Assessment of atrial function by myocardial deformation techniques in hypertrophic cardiomyopathy.

BACKGROUND: Diastolic dysfunction in hypertrophic cardiomyopathy (HCM) is common, but its assessment is difficult using conventional echocardiography. AIMS: To assess left atrial (LA) function in HCM by longitudinal strain and determine its role in understanding of symptoms. METHODS: We studied 144 patients divided into 3 age- and sex-matched groups: 48 consecutive patients with HCM, 48 control subjects, and 48 athlete subjects. We assessed LA function by conventional echocardiographic parameters and by longitudinal atrial strain (early-diastolic left atrial strain during reservoir phase [LASr]; end-diastolic left atrial strain during conduit phase; end-systolic peak of the left atrial strain during contraction phase). RESULTS: NYHA classification was as follows in HCM group: I in 46%, II in 31%, III in 19%, and IV in 4%. Conventional echocardiographic parameters of diastolic function were depressed in the HCM group as compared to the control and athlete groups, but not related to symptoms. All longitudinal atrial strain parameters were significantly reduced in HCM group as compared to two groups (P < .0001). LASr was significantly correlated to peak VO2 (r = 0.44, P = .01) and was the best parameter for detecting symptomatic patients presenting with HCM, with a cutoff value of 15%: Sensitivity was 71%, specificity was 79%, PPV was 77%, and NPV was 73%. CONCLUSION: Assessment of LA function in HCM is feasible using longitudinal strain, and this technique is more reliable than conventional echocardiographic parameters for the understanding of determinants of symptoms.

Annual cost of stable coronary artery disease in France: A modeling study.

BACKGROUND: Few studies have analyzed the cost of treatment of chronic angina pectoris, especially in European countries. AIM: To determine, using a modeling approach, the cost of care in 2012 for 1year of treatment of patients with stable angina, according to four therapeutic options: optimal medical therapy (OMT); percutaneous coronary intervention with bare-metal stent (PCI-BMS); PCI with drug-eluting stent (PCI-DES); and coronary artery bypass graft (CABG). METHODS: Six different clinical scenarios that could occur over 1year were defined: clinical success; recurrence of symptoms without hospitalization; myocardial infarction (MI); subsequent revascularization; death from non-cardiac cause; and cardiac death. The probability of a patient being in one of the six clinical scenarios, according to the therapeutic options used, was determined from a literature search. A direct medical cost for each of the therapeutic options was calculated from the perspective of French statutory health insurance. RESULTS: The annual costs per patient for each strategy, according to their efficacy results, were, in our models, €1567 with OMT, €5908 with PCI-BMS, €6623 with PCI-DES and €16,612 with CABG. These costs were significantly different (P<0.05). A part of these costs was related to management of complications (recurrence of symptoms, MI and death) during the year (between 3% and 38% depending on the therapeutic options studied); this part of the expenditure was lowest with the CABG therapeutic option. CONCLUSION: OMT appears to be the least costly option, and, if reasonable from a clinical point of view, might achieve appreciable savings in health expenditure.

Cost-effectiveness modelling of percutaneous coronary interventions in stable coronary artery disease.

The objective of this study is to develop a cost-effectiveness model comparing drug eluting stents (DES) vs bare metal stent (BMS) in patients suffering of stable coronary artery disease. Using a 2-years time horizon, two simulation models have been developed: BMS first line strategy and DES first line strategy. Direct medical costs were estimated considering ambulatory and hospital costs. The effectiveness endpoint was defined as treatment success, which is the absence of major adverse cardiac events. Probabilistic sensitivity analyses were carried out using 10000 Monte-Carlo simulations. DES appeared slightly more efficacious over 2 years (60% of success) when compared to BMS (58% of success). Total costs over 2 years were estimated at 9303 € for the DES and at 8926 € for bare metal stent. Hence, corresponding mean cost-effectiveness ratios showed slightly lower costs (P < 0.05) per success for the BMS strategy (15520 €/success), as compared to the DES strategy (15588 €/success). Incremental cost-effectiveness ratio is 18850 € for one additional percent of success. The sequential strategy including BMS as the first option appears to be slightly less efficacious but more cost-effective compared to the strategy including DES as first option. Future modelling approaches should confirm these results as further comparative data in stable coronary artery disease and long-term evidence become available.

Treatment for stable coronary artery disease: a network meta-analysis of cost-effectiveness studies.

INTRODUCTION AND OBJECTIVES: Numerous studies have assessed cost-effectiveness of different treatment modalities for stable angina. Direct comparisons, however, are uncommon. We therefore set out to compare the efficacy and mean cost per patient after 1 and 3 years of follow-up, of the following treatments as assessed in randomized controlled trials (RCT): medical therapy (MT), percutaneous coronary intervention (PCI) without stent (PTCA), with bare-metal stent (BMS), with drug-eluting stent (DES), and elective coronary artery bypass graft (CABG). METHODS: RCT comparing at least two of the five treatments and reporting clinical and cost data were identified by a systematic search. Clinical end-points were mortality and myocardial infarction (MI). The costs described in the different trials were standardized and expressed in US $ 2008, based on purchasing power parity. A network meta-analysis was used to compare costs. RESULTS: Fifteen RCT were selected. Mortality and MI rates were similar in the five treatment groups both for 1-year and 3-year follow-up. Weighted cost per patient however differed markedly for the five treatment modalities, at both one year and three years (P<0.0001). MT was the least expensive treatment modality: US $3069 and 13 864 after one and three years of follow-up, while CABG was the most costly: US $27 003 and 28 670 after one and three years. PCI, whether with plain balloon, BMS or DES came in between, but was closer to the costs of CABG. CONCLUSIONS: Appreciable savings in health expenditures can be achieved by using MT in the management of patients with stable angina.

Prospective assessment of incidence of Tako-Tsubo cardiomyopathy in a very large urban agglomeration.

BACKGROUND: Tako-Tsubo cardiomyopathy (TTC) is a recently described medical entity and the incidence of TTC in a global population is still uncertain. We sought to prospectively assess the incidence of TTC in a large urban area. METHODS AND RESULTS: We included all consecutive patients referred for coronary angiography in three hospitals located in Paris and its suburbs. We prospectively estimated the percentage of TTC among patients referred for coronary angiography and extrapolated the number of cases of TTC in the greater Paris area (11,598,866 inhabitants) according to the CARDIO-ARHIF registry (government agency). Among 2547 patients (2972 coronary angiographies) including 815 acute coronary syndromes, 20 patients presented with TTC (19 women, mean age 66 ± 13 years). The percentage of TTC among suspected acute coronary syndromes was 2.5% (8.2% in women versus 0.2% in men, p<0.001). In the CARDIO-ARHIF registry, we individualized 51,403 coronary angiographies performed in all catheterization laboratories in one year (13,820 women and 10,246 women ≥ 60 years). In this region, the yearly number of TTC cases is estimated to be 346 (95% CI: 216-520). The annual incidence of TTC is estimated to be 29.8 per 1,000,000 inhabitants (95% CI: 18.6-44.9), 48.2 per 1,000,000 inhabitants (95% CI: 29.7-73.0) among women and 187.4 per 1,000,000 inhabitants (95% CI: 103.3-307.2) among women ≥ 60 years. CONCLUSIONS: Within a large urban agglomeration, the incidence of TTC is high in women ≥ 60 years. The current rate of this recently described cardiomyopathy has been underestimated in previous retrospective studies and will probably rise with the increase of life expectancy.

Usefulness of contrast echocardiography for assessment of intracardiac masses.

BACKGROUND: Conventional echocardiography is not a reliable method for characterizing tissue patterns of intracardiac masses. AIMS: To assess the ability of contrast echocardiography to characterize intracardiac masses. METHODS: Thirty-one consecutive patients with an intracardiac mass were included in this prospective study. All patients underwent conventional and contrast echocardiographic examinations. Analysis of characteristics by contrast agent allowed classification of intracardiac masses as follows: complete lack of enhancement, suggesting thrombus; partial and/or incomplete enhancement, suggesting myxoma; complete enhancement, suggesting intracardiac tumor. Tissue characteristics of intracardiac masses were also analyzed using at least one of the following techniques: cardiac magnetic resonance, pathology of intracardiac mass and/or mass resolved after anticoagulation during follow-up. RESULTS: Using contrast echocardiography, an accurate diagnosis was made in all patients by an experienced investigator and in all patients except one (97%), by a physician trainee (p=0.31). Among patients with a history of tumor, echocardiography allowed accurate diagnosis of the nature of the mass in all patients; 50% of these patients presented with a secondary cardiac tumor and the others had a thrombus. Of the 14patients with a thrombus located in the left ventricle, 12 (86%) presented with left ventricular motion abnormalities using conventional echocardiography, whereas wall motion abnormalities were observed in all 14patients (100%) using contrast agent. In these patients, 91 and 99% of left ventricular segments were well visualized using conventional and contrast echocardiography, respectively (p<0.0001). CONCLUSIONS: Contrast echocardiography may be useful for the tissue characterization of intracardiac masses.

Usefulness of two-dimensional speckle tracking echocardiography for assessment of Tako-Tsubo cardiomyopathy.

The aim of this study was to characterize left ventricular (LV) systolic function using 2-dimensional strain in Tako-Tsubo cardiomyopathy (TTC). Forty-two women were prospectively studied using 2-dimensional speckle-tracking echocardiography, divided into 3 groups: 14 patients with TTC (group 1), 14 patients with coronary artery disease (group 2), and 14 healthy patients (group 3). In patients with TTC, mean values of systolic peak velocity, strain, and strain rate were significantly lower than those in group 3 (p <0.04), but these values were similar between the basal septum and lateral wall, between the middle septum and lateral wall, and between the apical septum and lateral wall. LV ejection fractions were significantly improved during follow-up (p <0.0001). All values of velocities were significantly increased at day 7 compared with the acute phase (p < or =0.01). This improvement differed between the middle septum and lateral wall (p <0.0001), and values for the middle septum and lateral wall in patients with TTC were not significantly different from those observed in patients with coronary artery disease (p = NS). At 1-month follow-up, no significant difference was noted between patients in groups 1 and 3. In conclusion, 2-dimensional speckle-tracking echocardiography is a reliable tool for assessing circular dysfunction in patients with TTC. Once the acute phase has passed, TTC may mimic the LV systematized dysfunction observed in patients with coronary artery disease and so lead to misdiagnosis. This novel echocardiographic technique can also be used in the follow-up of LV functional recovery.

Reliability of echocardiography for hemodynamic assessment of end-stage heart failure.

The management of patients with end-stage heart failure is difficult and may require the monitoring of intracardiac pressures. The aim of this prospective study was to assess the reliability of echocardiography in patients with end-stage HF. Twenty consecutive patients presenting with severe left ventricular dysfunction in end-stage heart failure were prospectively studied. All patients underwent right-sided cardiac catheterization and transthoracic echocardiography. Right atrial pressure, estimated using a new echocardiographic parameter, was significantly improved. There was good agreement between systemic and pulmonary vascular resistance, determined by catheterization and echocardiography. All patients with echocardiographic pulmonary vascular resistance<6 Wood units also had invasive pulmonary vascular resistance<6 Wood units. Only echocardiographic mean right atrial pressure was related to the use of saline infusion or bolus infusion of furosemide. All patients requiring intravenous furosemide had pulmonary capillary wedge pressures persistently>or=15 mm Hg despite adequate medication. In conclusion, this study indicates that echocardiography may be a reliable tool for the management of patients with end-stage heart failure.

Usefulness of contrast echocardiography for assessment of left ventricular thrombus after acute myocardial infarction.

Fifty consecutive patients referred to a coronary care unit for acute anterior myocardial infarction with ST-segment elevation underwent coronary arteriography, left ventricular (LV) angiography, and revascularization. Transthoracic echocardiography was systematically performed using fundamental imaging, second harmonic imaging, and contrast agents to assess the LV chamber. Six patients (12%) presented with a confirmed LV mural thrombus. Thirty-five percent of patients with time to revascularization>3 hours presented with an LV mural thrombus versus 0 patients with time to revascularization3 hours.

Assessment of patent foramen ovale in carcinoid heart disease.

BACKGROUND AND OBJECTIVE: Carcinoid syndrome may involve right carcinoid heart disease (CHD), secondary to the release of vasoactive substances. Left CHD is rare, as the inactivation of serotonin by the lung protects the left heart. We attempted to evaluate the prevalence of CHD and patent foramen ovale (PFO) with serial contrast transthoracic echocardiographic studies and to determine the markers of right and left CHD progression. METHODS: Forty-one consecutive patients with proved digestive endocrine tumor and carcinoid syndrome were prospectively enrolled. All patients underwent serial conventional and contrast transthoracic echocardiographic studies. Right and left CHD, PFO, radiological examinations, and biological carcinoid markers were systematically assessed. RESULTS: Left CHD was present in 5 patients at baseline and in 13 patients (32%) during follow-up (P = .03). The 13 patients with left CHD also had PFO, and no left CHD occurred without PFO (P < .0001). Right CHD was present in 16 patients (39%) at baseline and in 25 patients (61%) at the end of follow-up (P = .04). The prevalence of right and left CHD was significantly higher in patients with PFO (88% and 76%, respectively; P < .04). A progression of right and left CHD was present, respectively, in 19 and 9 patients but was mainly found in patients with PFO (15 and 9 patients; P < .0001). The main marker of CHD progression was the presence of PFO (odds ratio 44.2, 95% confidence interval 4.4-447.7; P = .001). CONCLUSIONS: PFO is a new marker of CHD progression and should be systematically assessed with routine contrast transthoracic echocardiography in patients with carcinoid syndrome to determine patients at high risk of CHD progression.

Plasma N-terminal pro-brain natriuretic peptide and brain natriuretic peptide in assessment of acute dyspnea.

We examined the analytical correlation between non-radioimmunometric plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) and B-type natriuretic peptide (BNP) and evaluated whether NT-proBNP or BNP was superior in the emergency diagnosis of heart failure and whether this was influenced by age, gender, body mass index (BMI) and renal function. Data were collected prospectively from patients admitted to the emergency department for acute dyspnea. Plasma BNP (Triage, Biosite) and NT-proBNP (Elecsys, Roche diagnostic(R)) were measured at admission in addition to other standard biological parameters and clinical variables. Reference diagnosis was adjudicated by two independent cardiologists using the European society of cardiology guidelines. We evaluated the influence of creatinine clearance, age, gender and BMI on plasma BNP and NT-proBNP levels. One hundred and sixty consecutive patients were included: 84 females and 76 males, mean age 80.1 + 13.5 (16-98). The analytical correlation between the automated electro-chemiluminescence immunoassay for NT-proBNP and the single use fluorescence immunoassay for BNP was satisfactory using the equation: NT-proBNP = 1.1 BNP + 0.57 and a correlation r = 0.93. This was established over a wide range of concentration (5-6400 pg/ml for BNP). Areas under receiver operating characteristic (ROC) curve for BNP and NT-proBNP as a diagnostic marker for heart failure were 0.82 and 0.84, respectively and a BNP level of 150 pg/ml has similar sensitivity and specificity that NT-proBNP level of 1000 pg/ml. The correlation was not influenced by age, gender and BMI of patients. Renal dysfunction did not affect significantly this correlation (r = 0.93). We conclude that NT-proBNP, as assayed in the present study, correlates closely with BNP. This correlation is only slightly modulated by creatinine clearance values. The NT-proBNP appears as accurate as BNP according to area under ROC curve. Used in conjunction with other clinical information, rapid measurement of BNP or NT-proBNP is useful in establishing or excluding the diagnosis of congestive heart failure in patients with acute dyspnea.

Serial echocardiographic assessment of left ventricular mass: how blinded should readers be?

OBJECTIVES: In addition to the interest of mixing the sequence of echo-exam in a central blinded review, we studied the effect that might result from group-analysis of all echocardiograms simultaneously for each patient, with their sequence kept blind. A priori, this method of reading has the potential of decreasing measurement variability. METHODS: We included 630 echocardiograms from 210 hypertensive patients participating in a randomized clinical trial comparing two antihypertensive agents for regression of left ventricular (LV) hypertrophy. Three echocardiograms per patient [selection (4 weeks before; W-4), at inclusion (week 0; W0), and the end of treatment (week 52; W52)], were read twice, according to two methods, blind to centre, patient numbers and sequence of visits: (1) examination of individual serial echocardiograms, (2) examination of all-patient mixed echocardiograms. The first method was expected to increase the power of treatment comparison by reducing variability of measurements of left ventricular mass (LVM). RESULTS: Pooling echocardiograms of all patients reduces variability of LVM change under treatment: absolute LVM (W52 - W0) standard deviation was reduced by 22%. Nevertheless, despite a good between-methods agreement for LVM values at each visit (intra-class coefficient of correlation from 0.88 to 0.92), LVM change under treatment was reduced even more, by 41%. Thus, the slight decrease of variability induced by gathering the echocardiograms is associated with an even greater reduction of LVM change. CONCLUSIONS: According to these findings, the 'full-blind' methodology for a central blinded review in clinical trials appears to produce the maximum power of the study with the lowest sample size.