Global longitudinal strain and long-term outcome in patients presenting to the emergency department with suspected acute coronary syndrome.

AIMS: We have previously shown that 2-dimentional strain is not a useful tool for ruling out acute coronary syndrome (ACS) in the emergency department (ED). The aim of the present study was to determine whether in patients with suspected ACS, global longitudinal strain (GLS), measured in the ED using 2-dimensional strain imaging, can predict long-term outcome. METHODS: Long-term (median 7.7 years [IQR 6.7-8.2]) major adverse cardiac events (MACE; cardiac death, ACS, revascularization, hospitalization for heart failure, or atrial fibrillation) and all-cause mortality data were available in 525/605 patients (87%) enrolled in the Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER) study. The study prospectively enrolled patients presenting to the ED with chest pain and suspected ACS but without a diagnostic ECG or elevated troponin. GLS was computed using echocardiograms performed within 24 hours of chest pain. MACE of patients with worse GLS (>median GLS) were compared to patients with better GLS (≤ median GLS). RESULTS: Median GLS was -18.7%. MACE occurred in 47/261 (18%) of patients with worse GLS as compared with 45/264 (17%) with better GLS, adjusted HR 0.87 (95% CI 0.57-1.33, P = .57). There was no significant difference in all-cause mortality or individual endpoints between groups. GLS did not predict MACE even in patients with optimal 2-dimensional image quality (n = 164, adjusted HR=1.51, 95% CI 0.76-3.0). CONCLUSIONS: Global longitudinal strain did not predict long-term outcome in patients presenting to the ED with chest pain and suspected ACS, supporting our findings in the 2DSPER study.

[DIRECT ADMISSION OF STEMI PATIENTS TO THE CARDIAC CARE UNIT VERSUS ADMISSION VIA THE EMERGENCY DEPARTMENT FOR PRIMARY CORONARY INTERVENTION IMPROVES SHORT AND LONG-TERM SURVIVAL].

INTRODUCTION: Shortening door-to-balloon time intervals in ST-elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PPCI) is necessary in order to limit myocardial damage. Direct admission to the cardiac care unit (CCU) facilitates this goal. We compared characteristics and short- and long-term mortality of PPCI-treated STEMI patients admitted directly to the CCU with those admitted via the emergency department (ED). METHODS: To compare 303 patients admitted directly to the CCU (42%) with 427 admitted via the ED (58%) included in the current registry comprising 730 consecutive PPCI-treated STEMI patients. RESULTS: Groups were similar regarding demographics, medical history and risk factors. Pain-to-CCU time was 151±164 minutes (median-94) for patients admitted directly and 242±226 minutes (160) for those admitted via the ED, while door-to-balloon intervals were 69±42 minutes (61) and 133±102 minutes (111), respectively. LVEF evaluated during admission (48.3±13% [47.5%] vs. 47.7±13.7% [47.5%]) and mean CK level (893±1157 [527] vs. 891±1255 [507], p=0.45) were similar between groups. Mortality was 4.2% vs. 10.3% at 30-days (p<0.002), 7.6% and 14.3% at one-year (p<0.01), reaching 12.2% and 21.9% at 3.9±2.3 years (median-3.5, p<0.004) among directly-admitted patients vs. those admitted via the ED, respectively. Long-term mortality was 4.1%, 9.4%, 21.4%, and 16% for pain-to-balloon quartiles of <140 min, 141-207 min, 208-330 min, and >330 mins, respectively (p=0.026). CONCLUSIONS: Direct admission of STEMI patients to the CCU for PPCI facilitated the attainment of guidelines-dictated door-to-balloon time intervals and yielded improved short- and long-term mortality. Longer pain-to-balloon time was associated with higher long-term mortality.

Enhancement of Standard ECGs by a New Method for Multi-Cycle Superimposition and Summation.

BACKGROUND: Since the introduction of the electrocardiogram (ECG) in 1902, the fundamentals of ECG data acquisition, display, and interpretation in the clinical arena have not changed much. OBJECTIVES: To present a new method to enhance and improve acquisition, analysis, and display of the standard ECG. METHODS: We performed ECG enhancement by superimposition and summation of multiple standard ECG cycles of each lead, by temporal alignment to peak R wave and voltage alignment to an improved baseline, at the T-P segment. RESULTS: We enhanced ECG recordings of 504 patients who underwent coronary angiograms for routine indications. Several new ECG features were noted on the enhanced recordings. Examination of a subgroup of 152 patients with a normal rest 12-lead ECG led to the discovery of a new observation, which may help to distinguish between patients with and without coronary artery disease (CAD): namely, a spontaneous cycle-to-cycle voltage spread (VS) at the S-T interval, normalized to VS at the T-P interval. The mean normalized VS was significantly greater in those with CAD (n=61, 40%) than without (n=91, 60%), 5.61 ± 3.79 vs. 4.01 ± 2.1 (P < 0.05). CONCLUSIONS: Our novel method of multiple ECG-cycle superimposition enhances the ECG display and improves detection of subtle electrical abnormalities, thus facilitating the standard rest ECG diagnostic power. We describe, for the first time, voltage spread at the S-T interval, an observed phenomenon that can help detect CAD among individuals with normal rest 12-lead ECG.

Primary Percutaneous Coronary Intervention Versus In-hospital thrombolysis as Reperfusion Therapy in Early-Arriving Low-risk STEMI Patients.

BACKGROUND: Trials have shown superiority of primary percutaneous intervention (PPCI) over in-hospital thrombolysis in ST-elevation myocardial infarction (STEMI) patients treated within 6-12 hours from symptom onset. These studies also included high-risk patients not all of whom underwent a therapeutic intervention. OBJECTIVES: To compare the outcome of early-arriving stable STEMI patients treated by thrombolysis with or without coronary angiography to the outcome of PPCI-treated STEMI patients. METHODS: Based on six biannual Acute Coronary Syndrome Israeli Surveys comprising 5474 STEMI patients, we analyzed the outcome of 1464 hemodynamically stable STEMI patients treated within 3 hours of onset. Of these, 899 patients underwent PPCI, 383 received in-hospital thrombolysis followed by angiography (TFA), and 182 were treated by thrombolysis only. RESULTS: Median time intervals from symptom onset to admission were similar while door-to-reperfusion intervals were 63, 45 and 52.5 minutes for PPCI, TFA and thrombolysis only, respectively (P < 0.001). The 30-day composite endpoint of death, post-infarction angina and myocardial infarction occurred in 77 patients of the PPCI group (8.6%), 64 patients treated by TFA (16.7%), and 36 patients of the thrombolysis only group (19.8%, P < 0.001), with differences mostly due to post-infarction angina. One-year mortality rate was 27 (3%), 13 (3.4%) and 11 (6.1%) for PPCI, TFA and thrombolysis only, respectively (P = 0.12). CONCLUSIONS: PPCI was superior to thrombolysis in early-arriving stable STEMI patients with regard to 30-day composite endpoint driven by a decreased incidence of post-infarction angina. No 1 year survival benefit for PPCI over thrombolysis was observed in early-arriving stable STEMI patients.

Non-Invasive Lung IMPEDANCE-Guided Preemptive Treatment in Chronic Heart Failure Patients: A Randomized Controlled Trial (IMPEDANCE-HF Trial).

BACKGROUND: Previous investigations have suggested that lung impedance (LI)-guided treatment reduces hospitalizations for acute heart failure (AHF). A single-blind 2-center trial was performed to evaluate this hypothesis (ClinicalTrials.gov-NCT01315223). METHODS: The study population included 256 patients from 2 medical centers with chronic heart failure and left ventricular ejection fraction ≤35% in New York Heart Association class II-IV, who were admitted for AHF within 12 months before recruitment. Patients were randomized to a control group treated by clinical assessment and a monitored group whose therapy was also assisted by LI, and followed for at least 12 months. Noninvasive LI measurements were performed with a new high-sensitivity device. Patients, blinded to their assignment group, were scheduled for monthly visits in the outpatient clinics. The primary efficacy endpoint was AHF hospitalizations; the secondary endpoints were all-cause hospitalizations and mortality. RESULTS: There were 67 vs 158 AHF hospitalizations during the first year (P < .001) and 211 vs 386 AHF hospitalizations (P < .001) during the entire follow-up among the monitored patients (48 ± 32 months) and control patients (39 ± 26 months, P = .01), respectively. During the follow-up, there were 42 and 59 deaths (hazard ratio 0.52, 95% confidence interval 0.35-0.78, P = .002) with 13 and 31 of them resulting from heart failure (hazard ratio 0.30, 95% confidence interval 0.15-0.58 P < .001) in the monitored and control groups, respectively. The incidence of noncardiovascular death was similar. CONCLUSION: Our results seem to validate the concept that LI-guided preemptive treatment of chronic heart failure patients reduces hospitalizations for AHF as well as the incidence of heart failure, cardiovascular, and all-cause mortality.

Novel Method for Real Time Co-Registration of IVUS and Coronary Angiography.

OBJECTIVES: We present our experience with a novel method for real time co-registration of intravascular ultrasound (IVUS) and coronary angiography. BACKGROUND: A major limitation of the current practice of concomitant use of coronary angiography and IVUS is that the locations of the acquired IVUS images are not correlated with their exact locations on the vessel roadmap obtained by coronary angiography. METHODS: Phantoms simulating the coronary tree were used to test the accuracy and potential of co-registration. Subsequently we examined patients who underwent IVUS during cardiac catheterization. Analysis and feasibility were performed in 42 arteries of 36 patients. RESULTS: The statistical validation in phantoms resulted in a co-registration accuracy of 1.12 mm. The length measurement on an angiogram resulted in an accuracy of 0.38 mm. Co-registration in patients was successful in all cases and four categories were assisted by 1(bad) to 5 (good) grading. Accuracy (the co-registration precision in pointing at the exact corresponding location): 4.8±0.41; Ease of use and workflow: 4.74±0.44; Stent landing zone detection and evaluation: 4.58±0.5; Stent landing zone length and diameter measurement: 4.94±0.23. The co-registration error was estimated as no more than 1 mm. CONCLUSION: In this pilot study, we found that the novel IVUS and coronary angiography co-registration method is accurate, easy to use, fast and user-friendly. This method precludes the need to use motorized automated pull back device.

Derivation of baseline lung impedance in chronic heart failure patients: use for monitoring pulmonary congestion and predicting admissions for decompensation.

The instantaneous lung impedance (ILI) is one of the methods to assess pulmonary congestion or edema (PCE) in chronic heart failure (CHF) patients. Due to usually existing PCE in CHF patients when evaluated, baseline lung impedance (BLI) is unknown. Therefore, the relation of ILI to BLI is unknown. Our aim was to evaluate methods to calculate and appraise BLI or its derivative as reflecting the clinical status of CHF patients. ILI and New York Heart Association (NYHA) class were assessed in 222 patients (67 ± 11 years, LVEF <35 %) during 32 months of frequent outpatient clinic visits. ILI, measured in 120 asymptomatic patients at NYHA class I, with no congestion on the chest X-ray and a low-normal 6-min walk, was defined as BLI. Using measured BLI and ILI values in these patients, formulas for BLI calculation were derived based on logistic regression analysis or on the disparity between BLI and ILI values at different NYHA stages. Both models were equally reliable with <3 % difference between measured and calculated BLI (p = NS). ΔLIR = (ILI/BLI - 1) × 100 % reflected the degree of PCE, or deviation from baseline, correlated with NYHA class (r = -0.9, p < 0.001) and could serve for monitoring. Of study patients, 123 were re-hospitalized for PCE during follow up. Their ΔLIR decreased gradually from -21.7 ± 8.2 % 4 weeks pre-admission to -37.8 ± 9.3 % on admission (p < 0.001). Patients improved during hospital stay (NYHA 3.7 ± 0.5 to 2.9 ± 0.8, p < 0.0001) with ΔLIR increasing to -29.1 ± 12.0 % (p < 0.001). ΔLIR based on calculated BLI correlated with the clinical status of CHF patients and allowed the prediction of hospitalizations for PCE.

Novel acute collateral flow index in patients with total coronary artery occlusion during ST-elevation myocardial infarction.

BACKGROUND: The effect of collaterals to occluded coronary arteries during ST-elevation myocardial infarction (STEMI) is unclear. The conventional CVP-based formula to calculate collateral flow index during STEMI yields values higher than in elective patients, which prompted derivation of a modified formula, pertinent in STEMI when left ventricular mean diastolic pressure (LVMDP) is the extravascular pressure limiting collateral flow. We aimed to evaluate this new LVMDP-based acute collateral flow index (ACFI). METHODS AND RESULTS: The pressure distal to coronary artery occlusion (P(d)) was measured during intervention in 111 consecutive STEMI patients, 67 (61%) of whom underwent primary intervention, followed for 58 months. ACFI (0.18 ± 0.17, median 0.15) correlated with both P(d) and collateral grade (P<0.0001). Higher creatine kinase levels and white cell counts were measured in the lowest ACFI tertile compared with the highest tertile group (P<0.012). ACFI correlated slightly with early regional but not with global left ventricular ejection fraction or with long-term coronary events and mortality. CONCLUSIONS: The ACFI is appropriate for evaluating collateral function during STEMI. Collateral flow during STEMI may marginally limit myocardial damage but had no effect on left ventricular contraction or long-term mortality, most likely because of the low flow provided by emerging collaterals and the high proportion of patients undergoing intervention before the beneficial effect of collaterals could be realized.

Diagnosis of patent foramen ovale using maximum intensity T-projection imaging.

Accurate diagnosis of patent foramen ovale (PFO) and grading of right-to-left shunt severity by the standard method of transthoracic or transesophageal echocardiography (TEE) with bubble injection is often challenging. We proposed the novel Maximum Intensity T-Projection (MIP) Imaging method as a complementary or alternative approach for simplified diagnosis and grading of PFO. MIP Imaging represents the superimposition of all frames of an echocardiographic video onto one image. Thus, all bubbles passing from right to left atrium are represented in this single image. Diagnosis and quantification of PFO by MIP Images were compared to those obtained by standard echocardiographic methods, using the same echocardiography video loops. We applied the MIP Imaging approach to 122 echo examinations (75% of them TEE studies), performed to rule out PFOs. The average time needed to manually analyze video loops taken during bubble injection was 102 ± 52 s vs. less than 1 s using the MIP Imaging method. There was good concordance between the conventional echo method and MIP Imaging in the diagnosis and quantification of PFOs. MIP Imaging for diagnosis and quantification of PFOs was much less time consuming than the classical method and at least as accurate as the classical method. Thus MIP Imaging may be used initially as an adjunct method for PFO diagnosis and quantification and may eventually replace the classical method.

Collateral pressure and flow in acute myocardial infarction with total coronary occlusion correlate with angiographic collateral grade and creatine kinase levels.

BACKGROUND: The validity of angiographic collateral grade according to the Rentrop classification during acute myocardial infarction (AMI) and its relation to flow in occluded coronary arteries before angioplasty have never been evaluated. METHODS: We assessed the validity of the angiographic collateral grade according to Rentrop classification in relation to collateral pressure and flow beyond occluded coronary arteries during AMI. Pressure distal to coronary artery occlusions before balloon dilatation was measured in 111 patients undergoing angioplasty for AMI. We calculated the collateral flow index (CFI) and compared it to observed Rentrop grade and measured creatine kinase sum. RESULTS: The values of pressure distal to coronary artery occlusions with respect to collateral grades 0 to 3 were 33 +/- 12, 37 +/- 13, 42 +/- 10, and 60 +/- 14 mm Hg (P < .0001). Overall CFI was 0.35 +/- 0.13 (median 0.33), with CFI values of 0.3 +/- 0.13, 0.33 +/- 0.13, 0.39 +/- 0.1, and 0.57 +/- 0.2 for collateral grades 0 to 3, respectively (P < .0001). Larger creatine kinase elevation (P < .016) and higher white blood cell count (P < .022) were recorded in the lowest tertile CFI compared with highest tertile CFI group; but no difference in the global, regional, or infarct-related regional left ventricular contraction was found. CONCLUSIONS: These observations demonstrate that the Rentrop classification is valid in AMI patients with occluded coronary arteries and that collaterals are recruited acutely. These collaterals, whose pressure-derived CFI during AMI was shown for the first time to be higher than its value reported in chronic conditions, may limit the immediate myocardial damage or the systemic inflammatory response. No impact on global or regional cardiac contraction was detected in a population where most patients were treated early.

High-Resolution Fast Ultrasound Imaging With Adaptive-Lag Filtered Delay-Multiply-and-Sum Beamforming and Multiline Acquisition.

Multiline acquisition (MLA) is a well-established method for a high-frame-rate cardiac ultrasound imaging, which is commonly used in conjunction with delay-and-sum (DAS) beamforming. The block-like artifacts that occur secondary to the use of MLA can be reduced using interpolation of the data acquired from adjacent transmitted beams-a method called synthetic transmit beamforming (STB). A recently proposed filtered delay-multiply-and-sum (F-DMAS) is a novel beamforming method, based on modified autocorrelation of the aperture data, which provides superior contrast resolution compared to the DAS beamforming. In this study, we demonstrate that a combination of the F-DMAS with the STB compensated MLA results in superior contrast as compared to both DAS beamformed STB and DAS beamformed single-line acquisition. Moreover, we propose a novel formulation for adaptive-lag F-DMAS that outperforms both DAS and F-DMAS in terms of contrast and lateral resolutions. The results are demonstrated in tissue-mimicking phantom and in human cardiac data.

Optimal Timing for Coronary Intervention in Patients With Transient ST-Elevation Myocardial Infarction.

STEMI patients admitted urgently to the hospital but experience early complete resolution of both ischemic symptoms and ST-elevations on the electrocardiogram are diagnosed as transient STEMI (TSTEMI). Current evidence indicates that primary intervention is plausible but in certain circumstances intervention can be delayed. We sought to examine whether there is a time limit to such a delay that may affect long-term outcome. Study population included prospectively admitted TSTEMI patients whose demographics, pertinent medical history, and clinical and angiographic features were recorded. Study patients were divided by the median time interval from admission to intervention and their characteristics and long-term survival were compared. Study population comprised 260 consecutive patients (age: 57±10 years, men: 84%) diagnosed as TSTEMI who were included from January 2000 to June 2019, which represent 6% of all STEMI patients. Coronary angiography was performed in 254 patients. The median time interval from admission to angiography was 17 hours (IQR: 7.2 to 38.7 hours). Early (<17 hours from admission) and late (>17 hours from admission) study groups were comparable. One patient died during admission and 41 throughout the long follow-up period of 8.5 ± 5.2 years (median: 8.2 years, IQR: 3.4 to 13.1). Mortality of early-treated TSTEMI patients (11.2%) was significantly lower than of the late-treated patients (21.6%, p <0.04). The Kaplan-Meier curve demonstrated a clear tendency toward improved survival in early-treated TSTEMI patients (p <0.09). In conclusion, the present data suggest that TSTEMI patients should be treated, if not by primary coronary intervention, then at least within 17 hours from admission to achieve better long-term outcome.

Effect of image quality on accuracy of two-dimensional strain echocardiography for diagnosing ischemic chest pain: a 2DSPER multicenter trial substudy.

Few data exist regarding the effect of image quality on measurements of two-dimensional longitudinal strain (2DLS). In the 2DLS for Diagnosing Chest Pain in the Emergency Room (2DSPER) multicenter study, 2DLS was not useful for ruling out acute coronary syndromes (ACS) in the emergency department (ED). The aim of this substudy was to determine the effect of 2D image quality on the diagnostic accuracy of 2DLS for ACS. We reviewed apical views used for 2DLS analysis in all 605 patients included in the 2DSPER study. Studies with the best image quality (HighQ, n = 177), were compared to the lower quality group (LowQ, n = 428). Abnormal 2DLS was defined as PSS20% > - 17% (PSS20% being the peak left ventricular systolic strain value identifying the 20% worst strain values). Global longitudinal strain (GLS) and PSS20% were significantly worse in LowQ compared to HighQ patients. LowQ independently predicted abnormal 2DLS (OR 1.9, 95% CI 1.3-2.9, P = 0.003). The sensitivity of PSS20% > - 17% for ACS was 85% for LowQ vs. 73% for HighQ (P = 0.2), specificity 22% vs. 38% (P < 0.0001) and overall accuracy 29% vs. 44% (P = 0.0004). Despite better overall accuracy in the HighQ group there was no significant difference between the receiver operating characteristic curves of either GLS or PSS20% in the two groups and abnormal 2DLS did not predict ACS even in HighQ patients (OR 1.7, 95% CI 0.7-4.3, P = 0.3). LowQ echo is associated with worse 2DLS. Abnormal 2DLS was not clinically useful for excluding ACS in the ED even in patients with optimal 2D image quality.Clinical Trial Registration URL: http://www.clinicaltrials.gov . Unique identifier: NCT01163019.

Transient ST-elevation myocardial infarction: clinical course with intense medical therapy and early invasive approach, and comparison with persistent ST-elevation myocardial infarction.

Patients presenting with ST-elevation myocardial infarction (STEMI), whose symptoms and electrocardiographic changes completely resolve upon admission and before the administration of reperfusion therapy, pose a therapeutic dilemma. The optimal management of this syndrome, termed here as transient STEMI (TSTEMI), has not yet been fully determined. We describe 69 prospectively recorded patients with TSTEMI, of which 63 patients (56.7 +/- 11 years, 48 men) were available for long-term follow-up out of 1244 consecutive patients with acute myocardial infarction (5%). Patients with TSTEMI treated with intravenous isosorbide dinitrate, aspirin, and clopidogrel, and/or with glycoprotein IIb/IIIa inhibitors were compared with a control group of matched patients with STEMI without resolution, who were treated conventionally. The time interval from symptom onset to presentation at the emergency department of patients with TSTEMI was 1.7 +/- 1.3 hours, and to first recording of ST elevations, 1.5 +/- 1.4 hours. Symptoms and electrocardiographic changes fully resolved 1.2 +/- 0.8 hours later, 1 hour after aspirin and nitrate administration. Coronary angiography, performed 36 +/- 39 hours (median, 24 hours) from admission, demonstrated no obstructive lesion or single-vessel obstructive disease in 43 patients (70%). Primary coronary intervention was performed in 48 patients (77%), and 8 patients (13%) were referred to surgery. Left ventricular ejection fraction was within normal limits, and peak creatine kinase was mildly elevated. Patients with TSTEMI had less extensive coronary artery disease (P < .038), better thrombolysis in myocardial infarction flow on angiography (P < .01), lower peak creatine kinase level (P < .001), higher left ventricular ejection fraction (P < .0001), and lower likelihood to sustain a second additional coronary event after index admission (P = .024) than patients with STEMI. Transient STEMI was associated with less myocardial damage, less extensive coronary artery disease, higher thrombolysis in myocardial infarction flow grade in culprit artery, and better cardiac function. These data suggest that immediate intense medical therapy with an early invasive approach is an appropriate therapy in patients with TSTEMI.

Characteristics, Management, and Outcome of Transient ST-elevation Versus Persistent ST-elevation and Non-ST-elevation Myocardial Infarction.

Patients with acute myocardial infarctions (AMIs) present as persistent ST-elevation myocardial infarction (STEMI) or as non-ST-segment elevation myocardial infarction (NSTEMI). In some patients with STEMI, ST elevations are transient and resolve before coronary intervention (transient ST-elevation myocardial infarction [TSTEMI]). We analyzed our registry comprising all consecutive patients with AMI admitted during 2009 to 2014, and compared the characteristics, management, and outcome of patients with TSTEMI with those of patients with STEMI and NSTEMI. Of 1,847 patients with AMI included in the registry, 1,073 patients sustained a STEMI (58%), 649 had a NSTEMI (35%), and 126 presented with TSTEMI (6.9%). Patients with TSTEMI were younger than patients with NSTEMI and STEMI (56.5 vs 62.8, p <0.001, and 59.5 years, p <0.02, respectively), smoked more (77.8 vs 54.0, p <0.001, and 62.1%, p <0.0005), and fewer were hypertensive (52.4 vs 74.2% and 58.8%, both p <0.001) and diabetic (26.2% vs 47.7%, p <0.0001, and 36.9%, p <0.02). The extent of coronary artery disease in patients with TSTEMI was similar to that of patients with STEMI except for less involvement of the left anterior descending artery (p <0.001), but less extensive than in NSTEMI patients. TSTEMI involved less myocardial damage by troponin-T level (p <0.005) with better cardiac function (LVEF 61% vs 55% and 49%, both p <0.0001). Mortality was lower among TSTEMI both in-hospital (0 vs 2.3% [p = NS] and 4.2% [p <0.01]) and long-term (4.8% vs 14.7% and 14.2%, both p <0.003) at a median of 36 months. In conclusion, TSTEMI is an acute coronary syndrome distinct from NSTEMI and STEMI, characterized by fewer risk factors, a similar extent of coronary artery disease to STEMI, but is associated with less myocardial damage and portends a better outcome.

Prediction of readmissions and mortality in patients with heart failure: lessons from the IMPEDANCE-HF extended trial.

AIMS: Readmissions for heart failure (HF) are a major burden. We aimed to assess whether the extent of improvement in pulmonary fluid content (ΔPC) during HF hospitalization evaluated by lung impedance (LI), or indirectly by other clinical and laboratory parameters, predicts readmissions. METHODS AND RESULTS: The present study is based on pre-defined secondary analysis of the IMPEDANCE-HF extended trial comprising 266 HF patients at New York Heart Association Class II-IV and left ventricular ejection fraction ≤ 35% randomized to LI-guided or conventional therapy during long-term follow-up. Lung impedance-guided patients were followed for 58 ± 36 months and the control patients for 46 ± 34 months (P < 0.01) accounting for 253 and 478 HF hospitalizations, respectively (P < 0.01). Lung impedance, N-terminal pro-brain natriuretic peptide, weight, radiological score, New York Heart Association class, lung rales, leg oedema, or jugular venous pressure were measured at admission and discharge on each hospitalization in both groups with the difference defined as ΔPC. Average LI-assessed ΔPC was 12.1% vs. 9.2%, and time to HF readmission was 659 vs. 306 days in the LI-guided and control groups, respectively (P < 0.01). Lung impedance-based ΔPC predicted 30 and 90 day HF readmission better than ΔPC assessed by the other variables (P < 0.01). The readmission rate for HF was lower if ΔPC > median compared with ΔPC ≤ median for all parameters evaluated in both study groups with the most pronounced difference predicted by LI (P < 0.01). Net reclassification improvement analysis showed that adding LI to the traditional clinical and laboratory parameters improved the predictive power significantly. CONCLUSIONS: The extent of ΔPC improvement, primarily the LI based, during HF-hospitalization, and study group allocation strongly predicted readmission and event-free survival time.

Effect of medical therapy for heart failure on segmental myocardial function in patients with ischemic cardiomyopathy.

The adjustment of medications and dosages to the needs of individual patients with heart failure is mostly intuitive, but even when their effect on global myocardial function is measured by classic indexes, their effect on segmental function is overlooked. This study was conducted to assess the feasibility of using echocardiographic myocardial strain imaging to evaluate the effect of medication on global and segmental function in 21 ambulatory patients with heart failure (mean age 65+/-11 years) who had echocardiographic studies performed before and 2 hours after ingesting their regular morning medications. The ejection fraction, global and regional strain, and time to regional peak strain were compared between the 2 examinations. Medication induced no significant changes in mean ejection fraction (28.6+/-7.8% to 27.5+/-9.9%) and mean global strain (-9.5+/-3.6% to -9.8+/-3.2%). Changes in segmental strain depended on baseline function: normal segments (peak strain more negative than -12%) deteriorated (-15.5+/-2.7% to -13.7+/-4.6%, p<0.0001), but dysfunctional segments (peak strain less negative than -8%) improved (-5.3+/-2.0% to -7.4+/-4.3%, p<0.0001). Medication also improved segmental synchronization: average time to peak strain of segments in which peak strain was attained before aortic valve closure increased (325+/-69 to 375+/-100 ms, p<0.0001), but that of segments with postsystolic shortening at baseline decreased (451+/-93 to 435+/-93 ms, p<0.006). Thus, the time interval between time to peak strain of segments with systolic and post-systolic shortening at baseline was halved after medication. In conclusion, medications for heart failure induced an increase in the echocardiographically determined peak strain of myocardial segments with impaired function at baseline but decreased the peak strain of normally contracting segments. Medications also improved the synchronization of myocardial contraction. Neither the global ejection fraction nor global strain reflected these changes. Thus, medication tended to improve the homogeneity of left ventricular contraction.

Two-dimensional strain echocardiography for diagnosing chest pain in the emergency room: a multicentre prospective study by the Israeli echo research group.

AIMS: Left ventricular (LV) two-dimensional longitudinal strain (2DLS) analysis by echocardiography has been suggested as a useful tool for the detection of acute coronary syndromes (ACS). Our aim was to determine whether 2DLS analysis could assist in triage of patients with chest pain (CP) in the emergency department (ED). METHODS AND RESULTS: We prospectively enrolled patients presenting to the ED with CP and suspected ACS but without a diagnostic ECG or elevated troponin. An echocardiogram was performed within 24 h of CP. For each patient, a histogram of LV myocardial peak systolic strain (PSS) was generated and the value identifying the 20% worst strain values (PSS20%) was determined. A predefined value of greater than -17% was considered abnormal. 2DLS analysis was available for 605 patients (mean age 58 ± 9 years, 70% males), of which 74 (12.2%) had ACS. During a 6-month follow-up, MACE occurred in 4 (5.8%) patients with and in 3 (0.6%) without ACS. An abnormal PSS20% was present in 60/74 patients with ACS (sensitivity 81%, negative predictive value 91%), but also in 391/531 patients without ACS (specificity 26%, positive predictive value 13%). Similar results were found for global longitudinal strain (GLS). Receiver-operating characteristic curves showed an area under curve of 0.59 for PSS20% and 0.6 for GLS (P= 0.3). Independent predictors of abnormal 2DLS were male gender, body mass index, heart rate, and mean tissue Doppler e', but not ACS. CONCLUSION: In this large multicentre prospective study, 2DLS was not a useful tool to rule out ACS in the ED. CLINICAL TRIAL REGISTRATION: http://clinicaltrials.gov. UNIQUE IDENTIFIER: NCT01163019.

Pericardial Effusion due to Primary Malignant Pericardial Mesothelioma: A Common Finding but an Uncommon Cause.

This case report describes a 37-year-old female who was admitted to our Emergency Department because of shortness of breath. On physical examination, she had dyspnea and tachycardia and blood pressure was 80/50 mmHg with a pulsus paradoxus of 22 mmHg. Neck veins were distended, heart sounds were distant, and dullness was found on both lung bases. Her chest X-ray revealed bilateral pleural effusion and cardiomegaly. On both computed tomography and echocardiography the heart was of normal size and a large pericardial effusion was noted. The echocardiogram showed signs of impending tamponade, so the patient underwent an emergent pericardiocentesis. No infectious etiology was found and she was assumed to have viral pericarditis and was treated accordingly. However, when the pericardial effusion recurred and empirical therapy for tuberculosis failed, a pericardial window was performed. A typical staining pattern for mesothelioma was found on her pericardial biopsy specimen. Since no other mesodermal tissue was affected, a diagnosis of primary malignant pericardial mesothelioma was made. Chemotherapy was not effective and she passed away a year after the diagnosis was made. This case highlights the difficulties in diagnosing this uncommon disease in patients that present with the common finding of pericardial effusion.