myocardial perfusion imaging predicted cardiac mortality in men and women and compared this with other variables influencing prognosis. Six academic institutions with high-volume nuclear cardiology laboratories consecutively studied 5,009 men aged 62 +/- 12 years (mean ISD) and 3,402 women aged 66 +/- 11 years with symptomatic known or suspected coronary artery disease undergoing exercise (n = 7,486) or pharmacologic stress (n = 925) myocardial perfusion imaging. A pretest clinical risk index was calculated from age, history of myocardial infarction, diabetes, hypertension, and hypercholesterolemia. Myocardial perfusion images were analyzed for stress-induced defects or any defect in the territories of the three major coronary arteries. Stress-induced perfusion defects were seen in 39% of men and 25% of women (P = 0.0001). Extensive stress-induced or fixed defects (>2 vascular territories) were less common in women than men (10% vs 19%, and 4% vs 18%, both P = 0.0001). During a mean of 2.4 +/- 1.5 years of follow-up, 143 patients died of cardiac causes. The clinical risk index and number of territories with perfusion defects were associated with cardiac mortality in women and men. In women undergoing exercise myocardial perfusion imaging, the number of abnormal territories remained the strongest correlate of mortality after adjustment for exercise variables. The results of myocardial perfusion imaging are important, independent predictors of survival in both women and men.
Publisher: Wiley
Date: 02-2005
DOI: 10.1111/J.1445-5994.2004.00740.X
Abstract: Not all myocardium involved in a myocardial infarction is dead or irreversibly damaged. The balance between the amount of scar and live tissue, and the nature of the live tissue, determine the likelihood that contractile function will improve after revascularisation. This improvement (which defines viability) may be predicted with about 80% accuracy using several techniques. This review examines the determinants of functional recovery and how they may be integrated in making decisions regarding revascularisation.
Publisher: Ubiquity Press, Ltd.
Date: 12-2013
Publisher: The Korean Society of Cardiology
Date: 2015
Publisher: American Academy of Pediatrics (AAP)
Date: 08-2020
Abstract: Preterm birth is associated with incident heart failure in children and young adults. To determine the effect size of preterm birth on cardiac remodeling from birth to young adulthood. Data sources include Medline, Embase, Scopus, Cochrane databases, and clinical trial registries (inception to March 25, 2020). Studies in which cardiac phenotype was compared between preterm in iduals born at & weeks’ gestation and age-matched term controls were included. Random-effects models were used to calculate weighted mean differences with corresponding 95% confidence intervals. Thirty-two observational studies were included (preterm = 1471 term = 1665). All measures of left ventricular (LV) and right ventricular (RV) systolic function were lower in preterm neonates, including LV ejection fraction (P = .01). Preterm LV ejection fraction was similar from infancy, although LV stroke volume index was lower in young adulthood. Preterm LV peak early diastolic tissue velocity was lower throughout development, although preterm diastolic function worsened with higher estimated filling pressures from infancy. RV longitudinal strain was lower in preterm-born in iduals of all ages, proportional to the degree of prematurity (R2 = 0.64 P = .002). Preterm-born in iduals had persistently smaller LV internal dimensions, lower indexed LV end-diastolic volume in young adulthood, and an increase in indexed LV mass, compared with controls, of 0.71 g/m2 per year from childhood (P = .007). The influence of preterm-related complications on cardiac phenotype could not be fully explored. Preterm-born in iduals have morphologic and functional cardiac impairments across developmental stages. These changes may make the preterm heart more vulnerable to secondary insults, potentially underlying their increased risk of early heart failure.
Publisher: Elsevier BV
Date: 07-2009
DOI: 10.1016/J.JCMG.2009.02.014
Abstract: The aim of this study was to investigate the relative contributions of left ventricular hypertrophy (LVH) and myocardial ischemia to the association between abnormal myocardial deformation during dobutamine stress echocardiography (DSE) and mortality. Both left ventricular hypertrophy (LVH) and myocardial ischemia are known to convey a significant adverse prognostic impact. In addition, myocardial deformation is an independent predictor of outcome in patients undergoing DSE. The mechanism of this association, however, is undefined. We studied 223 consecutive in iduals with normal resting LV function undergoing DSE. The LV mass was indexed to height (g/m(2.7)) (LVMI), and LVH was designated as LVMI >or=51 g/m(2.7). Myocardial ischemia was defined on the basis of new, inducible wall motion abnormalities. Customized software was used to measure global strain rate (SRs), which was averaged in 18 myocardial segments at peak stress. In iduals were followed for all-cause mortality over a mean of 5.4 +/- 1.4 years. Left ventricular hypertrophy was identified in 83 in iduals (37%), and 63 (28%) had ischemia documented at DSE. In a Cox proportional hazards model, the strongest predictor of all-cause mortality for the total population was SRs (hazard ratio: 2.16, 95% confidence interval: 1.63 to 2.87, p < 0.01). Both LVH (p < 0.01) and ischemia (p < 0.05) had a significant adverse prognostic impact. In iduals with both LVH and ischemia had the worst outcome (p = 0.02) in comparison with the rest of the population. Among LV geometric patterns, concentric LVH had the worst outcome (p < 0.01). However, SRs was the strongest predictor of mortality in both LVH and ischemia. In a model reflecting clinical practice, SRs provided a significant increment in model power over baseline and variables identified at DSE. The SRs is a powerful, independent predictor of all-cause mortality in in iduals undergoing DSE and provides incremental information over baseline clinical and echocardiographic variables. Whereas SRs is influenced by both LVH and myocardial ischemia, both independently and additively, its predictive power for mortality is independent of both.
Publisher: Oxford University Press (OUP)
Date: 29-01-2013
DOI: 10.1093/AJH/HPS077
Abstract: The J-curve relationship between brachial diastolic blood pressure (DBP) and mortality is believed to be mediated through reduced myocardial perfusion. This study aimed to determine the relationship between DBP and subendocardial perfusion in patients with and without coronary artery disease (CAD) and to examine central hemodynamic variables that may explain the risk associated with low DBP (aortic stiffness, central pulse pressure, and augmentation index). Brachial DBP and radial tonometry were measured in 134 patients with CAD (aged 76±7years 69% male), 134 in iduals without a prior cardiovascular event (control subjects) (aged 77±2years 69% male) and 47 patients (aged 63±10years) during dobutamine stress echocardiography. Central hemodynamics and subendocardial viability ratio (SEVR), a marker of subendocardial perfusion, were recorded by tonometry. There was no difference in DBP or SEVR between control subjects and CAD patients (P > 0.05), nor was there a difference in SEVR across quartiles of DBP in CAD patients (P = 0.07) or control subjects (P = 0.14). After adjustment for age and height, associations between DBP and SEVR in control subjects (r = 0.185 P = 0.03) and CAD patients (r = 0.204 P = 0.02) were attenuated (P = 0.07 and P = 0.11, respectively). There were no significant relationships between DBP and central hemodynamics (P > 0.05 for all). At peak dobutamine stress, SEVR was significantly reduced in patients with inducible ischemia vs. those with nonischemic response (84±17 vs. 101±22% P = 0.01). However, DBP was not significantly different (65±14 vs. 67±15mm Hg P = 0.32). Brachial DBP is a poor marker of subendocardial perfusion. The J-curve relationship between DBP and mortality is unlikely attributable to reduced myocardial perfusion or adverse central hemodynamics.
Publisher: Elsevier BV
Date: 04-2007
DOI: 10.1016/J.AHJ.2007.01.004
Abstract: Exercise training improves functional capacity in patients with systolic dysfunction (SD), but the role of exercise training in diastolic dysfunction (DD) is unclear. We compared the responses of patients with exercise intolerance and SD or DD to 16 weeks of exercise training. Fifty-one patients with SD and DD were enrolled in exercise training, which was completed in 24 patients with SD (22 men, 62 +/- 8 years old, ejection fraction 45%). Peak VO2, quality of life (Minnesota Living with Heart Failure and Hare-Davis questionnaires), and echocardiographic measures (ejection fraction, systolic and diastolic tissue velocity, and filling pressure) were performed at baseline and after 16 weeks of training. Patients with SD and those with DD showed similar baseline peak VO2 (11.9 +/- 2.5 vs 12.5 +/- 4.1 mL/[kg min], P = .55) and E/E' ratio (21 +/- 13 vs 14.4 +/- 15, P = .07), but different systolic velocity (3.4 +/- 1.0 vs 5.5 +/- 1.7 cm/s, P < .001), diastolic velocity (3.9 +/- 1.5 vs 5.1 +/- 1.8 cm/s, P = .05), and ejection fraction (26 +/- 8% vs 55 +/- 9%, P < .001). Baseline quality of life scores were worse in patients with SD. There was a similar increment in peak VO2 in SD (24%, P = .001) and DD (30%, P < .001) after exercise training, but this did not correlate with improved diastolic parameters. Quality of life scores improved in both SD and DD, although SD scores remained significantly worse. In patients with exercise limitation attributed to DD, the improvement in peak VO2 and quality of life with exercise training is similar to those with SD, but unrelated to changes in diastolic function.
Publisher: Elsevier BV
Date: 03-2001
DOI: 10.1016/S0735-1097(00)01191-8
Abstract: We sought to find out whether dobutamine echocardiography (DbE) could provide independent prediction of total and cardiac mortality, incremental to clinical and angiographic variables. Existing outcome studies with DbE have examined composite end points, rather than death, over a relatively short follow-up. Clinical and stress data were collected in 3,156 patients (age 63 +/- 12 years, 1,801 men) undergoing DbE. Significant stenoses (>50% diameter) were identified in 70% of 1,073 patients undergoing coronary angiography. Total and cardiac mortality were identified over nine years of follow-up (mean 3.8 +/- 1.9). Cox models were used to analyze the effect of ischemia and other variables, independent of other determinants of mortality. The dobutamine echocardiogram was abnormal in 1,575 patients (50%). Death occurred in 716 patients (23%), 259 of whom (8%) were thought to have died from cardiac causes. Patients with normal DbE had a total mortality of 8% per year and a cardiac mortality of 1% per year over the first four years of follow-up. Ischemia and the extent of abnormal wall motion were independent predictors of cardiac death, together with age and heart failure. In sequential Cox models, the predictive power of clinical data alone (model chi-square 115) was strengthened by adding the resting left ventricular function (model chi-square 138) and the results of DbE (model chi-square 181). In the subgroup undergoing coronary angiography, the power of the model was increased to a minor degree by the addition of coronary anatomy data. Dobutamine echocardiography is an independent predictor of death, incremental to other data. While a normal dobutamine echocardiogram predicts low risk of cardiac death (on the order of 1% per year), this risk increases with the extent of abnormal wall motion at rest and stress.
Publisher: Elsevier BV
Date: 03-2015
DOI: 10.1016/J.JACC.2014.11.057
Abstract: Appropriate use criteria (AUC) for cardiac imaging have been available for almost 10 years. The extent to which there has been a reported improvement in appropriate use is undefined. This study systematically reviewed published evidence to identify whether the promulgation of AUC has led to an improvement in the proportion of appropriate cardiac imaging requests. Electronic databases were systematically searched for English-language papers related to AUC and cardiovascular imaging. We found 59 reports involving 103,567 tests that were published from 2000 to 2012. The rate of appropriate testing over time was analyzed in a meta-regression. New AUC were associated with apparent improvements in appropriateness for transthoracic echocardiography (TTE) (80% [95% confidence interval (CI): 0.75 to 0.84] vs. 85% [95% CI: 0.81 to 0.89]), transesophageal echocardiography (TEE) (89% [95% CI: 0.81 to 0.94] vs. 95% [95% CI: 0.93 to 0.96]) and computed tomography angiography (CTA) (37% [95% CI: 0.21 to 0.55] vs. 55% [95% CI: 0.44 to 0.65]) but not stress echocardiography (53% [95% CI: 0.45 to 0.61] vs. 52% [95% CI: 0.42 to 0.61]) or single-photon emission computed tomography (72% [95% CI: 0.66 to 0.77] vs. 68% [95% CI: 0.60 to 0.74]). Although there were no correlations between the proportion of appropriate TTEs and published year (p = 0.36) for 2007 AUC, there was a positive correlation between proportion of appropriateness and the year of publication (p = 0.01) for 2011 AUC. There was a significant decrease in the proportion of appropriateness over time using the 2007 TEE AUC (p = 0.03) and 2006 CT AUC (p = 0.02). There were no meaningful associations between appropriateness and publication year for stress echocardiography, CTA, or single-photon emission computed tomography. Rates of reported appropriate use in imaging show improvements for TTE and CTA but not for stress imaging and TEE. The observed reductions in imaging studies are not matched by reported rates of appropriate use.
Publisher: Elsevier BV
Date: 03-2007
DOI: 10.1016/J.NIOX.2006.10.003
Abstract: We tested the hypothesis that the presence of aortic stenosis (AS) is associated with elevation of plasma levels of asymmetric dimethylarginine (ADMA), a physiological inhibitor of nitric oxide synthase, a mediator and marker of endothelial dysfunction and an indicator of incremental cardiovascular risk. The presence of aortic sclerosis (ASC), the precursor of AS is independently associated both with endothelial dysfunction, and with incremental coronary event risk. It remains uncertain whether elevations of ADMA levels might mediate endothelial dysfunction in these conditions. Forty two consecutive patients referred for echocardiography for evaluation of AS, who had calculated aortic valve areas of <1.4 cm(2) (AS group) were evaluated together with 42 consecutive age-matched referred patients (non-AS group). Plasma ADMA levels were measured by high-performance liquid chromatography (HPLC). Determinants of elevation of plasma ADMA levels were identified via stepwise multiple linear regression analysis. Plasma ADMA levels were not statistically different between the AS and non-AS group (median 0.59 vs 0.54 micromol/L, p=0.13, Mann-Whitney test) on univariate analysis. However, in backward stepwise multiple linear regression, the presence of AS was a significant predictor of elevated ADMA levels (p=0.04, 95% CI=0.001, 0.072). In addition, elevated plasma ADMA levels were also associated with history of atrial fibrillation (p=0.009, 95% CI=0.015, 0.100), and negatively associated with creatinine clearance (p=0.01, 95% CI=-0.002, 0.000), and the use of statin therapy (p=0.01, 95% CI=-0.081, -0.011). AS is independently associated with elevation of ADMA levels, beyond that implied by "conventional" risk factors for endothelial dysfunction. The clinical status of AS as an incremental marker of cardiovascular risk may reflect ADMA-mediated endothelial dysfunction.
Publisher: Wiley
Date: 02-2022
DOI: 10.1113/JP282428
Abstract: Insulin infusion increases skeletal muscle microvascular blood flow (MBF) in healthy people but is impaired during insulin resistance. However, we have shown that eliciting insulin secretion via oral glucose loading in healthy people impairs muscle MBF, whilst others have demonstrated intravenous glucose infusion stimulates MBF. We aimed to show that the route of glucose administration (oral versus intravenous) influences muscle MBF, and explore potential gut‐derived hormones that may explain these ergent responses. Ten healthy in iduals underwent a 120 min oral glucose tolerance test (OGTT 75 g glucose) and on a subsequent occasion an intravenous glucose tolerance test (IVGTT, bypassing the gut) matched for similar blood glucose excursions. Femoral artery and thigh muscle microvascular (contrast‐enhanced ultrasound) haemodynamics were measured at baseline and during the OGTT/IVGTT. Plasma insulin, C‐peptide, glucagon, non‐esterified fatty acids and a range of gut‐derived hormones and incretins (gastric inhibitory polypeptide (GIP) and glucagon‐like peptide‐1(GLP‐1)) were measured at baseline and throughout the OGTT/IVGTT. The IVGTT increased whereas the OGTT impaired MBF (1.3‐fold versus 0.5‐fold from baseline, respectively, P = 0.0006). The impairment in MBF during the OGTT occurred despite producing 2.8‐fold higher plasma insulin concentrations ( P = 0.0001). The change in MBF from baseline (ΔMBF) negatively correlated with ΔGIP concentrations ( r = −0.665, P 0.0001). The natural log ratio of incretins GLP‐1:GIP was positively associated with ΔMBF ( r = 0.658, P 0.0001), suggesting they have opposing actions on the microvasculature. Postprandial hyperglycaemia per se does not acutely determine opposing microvascular responses between OGTT and IVGTT. Incretins may play a role in modulating skeletal muscle MBF in humans. Insulin or mixed nutrient meals stimulate skeletal muscle microvascular blood flow (MBF) to aid in the delivery of nutrients however, this vascular effect is lost during insulin resistance. Food/drinks containing large glucose loads impair MBF in healthy people however, this impairment is not observed when glucose is infused intravenously (bypassing the gut). We investigated skeletal muscle MBF responses to a 75 g oral glucose tolerance test and intravenous glucose infusion and aimed to identify potential gut hormones responsible for glucose‐mediated changes in MBF. Despite similar blood glucose concentrations, orally ingested glucose impaired, whereas intravenously infused glucose augmented, skeletal muscle MBF. The incretin gastric inhibitory polypeptide was negatively associated with MBF, suggestive of an incretin‐mediated MBF response to oral glucose ingestion. This work provides new insight into why diets high in glucose may be detrimental to vascular health and provides new avenues for novel treatment strategies targeting microvascular dysfunction.
Publisher: Elsevier BV
Date: 02-1996
DOI: 10.1016/S0002-8703(96)90344-0
Abstract: Early reperfusion after myocardial infarction improves survival rate and is thought to preserve myocardial function, but the reperfusion of ischemic tissue may release oxygen free radicals, which could adversely affect left ventricular function and diminish the beneficial effects of reperfusion. Measurements related to free radical scavenging (plasma and erythrocyte enzyme systems, which are involved in free radical control, alpha-tocopherol, selenium, and manganese superoxide dismutase) may be indirect markers of free radical production. We evaluated 10 patients undergoing coronary angioplasty within 4 hours of myocardial infarction to measure the impact of abrupt reperfusion on free radical scavenger-related indexes. Pulmonary artery s les were taken before, immediately after, and 3 hours after angioplasty. During reperfusion, significant reductions occurred in alpha-tocopherol (1.1 +/- 0.3 mg/dl before, 0.9 +/- 0.2 mg/dl immediately after [p = 0.03], and 0.8 +/- 0.2 mg/dl 3 hours after percutaneous transluminal coronary angioplasty [p = 0.02]), and selenium levels (13.7 +/- 2.4 micrograms/dl before, 12.9 +/- 2.4 micrograms/dl immediately after, and 10.2 +/- 3.0 micrograms/dl 3 hours after angioplasty [p = 0.0006]). Erythrocyte markers (glutathione peroxidase and superoxide dismutase) were not altered by reperfusion, possibly reflecting the relatively long half-life of the erythrocyte. The erythrocyte glutathione peroxidase value before reperfusion in patients (30.8 +/- 5.1 IU/gm of hemoglobin) was lower than in a control group (36.1 +/- 6.5 IU/gm of hemoglobin p = 0.01). Thus the decrease in plasma alpha-tocopherol and selenium after reperfusion in this group of patients may reflect a general alteration in plasma free radical scavenger levels, suggesting consumption of plasma free radical scavengers with reperfusion after acute myocardial infarction.
Publisher: Oxford University Press (OUP)
Date: 07-07-2015
DOI: 10.1093/AJH/HPV108
Abstract: Central blood pressure (BP) is an acknowledged contributor to end-organ damage and independent determinant of prognosis. Primary analysis from the BPGUIDE study demonstrated no detriment on left ventricular (LV) structure from central BP-guided hypertension management, despite significant medication withdrawal. However, the effect of this on LV function has not been investigated. In this study, we sought to investigate the impact of central BP-guided hypertension management on LV systolic and diastolic performance. A total of 286 enrollees with uncomplicated hypertension were randomized to therapeutic decisions guided by best-practice usual care (UC) or, in addition, by central BP intervention (CBP) for 12 months. Each participant underwent baseline and follow-up 2-dimensional echocardiography, with assessment undertaken by an expert blinded to participant allocation. Antihypertensive medication quantity remained unchanged for UC but significantly decreased with intervention. However, no significant between-group differences were noted for changes during follow-up in both brachial and central BP, as well as other central hemodynamic parameters: augmentation index and augmented pressure. Similarly, there were no differences between groups in parameters of LV diastolic function: tissue e' velocity (∆UC vs. ∆CBP P = 0.27) and E/e' ratio (∆UC vs. ∆CBP P = 0.60), and systolic parameters: LV longitudinal strain (∆UC vs. ∆CBP P = 0.55), circumferential strain (∆UC vs. ∆CBP P = 0.79), and ejection fraction (∆UC vs. ∆CBP P = 0.15). Hypertension management guided by central BP, resulting in significant withdrawal of medication to maintain appropriate BP control, had no adverse effect on LV systolic or diastolic function. Clinical trials registration: Australia New Zealand Clinical Trial Registry Number ACTRN12608 000041358.
Publisher: Springer Science and Business Media LLC
Date: 2007
DOI: 10.1186/AR2175
Publisher: Wiley
Date: 12-04-2017
DOI: 10.1002/EHF2.12151
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 04-12-2018
Abstract: Epicardial adipose tissue ( EAT ) is in immediate apposition to the underlying myocardium and, therefore, has the potential to influence myocardial systolic and diastolic function or myocardial geometry, through paracrine or compressive mechanical effects. We aimed to review the association between volumetric EAT and markers of myocardial function and geometry. PubMed, Medline, and Embase were searched from inception to May 2018. Studies were included only if complete EAT volume or mass was reported and related to a measure of myocardial function and/or geometry. Meta‐analysis and meta‐regression were used to evaluate the weighted mean difference of EAT in patients with and without diastolic dysfunction. Heterogeneity of data reporting precluded meta‐analysis for systolic and geometric associations. In the 22 studies included in the analysis, there was a significant correlation with increasing EAT and presence of diastolic dysfunction and mean e′ (average mitral annular tissue Doppler velocity) and E/e′ (early inflow / annular velocity ratio) but not E/A (ratio of peak early (E) and late (A) transmitral inflow velocities), independent of adiposity measures. There was a greater EAT in patients with diastolic dysfunction (weighted mean difference, 24.43 mL 95% confidence interval, 18.5–30.4 mL P .001), and meta‐regression confirmed the association of increasing EAT with diastolic dysfunction ( P =0.001). Reported associations of increasing EAT with increasing left ventricular mass and the inverse correlation of EAT with left ventricular ejection fraction were inconsistent, and not independent from other adiposity measures. EAT is associated with diastolic function, independent of other influential variables. EAT is an effect modifier for chamber size but not systolic function.
Publisher: BMJ
Date: 15-12-2008
Abstract: Diastolic dysfunction (DD) is highly prevalent and associated with increased morbidity and mortality, but its natural history remains poorly defined. This cohort study sought to characterise the influence of clinical features, medical therapy and echocardiographic parameters on the progression of DD. We identified 926 consecutive patients (aged 62 (14) years, 221 women) with DD and preserved systolic function. A repeat echocardiogram was performed in 199 patients > or =1 year after the baseline study (average 3.6 (1.4) years). Follow-up for 4.8 (2.5) years was 97% complete for the major endpoint of all-cause mortality. Cox regression analyses were performed to identify the associations of mortality. Over follow-up, 142 patients died and 22 were admitted with heart failure. The independent predictors of death were age, hyperlipidaemia, co-morbid disease and restrictive filling. The degree of diastolic dysfunction remained stable in 52%, deteriorated in 27% and improved in 21%. There was a greater use of medical therapy in those with stable or worsening diastolic function when the protective effects of these agents were taken into account in a multivariate model, improvement in diastolic dysfunction was associated with a survival benefit. DD is associated with all-cause mortality, independent of the presence of a major co-morbidity. The degree of DD remains stable in about 50% of patients, the population whose diastolic function improves over time has a more favourable outcome.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2000
Publisher: Elsevier BV
Date: 11-2012
DOI: 10.1016/J.JCMG.2012.07.013
Abstract: Decisions regarding surgery for mitral regurgitation (MR) are predicated on the accurate quantification of MR severity. Quantitative parameters, including vena contracta width, regurgitant volume and fraction, and effective regurgitant orifice area have prognostic significance and are recommended to be obtained from patients with more than mild MR. New tools for MR quantification have been provided by 3-dimensional echocardiography, cardiac magnetic resonance, and cardiac computed tomography, but limited guidance on appropriate image acquisition and post-processing techniques has hindered their clinical application and reproducibility. This review describes optimal image acquisition and post-processing methods for quantification of MR.
Publisher: Elsevier BV
Date: 07-1988
DOI: 10.1016/S0140-6736(88)90003-7
Abstract: Resuscitation for cardiac arrest was monitored over 4 years to examine the effect on survival of a change in the ventricular fibrillation (VF) protocol to include the routine early use of "high-dose" intravenous or transbronchial adrenaline. A significant reduction in the immediate survival of patients with VF was seen when the protocol was changed (22% after the change, 43% before). Prior predictors of poor response were similar in each group, except for the number of witnessed arrests, delay until cardiopulmonary resuscitation, and occurrence of endotracheal intubation, but multiple logistic regression showed the use of adrenaline to be an independent predictor of outcome. Early high-dose adrenaline was associated with a reduction in immediate survival in patients with persistent VF.
Publisher: Elsevier BV
Date: 03-2017
DOI: 10.1016/J.JCMG.2016.11.015
Abstract: The purpose of the study was to evaluate the benefit of care guided by the detection of stage B heart failure (SBHF) using advanced echocardiography for the reduction of new HF in the community. The detection of nonischemic SBHF has been facilitated by advanced echocardiographic imaging modalities. However, improved outcomes have not been proven as they are predicated on benefit of treatment. Between September 13, 2013 and November 6, 2015, 618 asymptomatic community-based patients with HF risks (age 71 ± 5 years) were randomized to care guided by advanced echocardiography (myocardial deformation and detailed diastolic function) versus usual care. Evidence of SBHF led to advice to the patients and their primary physicians to initiate treatment with angiotensin-converting enzyme inhibition and beta-adrenoceptor blockade. The trial followed the PROBE (Prospective Randomized Open Blinded Endpoint) design. Participants were followed for 1 year for the primary composite endpoint of death from cardiovascular causes and new HF. Advanced echocardiography identified 219 as having SBHF and treatment was advised. Over a mean follow-up of 13 ± 6 months, 67 reached the primary endpoint. The incidence rate of HF was no different between the 2 arms (p = 0.47), likely because only 43% initiated therapy, and only 9% achieved target dose. Among subjects needing therapy on the basis of imaging and adherence to therapy, imaging-guided care showed a 77% lower hazard for the primary outcome (p = 0.04). The detection of SBHF from strain and diastolic function evaluation was associated with a higher incidence of incidence HF and death. The efficacy of pharmacological intervention with angiotensin-converting enzyme inhibition and beta-adrenoceptor blockade is limited by its uptake, and alternative strategies should be considered. (Tasmanian Study of Echocardiographic Detection of Left Ventricular Dysfunction [TAS-ELF] ACTRN12614000080628).
Publisher: Elsevier BV
Date: 10-2021
Publisher: AMPCo
Date: 18-02-2019
DOI: 10.5694/MJA2.50021
Abstract: To compare the outcomes and safety of a rapid access chest pain clinic (RACPC) in Australia with those of a general cardiology clinic. Prospective comparison of the outcomes for patients attending an RACPC and those of historical controls. Royal Hobart Hospital cardiology outpatient department. 1914 patients referred for outpatient evaluation of new onset chest pain (1479 patients seen in the RACPC, 435 patients previously seen in the general cardiology clinic). Service outcomes (review times, number of clinic reviews) adverse events (unplanned emergency department re-attendances at 30 days and 12 months major adverse cardiovascular events at 12 months, including unplanned revascularisation, acute coronary syndrome, stroke, cardiac death). Median time to review was shorter for RACPC than for usual care patients (12 days [IQR, 8-15 days] v 45 days [IQR, 27-89 days]). All patients seen in the RACPC received a diagnosis at the first clinic visit, but only 139 patients in the usual care group (32.0%). There were fewer unplanned emergency department re-attendances for patients in the RACPC group at 30 days (1.6% v 4.4%) and 12 months (5.7% v 12.9%) than in the control group. Major adverse cardiovascular events were less frequent among patients evaluated in the RACPC (0.2% v 1.4%). Patients were evaluated more efficiently in the RACPC than in a traditional cardiology clinic, and their subsequent rates of emergency department re-attendances and adverse cardiovascular events were lower.
Publisher: Elsevier BV
Date: 2015
Publisher: Elsevier BV
Date: 02-2023
Publisher: Elsevier BV
Date: 02-2015
DOI: 10.1016/J.ECHO.2014.11.003
Abstract: Recognizing the critical need for standardization in strain imaging, in 2010, the European Association of Echocardiography (now the European Association of Cardiovascular Imaging, EACVI) and the American Society of Echocardiography (ASE) invited technical representatives from all interested vendors to participate in a concerted effort to reduce intervendor variability of strain measurement. As an initial product of the work of the EACVI/ASE/Industry initiative to standardize deformation imaging, we prepared this technical document which is intended to provide definitions, names, abbreviations, formulas, and procedures for calculation of physical quantities derived from speckle tracking echocardiography and thus create a common standard.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 13-03-2007
DOI: 10.1161/CIRCULATIONAHA.106.640334
Abstract: Background— Wall motion score at dobutamine stress echocardiography is an independent predictor of mortality. We sought to determine whether quantification of DSE by strain rate imaging was incremental to wall motion score for predicting outcome. Methods and Results— In 646 patients undergoing dobutamine stress echocardiography for the evaluation of known or suspected coronary disease, customized software was used to automatically measure peak systolic strain rate (SR s ) and end-systolic strain (S es ) in 18 segments. Results were expressed as the number of abnormal segments and the mean SR s and S es per patient. All-cause mortality was identified over 7 years of follow-up (mean, 5.2±1.5 years). Contributions of clinical, wall motion, and SR s and S es data to outcome were analyzed with Cox models, which also were used to define cut points for SR s and S es . Ischemia (new or worsening wall motion abnormalities) was detected in 45%, and 39% had a previous myocardial infarction. In patients with no ischemia, annualized mortality without and with previous myocardial infarction were 2% and 3% compared with 5% in patients with ischemia. Peak wall motion score index, mean SR s , segmental S es , and segmental SR s were all predictors of mortality, but only segmental SR s (hazard ratio, 3.6 95% CI, 1.7 to 7.2) was independently predictive. In sequential Cox models, the model based on clinical data (overall χ 2 , 12.7) was improved by peak wall motion score index (18.4, P =0.002) and further increased by either segmental SR s (31.8, P .001) or mean SR s (25.7, P =0.009). Conclusions— Segmental analysis by SR s , derived from automated strain rate imaging analysis of dobutamine stress echocardiography response, offers prognostic information that is independent and incremental to standard wall motion score index.
Publisher: Elsevier BV
Date: 03-2009
DOI: 10.1016/J.ECHO.2008.11.030
Abstract: Exercise 3-dimensional echocardiography (3DE) may avoid the problem of poorly matched pre- and post-exercise 2-dimensional echocardiograms (2DE), and contraction front mapping (CFM) may be used to quantify the temporal homogeneity of contraction. We compared 3DE with 2DE for identification of angiographically significant disease. Conventional 2DE and 3DE at rest and peak stress were performed in 110 patients (78 men, aged 60 +/- 11 years) who underwent angiography within 6 months. Offline assessment of CFM was performed qualitatively (delayed regional relaxation in a coronary territory) and quantitatively (difference in regional and global contraction delays from rest to peak in in idual segments). The accuracy of each test was calculated for identification of 70% or more diameter angiographic stenoses. Patients were excluded for nondiagnostic stress (n = 12) or poor-quality 3DE (n = 8). Time until end of 2DE acquisition was 58 +/- 25 seconds, and time until end of 3DE (taken after 2DE) was 109 +/- 55 seconds. Receiver operating characteristic analyses were used to define normal cutoff ranges of contraction delays for the following coronary territories: left anterior descending (<or=10%), left coronary artery (<or=10%), right coronary artery (<or=11%), and overall (<or=10%). The concordance between angiography and qualitative CFM (63%) was similar to quantitative CFM (70%). The sensitivity of wall motion assessment at 3DE (40%) was lower than CFM (55%, P = .04) and 2DE (83%, P < .01) at comparable levels of specificity (65%, 84%, and 78%). Although the higher specificity of 3DE may represent avoidance of false-positives from off-axis imaging, the sensitivity of 3DE is insufficient for clinical use. Analysis of the temporal distribution of contraction may be more sensitive than 3D wall motion assessment for identification of ischemia at exercise 3DE.
Publisher: Wiley
Date: 11-02-2021
DOI: 10.1002/EHF2.13247
Abstract: Several different diagnostic parameters can be used to assess left ventricular (LV) longitudinal systolic function, but no studies comparing their predictive value have been conducted. We sought to compare the prognostic value of LV long‐axis function parameters at rest and exercise using the population with heart failure with preserved ejection fraction (HFpEF). Clinical and biochemical variables were collected at baseline in 201 patients with HFpEF. Echocardiography was performed at rest and immediately after exercise, with measurement of mitral annular plane systolic excursion, systolic tissue velocity (s′), global longitudinal strain (GLS), and global longitudinal strain rate (GLSR). Participants were followed for 48 (24–60) months for heart failure hospitalization and cardiovascular death. Seventy‐four patients (36.8%) met the study endpoint. Cox regression analysis revealed that after adjustment for Meta‐Analysis Global Group in Chronic Heart Failure risk score, brain natriuretic peptide (BNP), and peak VO 2 , heart failure hospitalization and cardiovascular death were significantly associated with GLS at rest [hazard ratio (HR) 0.91 95% confidence interval (CI) 0.84–0.98 P = 0.016], GLS after exercise (HR 0.84 95% CI 0.77–0.91 P 0.001), and GLSR after exercise (HR 0.13 95% CI 0.04–0.48 P = 0.002). The addition of each of the following: exercise GLS and GLSR and resting GLS to the base model including Meta‐Analysis Global Group in Chronic Heart Failure, BNP, and peak VO 2 improved predictive power for the study endpoint [net reclassification improvement (NRI) = 49%, P 0.001 NRI = 42%, P = 0.004 and NRI = 38%, P = 0.009, respectively]. Exercise GLS was the only longitudinal parameter significantly improving c ‐statistics of the base model (0.68 vs. 0.73 P = 0.047). Echocardiographic parameters of LV longitudinal function are not equipotential in predicting adverse outcomes in HFpEF. LV deformation indices, especially assessed with exercise, show the highest predictive utility independent from and incremental to clinical data and BNP.
Publisher: Elsevier BV
Date: 10-2006
DOI: 10.1016/J.CARREV.2006.07.002
Abstract: Heart failure (HF) in association with acute myocardial infarction is an emerging clinical problem. The benefits of aldosterone blockade have now been extended, with the selective aldosterone antagonist eplerenone demonstrating reduced mortality compared to placebo, in patients with post-myocardial infarction HF. The evidence supporting this agent will be briefly reviewed, followed by a discussion on the clinical implications of aldosterone antagonists in this clinical setting.
Publisher: BMJ
Date: 23-05-2014
DOI: 10.1136/HEARTJNL-2014-305538
Abstract: Global longitudinal strain (GLS) is a robust, well validated and reproducible technique for the measurement of LV longitudinal deformation. We sought to assemble evidence that GLS is an accurate marker in predicting cardiovascular outcomes, compared to LVEF. We undertook a systematic review of the evidence from observational studies which compared GLS against LVEF in predicting major adverse cardiac events. The primary outcome was all-cause mortality. The secondary outcome was a composite of cardiac death, malignant arrhythmia, hospitalisation due to heart failure, urgent valve surgery or heart transplantation, and acute coronary ischaemic event. A random effects model was used to combine HR and 95% CIs. A meta-regression was undertaken to assess the impact of potential covariates. Data were collated from 16 published articles (n=5721 adults) comprising 15 prospective and 1 retrospective observational studies. The underlying cardiac conditions were heart failure, acute myocardial infarction, valvular heart disease, and miscellaneous cardiac diseases. Mortality was independently associated with each SD change in the absolute value of baseline GLS (HR 0.50, 95% CI 0.36 to 0.69 p<0.002) and less strongly with LVEF (HR 0.81, 95% CI 0.72 to 0.92 p=0.572). The HR per SD change in GLS was associated with a reduction in mortality 1.62 (95% CI 1.13 to 2.33 p=0.009) times greater than the HR per SD change in LVEF. There is strong evidence of the prognostic value of GLS, which appears to have superior prognostic value to EF for predicting major adverse cardiac events.
Publisher: Elsevier BV
Date: 12-2018
DOI: 10.1016/J.JCMG.2017.07.028
Abstract: This study sought to determine the prognostic value of abnormal diastolic and systolic responses to exercise (on the basis of exertional E/e' and global longitudinal strain rate [GSR]) in a well-characterized population of patients with heart failure with preserved ejection fraction (HFpEF). Impaired cardiovascular functional reserve is believed to contribute to adverse outcomes in HFpEF. However, the exact characteristics of pathophysiological profiles associated with increased clinical risk are still poorly defined. A complete echocardiogram (including assessment of myocardial deformation) was performed at rest in 205 patients (64 ± 8 years of age) with symptomatic HFpEF. Echocardiography following maximal exercise was undertaken to assess abnormal diastolic reserve (AbnDR) (exertional E/e' >14) and exercise GSR. Patients were followed over 26 ± 5 months for death and cardiovascular or heart failure (HF) hospitalization. Cardiovascular hospitalization or death occurred in 64 patients (31%), including 51 (25%) with HF hospitalization. The composite endpoint was associated with AbnDR (hazard ratio: 2.69 95% confidence interval: 1.44 to 5.04 p = 0.002) and reduced exercise GSR (hazard ratio: 0.14 95% confidence interval: 0.04 to 0.49 p = 0.002). Both exercise parameters showed prognostic value, independent from and incremental to clinical data and B-type natriuretic peptide. The ability of E/e' and GSR measurements to predict outcomes on exertion exceeded their prognostic value at rest, and the presence of reduced exertional GSR in patients with AbnDR was associated with worse prognosis (p = 0.03 for the composite endpoint and p = 0.01 for HF hospitalization). Both left ventricular systolic and diastolic reserves contribute to risk prediction in HFpEF. The inclusion of the exertional assessment of left ventricular function to diagnostic algorithms may improve the prognostication process in this disease condition.
Publisher: Elsevier BV
Date: 12-2016
DOI: 10.1016/J.AMJCARD.2016.08.050
Abstract: This investigation sought to identify and quantify any increased risk of long-term heart failure (HF) after thoracic radiotherapy (RT) for cancer and identify any population covariates that corresponded with increased risk. Electronic databases were systematically searched for studies reporting relative risk, odds ratio, and hazard ratio (HR) for symptomatic HF more than 5 years after RT administration. Clinical characteristics, study design, univariable effect sizes, and associated 95% CIs were extracted. Univariable effect size was pooled and computed in a meta-analysis using random-effects model weighted by inverse variance. Six studies (45,669 patients) with weighted median follow-up duration of 13.9 years were included, each data-linkage study that reported HRs for HF. Pooled HR for long-term HF was significant (HR 1.83 [1.09 to 3.08], p = 0.022), with significant between-study heterogeneity (Q 43.38, df = 5, p <0.001, I
Publisher: Elsevier BV
Date: 02-2005
DOI: 10.1016/J.AHJ.2004.06.021
Abstract: The prevalence of left ventricular hypertrophy (LVH), coronary artery disease, and subclinical cardiomyopathy in diabetic patients without known cardiac disease is unclear. We sought the frequency of these findings to determine whether plasma brain natriuretic peptide (BNP) could be used as an alternative screening tool to identify subclinical LV dysfunction. Asymptomatic patients with diabetes mellitus without known cardiac disease (n = 101) underwent clinical evaluation, measurement of BNP, exercise stress testing, and detailed echocardiographic assessment. After exclusion of overt dysfunction or ischemia, subclinical myocardial function was sought on the basis of myocardial systolic (Sm) and diastolic velocity (Em). Association was sought between subclinical dysfunction and clinical, biochemical, exercise, and echocardiographic variables. RESULTS Of 101 patients, 22 had LVH and 16 had ischemia evidenced by exercise-induced wall motion abnormalities. Only 4 patients had abnormal BNP levels BNP was significantly increased in patients with LVH. After exclusion of LVH and coronary artery disease, subclinical cardiomyopathy was identified in 24 of 66 patients. Subclinical disease could not be predicted by BNP. Even after exclusion of asymptomatic ischemia and hypertrophy, subclinical systolic and diastolic dysfunction occurs in a significant number of patients with type 2 diabetes. However, screening approaches, including BNP, do not appear to be sufficiently sensitive to identify subclinical dysfunction, which requires sophisticated echocardiographic analysis.
No related grants have been discovered for Thomas Marwick.