Left ventricular long axis function assessed during cine-cardiovascular magnetic resonance is an independent predictor of adverse cardiac events.

BACKGROUND: Left ventricular pump function requires a complex interplay involving myocardial fibers orientated in the longitudinal, oblique and circumferential directions. Long axis dysfunction appears to be an early marker for a number of pathological states. We hypothesized that mitral annular plane systolic excursion (MAPSE) measured during cine-cardiovascular magnetic resonance (CMR) reflects changes in long axis function and may be an early marker for adverse cardiovascular outcomes. The aims of this study were therefore: 1) To assess the feasibility and reproducibility of MAPSE measurements during routine cine-CMR; and 2) To assess whether MAPSE, as a surrogate for long axis function, is a predictor of major adverse cardiovascular events (MACE). METHODS: Four hundred consecutive patients undergoing CMR were prospectively enrolled. MAPSE was measured in the 4-chamber cine view. Patients were prospectively followed for major adverse cardiac events (MACE) - death, non-fatal myocardial infarction, hospitalization for heart failure or unstable angina, and late revascularization. Cox proportional hazards regression modeling was used to identify factors independently associated with MACE. Net reclassification improvement (NRI) was calculated to assess whether addition of MAPSE resulted in improved risk reclassification of MACE. RESULTS: Seventy-two MACE occurred during a median follow-up of 14.5 months. By Kaplan-Meier analysis, patients with lateral MAPSE <1.11 cm (median) experienced significantly higher incidence of MACE than patients with a MAPSE ≥1.11 cm (p = 0.027). After adjustment for established clinical risk factors which were univariate predictors (age, diabetes, hypertension, NYHA class, LV mass), lateral MAPSE remained a significant independent predictor of MACE (HR = 4.384 per cm decrease or 1.344 per 2 mm decrease; p = 0.020). Incorporation of lateral MAPSE into this risk model resulted in a net reclassification improvement (NRI) of 0.18 (p = 0.006). CONCLUSIONS: Reduced long axis function assessed with lateral MAPSE during cine-CMR is an independent predictor of MACE.

Vitamin D Attenuates Left Atrial Volume Changes in African American Males with Obesity and Prediabetes.

Vitamin D deficiency is common among African Americans in the United States and is associated with increased cardiovascular disease risk. In this study, prediabetic African American males who were found to be vitamin D-deficient were randomized to vitamin D supplementation and assessed for changes in left atrial (LA) volume. Prediabetic African American males who were vitamin D-deficient (25(OH)D: 5.0-29 ng/mL) were randomized to high-dose ergocalciferol or placebo. Echocardiography was performed at baseline and at 1 year. Ejection fraction (EF), septal and posterior wall thickness, LA area, LA length, LA volume, E, A, septal and lateral e' and a', deceleration time, and isovolumetric relaxation time were collected. Eighty-one of 158 (51%) subjects received vitamin D2 . Baseline characteristics were similar among both groups. In the placebo group, left atrial volume significantly increased on follow-up (LA volume increased 6.3 mL, P = 0.0025). Compared with placebo group, the treatment group with ergocalciferol had attenuated increases in left atrial volume (LA volume increased 2.6 mL, P = 0.29). Changes in left atrial volume persisted when indexed to body surface area. There was no significant difference in other diastolic parameters and blood pressure between groups. In conclusion, vitamin D-deficient prediabetic African American males who were treated with high-dose vitamin D2 were found to have attenuated increases in left atrial volume compared with controls over 12-month follow-up.

Prosthesis-patient mismatch in bovine pericardial aortic valves: evaluation using 3 different modalities and associated medium-term outcomes.

BACKGROUND: The prevalence of prosthesis-patient mismatch (PPM) and its impact on survival after aortic valve replacement have not been clearly defined. Historically, the presence of PPM was identified from postoperative echocardiograms or preoperative manufacturer-provided charts, resulting in wide discrepancies. The 2009 American Society of Echocardiography (ASE) guidelines proposed an algorithmic approach to calculate PPM. This study compared PPM prevalence and its impact on survival using 3 modalities: (1) the ASE guidelines-suggested algorithm (ASE PPM); (2) the manufacturer-provided charts (M PPM); and (3) the echocardiographically measured, body surface area-indexed, effective orifice area (EOAi PPM) measurement. METHODS AND RESULTS: A total of 614 patients underwent aortic valve replacement with bovine pericardial valves from 2004 to 2009 and had normal preoperative systolic function. EOAi PPM was severe if EOAi was ≤ 0.60 cm(2)/m(2), moderate if EOAi was 0.60 to 0.85 cm(2)/m(2), and absent (none) if EOAi was ≥ 0.85 cm(2)/m(2). ASE PPM was severe in 22 (3.6%), moderate in 6 (1%), and absent (none) in 586 (95.4%). ASE PPM was similar to manufacturer-provided PPM (P=1.00). ASE PPM differed significantly from EOAi PPM (P<0.001), which identified severe mismatch in 170 (29.7%), moderate in 191 (33.4%), and absent (none) in 211 patients (36.9%). Irrespective of the PPM classification method, PPM did not adversely affect midterm survival (average follow-up, 4.1 ± 1.8 years; median, 3.9 years; range, 0.01-8 years). There were no reoperations for PPM. CONCLUSIONS: In patients with normal systolic function undergoing bovine pericardial aortic valve replacement, the prevalence of PPM using the algorithmic-ASE approach was low and correlated well with manufacturer-provided PPM. Independent of the method of PPM assessment, PPM was not associated with medium-term mortality.

A decade of reversal: an analysis of 146 contradicted medical practices.

OBJECTIVE: To identify medical practices that offer no net benefits. METHODS: We reviewed all original articles published in 10 years (2001-2010) in one high-impact journal. Articles were classified on the basis of whether they addressed a medical practice, whether they tested a new or existing therapy, and whether results were positive or negative. Articles were then classified as 1 of 4 types: replacement, when a new practice surpasses standard of care; back to the drawing board, when a new practice is no better than current practice; reaffirmation, when an existing practice is found to be better than a lesser standard; and reversal, when an existing practice is found to be no better than a lesser therapy. This study was conducted from August 1, 2011, through October 31, 2012. RESULTS: We reviewed 2044 original articles, 1344 of which concerned a medical practice. Of these, 981 articles (73.0%) examined a new medical practice, whereas 363 (27.0%) tested an established practice. A total of 947 studies (70.5%) had positive findings, whereas 397 (29.5%) reached a negative conclusion. A total of 756 articles addressing a medical practice constituted replacement, 165 were back to the drawing board, 146 were medical reversals, 138 were reaffirmations, and 139 were inconclusive. Of the 363 articles testing standard of care, 146 (40.2%) reversed that practice, whereas 138 (38.0%) reaffirmed it. CONCLUSION: The reversal of established medical practice is common and occurs across all classes of medical practice. This investigation sheds light on low-value practices and patterns of medical research.

Clinical characteristics and prevalence of early repolarization associated with ventricular arrhythmias following acute ST-elevation myocardial infarction.

Early repolarization (ER) on a 12-lead electrocardiogram has recently been associated with ventricular tachyarrhythmias (VTAs) in patients without structural heart disease and in patients with healed myocardial infarction (MI). An association between ER and VTAs in the setting of acute ST-segment elevation MI (STEMI) has not been explored. In a single-center retrospective case-control design, 50 patients with STEMI complicated by VTAs (cases), defined as ventricular fibrillation, sustained ventricular tachycardia, or nonsustained ventricular tachycardia within 72 hours of the index hospitalization, were matched for age and gender with 50 subjects with STEMI without VTAs (controls). Electrocardiograms obtained an average of 1 year before STEMI were analyzed for ER pattern, defined as notching or slurring of the terminal QRS complex or J-point elevation >0.1 mV above baseline in ≥ 2 contiguous leads. A higher prevalence of ER was associated with VTAs overall in cases compared to controls (26% vs 4%, p = 0.01) and localized to anterior (16% vs 0%) and inferior (14% vs 2%, p = 0.07) leads but not lateral limb leads. Notching (10% vs 2%, p = 0.1) and J-point elevation (16% vs 0%) were more common in cases. Slurring was uncommon. ER was associated with VTAs (odds ratio [OR] 6.5, 95% confidence interval [CI] 1.5 to 28.8, p = 0.01), even after adjustment for creatine kinase-MB (OR 9.2, 95% CI 1.6 to 53.4, p = 0.01) and ejection fraction (OR 5.7, 95% CI 1.2 to 27.1, p = 0.03). In conclusion, ER is associated with VTAs in patients with STEMI even after adjustment for left ventricular ejection fraction or creatine kinas-MB levels. Larger prospective studies exploring potential associations and mechanisms of ventricular arrhythmogenesis with ER pattern are needed.