High Resting Coronary Flow Velocity by Echocardiography Is Associated With Worse Survival in Patients With Chronic Coronary Syndromes.

BACKGROUND: Resting coronary flow velocity (CFV) in the mid-distal left anterior descending coronary artery can be easily assessed with transthoracic echocardiography. In this observational study, the authors sought to assess the relationship between resting CFV, CFV reserve (CFVR), and outcome in patients with chronic coronary syndromes. METHODS AND RESULTS: In a prospective multicenter study design, the authors retrospectively analyzed 7576 patients (age, 66±11 years; 4312 men) with chronic coronary syndromes and left ventricular ejection fraction ≥50% referred for dipyridamole stress echocardiography. Recruitment (years 2003-2021) involved 7 accredited laboratories, with interobserver variability <10% for CFV measurement at study entry. Baseline peak diastolic CFV was obtained by pulsed-wave Doppler in the mid-distal left anterior descending coronary artery. CFVR (abnormal value ≤2.0) was assessed with dipyridamole. All-cause death was the only end point. The mean CFV of the left anterior descending coronary artery was 31±12 cm/s. The mean CFVR was 2.32±0.60. During a median follow-up of 5.9±4.3 years, 1121 (15%) patients died. At multivariable analysis, resting CFV ≥32 cm/s was identified by a receiver operating curve as the best cutoff and was independently associated with mortality (hazard ratio [HR], 1.24 [95% CI, 1.10-1.40]; P<0.0001) together with CFVR ≤2.0 (HR, 1.78 [95% CI, 1.57-2.02]; P<0.0001), age, diabetes, history of coronary surgery, and left ventricular ejection fraction. When both CFV and CFVR were considered, the mortality rate was highest in patients with resting CFV ≥32 cm/s and CFVR ≤2.0 and lowest in patients with resting CFV <32 cm/s and CFVR >2.0. CONCLUSIONS: High resting CFV is associated with worse survival in patients with chronic coronary syndromes and left ventricular ejection fraction ≥50%. The value is independent and additive to CFVR. The combination of high resting CFV and low CFVR is associated with the worst survival.

Stress Echo 2030: the new ABCDE protocol defining the future of cardiac imaging.

Functional testing with stress echocardiography is based on the detection of regional wall motion abnormality with two-dimensional echocardiography and is embedded in clinical guidelines. Yet, it under-uses the unique versatility of the technique, ideally suited to describe the different functional abnormalities underlying the same wall motion response during stress. Five parameters converge conceptually and methodologically in the state-of-the-art ABCDE protocol, assessing multiple vulnerabilities of the ischemic patient. The five steps of the ABCDE protocol are (1) step A: regional wall motion; (2) step B: B-lines by lung ultrasound assessing extravascular lung water; (3) step C: left ventricular contractile reserve by volumetric two-dimensional echocardiography; (4) step D: coronary flow velocity reserve in mid-distal left anterior descending coronary with pulsed-wave Doppler; and (5) step E: assessment of heart rate reserve with a one-lead electrocardiogram. ABCDE stress echo offers insight into five functional reserves: epicardial flow (A); diastolic (B), contractile (C), coronary microcirculatory (D), and chronotropic reserve (E). The new format is more comprehensive and allows better functional characterization, risk stratification, and personalized tailoring of therapy. ABCDE protocol is an 'ecumenic' and 'omnivorous' functional test, suitable for all stresses and all patients also beyond coronary artery disease. It fits the need for sustainability of the current era in healthcare, since it requires universally available technology, and is low-cost, radiation-free, and nearly carbon-neutral.

Myocardial Wringing and Rigid Rotation in Cardiac Amyloidosis.

Background: The motion of the heart is a result of the helicoidal arrangement of the myofibers in the organ's wall. We aimed to study the relationship between the wringing motion state and the degree of ventricular function in patients with cardiac amyloidosis (CA). Methods: Fifty patients with CA and decreased global longitudinal strain (LS) were evaluated using 2-dimensional speckle-tracking echocardiography. We have expressed LS as positive values to facilitate understanding. Normal twist, which occurs when basal and apical rotations occur in opposite directions, was coded as positive. When the apex and base rotate in the same direction (rigid rotation), twist was coded as negative. Left ventricular (LV) wringing (calculated as twist/LS, which takes into account actions that occur simultaneously during LV systole [ie, longitudinal shortening and twist]) was evaluated according to LV ejection fraction (LVEF). Results: Most of the patients (66%) who participated in the study were diagnosed with transthyretin amyloidosis. A positive relationship was observed between wringing and LVEF (r = 0.75, P < 0.0001). In advanced stages of ventricular dysfunction, rigid rotation appeared in 66.6% of patients with LVEF ≤ 40%, in whom negative values of twist and wringing were observed. LV wringing proved to be a good discriminator of LVEF (area under the curve 0.90, P < 0.001, 95% confidence interval 0.79-0.97); for example, wringing < 1.30°/% detected LVEF < 50% with 85.7% sensibility and 89.7% specificity. Conclusions: Wringing, which integrates twist and simultaneous LV longitudinal shortening, is a conditioning rotational parameter of the degree of ventricular function in patients with CA.

Contexte: Les mouvements du cœur sont le résultat de l'orientation hélicoïdale des fibres des parois du cœur. L'objectif de notre étude était d'étudier le lien entre le mouvement « d'essorage ¼ et la fonction ventriculaire chez les patients atteints d'amylose cardiaque (AC). Méthodologie: Cinquante patients atteints d'AC et présentant une déformation longitudinale (DL) globale réduite ont fait l'objet d'une évaluation à l'aide de l'échocardiographie bidimensionnelle de suivi des marqueurs acoustiques. Nous avons choisi d'exprimer la DL en valeurs positives pour faciliter la compréhension des données. Une torsion normale, caractérisée par les mouvements de rotation opposés entre la base et l'apex du cœur, a été codée comme positive. Lorsque l'apex et la base opéraient une rotation dans la même direction (rotation rigide), la torsion était codée comme négative. Le mouvement « d'essorage ¼ du ventricule gauche (VG) (calculé comme le rapport torsion/DL, qui tient compte des actions survenant simultanément durant la systole du VG [c.-à-d., raccourcissement longitudinal et torsion]) a été évalué en fonction de la fraction d'éjection du VG (FEVG). Résultats: La plupart des patients (66 %) ayant participé à l'étude avaient reçu un diagnostic d'amylose à transthyrétine. Un lien positif a été établi entre le mouvement d'essorage et la FEVG (coefficient de corrélation [r] = 0,75, p < 0,0001). Aux stades avancés de la dysfonction ventriculaire, une rotation rigide a été observée chez 66,6 % des patients ayant une FEVG ≤ 40 % et chez qui les valeurs de torsion et d'essorage étaient négatives. L'essorage du VG s'est révélé être un facteur fiable de détermination de la FEVG (aire sous la courbe : 0,90; p < 0,001, intervalle de confiance [IC] à 95 % : 0,79-0,97); par exemple, un mouvement d'essorage < 1,30 °/% a permis de détecter une FEVG < 50 % avec une sensibilité de 85,7 % et une spécificité de 89,7 %. Conclusions: Le mouvement d'essorage, qui intègre simultanément la torsion et le raccourcissement longitudinal du VG, est un paramètre rotationnel qui influence le degré de fonction ventriculaire chez les patients atteints d'AC.

Reserva contráctil por fracción de eyección sola, o con elastancia. ¿Cuál es el mejor predictor de eventos luego de un Eco Estrés sin isquemia? / Contractile Reserve by Left Ventricular Ejection Fraction Alone, o Considering Elastance. ¿Which is the Best Predictor of Events After a Stress Echo Without Ischemia?

RESUMEN Introducción: El comportamiento de la fracción de eyección del ventrículo izquierdo (FEVI) durante el ejercicio se utiliza para medir la reserva contráctil (RC). La RC medida por elastancia podría tener mayor valor pronóstico. Objetivo: Establecer si la medición de la RC por elastancia añade valor pronóstico a largo plazo en relación al comportamiento aislado de la FEVI en pacientes con un Eco Estrés sin isquemia miocárdica. Material y métodos: Estudio retrospectivo, realizado en 904 pacientes con Eco Estrés con ejercicio sin isquemia. Se valoró la RC por FEVI y por elastancia. Se dividieron en 2 grupos: Grupo 1: RC por FEVI presente (a su vez este grupo se dividió en 2 subgrupos: Grupo 1 A, RC con elastancia presente y Grupo 1B: ausencia de RC por elastancia), y Grupo 2: pacientes con ausencia de RC por FEVI. El seguimiento fue de 17,7 ± 5,4 meses. Se consideraron como eventos: muerte, infarto agudo de miocardio (IAM), accidente cerebrovascular (ACV) y/o internación de causa cardiovascular. Resultados: Del total del Grupo 1 (536 pacientes), 200 (37,3%) se incluyeron en el Grupo 1A y 336 (62,7%) en el Grupo 1B. En el Grupo 2, se incluyeron 368 pacientes. En el seguimiento, los pacientes del Grupo 2 tuvieron más eventos, 30 (8,1%) vs. 22 (2,6%) (HR 3,14, IC95% 1,95-5,9, log rank test p<0,001). Dentro del G1, los pacientes del Grupo 1B presentaron más eventos: 18 (5,3%) vs 4 eventos (2%) (HR 2,46 IC95% 1,06-7,3, log rank test p<0,05). En el modelo de regresión, la elastancia fue la única variable predictora de eventos (HR 3,2, IC95% 1,83-5,6, p<0,001). Conclusiones: En el Eco Estrés ejercicio negativo para isquemia, el comportamiento de la RC evaluada por elastancia permitió identificar un subgrupo de peor pronóstico a largo plazo en pacientes con comportamiento normal de la FEVI.

ABSTRACT Background: The behavior of left ventricular ejection fraction (LVEF) during exercise is used to measure contractile reserve (CR). CR measured by elastance could have greater prognostic value. Objective: To establish whether the measurement of CR by elastance adds long-term prognostic value to CR measured by LVEF in patients with a Stress Echo without myocardial ischemia. Material and methods: Retrospective study, carried out in 904 patients with an exercise Stress Echo without ischemia. CR was assessed by LVEF and by elastance. Patients were divided into 2 groups: Group 1: presence of CR by LVEF (in turn this group was divided into 2 subgroups: Group 1A, CR with elastance present, and Group 1B: absence of CR by elastance), and Group 2: patients with absence of CR by LVEF. The follow-up was 17,7 ± 5,4 months. Outcomes considered were death, acute myocardial infarction (AMI), stroke, and cardiovascular hospitalization. Results: 536 patients were included in Group 1, 200 (37,3 %) in Group 1A and 336 (62,7%) in Group 1B. In Group 2, 368 patients were included. At follow-up, patients in Group 2 had more events, 30 (8.1%) vs. 22 (2.6%) (HR 3.14, 95% CI 1.95-5.9, log rank test p <0.001). Within G1, patients in Group 1B presented more events: 18(5.3%) vs 4 (2%) (HR 2.46 CI 95% 1.06-7.3, log rank test p <0.05). In the regression model, CR assessed by LVEF and additionally by elastance was the only significant outcome predictor (HR 3.2, 95% CI 1.83-5.6, p <0.001). Conclusions: In an exercise Stress Echo negative for ischemia, CR behavior evaluated by elastance allowed us to identify a subgroup with a worse long-term prognosis in patients with normal LVEF response.

Fisiopatología y pronóstico de la deformación longitudinal regional durante el eco estrés con dipiridamol / Pathophysiology and Prognosis of Apical Longitudinal Strain During Dipyridamole Stress Echocardiography

RESUMEN Introducción: El strain longitudinal apical regional permite corroborar el diagnóstico de alteraciones regionales de la motilidad parietal sobre una base cuantitativa, pero faltan datos sobre su valor pronóstico a largo plazo. Objetivos: Evaluar el correlato fisiológico y el valor pronóstico del strain longitudinal apical en el eco estrés con dipiridamol frente a la motilidad parietal. Métodos: Estudio retrospectivo, que incluyó 150 pacientes remitidos para eco estrés con dipiridamol. Se evaluó el strain longitudinal apical, la reserva coronaria (RC) de la arteria descendente anterior y el análisis visual de la motilidad parietal. Los pacientes se dividieron en dos grupos. Grupo1: pacientes con strain longitudinal apical normal y Grupo 2: con strain anormal. Se realizó seguimiento por 36 ± 9,3 meses. Evento mayor fue definido como: muerte, infarto de miocardio, revascularización e internación por causa cardíaca. Resultados: Fueron incluidos en el análisis 142 pacientes (8 pacientes fueron excluidos por ventana ultrasónica subóptima), 87 (61,3%) en el Grupo 1 y 55 (38,7%) en el Grupo 2. No hubo diferencias en el strain longitudinal apical en reposo entre ambos grupos. Durante el apremio, los pacientes del Grupo1 evidenciaron mejor motilidad parietal visual y una RC más alta (p < 0,001). La RC y los cambios del strain longitudinal apical presentaron una correlación positiva (coeficiente r de Pearson = 0,89, p < 0,0001). En el seguimiento hubo 24 eventos mayores. Los pacientes del Grupo1 tuvieron una mejor supervivencia libre de eventos (p<0,01) y el strain longitudinal apical demostró ser un predictor independiente de evento, mejor que el análisis de motilidad parietal (p = 0,002 vs p = 0,1), en el análisis de regresión logística. Conclusiones: El strain longitudinal apical tiene muy buena correlación con: la reserva de velocidad del flujo coronario y se asocia mejor con el pronóstico a largo plazo. El strain longitudinal apical anormal durante el eco dipiridamol predijo un peor resultado, independientemente del análisis visual de la motilidad parietal.

ABSTRACT Background: Regional apical longitudinal strain can corroborate the diagnosis of regional wall motion abnormalities on a quantitative basis, but data on long-term prognostic value are lacking. Objectives: To evaluate the physiological correlate and the prognostic value of apical longitudinal strain versus wall motility during dipyridamole stress echocardiography. Methods: Retrospective study, which included 150 patients referred for dipyridamole stress echocardiography. Apical longitudinal strain, anterior descending artery coronary reserve, and visual analysis of wall motility were evaluated. Patients were divided into two groups. Group 1: patients with normal apical longitudinal strain, and Group 2: abnormal strain. Follow-up was carried out for 36 ± 9.3 months. Major event was defined as: death, myocardial infarction, revascularization and hospitalization for cardiac causes. Results. Eighty-seven patients (61.3%) in Group 1 and 55 (38.7%) patients in Group 2 were included (8 patients were excluded due to a suboptimal ultrasound window). There were no differences in apical longitudinal strain at rest between the groups. During the stress, Group 1 patients showed better visual wall motility and a higher coronary reserve (p < 0.001). The coronary reserve showed a linear correlation with the changes in the apical longitudinal strain (Pearson's correlation coefficient 0.89, p < 0.0001). At follow-up, there were 24 major events. Group 1 patients had better event-free survival (p < 0.01) and apical longitudinal strain proved to be a better independent event predictor than wall motion analysis (p = 0.002 vs p = 0.1) in logistic regression analysis. Conclusions: Apical longitudinal strain has a very good correlation with physiological standards -coronary flow velocity reserve- and its association with long-term prognosis is better. Abnormal apical longitudinal strain during dipyridamole stress echocardiography predicted a worse outcome, regardless of visual wall motion analysis.

Feasibility and value of two-dimensional volumetric stress echocardiography.

BACKGROUND: Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV). METHODS: We enrolled 4735 patients (age 63.6±11.3 years, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (N.=1992 patients) and adenosine (N.=18); ≤2.0 for exercise (N.=2087) or dobutamine (N.=638). RESULTS: Force-based LVCR was obtained in all 4735 patients. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57% of patients with abnormal LVCR nevertheless showed increase in stroke volume. CONCLUSIONS: Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

Stress Echo 2030: The Novel ABCDE-(FGLPR) Protocol to Define the Future of Imaging.

With stress echo (SE) 2020 study, a new standard of practice in stress imaging was developed and disseminated: the ABCDE protocol for functional testing within and beyond CAD. ABCDE protocol was the fruit of SE 2020, and is the seed of SE 2030, which is articulated in 12 projects: 1-SE in coronary artery disease (SECAD); 2-SE in diastolic heart failure (SEDIA); 3-SE in hypertrophic cardiomyopathy (SEHCA); 4-SE post-chest radiotherapy and chemotherapy (SERA); 5-Artificial intelligence SE evaluation (AI-SEE); 6-Environmental stress echocardiography and air pollution (ESTER); 7-SE in repaired Tetralogy of Fallot (SETOF); 8-SE in post-COVID-19 (SECOV); 9: Recovery by stress echo of conventionally unfit donor good hearts (RESURGE); 10-SE for mitral ischemic regurgitation (SEMIR); 11-SE in valvular heart disease (SEVA); 12-SE for coronary vasospasm (SESPASM). The study aims to recruit in the next 5 years (2021-2025) ≥10,000 patients followed for ≥5 years (up to 2030) from ≥20 quality-controlled laboratories from ≥10 countries. In this COVID-19 era of sustainable health care delivery, SE2030 will provide the evidence to finally recommend SE as the optimal and versatile imaging modality for functional testing anywhere, any time, and in any patient.

Fibrilación auricular de novo en pacientes con síndrome coronario agudo sin elevación del segmento ST. Datos del Registro Buenos Aires I / De Novo Atrial Fibrillation in Patients with Non-ST-Segment Elevation Acute Coronary Syndrome. Data from the Buenos Aires I Registry

RESUMEN Introducción: La fibrilación auricular (FA) es la arritmia con mayor incidencia a nivel mundial y tiene una clara asociación con los síndromes coronarios agudos. El propósito de nuestro trabajo es describir la incidencia, los factores predisponentes y el pronóstico de pacientes con FA de novo luego de un síndrome coronario agudo, en una población representativa de nuestro medio. Material y métodos: Se realizó un subanálisis del registro BUENOS AIRES I, el cual incluyó 1110 pacientes con síndrome coronario agudo sin elevación del ST (SCASEST), con un seguimiento a 6 meses. Resultados: Se evidenció una incidencia del 7,7% de FA de novo y se identificaron como factores predictores independientes de su desarrollo la edad (OR 1,04; IC95% 1,02-1,08; p = 0,001), la presentación inicial con infarto agudo de miocardio (OR 2,35; IC95% 1,20-4,57; p = 0,012) y la necesidad de revascularización quirúrgica (OR 6,86; IC95% 3,95-11,89; p <0,001). Los pacientes que desarrollaron FA presentaron mayor mortalidad por todas las causas, mayor mortalidad cardiovascular y eventos de sangrado BARC ≥2. Se identificó a la FA de novo post-SCASEST como un factor predictor independiente de mortalidad cardiovascular (OR 3,67; IC95% 1,25-10,76; p = 0,018) y sangrado a 6 meses BARC ≥2 (OR 3,024; IC95% 1,49-6,11; p = 0,002). Conclusiones: Este subanálisis preespecificado del registro BUENOS AIRES I demostró una incidencia significativa de FA de novo en el contexto de un SCASEST, vinculada a una mayor edad, mayor daño estructural cardíaco agudo y requerimiento de cirugía de revascularización, y con una peor evolución en términos de eventos clínicos adversos en el seguimiento a mediano plazo.

ABSTRACT Background: Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia worldwide and has a close correlation with acute coronary syndromes. The aim of our study is to describe the incidence, predisposing factors and outcome of patients with de novo AF after an acute coronary syndrome in a population representative of our environment. Methods: We conducted a sub-analysis of the BUENOS AIRES I registry, which included 1110 patients with non- ST-segment elevation acute coronary syndrome (NSTE-ACS) followed-up at 6 months. Results: The incidence of de novo AF was 7.7%. The independent predictors of de novo AF were age (OR, 1.04; 95% CI, 1.021.08; p = 0.001), initial presentation as MI (OR, 2.35; 95% CI, 1.20-4.57; p = 0.012) and requirement of myocardial revascularization surgery (OR 6.86; 95% CI 3.95-11.89; p < 0.001). Patients who developed AF had greater all-cause mortality, cardiovascular mortality and bleeding events ≥BARC type 2. The development of de novo AF after NSTE-ACS was identified as an independent predictor of cardiovascular mortality (OR, 3.67; 95% CI 1.25-10.76; p = 0.018) and of bleeding events ≥ BARC type 2 (OR, 3.024; 95% CI, 1.49-6.11; p = 0.002). Conclusions: This prespecified sub-analysis of the BUENOS AIRES I registry demonstrated a significant incidence of de novo AF in the setting of a NSTE-ACS, associated with elderly patients, greater acute myocardial structural damage and need for myocardial revascularization surgery, with worse outcome in terms of adverse clinical events at mid-term follow-up.

Influence of Ventricular Wringing on the Preservation of Left Ventricular Ejection Fraction in Cardiac Amyloidosis.

BACKGROUND: The purpose of this work was to determine the influence of myocardial wringing on ventricular function in patients with cardiac amyloidosis (CA). METHODS: Fifteen healthy volunteers (group 1) and 34 patients with CA (17 with left ventricular ejection fractions [LVEFs] ≥ 53% [group 2] and 17 with LVEFs < 53% [group 3]) were evaluated using two-dimensional speckle-tracking echocardiography. A control group of mass-matched patients (n = 20) with left ventricular (LV) hypertrophy and LVEFs ≥ 53% was also included. Longitudinal strain (LS), circumferential strain, and LV twist and torsion were calculated. Deformation index (DefI), a new parameter of wringing, calculated as twist/LS, that takes into account actions that occur simultaneously during LV systole (i.e., longitudinal shortening and twist), was evaluated. Torsional and wringing parameters were calculated according to LVEF. RESULTS: Lower global values of LS and circumferential strain were observed among patients with CA (LS: group 1, -20.6 ± 2.5%; group 2, -11.6 ± 4.1%; group 3, -9.0 ± 3.1%; circumferential strain: group 1, -22.7 ± 4.9%; group 2, -14.4 ± 8.0%; group 3, -13.6 ± 3.8%; P < .001 for both). Torsion did not vary between group 2 and group 1 (2.5 ± 1.1°/cm vs 2.7 ± 0.8°/cm, P = NS). In contrast, DefI was greater in group 2 than in group 1 (-1.8 ± 0.8°/% vs -1.0 ± 0.3°/%, P < .01). Torsion and DefI were lower in group 3 (1.2 ± 0.7°/cm and -1.1 ± 0.6°/%, respectively, P < .001 for both) than in group 2. DefI was similar in patients with LV hypertrophy (-1.7 ± 0.6°/%, P = NS) and group 2. CONCLUSIONS: In patients with CA, preservation of LVEF depends on greater ventricular wringing. DefI, a parameter that integrates the twist and the simultaneous longitudinal shortening of the left ventricle, is a more accurate indicator of the efficacy of this mechanism.

Feasibility and functional correlates of left atrial volume changes during stress echocardiography in chronic coronary syndromes.

An enlarged left atrial volume index (LAVI) at rest mirrors increased LA pressure and/or impairment of LA function. A cardiovascular stress may acutely modify left atrial volume (LAV) within minutes. Aim of this study was to assess the feasibility and functional correlates of LAV-stress echocardiography (SE) Out of 514 subjects referred to 10 quality-controlled labs, LAV-SE was completed in 490 (359 male, age 67 ± 12 years) with suspected or known chronic coronary syndromes (n = 462) or asymptomatic controls (n = 28). The utilized stress was exercise in 177, vasodilator in 167, dobutamine in 146. LAV was measured with the biplane disk summation method. SE was performed with the ABCDE protocol. The intra-observer and inter-observer LAV variability were 5% and 8%, respectively. ∆-LAVI changes (stress-rest) were negatively correlated with resting LAVI (r = - 0.271, p < 0.001) and heart rate reserve (r = -.239, p < 0.001). LAV-dilators were defined as those with stress-rest increase ≥ 6.8 ml/m2, a cutoff derived from a calculated reference change value above the biological, analytical and observer variability of LAVI. LAV dilation occurred in 56 patients (11%), more frequently with exercise (16%) and dipyridamole (13%) compared to dobutamine (4%, p < 0.01). At multivariable logistic regression analysis, B-lines ≥ 2 (OR: 2.586, 95% CI = 1.1293-5.169, p = 0.007) and abnormal contractile reserve (OR: 2.207, 95% CI = 1.111-4.386, p = 0.024) were associated with LAV dilation. In conclusion, LAV-SE is feasible with high success rate and low variability in patients with chronic coronary syndromes. LAV dilation is more likely with reduced left ventricular contractile reserve and pulmonary congestion.

Registro multicéntrico prospectivo de pacientes hospitalizados por síndrome coronario agudo sin elevación del segmento ST en centros de alta complejidad. Resultados intrahospitalarios y evolución a 6 meses (Buenos Aires I) / Prospective multicenter registry of patients hospitalized for acute coronary syndrome without ST segment elevation in highly complex centers

RESUMEN Introducción: El manejo de los síndromes coronarios agudos (SCA) sin elevación del segmento ST (SCASEST) ha presentado cambios en los últimos años, basados en nuevos agentes farmacológicos y en el avance de las técnicas de revascularización coronaria. El objetivo de este estudio fue determinar cómo es el manejo de los SCASEST en la actualidad, en centros de alta complejidad de la ciudad de Buenos Aires y la provincia de Buenos Aires. Métodos: Se registraron en forma prospectiva pacientes hospitalizados en 21 centros con servicio de unidad coronaria, hemodinamia disponible las 24 horas y cirugía cardíaca. Se realizó seguimiento a 6 meses del alta hospitalaria. Resultados: Se incluyeron 1 100 pacientes consecutivos; el 62,6% fue catalogado como infarto sin elevación del ST y, 37,4% como angina inestable. La edad media fue de 65,4 ± 11,5 años, con el 77,2% de sexo masculino. El 27,6% presentaba diabetes mellitus y el 31,5% infarto previo. El manejo inicial fue invasivo en el 86,7%, con una mediana de tiempo a la cinecoronariografía de 18 horas (RIC 7-27,7). En la evolución intrahospitalaria, la incidencia de nuevo infarto fue del 5,2%, el accidente cerebrovascular de 0,3% y la mortalidad total, 2,7%. La tasa de sangrado BARC ≥2 fue del 10,1%. En el seguimiento extrahospitalario a los 6 meses del alta hospitalaria, la tasa de infarto fue de 8,4%, SCA 10,9% y la mortalidad total de 5,7%. Conclusiones: El registro evidenció un abordaje terapéutico predominantemente invasivo de los pacientes con SCASEST en los centros con alta complejidad, con baja prevalencia de complicaciones intrahospitalarias y en la evolución.

ABSTRACT Introduction: The medical management of acute coronary syndromes (ACS) has changed significantly over the past few decades, primarily due to novel pharmacotherapies and improvement in coronary revascularization strategies. This registry was compiled from data from management of patient populations in high complexity centers from Buenos Aires, Argentina. Methods: Patients hospitalized in 21 centers in the city of Buenos Aires and peripheries, with a coronary unit service, hemodynamics available 24 hours and cardiac surgery are prospectively registered. Follow-up was performed at 6 months. Results: A total of 1100 patients were included; the final diagnosis was myocardial infarction in 62.% and unstable angina in 37.4%. The mean age of the population was 65.4 ± 11.5 and 77.2% were male. 27.6% of patients having diabetes mellitus, with 31.5% having a medical history of myocardial infarction. The initial management was invasive in 86.7%, with a median time for PCI of 18 hours (IQR 7-27,7). Over the course of the in-hospital stay, the rate of myocardial infarction was 5.2%, stroke 0.3% and total all-cause mortality 2.7%. The rate of in-hospital total bleeding events was 20.1%, with BARC ≥2 in 10.1% of patients. In the 6-month follow-up, the infarction rate was 8.4%, ACS 10.9%, and total mortality 5.7%. Conclusions: This registry shows the predominant usage of invasive approaches in management of patients with acute coronary syndrome without ST elevation, in high complexity medical centers. In this subset of patients, a low rate of in-hospital and follow up complications were also observed.

El comportamiento del strain longitudinal regional depende de la reserva coronaria en un análisis simultáneo durante el eco-estrés con dipiridamol / The Behavior of Regional Longitudinal Strain Depends on Coronary Flow Reserve in a Simultaneous Analysis during Dipyridamole Stress Echocardiography

RESUMEN Introducción: Está poco estudiado el comportamiento del strain longitudinal regional y global en relación al valor de la reserva coronaria. Objetivos: Comparar el comportamiento del strain longitudinal apical y global con el valor de la reserva coronaria de la arteria descendente anterior y secundariamente comparar estas respuestas con el análisis visual de la motilidad parietal durante el eco-estrés con dipiridamol. Material y métodos: Estudio retrospectivo de 179 pacientes (edad 68,7 ± 7,8), 90 hombres (50,3%). En el pico del efecto de dipiridamol, se midió la reserva coronaria, simultáneamente al strain longitudinal y el análisis visual de la contractilidad. Se organizó a los pacientes en dos grupos: grupo 1: reserva coronaria ≥ 2 y grupo 2: < 2. Strain apical se definió como el promedio de 4 segmentos apicales y global de los 17 segmentos. Se consideró normal a todo incremento del strain. Resultados: Se incluyeron 113 pacientes (63,12%) en el grupo 1 y 66 (36,87%) en el grupo 2. Strain apical: el 96,77% del grupo 1 incrementaron su valor con el apremio, mientras que, en el grupo 2, el 95,31% presentaron una caída (p < 0,0001). Strain global: el 82,8% del grupo 1 presentaron incremento de sus valores, en cambio, en el grupo 2, el 78,8% empeoraron (p < 0,01). Análisis de la motilidad parietal posdipiridamol: el 96,46% del grupo 1 tenían motilidad parietal conservada y el 54,5% del grupo 2 (solo en 4 pacientes aumentó el strain apical). Conclusiones: Se comprobó una estrecha correlación entre la reserva coronaria y el strain longitudinal. El strain longitudinal apical resultó ser superior del global. El strain apical demostró tener una mejor correlación con la reserva coronaria que con el análisis visual de la contractilidad.

ABSTRACT Background: The behavior of regional and global longitudinal strain in relation to the value of the coronary reserve is poorly studied. Objectives: Compare the behavior of the Apical and global longitudinal Strain with the value of the coronary reserve of the anterior descending artery and as a secondary aim compare these responses with the visual analysis of parietal motility during Echo Stress with Dipyridamole. Materials and methods: Retrospective study of 179 patients (age 68.7±7.8), 90 patients (50.3%) were men. At the peak of the dipyridamole effect, the coronary reserve was measured, simultaneously with the Longitudinal Strain and the visual analisis of contractility. Two groups were divided: Group 1: Coronary reserve ≥2 and Group 2: <2. Apical Strain was defined as the average of 4 apical segments and global as the average of the 17 segments. It was considered normal any increased of deformation. Results: 113 patients (63.12%) were included in Group 1 and 66 (36.87%) in Group 2. Strain Apical: 96.77% of Group 1 increased their strain values with the stress, while in group 2, 95.31% presented a worsening strain values (p<0.0001). Global Strain: 82.8% of Group 1 had an increase in their values, while in Group 2, 78.8% showed worsening (p<0.01). Post Dipyridamole parietal Motility Analysis: 96.46% of Group 1 had preserved parietal motility and only 54.5% of Group 2 (4 patients had increased apical Strain in this group). Conclusions: There was a close correlation between the coronary reserve of the anterior descending artery and the contractile reserve evaluated by regional apical longitudinal strain of the 4 apical segments, which was superior to the use of global strain. The Apical Strain showed a better correlation with ADA coronary reserve than with the visual analysis of contractility.

Resultados de los primeros pacientes con sospecha de síndrome coronario agudo evaluados con el algoritmo de 1 hora propuesto por la Sociedad Europea de Cardiología / Results of the First Patients with Suspected Acute Coronary Syndrome Evaluated with the 1-hour Algorithm Proposed by the European Society of Cardiology

RESUMEN Introducción: La Sociedad Europea de Cardiología recomienda para la evaluación del dolor torácico un algoritmo con medición seriada de dos troponinas de alta sensibilidad separadas por una hora. Sin embargo, la alta eficacia y seguridad solo se han estimado según supuestos basados en modelos teóricos. Probamos por primera vez su desempeño en nuestro medio cuando se integra en la rutina diaria. Métodos: Estudio prospectivo unicéntrico que incluyó a pacientes no seleccionados que presentaban sospecha de infarto sin elevación del ST en el servicio de emergencias, a los que se les practicó el algoritmo SEC 0/1h utilizando troponina T de alta sensiblidad. Se evaluó el comportamiento en términos de incidencia a 30 días de los eventos de infarto agudo de miocardio, muerte cardiovascular y el combinado de infarto agudo de miocardio, muerte o revascularización coronaria. Resultados: Se incluyeron 1351 pacientes con una edad media de 61 ± 14 años, 12,4% de diabéticos y 35,8% de evento coronario previo. La tasa de infarto agudo de miocardio fue del 11% con una mortalidad del 0,29%. De acuerdo con la aplicación del algoritmo, 917 pacientes fueron catalogados como "externar" (67%); 270, como "observar" (20%); y 164, como "internar" (13%). La tasa del evento infarto agudo de miocardio resultó del 0,3% en "externar"; del 7%, en "observar"; y del 77,4%, en "internar" (p < 0,001). Por su lado, la muerte o revascularización coronaria resultó de 7,7% en "externar"; del 17,7%, en "observar"; y del 80,4%, en "internar" (p < 0,001). Conclusiones: El algoritmo de 1 hora presentó una buena capacidad para estratificar a pacientes que consultan con sospecha de infarto agudo de miocardio con un gran valor predictivo negativo para excluir el evento de infarto a los 30 días, aunque dicho valor disminuye cuando el evento considerado es la necesidad de revascularización coronaria.

ABSTRACT Background: The European Society of Cardiology (ESC) recommends an algorithm for the evaluation of chest pain with serial measurement of two high sensitivity troponins separated by one hour. However, the high efficacy and safety of the algorithm has only been estimated according to assumptions based on theoretical models. We tested for the first time its performance in the real world by incorporating it into the daily routine of our center. Methods: This is a prospective, single center study using the ESC 0/1h algorithm with high sensitivity troponin T on unselected patients who presented at the emergency department with suspected non-ST-segment elevation acute myocardial infarction. Efficacy and safety were assessed in terms of the 30-day incidence of acute myocardial infarction, cardiovascular death and the composite of acute myocardial infarction, death or coronary revascularization. Results: A total of 1,351 patients were included in the study. Mean age was 61±14 years, 12.4% were diabetics and 35.8% had previous history of coronary events. The rate of acute myocardial infarction was 11% and the rate of mortality 0.29%. According to the application of the algorithm, 917 patients were catalogued as "rule out" (67%), 270 as "observe" (20%) and 164 as "rule in" (13%). The rate of acute myocardial infarction was 0.3% in "rule out", 7% in "observe" and 77.4% in "rule in" (p <0.001). Moreover, death or coronary revascularization was 7.7% in "rule out", 17.7% in "observe" and 80.4% in "rule in" (p <0.001). Conclusions: The 1-hour algorithm showed a good capacity to stratify patients presenting with suspicion of acute myocardial infarction and a high negative predictive value to exclude infarction at 30 days, although this capacity decreases when the event considered is the need for coronary revascularization.

Perfiles ecocardiográficos del strain 2D permiten diferenciar a la amiloidosis cardíaca de la miocardiopatía hipertrófica con fracción de eyección conservada / Two-dimensional Strain Echocardiography Differentiates Cardiac Amyloidosis from Hypertrophic Cardiomyopathy with Preserved Ejection Fraction

RESUMEN Introducción: La fracción de eyección es un parámetro débil para evaluar la función ventricular en la hipertrofia ventricular. Es de fundamental importancia analizar aspectos de la mecánica ventricular que podrían diferenciar una amiloidosis cardiaca de una miocardiopatía hipertrófica. Objetivo: Comparar el comportamiento del strain longitudinal y otros parámetros de la mecánica ventricular entre pacientes con miocardiopatía hipertrófica y amiloidosis cardíaca ambos con fracción de eyección conservada. Material y métodos: Estudio comparativo, prospectivo realizado en 15 pacientes con amiloidosis cardíaca (Grupo G 1) y 15 pacientes con miocardiopatía hipertrófica (G 2), ambos con fracción de eyección conservada (> 50%). Fueron analizados con ecocardiografía por seguimiento de marcas (speckle tracking), parámetros de strain y rotacionales del VI. El strain longitudinal se obtuvo a partir de planos apicales de 4, 3 y 2 cámaras. El strain circunferencial y la rotación ventricular a partir de planos transversales del VI. Se calculó el giro: suma de rotación apical y basal (°), torsión (giro / distancia base-ápex del VI (°/cm)) y los nuevos parámetros: producto de deformación (multiplicación entre el strain longitudinal global y el strain circunferencial apical); índice de deformación (°/%): (giro / strain longitudinal) y el cociente fracción de eyección / strain longitudinal global Resultados: Los pacientes con amiloidosis cardíaca presentaron valores significativamente menores de fracción de eyección (58,08% ± 6,16 vs. 67,15% ± 8,09; p = 0,012) y de strain longitudinal global (-12,61% ± 4,32 vs. -17,15% ± 3,95; p = 0,008) a expensas de los segmentos basales. No se constataron diferencias significativas con el giro, la torsión, el strain circunferencial y el radial. El producto entre strain longitudinal y el circunferencial apical resultó disminuido mientras que el cociente fracción de eyección / strain longitudinal global se encontró aumentado de manera significativa en los pacientes con amiloidosis. Conclusiones: El producto strain longitudinal x strain circunferencial apical y el cociente fracción de eyección / strain longitudinal global son parámetros útiles que permiten diferenciar pacientes con amiloidosis cardíaca de pacientes con miocardiopatía hipertrófica.

ABSTRACT Background: Ejection fraction is a poor parameter to assess left ventricular function in ventricular hypertrophy. It is highly important to analyze aspectis of ventricular mechanics that could differentiate cardiac amyloidosis from hypertrophic car-diomyopathy. Objective: The aim of this study was to compare longitudinal strain and other ventricular mechanical parameters between patientis with hypertrophic cardiomyopathy and cardiac amyloidosis, both with preserved ejection fraction. Methods: A comparative, prospective study was conducted in 15 patientis with cardiac amyloidosis Group (G) 1 and 15 pa-tientis with hypertrophic cardiomyopathy (G2), both presenting preserved ejection fraction (>50%). Patientis were analyzed with speckle tracking echocardiography and strain and left ventricular (LV) rotational parameters. Longitudinal strain was obtained from apical 4-, 3- and 2-chamber planes. Circumferential strain and ventricular rotation were obtained from LV transverse planes. Twist: algebraic sum of apical and basal rotation (°), torsion [twist/LV base-apex distance (º/cm)] and the new parameters: deformation product (global longitudinal strain × apical circumferential strain); deformation index: twist/ longitudinal strain (°/%) and ejection fraction/global longitudinal strain ratio were calculated. Resultis: Patientis with cardiac amyloidosis presented significantly lower ejection fraction (58.08%±6.16 vs. 67.15%±8.09; p=0.012) and global longitudinal strain values (-12.61%±4.32 vs. -17.15%±3.95; p=0.008) at the expense of basal segmentis. No significant differences were found for twist, torsion, and circumferential and radial strain. The product between longitudinal strain and apical circumferential strain decreased, while the ejection fraction/global longitudinal strain ratio was significantly increased in patientis with cardiac amyloidosis. Conclusions: The product of longitudinal strain × apical circumferential strain and the ejection fraction/global longitudinal strain ratio are useful parameters that allow differentiating cardiac amyloidosis from hypertrophic cardiomyopathy patientis.

Utilidad del score HEART con troponina T de alta sensibilidad para la evaluación de pacientes con dolor torácico / Usefulness of the HEART Score with High-Sensitivity Troponin T for the Evaluation of Patients withChest Pain

RESUMEN Introducción: El score HEART consiste en una prueba sencilla que fue diseñada para estratificar a los pacientes que consultan al servicio de emergencias por dolor torácico, según su riesgo de presentar un síndrome coronario agudo a corto plazo. Fue creado inicialmente con troponina de cuarta generación, pero el advenimiento de la troponina de alta sensibilidad impuso su incorporación al score y la reevaluación de su comportamiento. Objetivo: Nos propusimos evaluar el comportamiento del score HEART con troponina de alta sensibilidad. Material y métodos: Se realizó un estudio prospectivo que incluyó 1464 pacientes (p) que consultaron al servicio de emergencia por dolor torácico y que tenían electrocardiograma sin elevación del segmento ST. Se evaluó la incidencia de MACE (combinado de infarto agudo de miocardio, muerte y revascularización) a 30 días. Resultados: El índice clasificó 739 pacientes (50,5 %) como de bajo riesgo, 515 pacientes (35,2%) de riesgo intermedio y 210 pacientes (14,3%) de alto riesgo. La incidencia de la combinación de infarto agudo de miocardio, muerte y revascularización fue del 1,35% en el primer grupo; del 20%, en el segundo; y del 71%, en el tercero (long rank test p < 0,001). El área bajo la curva global para la combinación de infarto agudo de miocardio, muerte y revascularización fue de 0,91 (0,89-0,93). Conclusiones: El score HEART que utiliza troponina de alta sensibilidad tiene una gran capacidad para clasificar pacientes con dolor torácico de acuerdo con su riesgo de presentar eventos cardiovasculares en el corto plazo.