Ambulatory cardiac rehabilitation improves pulsatile arterial hemodynamics: a pilot trial.

BACKGROUND: In patients with coronary heart disease, both arterial stiffness and wave reflections are increased and predict unfavorable cardiovascular events. Cardiac rehabilitation has the goal to reduce risk factors and slow the progression of the disease. The aim of this study was to prospectively determine the impact of an ambulatory cardiac rehabilitation program on pulsatile hemodynamics. METHODS: Male patients after coronary interventions, bypass surgery, or acute coronary syndromes underwent exercise and resistance training. Before and after the program, pulsatile hemodynamics was measured. Exercise capacity was assessed with an incremental cycle ergometer protocol. A detailed two-dimensional and Doppler echocardiogram was obtained for systolic and diastolic left ventricular function. RESULTS: A total of 27 men participated in the study. After the intervention (n = 24), carotid-femoral pulse wave velocity decreased significantly from 8.7 (standard deviation (SD): 1.7) to 7.9 (SD: 1.9) m/s (p = 0.019), and augmentation index normalized for a heart rate of 75/min decreased significantly from 20.4 (SD: 8.7) to 17.5 (SD: 8.1; p = 0.017). CONCLUSION: The results suggest that a structured ambulatory rehabilitation program may improve pulsatile hemodynamics in coronary artery disease (CAD) patients.

Are there differences in LDL-C target value attainment in Austrian federal states? Yes!

UNLABELLED: Low density lipoprotein (LDL-C) levels determine the cardiovascular risk. Previous studies indicated an LDL-C target attainment of around 50%, but no Austrian wide analysis on results for the federal states was available. We therefore sought to detect potential differences. DESIGN: Open-label, non-interventional, longitudinal study, registered: www.clinicaltrials.gov NCT 01381679. In all, 746 statin treated patients not at LDL-C goal received intensified therapy for 12 months. The sample was split into nine subgroups, representing the federal states of Austria.We detected an east-west gradient for baseline LDL-C. Individual target values were achieved by 37.2% (range: 26.1-57.7%). After 12 months, LDL-C < 70 mg/l was achieved by 13.5% (5.9-38.5%). Univariate ANCOVA retrieved significant differences within the states (Upper Austria and Salzburg, p = 0.001 and p = 0.0015, respectively). Furthermore, the capacity of intensified lipid lowering therapy applied in practice was as high as -42% as compared to previous standard therapy (additional LDL-C reduction after switch from baseline therapy in Vorarlberg).

Manual vs. automatic capture management in implantable cardioverter defibrillators and cardiac resynchronization therapy defibrillators.

AIMS: The Secura ICD and Consulta CRT-D are the first defibrillators to have automatic right atrial (RA), right ventricular (RV), and left ventricular (LV) capture management (CM). Complete CM was evaluated in an implantable cardioverter defibrillator (ICD) population. METHODS AND RESULTS: Two prospective clinical studies were conducted in 28 centres in Europe and Israel. Automatic CM data were compared with manual threshold measurements, the CM applicability was determined, and adjustments to pacing outputs were analysed. In total, 160 patients [age 64.6 +/- 10.4 years, 77% male, 80 ICD and 80 cardiac resynchronization therapy defibrillator (CRT-D)] were included. The differences between automatic and manual measurements were 2.5 V) due to raised RA threshold in seven (4.4%), high RV threshold in nine (5.6%), and high LV threshold in three patients (3.8%). All high threshold detections and all automatic modulations of pacing output were adjudicated appropriate. CONCLUSION: Complete CM adjusts pacing output appropriately, permitting a reduction in office visits while it may maximize device longevity. The study was registered at ClinicalTrials.gov identifiers: NCT00526227 and NCT00526162.

Efficacy and safety of rosuvastatin 40 mg alone or in combination with ezetimibe in patients at high risk of cardiovascular disease (results from the EXPLORER study).

Patients at risk of coronary heart disease may not achieve recommended low-density lipoprotein (LDL) cholesterol goals on statin monotherapy. This study was designed to investigate the efficacy and safety of rosuvastatin 40 mg alone or in combination with ezetimibe 10 mg in patients at high risk of coronary heart disease. Four hundred sixty-nine patients were randomly assigned to rosuvastatin alone or in combination with ezetimibe for 6 weeks. The primary end point was the percentage of patients achieving the Adult Treatment Panel III (ATP III) LDL cholesterol goal (<100 mg/dl) at week 6. Secondary end points included the percentage of patients achieving other ATP III and 2003 European lipid goals, changes from baseline in lipid, lipoprotein, and inflammatory parameters, and safety and tolerability. Significantly more patients receiving rosuvastatin/ezetimibe than rosuvastatin alone achieved their ATP III LDL cholesterol goal (<100 mg/dl, 94.0% vs 79.1%, p <0.001) and the optional LDL cholesterol goal (<70 mg/dl) for very high-risk patients (79.6% vs 35.0%, p <0.001). The combination of rosuvastatin/ezetimibe reduced LDL cholesterol significantly more than rosuvastatin (-69.8% vs -57.1%, p <0.001). Other components of the lipid/lipoprotein profile were also significantly (p <0.001) improved with rosuvastatin/ezetimibe. Both treatments generally were well tolerated. Rosuvastatin 40 mg was effective at improving the atherogenic lipid profile in this high-risk population. Combination rosuvastatin with ezetimibe 10 mg enabled greater decreases in LDL cholesterol and allowed more patients to achieve LDL cholesterol goals. In conclusion, rosuvastatin plus ezetimibe may improve the management of high-risk patients who cannot achieve goal on maximal statin monotherapy.

Arterial stiffness, central blood pressures, and wave reflections in cardiomyopathy-implications for risk stratification.

BACKGROUND: In general, pulse pressure (PP), augmentation index (AIx), and pulse wave velocity (PWV) are directly and positively associated with cardiovascular risk. However, in patients with systolic heart failure, the opposite (ie, an association between a lower PP and a worse outcome) has been reported as well. METHODS AND RESULTS: We assessed central PP and AIx, using applanation tonometry (SphygmoCor, AtCor Medical) in 63 patients with cardiomyopathy (CMP) and 126 controls, matched for age, gender, and brachial blood pressure (BP). All patients underwent coronary angiography for suspected coronary artery disease. In a subgroup (21 patients, 42 controls), we additionally measured aortic PWV invasively during catheter pullback. Mean age was 63.9 versus 64.1 years and ejection fraction (EF) was 29.9 versus 72.2% in patients versus controls, respectively. Calculated aortic systolic BP as well as invasively measured systolic BP was lower in patients versus controls. Central (but not peripheral) PP (33.8 versus 37.8 mm Hg, P = .01) and AIx (17.5 versus 23.3, P = .002) were lower and ejection duration was shorter (265 versus 314 ms, P < .00001) in patients as compared with controls. When we subdivided the CMP patients with respect to AIx, those with values below and equal to the median (median AIx = 17) had more advanced systolic dysfunction. In multiple regression analysis, EF was an independent predictor of AIx. PVW did not differ between CMP patients and controls (8.6 versus 8.2 m/s in patients versus controls, P = .43). Within the group of CMP patients, however, we observed a strong, positive correlation (r = 0.62, P = .003) between PWV and EF. CONCLUSIONS: Central PP, AIx, but also aortic PWV, key measures of arterial function, are susceptible to left ventricular performance.

Arterial wave reflections and determinants of endothelial function a hypothesis based on peripheral mode of action.

BACKGROUND: Pulse waveform analysis (PWA) for determination of augmentation index (AIx), a measure of arterial wave reflections, has been used to assess endothelial function, but only in combination with provocative pharmacologic testing. We hypothesized that AIx under basal conditions would be related to endothelial function as well. METHODS: We quantified arterial wave reflections as aortic AIx, using applanation tonometry of the radial artery, and PWA in 424 patients (mean age 64.6 years) undergoing coronary angiography. Plasma levels of asymmetric dimethylarginine (ADMA), an endogenous inhibitor of endothelial nitric oxide (NO) synthase, were determined with a validated ELISA assay. In a group of the patients (n = 160), pulse wave velocity (PWV) was measured invasively during catheter pullback. Statistics were Spearman's correlation coefficient and multiple linear regression models. RESULTS: We observed a positive, statistically significant correlation between AIx and ADMA (R = 0.11, P = .03), that was closer in 134 patients up to 60 years of age (R = 0.28, P = .001). In the latter group, the correlation was independent of age, gender, smoking, lipids, heart rate, diastolic blood pressure (BP), the presence of hypertension or diabetes, and the extent of coronary artery disease. In contrast, we observed a significant (R = 0.19, P = .02) correlation between PWV and ADMA that disappeared after correction for age and BP. CONCLUSIONS: Our cross-sectional data indicate that ADMA levels are associated with increased arterial wave reflections, most likely due to decreased NO activity in small arteries and arterioles. This relationship is more pronounced in patients up to 60 years of age.

Renal function is associated with risk of atrial fibrillation after cardiac surgery.

BACKGROUND: Atrial fibrillation (AF) frequently occurs after cardiac surgery and is responsible for increased morbidity and resource use. The aim of the present study was to evaluate the association of impaired renal function and the development of postoperative AF. METHODS AND RESULTS: Patients undergoing elective cardiac surgery in the absence of significant left ventricular dysfunction (n=253; average age 65+/-11 years) were recruited to the present prospective study. Ninety-nine patients (39.1%) developed AF during the postoperative period. Creatinine clearance, estimated by the calculated glomerular filtration rate (GFR), was prospectively assessed to determine the association of baseline renal function and the development of postoperative AF. Baseline calculated GFR was assessed as a continuous and a categorical variable (normal: greater than 90 mL/min/1.73 m(2); mildly decreased: 60 mL/min/1.73 m(2) to 89 mL/min/1.73 m(2); and moderately to severely decreased: less than 60 mL/min/1.73 m(2)). Baseline creatinine clearance was 72+/-22.2 mL/min/1.73 m(2) and 78.8+/-23.5 mL/min/1.73 m(2) in patients with and without postoperative AF, respectively (P=0.02). There was an independent association between decreasing calculated GFR and the development of postoperative AF (OR for 10 mL decrease in calculated GFR: 1.21, 95% CI 1.02 to 1.39). In addition to calculated GFR, surgery for valvular heart disease (versus coronary artery bypass grafting [OR 2.23, 95% CI 1.09 to 3.14; P<0.01]), age (OR per 10-year increase in age 1.92, 1.18 to 2.59) and perioperative nonuse of beta-adrenergic blockers (OR 1.62, 95% CI 1.12 to 3.55; P<0.01) were identified as independent predictors of postoperative AF. CONCLUSIONS: In the setting of cardiac surgery, impaired calculated GFR is associated with an increased risk for the development of postoperative AF. These data provide additional evidence supporting the association between renal dysfunction and adverse cardiovascular outcomes.

Changes in renal artery dimensions are associated with clinical response to radiofrequency renal denervation: a series of studies using quantitative angiography and intravascular ultrasound.

OBJECTIVE: Renal denervation (RDN) can cause focal (notches) and global (spasms) changes in renal artery dimensions. We quantified these changes and related them to renal norepinephrin tissue content in animals and to blood pressure (BP) changes in patients. METHODS: We measured renal artery dimensions pre-RDN and post-RDN, utilizing quantitative renal angiography (QRA) in a porcine model and in a retrospective patient cohort, and intravascular ultrasound (IVUS) in a prospective patient cohort. Focal and global measurements were minimum and mean diameter/area/volume with QRA, minimum lumen/vessel/wall area and volume with IVUS. BP was assessed with 24-h ambulatory monitoring, norepinephrin content with liquid chromatography. RESULTS: In 36 pigs treated unilaterally with RDN, norepinephrin content of the treated right kidney was 48.2% of the untreated left kidney. QRA measurements following RDN were associated with norepinephrin content only of the (treated) right kidney. In the human QRA study (n = 43 patients), mean 24-h BP fell by 8/4 and 12/6 mmHg at 1 and 12 months, respectively. More pronounced changes in QRA measurements were associated with a more pronounced BP drop. In multiple regression models, the change in minimum diameter was independently associated with BP changes at 12 months. In the prospective IVUS study (n = 17 patients), a larger decrease in minimum lumen/vessel area and larger increase of wall area/volume were associated with a larger BP drop. CONCLUSION: Focal and global changes in renal arteries following RDN can be quantified, using QRA or IVUS, and may serve as markers of a successful procedure.

Contemporary use of P2Y12-inhibitors in patients with acute coronary syndrome undergoing percutaneous coronary intervention in Austria: A prospective, multi-centre registry.

BACKGROUND: To this day, there is no data concerning guideline adherence on P2Y12-inhibitors in Austria. Prasugrel and ticagrelor have been shown to be superior to clopidogrel in the treatment of acute coronary syndromes (ACS). However, recent data from European registries showed a reluctant prescription policy with rates of clopidogrel at discharge ranging from 35 to 55%. METHODS: In this prospective, multi-centre registry we assessed prescription rates of P2Y12-inhibitors in patients with ACS in four Austrian PCI centres. Parameters associated with the use of clopidogrel have been evaluated in multivariate logistic regression. RESULTS: Between January and June 2015, 808 patients with ACS undergoing PCI were considered for further analysis. 416 (51.5%) presented with STEMI and 392 (48.5%) with NSTE-ACS. Mean age was 65.7 ± 12.4 and 240 (30.9%) were female. Twenty-eight (3.5%) died during the hospital stay. At discharge, 212 (27.2% of all patients) received clopidogrel, 260 (32.2%) prasugrel and 297 (36.8%) ticagrelor, while 11 (1.4%) did not receive any P2Y12-inhibitor. Of those patients, who were discharged with clopidogrel, 117 (55.2%) had no absolute contraindication against a more potent P2Y12-inhibitor. Diagnosis of NSTE-ACS (p<0.001), COPD (p = 0.049), and age (p<0.001) next to factors contributing to absolute contraindication were positively associated with the use of clopidogrel. CONCLUSIONS: Despite a high level of care, a considerable number of patients were not treated with the more potent P2Y12-inhibitors. Parameters associated with a presumably higher risk of bleeding and side-effects against the more effective P2Y12 inhibitors were the most prominent factors for the prescription of clopidogrel.

In-Hospital Outcome Comparing Bivalirudin to Heparin in Real-World Primary Percutaneous Coronary Intervention.

Randomized controlled trials have shown conflicting results regarding the outcome of bivalirudin in primary percutaneous coronary intervention (PPCI). The aim of this study was to evaluate the in-hospital outcomes of patients receiving heparin or bivalirudin in a real-world setting of PPCI: 7,023 consecutive patients enrolled in the Austrian Acute PCI Registry were included between January 2010 and December 2014. Patients were classified according to the peri-interventional anticoagulation regimen receiving heparin (n = 6430) or bivalirudin (n = 593) with or without GpIIb/IIIa inhibitors (GPIs). In-hospital mortality (odds ratio [OR] 1.13, 95% confidence interval [CI] 0.57 to 2.25, p = 0.72), major adverse cardiovascular events (OR 1.18, 95% CI 0.65 to 2.14, p = 0.59), net adverse clinical events (OR 1.01, 95% CI 0.57 to 1.77, p = 0.99), and TIMI non-coronary artery bypass graft-related major bleeding (OR 0.41, 95% CI 0.09 to 1.86, p = 0.25) were not significantly different between the groups. However, we detected potential effect modifications of anticoagulants on mortality by GPIs (OR 0.12, 95% CI 0.01 to 1.07, p = 0.06) and access site (OR 0.25, 95% CI 0.06 to 1.03, p = 0.06) favoring bivalirudin in femoral access. In conclusion, this large real-world cohort of PPCI, heparin-based anticoagulation showed similar results of short-term mortality compared with bivalirudin. We observed a potential effect modification by additional GPI use and access favoring bivalirudin over heparin in femoral, but not radial, access.

Left ventricular apical ballooning--a novel cardiac disease mimicking acute coronary syndrome: a case report in a Caucasian patient.

The syndrome of "apical ballooning" consists of an acute onset of transient extensive akinesia of the apical portion of the left ventricle, without significant stenosis on the coronary angiogram, accompanied by chest symptoms, ECG changes, and a limited release of cardiac markers disproportionate to the extent of akinesia. So far, the vast majority of cases with this syndrome have been reported from Japanese patients and only a few cases of Caucasian patients have been described. Emotional or physical stress or other preceding triggering factors might play a key role in this cardiomyopathy, but the precise etiology remains unknown. We describe a case of "apical ballooning" in a white patient, who presented at our institution with this novel heart syndrome. Despite severe initial presentation, conservative medical management leads to good long term outcome in most patients.

Ability of neuron-specific enolase to predict survival to hospital discharge after successful cardiopulmonary resuscitation.

BACKGROUND: Accurate prediction of survival to hospital discharge in patients who achieve return of spontaneous circulation after cardiopulmonary resuscitation (CPR) has significant ethical and socioeconomic implications. We investigated the prognostic performance of serum neuron-specific enolase (NSE), a biochemical marker of ischemic brain injury, after successful CPR. METHODS: In-hospital or out-of-hospital patients with nontraumatic normothermic cardiac arrest who achieved return of spontaneous circulation (ROSC) following at least 5 minutes of CPR were eligible. Neuron-specific enolase levels were assessed immediately, 6 hours, 12 hours and 2 days after ROSC. Subjects were followed to death or hospital discharge. RESULTS: Seventeen patients (7 men, 10 women) were enrolled during a 1-year period. Median (range) NSE levels in survivors and non-survivors respectively were as follows: immediately after ROSC: 14.0 microg/L (9.1-51.4 microg/L) versus 25.9 microg/L (10.2-57.5 microg/L); 6 hours after ROSC: 15.2 microg/L (9.7-30.8 microg/L) versus 25.6 microg/L (12.7-38.2 microg/L); 12 hours after ROSC: 14.0 microg/L (8.6-32.4 microg/L) versus 28.5 microg/L (11.0-50.7 microg/L); and 48 hours after ROSC: 13.1 microg/L (7.8-29.5 microg/L) versus 52.0 microg/L (29.1-254.0 microg/L). Non-survivors had significantly higher NSE levels 48 hours after ROSC than surivors (p = 0.04) and showed a trend toward higher values during the entire time course following ROSC. An NSE concentration of >30 microg/L 48 hours after ROSC predicted death with a high specificity (100%: 95% confidence interval [CI] 85%-100%), and a level of 29 microg/L or less at 48 hours predicted survival with a high specificity (100%: 95% CI 83%-100%). CONCLUSIONS: Serum NSE levels may have clinical utility for the prediction of survival to hospital discharge in patients after ROSC following CPR over 5 minutes in duration. This study is small, and our results are limited by wide confidence intervals. Further research on ability of NSE to facilitate prediction and clinical decision-making after cardiac arrest is warranted.

[Diabetes mellitus, coronary artery disease and heart disease]. / Diabetes mellitus, koronare Herzkrankheit und Herzinsuffizienz.

Diabetes mellitus, cardiovascular disease and heart failure are interacting dynamically. Patients being diagnosed with cardiovascular disease should be screened for diabetes mellitus. Enhanced cardiovascular risk stratification based on biomarkers, symptoms and classical risk factors should be performed in patients with pre-existing diabetes mellitus.

Hypertension and coronary artery disease: epidemiology, physiology, effects of treatment, and recommendations : A joint scientific statement from the Austrian Society of Cardiology and the Austrian Society of Hypertension.

High blood pressure is a major modifiable risk factor for all clinical manifestations of coronary artery disease (CAD). In people without known cardiovascular disease, the lowest systolic (down to 90-114 mmHg) and the lowest diastolic (down to 60-74 mmHg) pressures are associated with the lowest risk for developing CAD. Although diastolic blood pressure is the strongest predictor of CAD in younger and middle-aged people, this relationship becomes inverted and pulse pressure shows the strongest direct relationship with CAD in people above 60 years of age.Pathophysiological mechanisms of blood pressure as a risk factor for CAD are complex and include the influence of blood pressure as a physical force on the development of the atherosclerotic plaque, and the relationship between pulsatile hemodynamics/arterial stiffness and coronary perfusion. Treatment of arterial hypertension has been proven to prevent coronary events in patients without clinical CAD. In patients with established CAD, the effect of blood pressure lowering per se is beneficial, probably more than specific drugs or drug classes. The important exceptions are beta blockers (BBs), which are superior to all other drug classes for use after a recent myocardial infarction. Blood pressure targets in patients with established CAD have created controversy in the light of the so-called J-curve phenomenon, which describes an increase in coronary events at lower diastolic blood pressures. One explanation for this observation is that perfusion of the left ventricle occurs predominantly during diastole, and that coronary autoregulation may be exhausted with low diastolic blood pressure in the setting of left ventricular hypertrophy and atherosclerotic narrowing of the epicardial coronaries. The worst situation is a high systolic blood pressure in the presence of a low diastolic blood pressure, both a hallmark of increased aortic stiffness. However, the lowering of systolic blood pressure is clearly beneficial in this setting, even at the price of further lowering diastolic pressure. Primary blood pressure goal in patients with established CAD is below 140/90 mmHg. Recent studies suggest that a lower systolic blood pressure may be appropriate, whereas caution is advised with diastolic blood pressure below 60 mmHg.

Electrocardiogram changes and wall motion abnormalities in the acute phase of Tako-Tsubo syndrome.

BACKGROUND: The Tako-Tsubo syndrome is still rarely diagnosed in patients presenting with symptoms of acute myocardial ischaemia. It is accompanied by wall motion abnormalities of the left ventricle but significant narrowings or occlusions of epicardial coronary arteries are absent. We investigated a potential relationship between electrocardiogram (ECG) changes, wall motion abnormalities and gender influence of Tako-Tsubo syndrome in an Austrian cohort of Tako-Tsubo syndrome patients. METHODS AND RESULTS: We were recently able to describe four different anatomical types of Tako-Tsubo syndrome in 153 patients of the Austrian Tako-Tsubo syndrome registry. In the present retrospective analysis we investigated ischaemia-related changes in the first diagnostic ECG for the different types of Tako-Tsubo syndrome: the apical and the combined apical-midventricular type showed most frequently a ST elevation (41.1% and 35.3%), whereas the midventricular type of Tako-Tsubo syndrome was more often accompanied by T wave inversion (60%). ECG changes in relation to the Tako-Tsubo syndrome type were similar in women and men. There was no difference in the prevalence of clinical complications among patients presenting with ST elevation or left bundle branch block (14.5%) compared with patients without ST elevation (10.4%) (p=0.476). CONCLUSION: Patients with Tako-Tsubo syndrome show characteristic ECG changes in the first diagnostic ECG which are associated to some extent with the anatomical type of Tako-Tsubo syndrome, but these ECG changes were not related to clinical outcome.

Arterial stiffness, wave reflections, and the risk of coronary artery disease.

BACKGROUND: Increased arterial stiffness, determined invasively, has been shown to predict a higher risk of coronary atherosclerosis. However, invasive techniques are of limited value for screening and risk stratification in larger patient groups. METHODS AND RESULTS: We prospectively enrolled 465 consecutive, symptomatic men undergoing coronary angiography for the assessment of suspected coronary artery disease. Arterial stiffness and wave reflections were quantified noninvasively using applanation tonometry of the radial artery with a validated transfer function to generate the corresponding ascending aortic pressure waveform. Augmented pressure (AP) was defined as the difference between the second and the first systolic peak, and augmentation index (AIx) was AP expressed as a percentage of the pulse pressure. In univariate analysis, a higher AIx was associated with an increased risk for coronary artery disease (OR, 4.06 for the difference between the first and the fourth quartile [1.72 to 9.57; P<0.01]). In multivariate analysis, after controlling for age, height, presence of hypertension, HDL cholesterol, and medications, the association with coronary artery disease risk remained significant (OR, 6.91; P<0.05). The results were exclusively driven by an increase in risk with premature vessel stiffening in the younger patient group (up to 60 years of age), with an unadjusted OR between AIx quartiles I and IV of 8.25 (P<0.01) and a multiple-adjusted OR between these quartiles of 16.81 (P<0.05). CONCLUSIONS: AIx and AP, noninvasively determined manifestations of arterial stiffening and increased wave reflections, are strong, independent risk markers for premature coronary artery disease.

The diagnostic and prognostic value of brain natriuretic peptide and aminoterminal (nt)-pro brain natriuretic peptide.

The discovery of B-type natriuretic peptide (BNP) and n-terminal pro BNP (nt-proBNP) as markers for the diagnosis, severity and prognosis of patients with congestive heart failure has been called a true breakthrough for patients and physicians faced with this disorder. Moreover, the literature on their prognostic value in other clinical conditions like acute coronary syndromes, right-sided heart failure and even in the general population is rapidly growing. This review aims to sort out the current evidence on the clinical utility of the natriuretic peptides with a focus on their diagnostic and prognostic values. With respect to their diagnostic properties, the test is best used to rule out heart failure in patients with acute dyspnoe, because low levels of these neurohormones in this clinical context make the presence of heart failure very unlikely. In patients with elevated values of BNP or nt-proBNP, further cardiological assessment is necessary, as their plasma levels are affected not only by left ventricular function.

Noninvasive methods to assess pulse wave velocity: comparison with the invasive gold standard and relationship with organ damage.

OBJECTIVES: To compare noninvasive methods to assess pulse wave velocity (PWV) with the invasive gold standard in terms of absolute values, age-related changes, and relationship with subclinical organ damage. METHODS: Invasive aortic PWV (aoPWVinv) was measured in 915 patients undergoing cardiac catheterization (mean age 61 years, range 27-87 years). Carotid-femoral PWV (cfPWV) was measured with tonometry, using subtracted distance (cfPWVsub), body height-based estimated distance (cfPWVbh), direct distance × 0.8 (cfPWVdir0.8), and caliper-based distance (cfPWVcalip) for travel distance calculation. Aortic PWV was estimated (aoPWVestim) from single-point radial waveforms, age, and SBP. RESULTS: Invasive and noninvasive transit times were strikingly similar (median values 60.8 versus 61.7 ms). In the entire group, median value of aoPWVinv was 8.3 m/s, of cfPWVsub and cfPWVbh 8.1 m/s, and of aoPWVest 8.5 m/s. CfPWVsub overestimated aoPWVinv in younger patients by 0.7 m/s and underestimated aoPWVinv in older patients by 1.7 m/s, with good agreement from 50 to 70 years of age. AoPWVestim differed from aoPWVinv by no more than 0.4 m/s across all age groups. CfPWVdir0.8, measured in 632 patients, overestimated aoPWVinv by 1.7 m/s in younger patients, with good agreement in middle-aged and older patients. CfPWVcalip, measured in 336 patients, underestimated aoPWVinv in all ages. In 536 patients with preserved systolic function, aoPWVinv and aoPWVestim were superior to cfPWVs in predicting coronary atherosclerosis, renal function impairment, left atrial enlargement, and diastolic dysfunction. CONCLUSION: CfPWVsub, cfPWVdir0.8, and aoPWVestim are reasonable surrogates for aoPWVinv. AoPWVinv predicts subclinical organ damage better than cfPWVs, and as good as aoPWVestim.

Non-invasive wave reflection quantification in patients with reduced ejection fraction.

The non-invasive quantification of arterial wave reflection is an increasingly important concept in cardiovascular research. It is commonly based on pulse wave analysis (PWA) of aortic pressure. Alternatively, wave separation analysis (WSA) considering both aortic pressure and flow waveforms can be applied. Necessary estimates of aortic flow can be measured by Doppler ultrasound or provided by mathematical models. However, this approach has not been investigated intensively up to now in subjects developing systolic heart failure characterized by highly reduced ejection fraction (EF). We used non-invasively generated aortic pressure waveforms and Doppler flow measurements to derive wave reflection parameters in 61 patients with highly reduced and 122 patients with normal EF. Additionally we compared these readings with estimates from three different flow models known from literature (triangular, averaged, Windkessel). After correction for confounding factors, all parameters of wave reflection (PWA and WSA) were comparable for patients with reduced and normal EF. Wave separations assessed with the Windkessel based model were similar to those derived from Doppler flow in both groups. The averaged waveform performed poorer in reduced than in normal EF, whereas triangular flow represented a better approximation for reduced EF. Overall, the non-invasive assessment of WSA parameters based on mathematical models compared to ultrasound seems feasible in patients with reduced EF.