Myocardial Contraction Fraction is not a Predictor of Clinical Outcomes in Acute Systolic Heart Failure: A Brief Report.

Introduction: The utility of myocardial contraction fraction (MCF), a volumetric measure of myocardial shortening, has not been well evaluated in patients with systolic heart failure (SHF). Materials and Methods: A single-center, retrospective cohort study of all adults admitted with acute SHF from 2013 to 2018 at an academic medical center. A chart review was performed to identify key echocardiographic transthoracic echocardiogram (TTE), laboratory, and demographic characteristics. MCF was calculated based on M-mode measurements of estimated stroke volume and myocardial volume based on admission TTE. The primary outcome was 30-day combined all-cause readmission/mortality and 365-day all-cause mortality. Results: A total of 1282 patients were analyzed. The 30-day composite outcome occurred in 310 patients (24.2%), and all-cause death at 365 days occurred in 375 patients (29.3%). There was a weak correlation between the visually estimated ejection fraction (EF) and MCF (r = 0.356, P < 0.001). Neither MCF nor EF was associated with either component of the primary outcome. Other parameters on TTE that were associated with higher risk of primary outcome were higher tricuspid regurgitation (TR) velocity, larger left atrial (LA) diameter, and moderate or greater TR and mitral regurgitation (MR). Conclusion: Echocardiographic predictors of postdischarge adverse events among patients hospitalized with acute SHF include higher TR velocity, larger LA diameter, and at least moderate MR or TR. MCF does not correlate well with visually assessed EF among patients with acute SHF, and neither MCF nor EF provides prognostic information in this population.

Asymptomatic left ventricular systolic dysfunction in patients with severe aortic stenosis: characteristics and outcomes.

OBJECTIVES: This study sought to determine the prevalence, characteristics, and outcomes of asymptomatic left ventricular (LV) systolic dysfunction in patients with severe aortic stenosis (AS). BACKGROUND: Management of asymptomatic patients with severe AS remains controversial. In these patients, LV systolic dysfunction, defined in the guidelines as ejection fraction <50%, is a Class I(C) indication for aortic valve replacement (AVR), but its prevalence is unknown. METHODS: A retrospective study of adults ≥40 years of age with severe valvular AS (peak velocity ≥4 m/s, mean gradient >40 mm Hg, aortic valve area [AVA] <1 cm(2), or AVA index <0.6 cm(2)/m(2)) from 1984 to 2010 was undertaken. Patients with prior cardiac surgery, severe coronary artery disease, or greater than moderate aortic regurgitation were excluded. RESULTS: Of 9,940 patients with severe AS, 43 (0.4%) patients had asymptomatic LV dysfunction. Age was 73 ± 14 years and 70% were male. Hypertension (78%) and LV hypertrophy (LV mass index 143 ± 36 g/m(2)) were characteristic. Fifty-three percent of these patients developed symptoms at 21 ± 19 months after diagnosis. During 7.5 ± 6.7-year follow-up, 5-year mortality was 48%. After multivariable adjustment, there was no survival advantage with AVR in asymptomatic, severe AS with LV dysfunction (p = 0.51). CONCLUSIONS: In severe AS, the prevalence of asymptomatic LV systolic dysfunction is 0.4%. Despite an asymptomatic clinical status, patients with severe AS and LV ejection fraction <50% have a poor prognosis, with or without AVR.

Association of myocardial fibrosis, B-type natriuretic peptide, and cardiac magnetic resonance parameters of remodeling in chronic ischemic cardiomyopathy.

The left ventricular (LV) scar size detected by cardiac magnetic resonance (CMR) imaging in ischemic cardiomyopathy (IC) has been correlated with mortality. However, the associations among myocardial fibrosis, ventricular geometry, and physiologic measures of myocardial performance remain to be defined. A retrospective analysis of patients with stable chronic IC (LV ejection fraction ≤50%) who underwent CMR imaging from 2004 to 2010 and had plasma B-type natriuretic peptide (BNP) measured within 14 days of the CMR study was undertaken. A total of 38 patients met the criteria (mean age 66 ± 10 years; 31 men [82%]). The duration of IC was 67 ± 69 months. The CMR characteristics included LV dilation (LV end-diastolic dimension 62 ± 8 mm) and severe systolic dysfunction (LV ejection fraction 28 ± 11%). The average quantitated myocardial fibrosis was 20 ± 12% of the LV mass. When stratified by fibrotic mass, increased myocardial scar size was associated with increased LV cavity size (p = 0.007), lower LV ejection fraction (p = 0.04), and higher BNP (p = 0.013). In comparison, when stratified by median BNP (475 pg/ml), an elevated BNP level was associated, not only with LV size, function, and degree of fibrosis, but also with increased meridional wall stress (p = 0.002) and worse New York Heart Association functional class (p = 0.006). In conclusion, in chronic IC, quantitated myocardial fibrosis is associated with CMR structural and functional LV abnormalities. Elevated BNP levels are related to high-risk structural and functional CMR abnormalities and wall stress and functional status. Myocardial fibrosis appears to be related to plasma BNP through the processes of ventricular remodeling.

Death in heart failure: a community perspective.

BACKGROUND: Mortality in heart failure (HF) remains high but causes of death are incompletely defined. As HF is heterogeneous syndrome categorized according to ejection fraction (EF), the association between EF and causes of death is important, yet elusive. METHOD AND RESULTS: Community subjects with HF were classified according to preserved (> or =50%) and reduced EF (<50%). Deaths were classified as coronary heart disease (CHD), other cardiovascular and non-cardiovascular. Among 1063 persons with HF, 45% had preserved EF with less cardiovascular risk factors and less coronary disease than those with reduced EF. At 5 years, survival was 45% (95% CI 43%-49%) and 43% of the deaths were non-cardiovascular. The leading cause of death in subjects with preserved EF was non-cardiovascular (49%) vs CHD (43%) for subjects with reduced EF. The proportion of cardiovascular deaths decreased from 69% in 1979-1984 to 40% in 1997-2002 (p=0.007) among subjects with preserved EF contrasting with a modest change among those with reduced EF (77% in to 64%, p=0.08). Advanced age, male sex, diabetes, smoking and kidney disease were associated with an increase risk of all cause and cardiovascular death. After adjustment, preserved EF was associated with a lower risk of cardiovascular death but not all cause death. CONCLUSION: Community subjects with HF experience a persistently high mortality and a large proportion of deaths are non-cardiovascular. Subjects with preserved EF have less cardiovascular disease before death, are less likely to experience cardiovascular deaths than those with reduced EF and the proportion of cardiovascular deaths declined over time.

Ventricular arrhythmias after acute myocardial infarction: a 20-year community study.

BACKGROUND: Although myocardial infarction (MI) severity is declining, the occurrence of ventricular arrhythmia (VA) after MI and its effect on outcome is unknown. This study was undertaken to examine the frequency and timing of VA and the effect of VA on mortality after MI. METHODS: Myocardial infarctions recorded between 1979 and 1998 were validated. Baseline characteristics, occurrence of VA, and survival were determined. Ventricular arrhythmias were categorized as primary ventricular fibrillation (VF), nonprimary VF, and ventricular tachycardia (VT). Logistic regression was used to analyze associations between VA and baseline characteristics. Temporal trends were assessed with the Mantel-Haenszel chi2. Survival was analyzed with the Kaplan-Meier method. Proportional hazards regression was used to examine the association between death and occurrence of VA. RESULTS: Among 2317 persons with incident MI, 7.5% experienced VA (3.6% nonprimary VF, 2.1% primary VF, 1.8% VT). Ventricular arrhythmia-associated factors were younger age, female sex, higher Killip class, ST elevation, and atrial fibrillation. Ventricular arrhythmias were associated with increased risk of death at 30 days. CONCLUSION: Ventricular arrhythmias after MI are relatively common, particularly among persons with more severe MI and no prior history of coronary disease. Over time, the incidence of VF declined, whereas VT did not change. Ventricular arrhythmia after MI was associated with a 6-fold increase in morality. Thus, identification of high-risk MI survivors and prevention of VA could markedly improve outcomes. Further studies are needed to determine the cause of the shift in distribution of VA subtype.