Factors associated with reporting left ventricular ejection fraction with 3D echocardiography in real-world practice.

BACKGROUND: Guidelines recommend 3D echocardiography (3DE) to assess left ventricular ejection fraction (LVEF) on transthoracic echocardiogram (TTE) when possible, but it is unclear which factors are most strongly associated with reporting 3DE LVEF in real-world practice. METHODS: We evaluated 3DE LVEF reporting by age, sex, BMI, TTE location and variation in reporting by sonographer and reader. All TTEs were performed without contrast enhancement agent at a large medical center from 9/2015 to 12/2020 using ultrasound machines capable of 3DE. We used multivariable logistic regression to assess which factors were most associated with reporting 3DE LVEF. RESULTS: Among 35 641 TTEs included in this study, 57.4% were performed on women. 3DE LVEF was reported on 18 391 TTEs (51.6% of cohort; 50.5% for women and 52.4% for men). Portable inpatient TTEs (n = 5569) had the lowest rates of 3DE LVEF reporting (30.9%), while general outpatient TTEs (n = 15 933) had greater reporting (56.9%). Outpatient TTEs with an indication for chemotherapy (n = 3244) had the highest rates of 3DE LVEF (87.2%). The median (IQR) percentage of TTEs reporting 3D LVEF was 52.7% (43.1%-68.1%) among sonographers and 51.6% (46.5%-59.6%) among readers. Among 20082 (56.3%) TTEs with 3DE LVEF measured by sonographers, 91.6% were included by readers in the final report. After adjustment, performing sonographer in the highest reporting quartile was most strongly associated with reporting 3DE LVEF (OR 7.04, 95% CI 6.55-7.56), while an inpatient portable study had the strongest negative association for reporting (OR .38, 95% CI .35-.40). CONCLUSIONS: Use of 3DE LVEF in real-world practice varies substantially based on performing sonographer and is low for hospitalized patients, but can be frequently used for chemotherapy. Initiatives are needed to increase sonographer 3DE acquisition in most clinical settings.

Routine Use of Contrast on Admission Transthoracic Echocardiography for Heart Failure Reduces the Rate of Repeat Echocardiography during Index Admission.

BACKGROUND: The authors retrospectively evaluated the impact of ultrasound enhancing agent (UEA) use in the first transthoracic echocardiographic (TTE) examination, regardless of baseline image quality, on the number of repeat TTEs and length of stay (LOS) during a heart failure (HF) admission. METHODS: There were 9,115 HF admissions associated with admission TTE examinations over a 4-year period (5,337 men; mean age, 67.6 ± 15.0 years). Patients were grouped into those who received UEAs (contrast group) in the first TTE study and those who did not (noncontrast group). Repeat TTE examinations were classified as justified if performed for concrete clinical indications during hospitalization. RESULTS: In the 9,115 admissions for HF (5,600 in the contrast group, 3,515 in the noncontrast group), 927 patients underwent repeat TTE studies (505 in the contrast group, 422 in the noncontrast group), which were considered justified in 823 patients. Of the 104 patients who underwent unjustified repeat TTE studies, 80 (76.7%) belonged to the noncontrast group and 24 to the contrast group. Also, UEA use increased from 50.4% in 2014 to 74.3%, and the rate of unjustified repeat studies decreased from 1.3% to 0.9%. The rates of unjustified repeat TTE imaging were 2.3% and 0.4% (in the noncontrast and contrast groups, respectively), and patients in the contrast group were less likely to undergo unjustified repeat examinations (odds ratio, 0.18; 95% CI, 0.12-0.29; P < .0001). The mean LOS was significantly lower in the contrast group (9.5 ± 10.5 vs 11.1 ± 13.7 days). The use of UEA in the first TTE study was also associated with reduced LOS (linear regression, ß1 = -0.47, P = .036), with 20% lower odds for odds of prolonged (>6 days) LOS. CONCLUSIONS: The routine use of UEA in the first TTE examination for HF irrespective of image quality is associated with reduced unjustified repeat TTE testing and may reduce LOS during an index HF admission.

Revised Framingham Stroke Risk Score, Nontraditional Risk Markers, and Incident Stroke in a Multiethnic Cohort.

BACKGROUND AND PURPOSE: Limited data exist on the performance of the revised Framingham Stroke Risk Score (R-FSRS) and the R-FSRS in conjunction with nontraditional risk markers. We compared the R-FSRS, original FSRS, and the Pooled Cohort Equation for stroke prediction and assessed the improvement in discrimination by nontraditional risk markers. METHODS: Six thousand seven hundred twelve of 6814 participants of the MESA (Multi-Ethnic Study of Atherosclerosis) were included. Cox proportional hazard, area under the curve, net reclassification improvement, and integrated discrimination increment analysis were used to assess and compare each stroke prediction risk score. Stroke was defined as fatal/nonfatal strokes (hemorrhagic or ischemic). RESULTS: After mean follow-up of 10.7 years, 231 of 6712 (3.4%) strokes were adjudicated (2.7% ischemic strokes). Mean stroke risks using the R-FSRS, original FSRS, and Pooled Cohort Equation were 4.7%, 5.9%, and 13.5%. The R-FSRS had the best calibration (Hosmer-Lemeshow goodness-of-fit, χ2=6.55; P=0.59). All risk scores were predictive of incident stroke. C statistics of R-FSRS (0.716) was similar to Pooled Cohort Equation (0.716), but significantly higher than the original FSRS (0.653; P=0.01 for comparison with R-FSRS). Adding nontraditional risk markers individually to the R-FSRS did not improve discrimination of the R-FSRS in the area under the curve analysis, but did improve category-less net reclassification improvement and integrated discrimination increment for incident stroke. The addition of coronary artery calcium to R-FSRS produced the highest category-less net reclassification improvement (0.36) and integrated discrimination increment (0.0027). Similar results were obtained when ischemic strokes were used as the outcome. CONCLUSIONS: The R-FSRS downgraded stroke risk but had better calibration and discriminative ability for incident stroke compared with the original FSRS. Nontraditional risk markers modestly improved the discriminative ability of the R-FSRS, with coronary artery calcium performing the best.

Bioprosthetic tricuspid valve thrombosis: Percutaneous PFO closure to improve hypoxia and respiratory failure.

Prosthetic valve thrombosis (PVT) is an increasingly recognized complication of bioprosthetic valve replacement, often resulting in abnormal hemodynamic, endothelial, and hemostatic conditions. Bioprosthetic PVT may lead to significant hemodynamic and clinical effects. In hemodynamically stable patients, first-line treatment for bioprosthetic PVT is systemic anticoagulation. However, concomitant cardiovascular pathology may lead to additional clinical sequalae that requires acute therapeutic interventions. We describe two cases in which bioprosthetic PVT leads to hemodynamically significant intracardiac shunting through pre-existing patent foramen ovales requiring percutaneous closure with a Cribriform AMPLATZER occluder device. We also review the treatment for bioprosthetic PVT and discuss important clinical and hemodynamic considerations.

Adult Height, Prevalent Coronary Artery Calcium Score, and Incident Cardiovascular Disease Outcomes in a Multiethnic Cohort.

We assessed the relationships among adult height, coronary artery calcium (CAC) score, incident atherosclerotic cardiovascular disease (ASCVD) events, and atrial fibrillation (AFib) in a multiethnic cohort. We used race/ethnicity-specific height (dichotomized by median value and in quartiles) as the predictor variable within the 4 racial/ethnic groups in the Multi-Ethnic Study of Atherosclerosis (n = 6,814). After a mean of 10.2 years of follow-up (2000-2012), 556 ASCVD events (8.2%) and 539 AFib events (7.9%) occurred. Adult height was not associated with prevalent CAC score (ln(CAC + 1) or categories). Tall stature (i.e., race/ethnicity-specific height ≥median) had a significant but opposite association with future ASCVD and AFib (hazard ratios were 0.72 (95% confidence interval: 0.56, 0.92) and 1.38 (95% confidence interval: 1.07, 1.79), respectively). We observed a gradient-response but opposite association between quartiles of race/ethnicity-specific height and ASCVD/AFib events in our multivariable models. A formal test of interaction between race/ethnicity-specific height and sex was not significant in the ASCVD model (P = 0.78) but was significant in the AFib model (P = 0.03). Tall stature was associated (in a gradient-response fashion) with reduced risk of ASCVD events and increased risk of AFib. Adult height may signal interactions between genetic and environmental factors and may provide risk information independent of current traditional risk factors and CAC score.

Adult Chest Pain in the Pediatric Emergency Department: Treatment and Timeliness From Door In To Door Out.

OBJECTIVES: The American College of Cardiology Foundation/American Heart Association guidelines for acute coronary syndrome (ACS) recommend immediate aspirin (ASA) administration, an electrocardiogram (ECG) in less than 10 minutes, and a door-in to door-out (DIDO) time less than 30 minutes for interfacility transfer. We sought to determine if compliance is hindered when adults with suspected ACS present to pediatric facilities. METHODS: Visits to the 2 tertiary care emergency departments of a pediatric healthcare system using an adult chest pain protocol were examined from October 2006 to September 2012. Patients older than 18 years with a diagnosis suggestive of ACS and an initial ECG interpretation were identified. Proportions of patients receiving ASA were calculated as well as median times to ECG and DIDO. Bivariate analysis of ECG and DIDO time and the proportion of the patients receiving ASA was conducted for ECG findings positive and negative for ACS. RESULTS: One hundred thirteen patients were identified. Aspirin was administered in 69% of eligible cases. Electrocardiogram and DIDO times met recommended intervals in 42% (median, 12 minutes) and 5% (median, 59 minutes) of the patients, respectively. No significant differences between positive (22% of total) and negative (78% of total) ECG findings groups were detected in median DIDO time (57 vs 59 minutes, P = 0.99), time to ECG (14 vs 12 minutes, P = 0.45), or the proportion receiving ASA (84% vs 64%, P = 0.08). CONCLUSIONS: Despite the use of an emergency department protocol, compliance with the American College of Cardiology Foundation/American Heart Association guidelines for adults with suspected ACS remained challenging at this pediatric center. The ECG findings did not seem to impact ASA administration, ECG time, or DIDO time.

Guideline-based statin/lipid-lowering therapy eligibility for primary prevention and accuracy of coronary artery calcium and clinical cardiovascular events: The Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND: With multiple cholesterol guidelines, we evaluated the accuracy of recommended statin therapy on identifying coronary artery calcium (CAC) and cardiovascular disease (CVD) events by 2004 NCEP/ ATP III, 2016 ESC/EAS, and 2013 ACC/AHA guidelines. HYPOTHESIS: ACC/AHA guidelines are more accurate in identifying persons at risk for CVD. METHODS: 5002/6814 participants age <75 years and free of CVD were included. CAC categories (>0, ≥100, and ≥300) and 10 years of CVD outcomes were considered. Sensitivity (SN), specificity (SP), positive and negative predictive value (PPV and NPV), and likelihood ratios (LR) were calculated. Mean age was 59 years; 47% of subjects were males. RESULTS: 1297 (26%), 1381 (28%), and 2538 (51%) had class I indications for statin/LLT by the NCEP ATP III, ESC/EAS, and AHA/ACC guidelines, respectively. SN, SP, NPV, and PPV for CAC ≥300 were: NCEP ATP III (41.1%, 75.5%, 93.3% and 13.4%), ESC/EAS (54.1%, 74.8%, 94.6% and16.6%), and ACC/AHA (87.2%, 52.6%, 97.8% and 14.5%). SN, SP, PPV, and NPV for corresponding CVD outcomes were: NCEP ATP III (45.8%, 75.1%, 96.3%, and 8.9%), ESC/EAS (50.5%, 72.9%, 98.7%, and 3.6%), and AHA/ACC (79.6%, 50.7%, 98%, and 7.7%). ESC/EAS had significantly higher positive LR 2.15 (95% CI, 1.95 - 2.38) and ACC/AHA had significantly lower negative LR [0.24, (95% CI 0.19 - 0.31)] for corresponding CVD. CONCLUSIONS: Despite the increased in SN of statin eligibility by the ACC/AHA, it has similar NPV and PPV for CAC/future CVD events. The ACC/AHA class I indications for statin may be a superior screening tool for subclinical and clinical CVD.

Impact of Replacing the Pooled Cohort Equation With Other Cardiovascular Disease Risk Scores on Atherosclerotic Cardiovascular Disease Risk Assessment (from the Multi-Ethnic Study of Atherosclerosis [MESA]).

The increase in statin eligibility by the new cholesterol guidelines is mostly driven by the Pooled Cohort Equation (PCE) criterion (≥7.5% 10-year PCE). The impact of replacing the PCE with either the modified Framingham Risk Score (FRS) or the Systematic Coronary Risk Evaluation (SCORE) on assessment of atherosclerotic cardiovascular disease (ASCVD) risk assessment and statin eligibility remains unknown. We assessed the comparative benefits of using the PCE, FRS, and SCORE for ASCVD risk assessment in the Multi-Ethnic Study of Atherosclerosis. Of 6,815 participants, 654 (mean age 61.4 ± 10.3; 47.1% men; 37.1% whites; 27.2% blacks; 22.3% Hispanics; 12.0% Chinese-Americans) were included in analysis. Area under the curve (AUC) and decision curve analysis were used to compare the 3 risk scores. Decision curve analysis is the plot of net benefit versus probability thresholds; net benefit = true positive rate - (false positive rate × weighting factor). Weighting factor = Threshold probability/1 - threshold probability. After a median of 8.6 years, 342 (6.0%) ASCVD events (myocardial infarction, coronary heart disease death, fatal or nonfatal stroke) occurred. All 4 risk scores had acceptable discriminative ability for incident ASCVD events; (AUC [95% CI] PCE: 0.737 [0.713 to 0.762]; FRS: 0.717 [0.691 to 0.743], SCORE (high risk) 0.722 [0.696 to 0.747], and SCORE (low risk): 0.721 [0.696 to 0.746]. At the ASCVD risk threshold recommended for statin eligibility for primary prevention (≥7.5%), the PCE provides the best net benefit. Replacing the PCE with the SCORE (high), SCORE (low) and FRS results in a 2.9%, 8.9%, and 17.1% further increase in statin eligibility. The PCE has the best discrimination and net benefit for primary ASCVD risk assessment in a US-based multiethnic cohort compared with the SCORE or the FRS.

Associations of ECG interval prolongations with mortality among ESRD patients evaluated for renal transplantation.

BACKGROUND: It is unknown whether prolongation of electrocardiogram (ECG) intervals is associated with mortality in end-stage renal disease (ESRD) patients evaluated for renal transplantation. MATERIAL AND METHODS: We examined the relationship between 12-lead ECG interval measurements (PR >200 ms, QRS >110 ms, or QTC >450 ms) and the presence of none, 1, and 2 or more ECG interval prolongations with all-cause mortality in 930 adult ESRD patients evaluated for renal transplantation from August 2006 to October 2008 and followed through November 2010. RESULTS: A total of 108 (11.6%) patients died after a median follow-up of 3.1 years. A stepwise increase in all-cause mortality occurred among adult ESRD patients with prolongation of 1, and 2 or more ECG intervals. In adjusted analyses, the rate of death in patients with at least 1 ECG interval prolongation was 69% higher than that of patients with no ECG prolongations (HR=1.69; 95% CI: 1.05-2.73). Patients with 2 or more ECG interval prolongations had a 2.5-fold increased likelihood of dying vs. patients with no ECG interval prolongations (HR 2.53, 95% CI 1.38-4.82). CONCLUSIONS: ECG interval prolongations are associated with higher mortality in patients evaluated for renal transplantation. The ECG is a potentially important evaluative tool for risk assessment in this population.

Partial papillary muscle rupture: a cause of acute mitral regurgitation.

A 56-year-old woman presented to the cardiology clinic with a 7-day history of dyspnea and chest pressure. An echocardiogram showed a flail posterior mitral valve leaflet, and subsequent left heart catheterization showed complete occlusion of the first obtuse marginal coronary artery. Further investigation demonstrated the culprit lesion to be ischemic partial rupture of the posteromedial papillary muscle. Timely recognition of this condition allowed for an optimal clinical outcome. In this Cardiology Grand Rounds, the authors further describe the above presentation of ischemic partial papillary muscle rupture and provide a brief review of the pathophysiology, diagnosis and treatment of this condition.

Long-term outcomes after percutaneous patent foramen ovale closure.

Percutaneous patent foramen ovale (PFO) closure is a treatment for cryptogenic stroke and migraine headache. The goal of this study was to assess long-term outcomes of patients treated with percutaneous PFO closure. Records of patients with percutaneous PFO closure at Emory University Hospital from February 2002 to July 2009 were reviewed. Follow-up telephone questionnaire and chart review assessed recurrent stroke, migraine, and complications. Data was reviewed on 414 consecutive patients. Long-term follow-up was obtained in 207 of patients, and mean follow up was 4.6 ± 2.0 years. Cryptogenic stroke was the primary indication for intervention in 193 (93%) patients. Thirteen (7%) patients had a recurrent neurologic event post closure. In patients with multiple neurological events at baseline, 17% (n = 11) had a recurrent event, compared with 2% (n = 2) of patients with a single neurological event prior to PFO-closure (P < 0.002). Post closure, migraine frequency and severity declined from 4.5 to 1.1 migraine/month (P < 0.01) and 7.2 to 3.6 out of 10 (P < 0.01) in patients with history of migraine (n = 60). Thirty-day mortality was 1% (n = 2). One patient had device erosion 5 years post-procedure requiring emergent surgery. Atrial fibrillation was newly diagnosed in 8 (4%) patients within 6 months. In conclusion, the long-term rate of recurrent stroke after PFO closure is low in patients with a single neurological event at baseline. Serious long-term complications after PFO closure are rare. PFO closure may decrease the frequency and severity of migraine.

Object familiarity modulates the relationship between visual object imagery and haptic shape perception.

Although visual cortical engagement in haptic shape perception is well established, its relationship with visual imagery remains controversial. We addressed this using functional magnetic resonance imaging during separate visual object imagery and haptic shape perception tasks. Two experiments were conducted. In the first experiment, the haptic shape task employed unfamiliar, meaningless objects, whereas familiar objects were used in the second experiment. The activations evoked by visual object imagery overlapped more extensively, and their magnitudes were more correlated, with those evoked during haptic shape perception of familiar, compared to unfamiliar, objects. In the companion paper (Deshpande et al., this issue), we used task-specific functional and effective connectivity analyses to provide convergent evidence: these analyses showed that the neural networks underlying visual imagery were similar to those underlying haptic shape perception of familiar, but not unfamiliar, objects. We conclude that visual object imagery is more closely linked to haptic shape perception when objects are familiar, compared to when they are unfamiliar.