Impact of preprocedural left ventricular systolic function on the safety and durability of percutaneous coronary intervention.

BACKGROUND: Percutaneous coronary intervention (PCI) is considered less safe in patients with reduced ejection fraction (EF), an impression based on older data. Whether the safety and durability of contemporary PCI are different in patients with reduced EF compared with normal EF patients is unknown. METHODS: Patients from the BIOFLOW II, IV and V clinical trials were grouped as normal EF (≥50%) and reduced EF (30%-50%). Using multivariable logistic regression and cox proportional hazards regression, we determined relations of EF category with procedural safety (a composite of cardiac death, myocardial infarction, stroke and urgent coronary artery bypass grafting within 30 days of PCI) and target lesion failure (TLF; comprising cardiac death, target vessel myocardial infarction, target vessel revascularization within 1 year of PCI) respectively. In sensitivity analyses, we regrouped patients into EF < 45% and ≥55% and repeated the aforementioned analyses. RESULTS: In 1685 patients with normal EF (mean age 65 years; 27% women; mean EF 61%) and 259 with low EF (mean age 64 years; 17% women; mean EF 41%), 101 safety and 148 TLF events occurred. Compared with patients in the normal EF group, those with reduced EF had neither a statistically significant higher proportion of safety events, nor a higher multivariable-adjusted risk for such events. Similarly, patients with reduced EF and normal EF did not differ in terms of TLF event proportions or multivariable-adjusted risk for TLF. The results were similar in sensitivity analyses with EF groups redefined to create a 10% between-group EF separation. CONCLUSION: PCI safety and durability outcomes are similar in patients with mild-moderately reduced EF and normal EF.

Assessment of subclinical left ventricular systolic and diastolic dysfunction in patients with type 2 diabetes mellitus under follow-up at Tikur Anbessa specialized hospital, Ethiopia: a case-control study.

BACKGROUND: Individuals with diabetes mellitus are at increased risk of cardiovascular diseases, which in turn are the most common cause of morbidity and mortality in the diabetic population. A peculiar feature of cardiovascular diseases in this population is that they can have significant cardiac disease while remaining asymptomatic. There is a paucity of data regarding subclinical cardiac imaging features among diabetic adults in Africa, particularly in Ethiopia. This study was conducted to compare the magnitude and spectrum of left ventricular systolic and diastolic dysfunction among asymptomatic type 2 diabetic adults versus a normotensive, non-diabetic control group and to evaluate the determinants of left ventricular diastolic and systolic dysfunction. METHODS: This was a case-control study conducted at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia. A standard transthoracic echocardiography was done for all study participants with type 2 diabetes mellitus and their normotensive and non-diabetic controls. Structured questionnaires were used to collect demographic and clinical characteristics and laboratory test results. Statistical analysis was done using the SPSS 25.0 software. The data was summarized using descriptive statistics. Bivariate and multivariate analysis was performed to determine the association between variables and echocardiographic parameters. The strength of statistical association was measured by adjusted odds ratios and 95% confidence intervals, with significant differences taken at p < 0.05. RESULTS: We analyzed age- and sex-matched 100 participants in the study (diabetic) group and 200 individuals in the control group. Left ventricular systolic and diastolic dysfunction were significantly more prevalent among diabetic adults than their sex and age matched controls. Among diabetic individuals, ages of 60 years and above, dyslipidemia, use of Metformin and Glibenclamide, high serum triglyceride level, presence of neuropathy and use of statins correlated significantly with the presence of left ventricular diastolic dysfunction. Chronic kidney disease and neuropathy were determinants of left ventricular systolic dysfunction. CONCLUSION: Left ventricular systolic and diastolic dysfunction were significantly more prevalent among diabetic patients than their sex- and age-matched controls in our study. We recommend early screening for subclinical left ventricular dysfunction, especially in the elderly and in those with chronic kidney disease, dyslipidemia, and microvascular complications such as neuropathy.

Artificial intelligence enabled ECG screening for left ventricular systolic dysfunction: a systematic review.

Screening for left ventricular systolic dysfunction (LVSD), defined as reduced left ventricular ejection fraction (LVEF), deserves renewed interest as the medical treatment for the prevention and progression of heart failure improves. We aimed to review the updated literature to outline the potential and caveats of using artificial intelligence-enabled electrocardiography (AIeECG) as an opportunistic screening tool for LVSD.We searched PubMed and Cochrane for variations of the terms "ECG," "Heart Failure," "systolic dysfunction," and "Artificial Intelligence" from January 2010 to April 2022 and selected studies that reported the diagnostic accuracy and confounders of using AIeECG to detect LVSD.Out of 40 articles, we identified 15 relevant studies; eleven retrospective cohorts, three prospective cohorts, and one case series. Although various LVEF thresholds were used, AIeECG detected LVSD with a median AUC of 0.90 (IQR from 0.85 to 0.95), a sensitivity of 83.3% (IQR from 73 to 86.9%) and a specificity of 87% (IQR from 84.5 to 90.9%). AIeECG algorithms succeeded across a wide range of sex, age, and comorbidity and seemed especially useful in non-cardiology settings and when combined with natriuretic peptide testing. Furthermore, a false-positive AIeECG indicated a future development of LVSD. No studies investigated the effect on treatment or patient outcomes.This systematic review corroborates the arrival of a new generic biomarker, AIeECG, to improve the detection of LVSD. AIeECG, in addition to natriuretic peptides and echocardiograms, will improve screening for LVSD, but prospective randomized implementation trials with added therapy are needed to show cost-effectiveness and clinical significance.

Association between systemic inflammatory response index and left ventricular remodeling and systolic dysfunction in atrial fibrillation patients.

BACKGROUND: Cardiac remodeling and dysfunction can be caused by atrial fibrillation (AF). The aim of this research is to investigate the relationship between the systemic inflammatory response index (SIRI) and left ventricular (LV) remodeling and systolic function in individuals with AF. METHODS: 416 patients with AF who were admitted to the Second Department of Cardiology in the East Ward of the Qingdao Municipal Hospital between January 2020 and May 2022 were included in the present retrospective research. The relationship between SIRI and various cardiac parameters was analyzed. The patients' left atrial (LA) enlargement and left ventricular (LV) hypertrophy and systolic dysfunction were evaluated. SIRI was calculated by the formula: neutrophil × monocyte/lymphocyte. RESULTS: SIRI significantly correlated with LV end-diastolic diameter (LVDd), LV posterior wall thickness at end-diastole (LVPWTd), interventricular septal thickness at end-diastole (IVSTd), LV mass index (LVMI), LV ejection fraction (LVEF), LA diameter (LAD), C-reactive protein (CRP), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with AF. In multivariate linear regression analyses, SIRI was discovered to be significantly related to LVMI (ln-transformed) (p = 0.025), LVEF (ln-transformed) (p = 0.005), and LAD (ln-transformed) (p = 0.007). In multivariate logistic regression, the highest quartile of SIRI (SIRI > 1.62) was significantly associated with LV hypertrophy (p = 0.026), impaired LV systolic function (p = 0.002), and LA enlargement (p = 0.025). CONCLUSIONS: SIRI was significantly associated with LV remodeling and systolic function impairment in patients with AF. SIRI may serve as a reliable and convenient inflammatory biomarker for detecting impaired cardiac structure and systolic function in patients with AF.

Influencing factors and prognostic value of left ventricular systolic dysfunction in patients with complete occlusion of the left anterior descending artery reperfused by primary percutaneous coronary intervention.

BACKGROUND: The aim of this study was to perform a retrospective analysis of patients with acute anterior wall ST-segment elevation myocardial infarction (AAW-STEMI) whose left anterior descending (LAD) artery was completely occluded and reperfused by primary percutaneous coronary intervention (PPCI) and to determine the influencing factors and prognostic value of left ventricular systolic dysfunction (LVSD) in the acute phase of acute myocardial infarction (AMI). METHODS: A total of 304 patients with AAW-STEMI were selected. The selected patients were divided into two groups: the preserved left ventricular ejection fraction (pLVEF) group (LVEF ≥ 50%, n = 185) and the reduced left ventricular ejection fraction (rLVEF) group (LVEF < 50%, n = 119). The influencing factors of LVSD and their predictive value for LVSD were analyzed. Patients were followed up by examining outpatient records and via telephone. The predictive value of LVSD for the cardiovascular mortality of patients with AAW-STEMI was analyzed. RESULTS: Age, heart rate (HR) at admission, number of ST-segment elevation leads (STELs), peak creatine kinase (CK) and symptom to wire-crossing (STW) time were independent risk factors for LVSD (P < 0.05). The receiver operating characteristic (ROC) analysis showed that the peak CK had the strongest predictive value for LVSD, with an area under the curve (AUC) of 0.742 (CI, 0.687 to 0.797) as the outcome. At a median follow-up of 47 months (interquartile range, 27 to 64 months), the Kaplan‒Meier survival curves up to 6-year follow-up revealed a total of 8 patients succumbed to cardiovascular disease, with 7 (6.54%) in the rLVEF group and 1 (0.56%) in the pLVEF group, respectively (hazard ratio: 12.11, [P = 0.02]). Univariate and multivariate Cox proportional hazards regression analysis demonstrated that rLVEF was an independent risk predictor of cardiovascular death in patients with AAW-STEMI discharged after PPCI (P < 0.01). CONCLUSIONS: Age, HR at admission, number of STELs, peak CK, and STW time may be used to identify patients with a high risk of heart failure (HF) in a timely manner and initiate early standard therapy for incident LVSD in the acute phase of AAW-STEMI reperfused by PPCI. A trend toward increased cardiovascular mortality at follow-up was significantly linked to LVSD.

Heart failure among Indigenous and non-Indigenous Australians in remote Central Australia.

BACKGROUND: There is a paucity of data on the burden of heart failure (HF) in Central Australia, the most populous Indigenous region in the country. AIMS: To characterize Indigenous and non-Indigenous Australians with HF in Central Australia. METHODS: Consecutive patients with HF and reduced ejection fraction <50% were included for the period 2019 to 2021. Clinical, echocardiographic and major adverse cardiovascular events (MACE) data were collected. RESULTS: Four hundred twenty-four patients with HF were included (70% Indigenous, 59% male; follow-up 2.2 ± 0.5 years). Indigenous Australians were younger (53 ± 15 vs 68 ± 13 years, P < 0.001) with higher rates of rheumatic heart disease (18% vs 1%, P < 0.001), diabetes (63% vs 33%, P < 0.001) and severe chronic kidney disease (CKD; 32% vs 7%, P < 0.001). HF was more prevalent among Indigenous (138 [95% confidence interval (CI), 123-155] per 10 000) compared with non-Indigenous Australians (53 [95% CI, 44-63] per 10 000), particularly among younger individuals and females. There were similar HF aetiologies between groups. Guideline-directed medical therapy (GDMT) was suboptimal and similar between the groups: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (64% vs 67%, P = 0.47) and ß-blockers (68% vs 71%, P = 0.47). Indigenous Australians had a significantly higher rate of MACE (54% vs 28%, P < 0.001) and death from any cause (24% vs 13%, P = 0.013). CONCLUSIONS: HF is more than two times as prevalent among Indigenous Central Australians, particularly among younger individuals and females. Despite similar HF aetiologies and GDMT, MACE and mortality outcomes are higher in Indigenous individuals with HF. These data have implications for efforts to close the Indigenous gap in morbidity and mortality.

How arrhythmias weaken the ventricle: an often underestimated vicious cycle.

Arrhythmia-induced cardiomyopathy (AIC) is classified as a form of dilated cardiomyopathy in which left ventricular systolic dysfunction (LVSD) is triggered by tachycardic or arrhythmic heart rates. On the one hand AIC can develop in patients without cardiac disease and on the other hand it can appear in patients with pre-existing LVSD, leading to a further reduction in left ventricular (LV) ejection fraction. A special aspect of AIC is the potential termination or partial reversibility of LVSD; thus, AIC is curatively treatable by the elimination of the underlying arrhythmia. Since arrhythmias are often seen merely as a consequence than as an underlying cause of LVSD, and due to the fact that the diagnosis of AIC can be made only after recovery of LV function, the prevalence of AIC is probably underestimated in clinical practice. Pathophysiologically, animal models have shown that continuous tachycardic pacing induces consecutive changes such as the occurrence of LVSD, increased filling pressures, LV dilatation, and decreased cardiac output. After termination of tachycardia, reversibility of the described pathologies can usually be observed. Studies in human ventricular myocardium have recently demonstrated that various cellular structural and functional mechanisms are activated even by normofrequent atrial fibrillation, which may help to explain the clinical AIC phenotype.

Primary care heart failure service identifies a missed cohort of heart failure patients with reduced ejection fraction.

AIMS: We explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service. METHODS AND RESULTS: PCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients' records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record. CONCLUSION: A PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription.

Catheter ablation for persistent atrial fibrillation with left ventricular systolic dysfunction: Who is the best candidate?

BACKGROUND: Tachycardia-induced cardiomyopathy is poorly recognized pre-ablation. It remains unclear of better patient selection and timing for catheter ablation in persistent atrial fibrillation (PerAF) with heart failure (HF). METHODS: Consecutive patients with PerAF and left ventricular ejection fraction (LVEF) <50% referred for AF ablation were retrospectively included. The impact of LV size, heart rate (HR), and LVEF pre-ablation were analyzed for assessing LV systolic function recovery, defined as LVEF increase of ≥20% or to a value ≥55% after ablation. RESULTS: A total of 120 patients (2017-2020) were included. After 19 ±14 months post ablation, LVEF improvement was similar in patients with normal or dilated LV (18.3 ± 9.4% vs. 16.1 ± 10.8%, P = .25), rapid or controlled HR (19.5 ± 10% vs. 16.1 ± 10%, P = .09), but higher in HFrEF (HF with reduced EF) than HFmrEF (HF with midrange EF) (21.6 ± 10.3% vs. 14.9 ± 9.3%, P < .01). There was more LV systolic function recovery in those with normal to moderate LV dilation (80%, odds ratio [OR] 15.22, P < .01), HR ≥80 bpm (79%, OR 5.38, P < .01) and HFmrEF (80%, OR 4.03, P < .01). The overall AF freedom was similar between normal and dilated LV (59% vs. 62%, P = .95), rapid and controlled HR (67% vs. 56%, P = .18), and HFmrEF and HFrEF (65% vs. 50%, P = .19). CONCLUSION: Catheter ablation is effective independent of LV dilation, rate control or HFrEF. Patients with normal to moderate LV dilation, resting HR ≥80 bpm and HFmrEF may be candidates for early PerAF ablation to achieve LVEF normalization.

Clinical profile and outcomes of multisystem inflammatory syndrome in children (MIS-C): Hospital-based prospective observational study from a tertiary care hospital in South India.

AIM: To study the clinical profile and outcomes in children with multisystem inflammatory syndrome in children (MIS-C). METHODS: Children aged 1 month to 15 years presenting with MIS-C (May 2020 to November 2021) were enrolled. Clinical, laboratory, echocardiography parameters and outcomes were analysed. RESULTS: Eighty-one children (median age 60 months (24-100)) were enrolled. Median duration of fever was 5 days (3-7). Twenty-nine (35.8%) had shock (severe MIS-C) including 23 (28.3%) requiring inotropes (median duration = 25 h (7.5-33)). Ten required mechanical ventilation, 12 had acute kidney injury and 1 child died. Left ventricular (LV) dysfunction was seen in 38 (46.9%), 16 (19.7%) had coronary artery abnormalities (CAA) and 13 (20%) had macrophage activation syndrome. Sixty-one (75.3%) were SARS CoV-2 positive (10 by RT-PCR and 51 by serology). Sixty-eight (83.9%) received immunomodulators. Younger age was significantly associated with CAA (P value = 0.05). Older age, LV dysfunction, SARS CoV-2 positivity, low platelet count and elevated serum ferritin were significantly associated with severe MIS-C (univariate analysis). Younger age was an independent predictor of CAA (P = 0.05); older age (P = 0.043) and low platelet count (P = 0.032) were independent predictors of severe MIS-C (multivariate logistic regression analysis). CONCLUSION: Our patients had diverse clinical manifestations with a good outcome. Younger age was significantly associated with CAA. Older age, LV dysfunction, low platelet count and elevated serum ferritin were significantly associated with severe MIS-C. Younger age is an independent predictor of CAA. Older age and low platelet count are independent predictors of severe MIS-C.

Association between left ventricular diastolic dysfunction and septic acute kidney injury in severe sepsis and septic shock: A multicenter retrospective study.

INTRODUCTION: Left ventricular diastolic dysfunction (LVDD) adversely impacts renal function, and E/e' is a significant predictor of adverse kidney events under different clinical conditions. However, no studies have evaluated the association between LVDD and septic acute kidney injury (AKI) among patients with severe sepsis and septic shock. METHODS: This multicenter retrospective study evaluated adult patients with severe sepsis or septic shock between January 1, 2013, and December 31, 2019, who underwent echocardiography within 24 hours after admission to an intensive care unit. RESULTS: A total of 495 adult patients were enrolled in the study. LVDD grades II and III were associated with severe (stage 3) AKI (p < 0.001, p for trend < 0.001). E/e' and e' were risk factors for septic AKI (OR, 1.155; 95% CI, 1.088-1.226, p < 0.001; and OR, 7.218; 95% CI, 2.942-17.712, p < 0.001, respectively) in the multivariate logistic regression analysis. The area under the receiver operating characteristic curve of E/e' and e' was 0.728 (95% CI, 0.680-0.777, p < 0.001) and 0.715 (95% CI, 0.665-0.764, p < 0.001), respectively. CONCLUSIONS: LVDD was associated with septic AKI, and E/e' and e' are useful predictors of septic AKI among patients with severe sepsis or septic shock. TRIAL REGISTRATION: The study was registered at the Chinese Clinical Trial Registry (Protocol No. ChiCTR2000033083).

Risk of arrhythmias after myocardial infarction in patients with left ventricular systolic dysfunction according to mode of revascularization: a Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) substudy.

AIMS: The Cardiac Arrhythmias and RIsk Stratification after Myocardial infArction (CARISMA) study was an observational trial including 312 patients with acute myocardial infarction (MI) and left ventricular ejection fraction (LVEF) <40%. Primary percutaneous intervention (pPCI) was introduced 2 years after start of the enrolment, dividing the population into two groups: pre- and post-pPCI. This substudy sought to describe the influence of the mode of revascularization on long-term risk of new-onset atrial fibrillation (AF), bradyarrhythmia, and ventricular tachycardia and the subsequent risk of relevant major cardiovascular events (MACE). METHODS AND RESULTS: The study included the 268 patients without a history of AF. All patients received an implantable cardiac monitor (ICM) and were followed for 2 years. The choice of revascularization was made by the treating team independently of the trial and retrospectively divided into pPCI, subacute PCI, primary thrombolysis, or no revascularization. Endpoints were new-onset arrhythmia and MACE.A total of 77 patients received no revascularization, whereas 49 received thrombolysis only and 142 received any PCI. The adjusted hazard ratio (HR) for developing any arrhythmia and the subsequently risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients (any arrhythmia, non-revascularization: HR = 1.7, P = 0.01 and thrombolysis: HR = 1.6, P = 0.05; MACE, non-revascularization: HR = 3.1, P = 0.05 and thrombolysis: HR = 3.1, P = 0.08). All HRs were adjusted for significant baseline and clinically considered covariates and stratified for calendar year. CONCLUSION: This study is the first to demonstrate that the long-term risk of arrhythmia documented by an ICM and the subsequent risk of MACE were increased in non-revascularized or thrombolysed patients compared with PCI-patients in a post-MI population with LVEF <40%.

Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention in Patients with Left Ventricular Systolic Dysfunction.

PURPOSE: There is a paucity of comparative data examining the optimal revascularization strategy in patients with left ventricular systolic dysfunction (LVD). METHODS: We performed an aggregate data meta-analysis of clinical outcomes comparing percutaneous coronary intervention (PCI) versus coronary artery bypass (CABG) in patients with LVD (left ventricle ejection fraction (LVEF) of ≤ 40%), using the random effects model. Effects size is reported as odds ratio (OR) and a 95% confidence interval. Outcomes included all-cause mortality, myocardial infarction, stroke, repeat revascularization, and a composite of major adverse cardiac and cerebrovascular events (MACCE) at 30-day, 3-year, and long-term (6.3 ± 0.9 years) follow-ups. Seventeen studies (16 observational, 1 randomized) and 18,599 patients (CABG 9651; PCI 8948) were included. RESULTS: PCI and CABG had comparable all-cause mortality at 30 days (OR 0.78, 95% CI 0.49-1.23) and 3 years (OR 1.05, 95% CI 0.91-1.21); however, PCI was associated with increased long-term morality after a mean follow-up of 6.3 ± 0.9 years (31.6% vs. 24.3%, OR 1.41, 95% CI 1.21-1.64). A similar mortality trend was observed in the subgroup of patients with EF ≤ 35%. PCI had a higher rate of repeat revascularization at 3-year and long-term follow-ups. The long-term rates of stroke and MI were comparable. PCI, on the other hand, had lower rates of stroke at 30-day and 3-year follow-ups. CONCLUSION: CABG was associated with lower rates of long-term mortality and revascularization but higher rate of upfront stroke in patients with LVD. However, the data included consisted predominantly of observational studies, highlighting the paucity and need for randomized trials.

Cardiovascular Magnetic Resonance May Avoid Unnecessary Coronary Angiography in Patients With Unexplained Left Ventricular Systolic Dysfunction: A Retrospective Diagnostic Pilot Study.

BACKGROUND: Coronary angiography (CA) is usually performed in patients with reduced left ventricular ejection fraction (LVEF) to search ischemic cardiomyopathy. Our aim was to examine the agreement between CA and cardiovascular magnetic resonance (CMR) imaging among a cohort of patients with unexplained reduced LVEF, and estimate what would have been the consequences of using CMR imaging as the first-line examination. METHODS: Three hundred five patients with unexplained reduced LVEF of ≤45% who underwent both CA and CMR imaging were retrospectively registered. Patients were classified as CMR+ or CMR- according to presence or absence of myocardial ischemic scar, and classified CA+ or CA- according to presence or absence of significant coronary artery disease. RESULTS: CMR+ (n = 89) included all 54 CA+ patients, except 2 with distal coronary artery disease in whom no revascularization was proposed. Among the 247 CA- patients, 15% were CMR+. CMR imaging had 96% sensitivity, 85% specificity, 99% negative predictive value, and 58% positive predictive value for detecting CA+ patients. Revascularization was performed in 6.5% of the patients (all CMR+). Performing CA only for CMR+ patients would have decreased the number of CAs by 71%. CONCLUSIONS: In reduced LVEF, performing CA only in CMR+ patients may significantly decrease the number of unnecessary CAs performed, without missing any patients requiring revascularization.

Advancements in the diagnostic workup, prognostic evaluation, and treatment of takotsubo syndrome.

Takotsubo syndrome (TTS) is an acute and mostly reversible cardiomyopathy that mimics an acute coronary syndrome with left ventricular (LV) systolic dysfunction without relevant obstructive coronary artery disease. Its prevalence is probably underestimated and reaches 1.2-2% in patients with acute coronary syndrome undergoing coronary catheterization. Although supraphysiological epinephrine levels have been associated with TTS, the detailed pathophysiology is incompletely understood. Chest pain is the most common clinical presentation; however, cardiac decompensation, cardiogenic shock, and sudden cardiac death due to ventricular fibrillation may also be the first clinical manifestations. Patients are mostly postmenopausal women, in whom the condition is commonly associated with emotional triggers; however, men have a higher prevalence of TTS being associated with physical triggers, which has a worse prognosis compared with TTS associated with emotional triggers. As a diagnosis of exclusion, TTS has no single definitive diagnostic test. According to the distribution of LV wall motion abnormalities, various morphological subtypes have been identified. The final diagnosis depends on cardiac imaging with left ventricular angiography during acute heart catheterization, as well as on echocardiography and cardiac magnetic resonance. Most patients recover completely, albeit several factors have been associated with worse prognosis. Management is based on observational data, while randomized multicenter studies are still lacking. This review provides a general overview of TTS and focuses on the hypothesized pathophysiology, and especially on current practices in diagnosis, prognosis, and treatment.

Augmented glycaemic gap is a marker for an increased risk of post-infarct left ventricular systolic dysfunction.

BACKGROUND: Left ventricular systolic dysfunction (LVSD) occurs frequently after acute ST-segment elevation myocardial infarction (STEMI). The predisposing factors and underlying mechanism of post-infarct LVSD are not fully understood. The present study mainly investigated the correlation between glycaemic gap, a novel index of stress-induced hyperglycaemia (SIH), and post-infarct LVSD. METHODS: A total of 274 first STEMI patients were enrolled in this cross-sectional study. Transthoracic echocardiography was performed within 48 h after admission and at 6 months after discharge to obtain left ventricular ejection fraction (LVEF). The change in LVEF was calculated as LVEF at 6 months after discharge minus baseline LVEF. Additionally, post-infarct LVSD was defined as LVEF ≤ 50%. Most importantly, glycaemic gap was calculated as admission blood glucose (ABG) minus the estimated average glucose over the previous 3 months. RESULTS: In patients without diabetes mellitus (DM), multivariate linear regression analysis revealed that both glycaemic gap (Beta = - 1.214, 95% CI - 1.886 to - 0.541, p < 0.001) and ABG (Beta = - 1.124, 95% CI - 1.795 to - 0.453, p = 0.001) were associated with change in LVEF. In DM patients, only glycaemic gap was still associated with change in LVEF, although this association was not observed in univariate linear regression analysis. Regarding the association between SIH and post-infarct LVSD, multivariate logistic regression analysis revealed that both glycaemic gap (OR = 1.490, 95% CI 1.043 to 2.129, p = 0.028) and ABG (OR = 1.600, 95% CI 1.148 to 2.229, p = 0.005) were associated with an increased risk of having post-infarct LVSD in non-DM patients. However, after multivariate adjustment in DM patients, only glycaemic gap (OR = 1.399, 95% CI 1.021 to 1.919, p = 0.037) remained associated with an increased risk of having post-infarct LVSD. Furthermore, the predictive value of glycaemic gap for post-infarct LVSD was not inferior to ABG in non-DM patients (p = 0.499), and only glycaemic gap, instead of ABG, could significantly predict post-infarct LVSD in DM patients (AUC = 0.688, 95% CI 0.591 to 0.774, p = 0.002). CONCLUSIONS: Glycaemic gap was strongly associated with a change in LVEF and an increased risk of having post-infarct LVSD in patients following STEMI. In STEMI patients with DM, glycaemic gap could provide more valuable information than ABG in identifying patients at high risk of developing post-infarct LVSD.

Left-sided heart disease and risk of death in patients with end-stage kidney disease receiving haemodialysis: an observational study.

BACKGROUND: Cardiovascular disease is the most common cause of death in patients with end-stage kidney disease on haemodialysis. The potential clinical consequence of systematic echocardiographic assessment is however not clear. In an unselected, contemporary population of patients on maintenance haemodialysis we aimed to assess: the prevalence of structural and functional heart disease, the potential therapeutic consequences of echocardiographic screening and whether left-sided heart disease is associated with prognosis. METHODS: Adult chronic haemodialysis patients in two large dialysis centres had transthoracic echocardiography performed prior to dialysis and were followed prospectively. Significant left-sided heart disease was defined as moderate or severe left-sided valve disease or left ventricular ejection fraction (LVEF) ≤40%. RESULTS: Among the 247 included patients (mean 66 years of age [95%CI 64-67], 68% male), 54 (22%) had significant left-sided heart disease. An LVEF ≤40% was observed in 31 patients (13%) and severe or moderate valve disease in 27 (11%) patients. The findings were not previously recognized in more than half of the patients (56%) prior to the study. Diagnosis had a potential impact on management in 31 (13%) patients including for 18 (7%) who would benefit from initiation of evidence-based heart failure therapy. After 2.8 years of follow-up, all-cause mortality among patients with and without left-sided heart disease was 52 and 32% respectively (hazard ratio [HR] 1.95 (95%CI 1.25-3.06). A multivariable adjusted Cox proportional hazard analysis showed that left-sided heart disease was an independent predictor of mortality with a HR of 1.60 (95%CI 1.01-2.55) along with age (HR per year 1.05 [95%CI 1.03-1.07]). CONCLUSION: Left ventricular systolic dysfunction and moderate to severe valve disease are common and often unrecognized in patients with end-stage kidney failure on haemodialysis and are associated with a higher risk of death. For more than 10% of the included patients, systematic echocardiographic assessment had a potential clinical consequence.

Triphasic mitral flow pattern may indicate subclinical left ventricular systolic dysfunction.

PURPOSE: In this study, the presence and severity of left ventricular (LV) systolic dysfunction were investigated by speckle tracking echocardiography (STE) technique in patients with mitral triphasic mitral flow pattern (TMFP). The aim of the study was to evaluate the possible role of TMFP in the ethiopathogenesis of congestive heart failure. METHODS AND RESULTS: A total of 45 patients who were diagnosed with TMFP and 30 age- and gender-matched healthy volunteers were included in the study. The mean age in the study and control groups was 64 ± 12 and 62 ± 11 (P = .642), respectively. When echocardiographic parameters were evaluated, LV ejection fraction was found to be 63% ± 14 and 64 ± 12 (P = .745), in the study and control groups, respectively. LV end-diastolic and systolic diameters and LV mass index were also similar (P < .05). When LV diastolic parameters were compared, diastolic dysfunction was detected in 38 (84.4%) patients in the study population and 13 patients (43.3%) in the control group (P < .001). When STE findings were evaluated, both global longitidunal strain and global circumferential strain were significantly lower in the TMFP group when compared to controls (18.3 ± 1.7 vs 21.5 ± 1.5, P < .001 and 17.9 ± 1.6 vs 21.3 ± 2.1, P < .001, respectively). CONCLUSION: TMFP results in LV systolic dysfunction. Therefore, these patients may develop congestive heart failure in the long term. It will be rational that the patients with TMFP should be followed up more closely in terms of preventing manifest heart failure symptoms.

Accuracy of Cardiac Nurse Acquired and Measured Three-Dimensional Echocardiographic Left Ventricular Ejection Fraction: Comparison to Echosonographer.

BACKGROUND: Three-dimensional echocardiography (3D-Echo) performed by novice health care staff to measure left ventricular ejection fraction (LVEF) could allow cost-effective screening and monitoring for left ventricular systolic dysfunction (LVSD) prior to the development of heart failure. The aim of this study was to determine feasibility and accuracy of cardiac nurses (after completing focussed training) independently acquiring 3D-Echo images, and measuring LVEF using semi-automated software when compared to an echosonographer. METHODS: One echosonographer and three cardiac nurses acquired 3D-Echo images on 73 patients (62 ± 16 years, 62% male) with good image quality, and subsequently measured LVEF using a semi-automated algorithm. RESULTS: Overall feasibility was 89% with the three nurses successfully acquiring 3D-Echo images suitable for LVEF assessment in 65 of the 73 patients. High accuracy (r = 0.82; p < 0.0001) with minimal bias (+0.1, -10.6 to +10.8 limits of agreement; p = 0.91) was observed comparing the nurses to the echosonographer for measuring LVEF. Individual nurses demonstrated high feasibility (86%-92%), accuracy (r = 0.83-0.87; all p < 0.0001) and intra-observer reproducibility (r = 0.96-0.97; all p < 0.0001), with good inter-observer consistency in accuracy compared to the echosonographer (one-way analysis of variance p = 0.559). CONCLUSIONS: We have demonstrated that, following a focussed training protocol, it was feasible for cardiac nurses to acquire 3D-Echo images of sufficient image quality to allow measurement of LVEF using a semi-automated algorithm, with comparable accuracy and intra-observer variability to an expert echosonographer. This could potentially allow the broader application of echocardiography to screen for LVSD in high-risk cohorts.

Global Longitudinal Strain (GLS) in Elderly and Its Associated Factors.

BACKGROUND: cardiovascular disease is very common and can be fatal in elderly patients. It is often preceded by asymptomatic or subclinical left ventricular systolic dysfunction (LVSD). Early detection of LVSD can reduce morbidity and mortality due to cardiovascular disease. One method used in the early detection of LVSD is an assessment of global longitudinal strain (GLS). This study aimed to determine the mean value of GLS and GLS-related factors. METHODS: this cross-sectional study was conducted among elderly patients aged > 60 years in the geriatric and cardiology clinic, Internal Medicine, CMH Hospital. Data were obtained from interviews, medical records, and transthoracic echocardiography examination. The variables of age, frailty, hypertension, coronary artery disease, dyslipidemia, and diabetes mellitus were analyzed as the determinants of a decrease in GLS. Univariate analysis was conducted for each variable. Bivariate analysis was conducted using the chi-square test with a significance level of p<0.25 and confidence interval (CI) of 95%, and multivariate analysis used a logistic regression test. RESULTS: a total of 194 patients were admitted according to the study criteria, with a mean age of 66 years. The proportion of women was 60.8%. The study revealed that the determinants with p<0.25 are frailty, hypertension, dyslipidemia, and diabetes mellitus, with multivariate analysis frailty having an OR of 2.002 (95% CI 1.042-3.925) and diabetes mellitus having an OR of 2.278 (95% CI 1.033-5.025). CONCLUSION: the mean value of GLS among the elderly was -21.6% (minimum value -5.3% and maximum value 29.9%). The factors that influence the decrease of GLS are frailty and diabetes mellitus.