Alternative Therapy for Medically Refractory Angina: Enhanced External Counterpulsation and Transmyocardial Laser Revascularization.

Medically refractory angina pectoris (RAP) is defined by presence of severe angina with objective evidence of ischemia and failure to relieve symptoms with coronary revascularization. Medication and invasive revascularization are the most common approaches for treating coronary artery disease (CAD). Although symptoms are eliminated or alleviated by these invasive approaches, the disease and its causes are present after treatment. New treatment approaches are needed to prevent the disease from progressing and symptoms from recurring. External enhanced counterpulsation therapy provides a treatment modality in the management of CAD and can complement invasive revascularization procedures. Data support that it should be considered a first-line treatment of RAP.

Percutaneous versus surgical interventions for coronary artery disease in those with diabetes mellitus.

Diabetes mellitus (DM) is a metabolic disorder of multiple etiologies that causes long-term damage of various organs including the cardiovascular system. A consistent observation shows that DM amplifies the risk of cardiovascular events by 4- to 6-fold. Since coronary artery disease (CAD) in diabetic patients exhibits diffuse and accelerated lesions, invasive revascularization continues to be a challenge and has worse outcomes than patients without DM. Owing to the pathogenesis of DM and the presence of severe endothelial dysfunction, investigators have been trying to find new treatment modalities that could target the treatment of the disease rather than the treatment of the lesion. Until new treatment modalities are proven and gain acceptance, invasive revascularization remains to be the choice of treatment in such patients. The focus of this review is to compare the results of percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for the treatment of stable CAD in patients with DM.

Pulsatile venous waveform quality affects the conduit performance in functional and "failing" Fontan circulations.

OBJECTIVE: To investigate the effect of pulsatility of venous flow waveform in the inferior and superior caval vessels on the performance of functional and "failing" Fontan patients based on two primary performance measures - the conduit power loss and the distribution of inferior caval flow (hepatic factors) to the lungs. METHODS: Doppler angiography flows were acquired from two typical extra-cardiac conduit "failing" Fontan patients, aged 13 and 25 years, with ventricle dysfunction. Using computational fluid dynamics, haemodynamic efficiencies of "failing", functional, and in vitro-generated mechanically assisted venous flow waveforms were evaluated inside an idealised total cavopulmonary connection with a caval offset. To investigate the effect of venous pulsatility alone, cardiac output was normalised to 3 litres per minute in all cases. To quantify the pulsatile behaviour of venous flows, two new performance indices were suggested. RESULTS: Variations in the pulsatile content of venous waveforms altered the conduit efficiency notably. High-frequency and low-amplitude oscillations lowered the pulsatile component of the power losses in "failing" Fontan flow waveforms. Owing to the offset geometry, hepatic flow distribution depended strongly on the ratio of time-dependent caval flows and the pulsatility content rather than mixing at the junction. "Failing" Fontan flow waveforms exhibited less balanced hepatic flow distribution to lungs. CONCLUSIONS: The haemodynamic efficiency of single-ventricle circulation depends strongly on the pulsatility of venous flow waveforms. The proposed performance indices can be calculated easily in the clinical setting in efforts to better quantify the energy efficiency of Fontan venous waveforms in pulsatile settings.

Comparison of long term clinical outcomes, event free survival rates of patients undergoing enhanced external counterpulsation for coronary artery disease in the United States and Turkey.

OBJECTIVES: This study assessed the long-term efficacy of EECP (Enhanced External Counterpulsation) in Turkish (TR) patients initially and compared these results with the United States (US) in a real world setting. STUDY DESIGN: In this study, 2072 patients were treated and followed in the US and 82 patients were treated and followed in TR. The International EECP Patient Registry Phase I and II was initiated and coordinated at the University of Pittsburgh. The aim of the "registry" was to assess the outcomes of clinical trials in a real world setting. Another unique feature of this study was to enroll patients not only from university hospitals but also from private hospitals, educational hospitals, and treatment centers. RESULTS: TR patients had less diabetes, hypertension, and hyperlipidemia than US patients (p<0.01). TR patients also had a higher proportion of diastolic augmentation (p<0.001). Both groups showed a significant reduction in the severity of angina after a 35 h EECP course (p<0.001). Major Adverse Cardiac Events (MACE) rate (death, coronary artery bypass graft, percutaneous coronary intervention, myocardial infarction) was low in both groups during treatment (2.5% vs. 2.7%). At 1 year follow up, 84% of TR and 76% of US patients had maintained the improvement of angina. CONCLUSION: Patients presenting for EECP treatment from TR had different baseline profiles from US patients. However, despite the high risk baseline characteristics, both cohorts achieved similar reduction in angina. In the long term follow-up, the MACE rate was low and the improvement after EECP was sustained in most of the patients.

[Frequency of sublingual nitroglycerin prescription in patients with coronary artery disease and angina and awareness of patients about the shelf life of the drug]. / Anginasi olan koroner arter hastalarinda dilalti nitrogliserin reçete edilme sikliginin ve hastalarin etkin ilaç kullanim ömrü hakkinda bilgilerinin degerlendirilmesi.

OBJECTIVES: ACC/AHA/ESC guidelines recommend sublingual nitroglycerin (SNG) in patients with stable angina pectoris and coronary artery disease (CAD). However, the shelf life of SNG following first use is six months for SNG tablets and two years for SNG sprays. We investigated the frequency of prescription of SNG tablets/sprays in patients having anginal symptoms and documented CAD and the awareness levels of patients about appropriate use of SNG. STUDY DESIGN: Three hundred patients (201 men, 99 women; mean age 61.7±10.8 years) with documented CAD and angina were enrolled into this study. Angina pectoris was categorized according to the functional classification system of the Canadian Cardiovascular Society. Data on cardiovascular past histories, risk factors, medications, and the use of SNG were recorded. RESULTS: At least one risk factor was present in 96% of the patients. Only 46% of the patients had a prescription for SNG. Of those with a prescription of SNG tablet and spray, 91.8% and 84.4% did not know the shelf life of the product, respectively. Of those who were routinely carrying SNG, 35.6% had an expired product. Of those with a prescription of SNG, only 65.9% were informed by the physician on the proper use of SNG. CONCLUSION: Our results show that, despite recommendations of the guidelines, SNG is not prescribed to a substantial percentage of patients with CAD and angina, a considerable fraction of patients carry an expired product, and that patients are not adequately informed by the physicians on the use of SNG. These problems will certainly affect the optimal medical management of CAD and its efficacy.

Cost of medical services in older patients with heart failure: those receiving enhanced monitoring using a computer-based telephonic monitoring system compared with those in usual care: the Heart Failure Home Care trial.

BACKGROUND: Prior studies suggest that disease management programs may be effective in improving clinical and economic outcomes in patients with heart failure. Whether these types of programs can lower health care cost and be adapted to the primary care setting is unknown. This study was designed to assess the impact of a home-based disease management program, the Alere DayLink HF Monitoring System (HFMS), on the clinical and economic outcomes of Medicare beneficiaries recently hospitalized for heart failure who received the care from a community-based primary care practitioner. METHODS AND RESULTS: The Heart Failure Home Care trial was a multicenter, randomized, controlled trial of sophisticated, monitoring of heart failure patients with an interactive program versus standard heart failure care with enhanced patient education and follow-up (SC) in Medicare-eligible patients. The study endpoints included cardiovascular death or rehospitalization for heart failure, length of hospital stay, total patient cost, and cost to Medicare at 6 months of enrollment. A total of 315 patients age ≥ 65 years old were randomized: 160 to the HFMS and 155 to SC. There were no significant statistical differences between the groups in regards to 6-month cardiac mortality, rehospitalizations for heart failure, or length of hospital stay. Of those, 304 patients had their Medicare data available. The information from the Medicare claims data was used to determine the cost. Information from the trial was used to determine costs of out-patient drugs and the interventions. The 6-month mean Medicare costs were estimated to be $17,837 and $13,886 for the HFMS and the SC groups, respectively. We found that overall medical costs of medicare patients were significantly higher for patients who were randomized to the HFMS arm than they were for the patients randomized to the SC arm. CONCLUSIONS: Our study results suggest that enhanced patient education and follow-up is as successful as a sophisticated home monitoring device with an interactive program and less costly in patients who are elderly and receive the care from a community-based primary care practitioner.

Effects of isolated obesity on left and right ventricular function: a tissue Doppler and strain rate imaging study.

OBJECTIVE: To determine the subclinical effects of isolated obesity and its duration on cardiac function by using routine echocardiography and tissue Doppler myocardial strain rate. METHODS: Forty-nine subjects were enrolled in this study; 29 with isolated obesity defined as a body mass index > or = 30 kg/m(2) with no other cardiovascular comorbidities, and 20 nonobese controls. All subjects underwent two-dimensional and Doppler echocardiography including tissue Doppler imaging and myocardial strain rate. RESULTS: The average duration of obesity was 12.1 years (4-18 years). Abnormalities of left ventricular (LV) wall thickness, mass, diastolic function, and left atrial size were detected in obese individuals, despite having preserved ejection fractions. The LV global longitudinal peak strain rate was significantly lower in obese subjects compared to nonobese control subjects (1.07 +/- 0.14 vs. 1.38 +/- 0.12, P < 0.001). Using multivariate analysis, the duration of obesity (ss=-0.76, P < 0.001), body mass index (ss=-0.35, P = 0.023), and age (ss=-0.29, P = 0.009) were independent predictors of the decreased LV global longitudinal peak strain rate, while the duration of obesity (ss=-0.66, P < 0.001) and body mass index (ss=-0.28, P = 0.037) were independent predictors of the decreased right ventricular (RV) peak strain rate. CONCLUSION: The presence and the duration of obesity were associated with impairment of subclinical biventricular systolic and diastolic function. These findings have the potential to increase awareness of subclinical cardiac manifestations in patients with isolated obesity and influence their early management.

A randomized clinical trial of the clinical effects of enhanced heart failure monitoring using a computer-based telephonic monitoring system in older minorities and women.

BACKGROUND: Prior studies suggest that disease management programs may be effective in improving clinical outcomes in patients with heart failure (HF). However, the use of these programs in settings with limited sources and among diverse population is not know. Thus the present study was designed to assess the impact of a computer-based home disease management program (Alere DayLink HF Monitoring System [HFMS]) on the clinical outcomes of Medicare beneficiaries with HF who were elderly, women, and non-white males who received the care from a community-based primary care practitioner. METHODS AND RESULTS: The Heart Failure Home Care (HFHC) trial was a multicenter, randomized, controlled trial of HFMS versus standard heart failure care (SC: enhanced patient education, education to clinicians, and follow-up). The primary study end point was treatment failure, defined as a composite of cardiovascular death or rehospitalization for heart failure within 6 months of enrollment. Among patients rehospitalized for HF, length of hospital stay was also considered a primary end point. A total of 315 patients were randomized: 160 to HFMS and 155 to SC. Although the incidence of the primary outcome was somewhat higher in the SC arm (28.8% versus 21.2%, P = .15), the difference was not statistically different. The length of hospital stay was also similar in both groups. CONCLUSIONS: Our study results suggest that enhanced patient education and follow-up is as successful as a sophisticated home monitoring device with an interactive program in patients with HF who are elderly, women and non-Caucasian males and receive the care from a community-based primary care practitioner.

Enhanced external counterpulsation in the treatment of chronic refractory angina: a long-term follow-up outcome from the International Enhanced External Counterpulsation Patient Registry.

BACKGROUND: The management of patients who suffer from medically refractory angina and are unsuitable for conventional revascularization therapy is often unsatisfactory. Enhanced external counterpulsation (EECP) is a noninvasive treatment that is safe and effective immediately after a course of treatment. However, the duration of benefit is less certain. HYPOTHESIS: To evaluate the 3-year outcome of EECP treatment. METHODS: One thousand four hundred and twenty seven patients from 36 centers registered in the International EECP Patient Registry (IEPR)-Phase 1 was prospectively followed for a median of 37 months. Two hundred and twenty patients (15.4%) died, while 1,061 patients (74.4%) completed their follow-up. RESULTS: The mean age was 66+/-11 years and 72% were men. Seventy-six percent had multivessel coronary disease for 11+/-8 years. Eighty-eight percent had a prior percutaneous or surgical revascularization and 82% were unsuitable for further coronary intervention. Immediately post-EECP, the proportion of patients with severe angina (Canadian Cardiovascular Angina Classification [CCS] III/IV) were reduced from 89% to 25%, p<0.001. The CCS class was improved by at least 1 class in 78% of the patients and by at least 2 classes in 38%. This was sustained in 74% of the patients during follow-up.Thirty-six percent of the patients had CCS II or less angina, which was better than pre-EECP state without a major adverse cardiovascular event during follow-up. More severe baseline angina and a history of heart failure or diabetes were independent predictors of unfavorable outcome. CONCLUSION: An EECP improves angina and quality of life immediately after a course of treatment. For most of the patients, these beneficial effects are sustained for 3 years.

Impact of external counterpulsation treatment on emergency department visits and hospitalizations in refractory angina patients with left ventricular dysfunction.

Patients with refractory angina and left ventricular (LV) dysfunction exert an enormous burden on health care resources primarily because of the number of recurrent emergency department (ED) visits and hospitalizations. Enhanced external counterpulsation (EECP) therapy has emerged as a treatment option for patients with angina and LV dysfunction and has been shown to improve clinical outcomes and LV function. Improvements in symptoms and laboratory assessments in these patients, however, do not necessarily correlate with a reduction in ED visits and hospitalizations. This is the first study to assess the impact of EECP therapy on ED visits and hospitalization rates at 6-month follow-up. This prospective cohort study included 450 patients with LV dysfunction (ejection fraction

Effectiveness of repeat enhanced external counterpulsation for refractory angina in patients failing to complete an initial course of therapy.

AIMS: This study examined the causes and results of retreatment of patients who failed to complete an initial 35-hour Enhanced External Counterpulsation (EECP) course. METHODS AND RESULTS: Data of 2,311 successive angina patients from the International EECP Patient Registry were analyzed, 86.5% completed their EECP course (Complete cohort). Of the 13.5% patients failing to complete the initial course (Incomplete cohort), 28.3% had repeat EECP within 1 year vs. 10.1% of the Complete group. The predictors of failure to complete the initial course of EECP were: female gender, heart failure, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and use of nitroglycerin. For the Complete group, 83.4% had a reduction of at least one Canadian Cardiovascular Society (CCS) class after their initial EECP course, vs. 21.7% in the Incomplete group (p < 0.001). After repeat treatment, 66.2% of the Incomplete group achieved at least one CCS class reduction vs. 69.4% of the Complete group (p = NS) undergoing retreatment. The independent predictors for those who return to successfully complete their second course were patients who stopped their first course because of clinical events, and candidacy for coronary artery bypass grafting at the time of initial treatment. CONCLUSION: The results of retreatment of those who failed to complete their initial EECP course were comparable to those who completed their initial treatment, with similar reductions of CCS angina class.

Post-discharge heart failure monitoring program in Turkey: Hit-PoinT.

OBJECTIVE: The aim of this study was to assess the efficacy and feasibility of an enhanced heart failure (HF) education with a 6-month telephone follow- up program in post-discharge ambulatory HF patients. METHODS: The Hit-Point trial was a multicenter, randomized, controlled trial of enhanced HF education with a 6-month telephone follow-up program (EHFP) vs routine care (RC) in patients with HF and reduced ejection fraction. A total of 248 patients from 10 centers in various geographical areas were randomized: 125 to EHFP and 123 to RC. Education included information on adherence to treatment, symptom recognition, diet and fluid intake, weight monitoring, activity and exercise training. Patients were contacted by telephone after 1, 3, and 6 months. The primary study endpoint was cardiovascular death. RESULTS: Although all-cause mortality didn't differ between the EHFP and RC groups (p=NS), the percentage of cardiovascular deaths in the EHFP group was significantly lower than in the RC group at the 6-month follow up (5.6% vs. 8.9%, p=0.04). The median number of emergency room visits was one and the median number of all cause hospitalizations and heart failure hospitalizations were zero. Twenty-tree percent of the EHFP group and 35% of the RC group had more than a median number of emergency room visits (p=0.05). There was no significant difference regarding the median number of all-cause or heart failure hospitalizations. At baseline, 60% of patients in EHFP and 61% in RC were in NYHA Class III or IV, while at the 6-month follow up only 12% in EHFP and 32% in RC were in NYHA Class III or IV (p=0.001). CONCLUSION: These results demonstrate the potential clinical benefits of an enhanced HF education and follow up program led by a cardiologist in reducing cardiovascular deaths and number of emergency room visits with an improvement in functional capacity at 6 months in post-discharge ambulatory HF patients.

Two-year clinical outcomes after enhanced external counterpulsation (EECP) therapy in patients with refractory angina pectoris and left ventricular dysfunction (report from The International EECP Patient Registry).

Enhanced external counterpulsation (EECP) is a noninvasive circulatory assist device that has recently emerged as a treatment option for refractory angina in left ventricular (LV) dysfunction. This 2-year cohort study describes the long-term follow-up of patients who had severe LV dysfunction that was treated with EECP for angina pectoris and reports clinical outcomes, event-free survival rates, and the incidence of repeat EECP. This study included 363 patients who had refractory angina and LV ejection fraction < or =35%. Most patients reported quality of life as poor. After completion of treatment, there was a significant decrease in severity of angina class (p < 0.001), and 72% improved from severe angina to no angina or mild angina. Fifty-two percent of patients discontinued nitroglycerin use. Quality of life improved substantially. At 2 years this decrease in angina was maintained in 55% of patients. The 2-year survival rate was 83%, and the major adverse cardiovascular event-free survival rate was 70%. Forty-three percent had no reported cardiac hospitalization; 81% had no reported congestive heart failure events. Repeat EECP was performed in 20% of these patients. The only significant independent predictor of repeat EECP in a proportional hazard model was failure to complete the first EECP treatment course (hazard ratio 2.9, 95% confidence interval 1.7 to 4.9). Improvements in angina symptoms and quality of life were maintained at 2 years. In conclusion, for patients who have high-risk LV dysfunction, EECP offers an effective, durable therapeutic approach for refractory angina. Decreased angina and improvement in quality of life were maintained at 2 years, with modest repeat EECP and low major cardiovascular event rates.

Two-year outcomes in patients with mild refractory angina treated with enhanced external counterpulsation.

BACKGROUND: In the International Enhanced External Counterpulsation Patient Registry (IEPR), approximately 85% of the patients treated are in Canadian Cardiovascular Society (CCS) class III-IV with no option for further invasive coronary revascularization procedures. HYPOTHESIS: This study sought to determine whether it is clinically important to establish whether the observed durable reduction in disabling severe angina with enhanced external counterpulsation (EECP) treatment can be extended to those with less severe CCS class II angina, who also have no option for further revascularization. METHODS: This study evaluated the immediate response, durability and clinical events over a 2-year period after EECP treatment in 112 patients with Canadian Cardiovascular Society (CCS) class II angina versus 1346 patients with class III-IV angina using data from the International EECP Patient Registry (IEPR). RESULTS: Treatment with EECP significantly (by at least one CCS class) reduced angina frequency, nitroglycerin use, and improved quality of life in both groups. At 2-year follow-up, 74% of class II and 70% of class III-IV patients remained free of major adverse cardiovascular events (MACE) and continued to demonstrate a durable CCS class improvement over baseline. CONCLUSION: The robust effectiveness of EECP as a noninvasive device, together with its relatively low start-up and recurrent costs, makes it an attractive consideration for treating patients with milder refractory angina in addition to the patient with severely disabling angina treated in current practice.

The effects of enhanced external counterpulsation on myocardial perfusion in patients with stable angina: a multicenter radionuclide study.

BACKGROUND: Enhanced external counterpulsation (EECP) reduces angina and extends time to exercise-induced ischemia in patients with symptomatic coronary disease. One- and two-center studies and a retrospective case series reported that EECP improves myocardial perfusion in stable angina pectoris. We sought to critically evaluate and quantify the effect of EECP on myocardial perfusion. METHODS: In 6 US university hospitals, EECP was performed for 35 hours in patients with class II to IV angina who had exercise-induced myocardial ischemia. Symptom-limited quantitative gated technetium Tc 99m sestamibi single photon emission computed tomography exercise perfusion imaging was performed at baseline and 1 month post-EECP. Sestamibi was injected at the same heart rate in both stress tests. Single photon emission computed tomography images were read at a blinded core laboratory. RESULTS: Thirty-seven patients were enrolled, 34 of whom completed pre- and post-EECP stress testing. The mean age was 61 +/- 10 years, 81% were male, 78% had prior revascularization, and 68% had 3-vessel disease. The mean angina class decreased from 2.7 +/- 0.7 at baseline to 1.7 +/- 0.7 after EECP (P < .001). Exercise duration increased from 9.1 +/- 3.7 minutes at baseline to 10.2 +/- 3.6 minutes post-EECP (P = .03). The average percentage of tracer uptake, magnitude of reversibility, average thickening fraction, and the left ventricular ejection fraction remained unchanged after EECP. CONCLUSIONS: We confirm previous report that EECP reduces angina and improves exercise capacity. There were no significant changes in mean defect magnitude, amount of reversibility, thickening fraction, and ejection fraction measured using myocardial quantitative single photon emission computed tomography imaging when compared at identical pre- and post-EECP heart rates.

Frequency and efficacy of repeat enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry).

We assessed the frequency, efficacy, predictors, and long-term success of repeat enhanced external counterpulsation (EECP) therapy in relieving angina in a large cohort of patients who had chronic angina pectoris and had undergone a full course of EECP. Within 2 years of the initial course of EECP, the rate of repeat EECP was 18%, which occurred at a mean interval of 378 days after initial EECP. Of those who underwent repeat EECP, 70% had a decrease of >/=1 angina class at the end of repeat EECP with similar decreases in nitroglycerin use.

Two-year outcomes after enhanced external counterpulsation for stable angina pectoris (from the International EECP Patient Registry [IEPR]).

We assessed the long-term outcomes of enhanced external counterpulsation in relieving angina and improving the quality of life in a large cohort of patients with chronic angina pectoris. Seventy-three percent had a reduction by > or =1 angina class at the end of treatment, and 50% reported an improvement in the quality-of-life assessment after enhanced external counterpulsation; these results were sustained at 2-year follow-up.

Comparison of patients undergoing enhanced external counterpulsation and percutaneous coronary intervention for stable angina pectoris.

Enhanced external counterpulsation (EECP) has recently emerged as a treatment option for angina in selected patients suitable for revascularization with percutaneous coronary intervention (PCI). We compared baseline characteristics and 1-year outcome in 2 cohorts of PCI candidates presenting with stable symptoms: 323 patients treated with EECP in the International EECP Patient Registry (IEPR), and 448 NHLBI Dynamic Registry patients treated with elective PCI. Compared with patients receiving PCI, IEPR patients had a higher prevalence of many risk factors including prior PCI (53.0% vs 33.3%, p <0.001), prior coronary artery bypass grafting (42.1% vs 18.6%, p <0.001), prior myocardial infarction (56.4% vs 27.8%, p <0.001), history of congestive heart failure (16.8% vs 9.2%, p <0.01), and history of diabetes (37.9% vs 23.5%, p <0.001). Left ventricular ejection fraction was lower among IEPR patients (mean 50.3% vs 59.2%, p <0.001). At 1 year, survival was comparable in the 2 cohorts (98.7% IEPR vs 96.8% PCI, p = NS), as were rates of coronary artery bypass grafting during follow-up (4.5% IEPR vs 5.7% PCI, p = NS). At 1 year, 43.7% of IEPR patients reported no anginal symptoms compared with 73.4% of Dynamic Registry patients (p <0.001). Rates of severe symptoms (Canadian Cardiovascular Society class III, IV, or unstable) at 1 year were 15.5% among IEPR patients and 9.5% in the Dynamic Registry (p = 0.02). PCI candidates suitable for and treated with EECP had 1-year major event rates comparable to patients receiving elective PCI. Although PCI was associated with substantially lower rates of 1-year symptoms, EECP may be a safe treatment option for selected patients with obstructive coronary disease.

Enhanced external counterpulsation as treatment for chronic angina in patients with left ventricular dysfunction: a report from the International EECP Patient Registry (IEPR).

The International Enhanced External Counterpulsation (EECP) Patient Registry tracks acute and long-term outcome for consecutive patients treated for chronic angina. Although EECP has previously been shown to be a safe and effective treatment for angina, little information is available on its use in patients with left ventricular (LV) dysfunction. This report compares the acute outcome and 6-month follow-up for a group of patients with severe LV dysfunction and a group of patients without LV dysfunction. Of 1,402 patients in the registry recruited in 1998-1999 who had recorded values of LV ejection fraction (LVEF) at baseline, 1,090 (77.7%) had preserved LV function (LVEF >35%) and 312 (22.3%) had LV dysfunction (LVEF