Echocardiographic predictors of all-cause mortality in patients with left ventricular ejection fraction >35%: Value of guideline based assessment of diastolic dysfunction.

BACKGROUND: Recent data suggests that the majority of cardiac deaths in patients with heart failure occur in patients with a left ventricular ejection fraction (LVEF) >35%. This study sought to determine the value of guideline based assessment of diastolic dysfunction in predicting all-cause mortality in patients with a first-ever myocardial infarction (MI) with an LVEF >35%. METHODS: A retrospective single centre study involving 383 patients with a first-ever MI (STEMI or NSTEMI) with LVEF >35% was performed. Clinical, angiographic and echocardiographic data were obtained from prospectively maintained institutional databases. Outcomes data were obtained from national death registry. Echocardiography was performed early post-admission for all patients. Significant diastolic dysfunction (DD) was defined was grade 2/3 diastolic dysfunction according to current American Society of Echocardiography/European Association of Cardiovascular Imaging guidelines. RESULTS: At a median follow up of 2 years, there were 32 deaths. On Cox proportional hazards multivariate analysis incorporating significant clinical variables (age, chronic kidney disease and extent of coronary artery disease), significant DD (HR 2.57, 95%CI 1.16-5.68, p = 0.020) and left ventricular end-diastolic volume index (HR 1.03, 1.04-1.07, p = 0.021) were the only independent echocardiographic predictors of all-cause mortality. Intermodel comparisons using model χ2 and Harrel's-C confirmed incremental value of DD. In the subgroup with LVEF 36-55% (n = 176), significant DD was the only independent echocardiographic predictor (HR 3.56, 95%CI 2.46-9.09, p = 0.006). CONCLUSIONS: The presence of significant DD identifies patients with LVEF >35% following MI who are at a higher risk of all-cause mortality, and who may benefit from further risk stratification and treatment.

Echo and BNP serial assessment in ambulatory heart failure care: Data on loop diuretic use and renal function.

We compared the follow-up data on loop diuretic use and renal function, as assessed by serum creatinine levels, and the estimated glomerular filtration rate (eGFR), of two groups of consecutive ambulatory HF patients: 1) the clinically-guided group, in which management was clinically driven based on the institutional protocol of the HF Unit of the Cardiovascular and Thoracic Department of Pisa (standard of care) and 2) the echo and B-type natriuretic peptide (BNP) guided group (patients conforming to the protocol of the Network Labs Ultrasound (NEBULA) in HF Study Group: Pisa, Perugia, Pavia; Verona, Auckland, and Veruno), in which therapy was delivered according to the serial assessment of BNP and echocardiography. Patients whose follow-up was based on standard of care had a significant higher prevalence of worsening renal function, that was likely related to higher diuretic dosages, whilst, a better management of renal function was observed in the echo-BNP-guided group. The data is related to "Echo and natriuretic peptide guided therapy improves outcome and reduces worsening renal function in systolic heart failure: An observational study of 1137 outpatients" (A. Simioniuc, E. Carluccio, S. Ghio, A. Rossi, P. Biagioli, G. Reboldi, G.G. Galeotti, F. Lu, C. Zara, G. Whalley, P.G. Temporelli, F.L. Dini, 2016; K.J. Harjai, H.K. Dinshaw, E. Nunez, M. Shah, H. Thompson, T. Turgut, H.O. Ventura, 1999; A. Ahmed, A. Husain, T.E. Love, G. Gambassi, L.J. Dell׳Italia, G.S. Francis, M. Gheorghiade, R.M. Allman, S. Meleth, R.C. Bourge, 2006) [1], [2], [3].

Echo and natriuretic peptide guided therapy improves outcome and reduces worsening renal function in systolic heart failure: An observational study of 1137 outpatients.

BACKGROUND: B-type natriuretic peptide (BNP) and echocardiography are potentially useful adjunct to guide management of patients with chronic heart failure (HF).Thus, the aim of this retrospective, multicenter study was to compare outcomes and renal function in outpatients with chronic HF with reduced ejection fraction (HFrEF) who underwent an echo and BNP guided or a clinically driven protocol for follow-up. METHODS AND RESULTS: In 1137 consecutive outpatients, management was guided according to echo-Doppler signs of elevated left ventricular filling pressure and BNP levels conforming to the protocol of the Network Labs Ultrasound (NEBULA) in HF Study Group in 570 (mean EF=30%), while management was clinically driven based on the institutional protocol of the HF Unit of the Cardiovascular and Thoracic Department in 567 (mean EF=33%). Propensity score, matching several confounding baseline variables, was used to match pairs based on treatment strategy. The median follow-up was 37.4months. After propensity matching, a lower incidence of death (HR 0.45, 95%CI: 0.30-0.67, p<0.0001), and death or worsening renal function (HR 0.49, 95%CI 0.36-0.67, p<0.0001) was apparent in echo-BNP-guided group compared to clinically-guided group. Worsening of renal function (≥0.3mg/dl increase in serum creatinine) was observed in 9.8% of echo-BNP-guided group and in 21.4% of clinical assessed group (p<0.0001). The daily dose of loop diuretics did not change in echo-BNP-guided group, while it increased in 65% of patients in clinically-guided group (p<0.0001). CONCLUSIONS: Echo and BNP guided management may improve the outcome and reduce worsening of renal function in outpatients with chronic HFrEF.

Assessment and impact of diastolic function by echocardiography in elderly patients.

Doppler echocardiography is the gold standard for assessment of diastolic dysfunction, which is increasingly recognised as a cause of heart failure, especially in the elderly. Using a combination of Doppler echocardiography techniques, it is possible to identify grades of diastolic dysfunction, estimate left ventricular filling pressures and establish the chronicity of diastolic dysfunction. These physiologically-derived measures have been widely validated against invasive measurements of left heart pressures and have been shown to be prognostically valuable in a wide range of clinical settings. This review explores the mechanisms, and approaches to the assessment of diastolic dysfunction in the elderly. The challenge for clinicians is to identify pathophysiological changes from those associated with normal ageing. When used in combination, and taking age into account, Doppler echocardiographic parameters are helpful in the assessment of dyspnoea in older patients and provide prognostic insights.

A new approach to assessment of the left ventricle.

Cardiac motion is a continuous process; however most measurements to assess cardiac function are taken at brief moments in the cardiac cycle. Using functional data analysis, repeated measurements of left ventricular volume recorded at each frame of a continuous image measured with cardiac ultrasound (echocardiography) were turned into a function of volume over time. The first derivative of the displacement of volume with respect to time is velocity; the second derivative is acceleration. Plotting volume, velocity, and acceleration against each other in a 3-dimensional plot results in a closed loop. The area within the loop is defined by the kinematics of volume change and so may represent ventricular function. •We have developed an approach to analyzing images of the left ventricle that incorporates information from throughout the cardiac cycle. •Comparing systolic and diastolic areas within a loop defined by volume, velocity, and acceleration of left ventricular volume highlights imbalances in the kinematics of the two phases, potentially indicating early sub-clinical disease.•Substantially more information about left ventricular function may be derived from a non-invasive clinically available tool such as echocardiography.

Echocardiography service provision in New Zealand: The implications of capacity modelling for the cardiac sonographer workforce.

AIM: Regional disparity in both utilisation and the cardiac sonographer workforce has previously been identified. We sought to model the capacity of the cardiac sonographer workforce at a national and District Health Board level to better understand these regional differences. METHOD: In 2013, surveys were distributed to 18 hospitals who employ cardiac sonographers (return rate 100%). Questions related to cardiac sonographer demographics, echo utilisation and workflow. Actual clinical capacity was calculated from scan duration and annual scan volumes. New Zealand national actual capacity was compared to predicted capacity from three international models. Potential clinical capacity was calculated from the workforce size in fulltime equivalent (FTE) and clinical availability. RESULTS: In New Zealand, scan duration and population-based clinical capacity varies between centres. The New Zealand capacity is similar to the UK 30:70 model, and consistently less than the US model for all scan types. There are marked regional differences in potential versus actual capacity, with 10/16 DHBs demonstrating excess potential capacity. CONCLUSION: There is regional disparity in the capacity of the cardiac sonographer workforce, which appears to be strongly related to scan duration. Workforce capacity modelling should be used with need and demand modelling to plan adequate levels of service provision.

A Kaupapa Maori approach to a community cohort study of heart disease in New Zealand.

OBJECTIVE: To report the processes and protocols that were developed in the design and implementation of the Hauora Manawa Project, a cohort study of heart disease in New Zealand and to report the participation at baseline. METHODS: This study utilised application of a Kaupapa Maori Methodology in gaining tribal and health community engagement, design of the project and random selection of participants from territorial electoral rolls, to obtain three cohorts: rural Maori, urban Maori and urban non-Maori. Logistic regression was used to model response rates. RESULTS: Time invested in gaining tribal and health community engagement assisted in the development and design of clear protocols and processes for the study. Response rates were 57.6%, 48.3% and 57.2%. Co-operation rates (participation among those with whom contact was established) were 74.7%, 66.6% and 71.4%. CONCLUSIONS: Use of electoral rolls enables straightforward sampling but results in low response rates because electors have moved. Co-operation rates highlight the acceptability of this research project to the participants; they indicate the strength of Kaupapa Maori Methodologies in engaging Maori participants and community. IMPLICATIONS: This study provides a model for conducting clinical/biomedical research projects that are compatible with cultural protocols and methodologies, in which the primary aim of the research was Maori health gain.

Changes in tissue-Doppler echocardiographic assessment of left ventricular filling during NT-proBNP guided heart failure treatment titration: a pilot study.

BACKGROUND: Although brain natriuretic peptide (BNP) and E/Ea are closely related in heart failure (HF) patients and may be helpful to guide HF therapy, the response of E/Ea to changes in BNP over several weeks of intensive HF treatment optimisation is unknown. This study was designed to investigate this relationship. METHODS AND RESULTS: In 17 patients with decompensated HF, treatment was titrated to reduce the NT-proBNP level to <200pg/mL over 10 weeks. Paired NT-proBNP measurements and echocardiograms were performed at two weekly intervals during the study. Treatment titration was associated with a reduction in E/Ea (17.6+/-6.8S.D. to 13.7+/-5.0S.D., p=0.018) in keeping with the reduction in NT-proBNP (median 603 [S.E. 561] to 311 [S.E. 235], p=0.045). This relationship remained in those who responded to titration (reduction in NT-proBNP of >or=50%), and those who did not. The overall change in E/Ea was similar to the changes observed in NT-proBNP in each group however there appeared to be temporal differences in the changes in E/Ea and NT-proBNP. CONCLUSION: This pilot study demonstrates that the E/Ea decreases after NT-proBNP guided HF therapy. E/Ea may be a complementary target for HF therapy optimisation; this hypothesis should be further evaluated in larger scale randomised trials.

Three-dimensional assessment of left ventricular systolic strain in patients with type 2 diabetes mellitus, diastolic dysfunction, and normal ejection fraction.

Left ventricular (LV) diastolic dysfunction often occurs in patients with type 2 diabetes mellitus (DM) independent of atherosclerotic coronary artery disease, myocardial ischemia, and regional wall motion anomalies. Limited information exists on LV myocardial tissue strain in this patient group. We measured 3-dimensional (3-D) parameters of LV systolic and diastolic functions in 28 patients who had type 2 DM (age 33 to 70 years), standard echocardiographic evidence of LV diastolic dysfunction, and normal LV ejection fraction, and 31 normal control subjects (age 19 to 74 years) who had no evidence of cardiac disease, with multislice cine anatomic and tagged magnetic resonance imaging. Three-dimensional analysis of the resulting images showed that peak systolic mitral valve plane displacement was 12% smaller (p = 0.040) and peak diastolic mitral valve plane velocity was 21% lower (p = 0.008) in patients who had DM than in normal controls. Peak systolic circumferential and longitudinal strains and principal 3-D shortening strain were 14%, 22%, and 10% smaller, respectively, in the DM group (p <0.001 for each). Peak diastolic rate of relaxation of circumferential and longitudinal strains and principal 3-D shortening strain were 35%, 32%, and 33% lower, respectively, in the DM group (p <0.001 for each). Thus, LV systolic circumferential, longitudinal and 3-D principal strains, and diastolic strain rates are impaired in patients who have type 2 DM, LV diastolic dysfunction, and normal LV ejection fraction.