Determinants of Diastolic Dysfunction Following Myocardial Infarction: Evidence for Causation Beyond Infarct Size.

BACKGROUND: The determinants of severe diastolic dysfunction (DD) following myocardial infarction (MI) are not well defined. This study sought to define the determinants of severe DD (restrictive mitral inflow pattern on Doppler echocardiography [RFP]) in patients with a first-ever MI, with particular emphasis on the impact of infarct size. METHODS: Retrospective single-centre study including consecutive patients admitted to a tertiary referral centre with a first-ever non-ST-elevation-MI (NSTEMI) or ST-elevation-MI (STEMI) (n=477). Peak troponin-I (Peak-TnI) was used as the principal measure of infarct size, whilst left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) were regarded as surrogate measures. Echocardiography was performed within 24 hours of admission for all patients. RFP was defined as E/A ratio >2.0 or E/A ratio >1.5 and E-wave deceleration time <140 ms. RESULTS: A total of 69 patients (14.5%) had RFP. Peak-TnI levels were higher in the RFP group (32.6±32.7 versus 16.9±25.2 µg/L, p<0.001). In sequential multivariable models incorporating significant clinical, angiographic and left ventricular (LV) size-related variables, Peak-TnI (OR 1.98, p=0.001), WMSI (OR 2.34, p=0.048) and LVEF (OR 0.97, p=0.044) were independent predictors of RFP. Presence of diabetes was also an independent predictor in all the models constructed. When patients were stratified according to an LVEF of 50%, 39% of RFP patients had a preserved LVEF (RFP/preserved EF group), and these patients had lower Peak-TnI levels compared to the RFP/reduced EF group (14.4±18.7 vs 44.5±35.5 µg/L). CONCLUSIONS: Whilst infarct size is a major determinant of severe diastolic dysfunction after MI, a significant subset of patients develop severe diastolic dysfunction despite a small infarct size and preserved LVEF, highlighting that other factors such as pre-existing diastolic dysfunction due to risk factors such as diabetes have an important role in causation.

Eustachian valve endocarditis: Case report and literature review.

In the intravenous drug user (IVDU) population, infected right-sided valvular lesions are common, and this has been well described in the literature. The Eustachian valve (also known as the valve of the inferior vena cava) is another valve in close proximity to the tricuspid valve, which can, in rare cases, be the focus of infection. Eustachian valve endocarditis may be an under-recognised complication of Staphylococcus bacteraemia in IVDU population, often only identified by transesophageal imaging. We present a case of tricuspid valve endocarditis in an IVDU with secondary seeding on the Eustachian valve, and an accompanying literature review on this rare topic.

Cardiac Society of Australia and New Zealand position statement executive summary: coronary artery calcium scoring.

Introduction This article summarises the Cardiac Society of Australia and New Zealand position statement on coronary artery calcium (CAC) scoring. CAC scoring is a non-invasive method for quantifying coronary artery calcification using computed tomography. It is a marker of atherosclerotic plaque burden and the strongest independent predictor of future myocardial infarction and mortality. CAC scoring provides incremental risk information beyond traditional risk calculators such as the Framingham Risk Score. Its use for risk stratification is confined to primary prevention of cardiovascular events, and can be considered as individualised coronary risk scoring for intermediate risk patients, allowing reclassification to low or high risk based on the score. Medical practitioners should carefully counsel patients before CAC testing, which should only be undertaken if an alteration in therapy, including embarking on pharmacotherapy, is being considered based on the test result. Main recommendations CAC scoring should primarily be performed on individuals without coronary disease aged 45-75 years (absolute 5-year cardiovascular risk of 10-15%) who are asymptomatic. CAC scoring is also reasonable in lower risk groups (absolute 5-year cardiovascular risk, < 10%) where risk scores traditionally underestimate risk (eg, family history of premature CVD) and in patients with diabetes aged 40-60 years. We recommend aspirin and a high efficacy statin in high risk patients, defined as those with a CAC score ≥ 400, or a CAC score of 100-399 and above the 75th percentile for age and sex. It is reasonable to treat patients with CAC scores ≥ 100 with aspirin and a statin. It is reasonable not to treat asymptomatic patients with a CAC score of zero. Changes in management as a result of this statement Cardiovascular risk is reclassified according to CAC score. High risk patients are treated with a high efficacy statin and aspirin. Very low risk patients (ie, CAC score of zero) do not benefit from treatment.

Cardiovascular risk profile in burn survivors.

OBJECTIVE: Burn patients have prolonged derangements in metabolic, endocrine, cardiac and psychosocial systems, potentially impacting on their cardiovascular health. There are no studies on the risk of cardiovascular disease (CVD) after-burn. The aim of our study was to record lipid values and evaluate CVD risk in adult burn survivors. METHODS: In a cross-sectional study patients ≥18 years with burn injury between 18-80% total burn surface area (TBSA) from 1998 to 2012 had total cholesterol, low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides measured via finger prick. Means were compared to optimal ranges. Multivariate regression models were performed to assess the association of lipids with age, years after-burn and total body surface area % (TBSA). A p value <0.05 was considered significant. The Framingham General Cardiovascular Risk Score (FGCRS) was calculated. RESULTS: Fifty patients were included in the study. Compared to optimal values, patients had low HDL and high triglycerides. Greater %TBSA was associated with statistically significant elevation of triglycerides (p=0.007) and total cholesterol/HDL ratio (p=0.027). The median FGCRS was 3.9% (low) 10-year risk of CVD with 82% of patients in the low-risk category. Patients involved in medium/high level of physical activity had optimal values of HDL, TC/HDL and triglycerides despite the magnitude of TBSA%. CONCLUSION: Adult burn survivors had alterations in lipid profile proportional to TBSA, which could be modified by exercise, and no increase in overall formally predicted CVD risk in this cross sectional study.

The approach to patients with possible cardiac chest pain.

Chest pain is a common reason for presentation in hospital emergency departments and general practice. Some patients presenting with chest pain to emergency departments and, to a lesser extent, general practice will be found to have a life-threatening cause, but most will not. The challenge is to identify those who do in a safe, timely and cost-effective manner. An acute coronary syndrome cannot be excluded on clinical grounds alone. In patients with ongoing symptoms of chest pain, without an obvious other cause, ST-segment-elevation myocardial infarction should be excluded with a 12-lead electrocardiogram at the first available opportunity. Significant recent advances in the clinical approach to patients with acute chest pain, including better understanding of risk stratification, increasingly sensitive cardiac biomarkers and new non-invasive tests for coronary disease, can help clinicians minimise the risk of unexpected short-term adverse cardiac events. An approach that integrates these advances is needed to deliver the best outcomes for patients with chest pain. All hospital emergency departments should adopt such a strategic approach, and general practitioners should be aware of when and how to access these facilities.

Response to steroid therapy in cardiac sarcoidosis: insights from myocardial strain.

Sarcoidosis is a multisystem granulomatous disease of unknown atiology and cardiac involvement can occur. Echocardiographic abnormalities, such as left ventricular dysfunction, segmental wall thinning, ventricular aneurysm, or valvular abnormalities are often subtle until the later stages of the disease. However, sarcoid has a predilection to cause ventricular arrhythmias or conduction system abnormalities in the early stages and hence may develop palpitations, syncope, or sudden death before structural abnormalities are detected. If patients with early cardiac sarcoid are identified, they respond well to corticosteroid therapy, and defibrillator implantation may reduce the risk of sudden death from malignant arrhythmias. We present a case of a patient with cardiac sarcoid, manifesting as conduction system disease. Cardiac magnetic resonance imaging demonstrated a sarcoid granuloma within the LV septum. Although the standard echocardiographic evaluation was unremarkable, this area corresponded to abnormal strain imaging on echo. Similarly, while conventional echocardiographic measurements failed to demonstrate a response to steroid therapy, strain imaging showed improved regional myocardial function. This coincided with improvement in the conduction abnormalities. This case study showed the potential of strain imaging in demonstrating cardiac involvement from sarcoidosis and in assessing the therapeutic response to corticosteroid therapy.

Cardiovascular magnetic resonance and single-photon emission computed tomography for diagnosis of coronary heart disease (CE-MARC): a prospective trial.

BACKGROUND: In patients with suspected coronary heart disease, single-photon emission computed tomography (SPECT) is the most widely used test for the assessment of myocardial ischaemia, but its diagnostic accuracy is reported to be variable and it exposes patients to ionising radiation. The aim of this study was to establish the diagnostic accuracy of a multiparametric cardiovascular magnetic resonance (CMR) protocol with x-ray coronary angiography as the reference standard, and to compare CMR with SPECT, in patients with suspected coronary heart disease. METHODS: In this prospective trial patients with suspected angina pectoris and at least one cardiovascular risk factor were scheduled for CMR, SPECT, and invasive x-ray coronary angiography. CMR consisted of rest and adenosine stress perfusion, cine imaging, late gadolinium enhancement, and MR coronary angiography. Gated adenosine stress and rest SPECT used (99m)Tc tetrofosmin. The primary outcome was diagnostic accuracy of CMR. This trial is registered at controlled-trials.com, number ISRCTN77246133. FINDINGS: In the 752 recruited patients, 39% had significant CHD as identified by x-ray angiography. For multiparametric CMR the sensitivity was 86·5% (95% CI 81·8-90·1), specificity 83·4% (79·5-86·7), positive predictive value 77·2%, (72·1-81·6) and negative predictive value 90·5% (87·1-93·0). The sensitivity of SPECT was 66·5% (95% CI 60·4-72·1), specificity 82·6% (78·5-86·1), positive predictive value 71·4% (65·3-76·9), and negative predictive value 79·1% (74·8-82·8). The sensitivity and negative predictive value of CMR and SPECT differed significantly (p<0·0001 for both) but specificity and positive predictive value did not (p=0·916 and p=0·061, respectively). INTERPRETATION: CE-MARC is the largest, prospective, real world evaluation of CMR and has established CMR's high diagnostic accuracy in coronary heart disease and CMR's superiority over SPECT. It should be adopted more widely than at present for the investigation of coronary heart disease. FUNDING: British Heart Foundation.

Usefulness of right ventricular myocardial strain in assessment of response to thrombolytic therapy in acute pulmonary embolism.

Acute pulmonary embolism (PE) is a life-threatening illness that is an important cause of morbidity and mortality. Patients with extensive emboli usually have associated right ventricular (RV) dysfunction. With anticoagulation therapy, RV function usually returns to normal. In patients with massive and submassive PE, echocardiography may directly visualize the embolus or more commonly provide evidence of its haemodynamic sequelae. The McConnell's sign involving sparing of RV apical contraction coupled with akinesia of the RV free wall has previously been reported in patients with acute PE. We present a case of a patient who had massive acute PE with severe RV systolic dysfunction that was demonstrated with both conventional Doppler and strain imaging. Strain imaging was also able to demonstrate the rapid improvement of RV function in response to thrombolytic therapy.

Visualization of coronary venous anatomy by cardiovascular magnetic resonance.

BACKGROUND: Coronary venous imaging with whole-heart cardiovascular magnetic resonance (CMR) angiography has recently been described using developmental pulse sequences and intravascular contrast agents. However, the practical utility of coronary venous imaging will be for patients with heart failure in whom cardiac resynchronisation therapy (CRT) is being considered. As such complementary information on ventricular function and myocardial viability will be required. The aim of this study was to determine if the coronary venous anatomy could be depicted as part of a comprehensive CMR protocol and using a standard extracellular contrast agent. METHODS AND RESULTS: Thirty-one 3D whole heart CMR studies, performed after intravenous administration of 0.05 mmol/kg gadolinium DTPA, were reviewed. The cardiac venous system was visualized in all patients. The lateral vein of the left ventricle was present in 74%, the anterior interventricular vein in 65%, and the posterior interventricular vein in 74% of patients. The mean maximum distance of demonstrable cardiac vein on the 3D images was 81.5 mm and was dependent on the quality of the 3D data set. Five patients showed evidence of myocardial infarction on late gadolinium enhancement (LGE) images. CONCLUSION: Coronary venous anatomy can be reliably demonstrated using a comprehensive CMR protocol and a standard extracellular contrast agent. The combination of coronary venous imaging, assessment of ventricular function and LGE may be useful in the management of patients with LV dysfunction being considered for CRT.

Clinical evaluation of magnetic resonance imaging in coronary heart disease: the CE-MARC study.

BACKGROUND: Several investigations are currently available to establish the diagnosis of coronary heart disease (CHD). Of these, cardiovascular magnetic resonance (CMR) offers the greatest information from a single test, allowing the assessment of myocardial function, perfusion, viability and coronary artery anatomy. However, data from large scale studies that prospectively evaluate the diagnostic accuracy of multi-parametric CMR for the detection of CHD in unselected populations are lacking, and there are few data on the performance of CMR compared with current diagnostic tests, its prognostic value and cost-effectiveness. METHODS/DESIGN: This is a prospective diagnostic accuracy cohort study of 750 patients referred to a cardiologist with suspected CHD. Exercise tolerance testing (ETT) will be preformed if patients are physically able. Recruited patients will then undergo CMR and single photon emission tomography (SPECT) followed in all patients by invasive X-ray coronary angiography. The order of the CMR and SPECT tests will be randomised. The CMR study will comprise rest and adenosine stress perfusion, cine imaging, late gadolinium enhancement and whole-heart MR coronary angiography. SPECT will use a gated stress/rest protocol. The primary objective of the study is to determine the diagnostic accuracy of CMR in detecting significant coronary stenosis, as defined by X-ray coronary angiography. Secondary objectives include an assessment of the prognostic value of CMR imaging, a comparison of its diagnostic accuracy against SPECT and ETT, and an assessment of cost-effectiveness. DISCUSSION: The CE-MARC study is a prospective, diagnostic accuracy cohort study of 750 patients assessing the performance of a multi-parametric CMR study in detecting CHD using invasive X-ray coronary angiography as the reference standard and comparing it with ETT and SPECT. TRIAL REGISTRATION: Current Controlled Trials ISRCTN77246133.

Cardiovascular magnetic resonance of scar and ischemia burden early after acute ST elevation and non-ST elevation myocardial infarction.

BACKGROUND: The acute coronary syndrome diagnosis includes different classifications of myocardial infarction, which have been shown to differ in their pathology, as well as their early and late prognosis. These differences may relate to the underlying extent of infarction and/or residual myocardial ischemia. The study aim was to compare scar and ischemia mass between acute non-ST elevation myocardial infarction (NSTEMI), ST-elevation MI with Q-wave formation (Q-STEMI) and ST-elevation MI without Q-wave formation (Non-Q STEMI) in-vivo, using cardiovascular magnetic resonance (CMR). METHODS AND RESULTS: This was a prospective cohort study of twenty five consecutive patients with NSTEMI, 25 patients with thrombolysed Q-STEMI and 25 patients with thrombolysed Non-Q STEMI. Myocardial function (cine imaging), ischemia (adenosine stress first pass myocardial perfusion) and scar (late gadolinium enhancement) were assessed by CMR 2-6 days after presentation and before any invasive revascularisation procedure. All subjects gave written informed consent and ethical committee approval was obtained. Scar mass was highest in Q-STEMI, followed by Non-Q STEMI and NSTEMI (24.1%, 15.2% and 3.8% of LV mass, respectively; p < 0.0001). Ischemia mass showed the reverse trend and was lowest in Q-STEMI, followed by Non-Q STEMI and NSTEMI (6.9%, 14.7% and 19.9% of LV mass, respectively; p = 0.012). The combined mass of scar and ischemia was similar between the three groups (p = 0.17). The ratio of scar to ischemia was 3.5, 1.0 and 0.2 for Q-STEMI, Non-Q STEMI and NSTEMI, respectively. CONCLUSION: Prior to revascularisation, the ratio of scar to ischemia differs between NSTEMI, Non-Q STEMI and Q-STEMI, whilst the combined scar and ischemia mass is similar between these three types of MI. These results provide in-vivo confirmation of the diverse pathophysiology of different types of acute myocardial infarction and may explain their divergent early and late prognosis.

A classic diagnosis with a new 'spin'.

We describe a case of pericardial constriction following viral pericarditis and illustrate the use of cardiac magnetic resonance imaging in the diagnostic process. The advantages of cardiac magnetic resonance in the investigation of pericardial disease are briefly explained.