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Infective endocarditis (IE) carries a high risk of morbidity and mortality. Timely diagnosis, effective treatment and prompt recognition of complications are essential to favourable patient outcomes. A collaborative, multidisciplinary team approach to the management of IE has been shown to improve prognosis. However, the clinical heterogeneity of IE and atypical presentations pose challenges to the endocarditis team. We present a case highlighting the role of valve histopathology in suspected IE, where there may be diagnostic uncertainty.
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Endocardite Bacteriana , Endocardite , Humanos , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/complicações , Endocardite Bacteriana/microbiologia , Endocardite/diagnóstico , Resultado do Tratamento , PrognósticoRESUMO
The COVID-19 pandemic has altered our approach to inpatient echocardiography delivery. There is now a greater focus to address key clinical questions likely to make an immediate impact in management, particularly during the period of widespread infection. Handheld echocardiography (HHE) can be used as a first-line assessment tool, limiting scanning time and exposure to high viral load. This article describes a potential role for HHE during a pandemic. We propose a protocol with a reporting template for a focused core dataset necessary in delivering an acute echocardiography service in the setting of a highly contagious disease, minimising risk to the operator. We cover the scenarios typically encountered in the acute cardiology setting and how an expert trained echocardiography team can identify such pathologies using a limited imaging format and include cardiac presentations encountered in those patients acutely unwell with COVID-19.
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COVID-19 , Cardiologia , Ecocardiografia , Humanos , Pandemias , SARS-CoV-2RESUMO
BACKGROUND: Myocardial strain using cardiac magnetic resonance (CMR) is a sensitive marker for predicting adverse outcomes in many cardiac disease states, but the prognostic value in the general population has not been studied conclusively. OBJECTIVES: The goal of this study was to assess the independent prognostic value of CMR feature tracking (FT)-derived LV global longitudinal (GLS), circumferential (GCS), and radial strain (GRS) metrics in predicting adverse outcomes (heart failure, myocardial infarction, stroke, and death). METHODS: Participants from the UK Biobank population imaging study were included. Univariable and multivariable Cox models were used for each outcome and each strain marker (GLS, GCS, GRS) separately. The multivariable models were tested with adjustment for prognostically important clinical features and conventional global LV imaging markers relevant for each outcome. RESULTS: Overall, 45,700 participants were included in the study (average age 65 ± 8 years), with a median follow-up period of 3 years. All univariable and multivariable models demonstrated that lower absolute GLS, GCS, and GRS were associated with increased incidence of heart failure, myocardial infarction, stroke, and death. All strain markers were independent predictors (incrementally above some respective conventional LV imaging markers) for the morbidity outcomes, but only GLS predicted death independently: (HR: 1.18; 95% CI: 1.07-1.30). CONCLUSIONS: In the general population, LV strain metrics derived using CMR-FT in radial, circumferential, and longitudinal directions are strongly and independently predictive of heart failure, myocardial infarction, and stroke, but only GLS is independently predictive of death in an adult population cohort.
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Imagem Cinética por Ressonância Magnética , Humanos , Masculino , Feminino , Idoso , Imagem Cinética por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Reino Unido/epidemiologia , Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/diagnóstico por imagemRESUMO
Aims: Left ventricular hypertrophy (LVH) is an established, independent predictor of cardiovascular disease. Indices derived from the electrocardiogram (ECG) have been used to infer the presence of LVH with limited sensitivity. This study aimed to classify LVH defined by cardiovascular magnetic resonance (CMR) imaging using the 12-lead ECG for cost-effective patient stratification. Methods and results: We extracted ECG biomarkers with a known physiological association with LVH from the 12-lead ECG of 37 534 participants in the UK Biobank imaging study. Classification models integrating ECG biomarkers and clinical variables were built using logistic regression, support vector machine (SVM) and random forest (RF). The dataset was split into 80% training and 20% test sets for performance evaluation. Ten-fold cross validation was applied with further validation testing performed by separating data based on UK Biobank imaging centres. QRS amplitude and blood pressure (P < 0.001) were the features most strongly associated with LVH. Classification with logistic regression had an accuracy of 81% [sensitivity 70%, specificity 81%, Area under the receiver operator curve (AUC) 0.86], SVM 81% accuracy (sensitivity 72%, specificity 81%, AUC 0.85) and RF 72% accuracy (sensitivity 74%, specificity 72%, AUC 0.83). ECG biomarkers enhanced model performance of all classifiers, compared to using clinical variables alone. Validation testing by UK Biobank imaging centres demonstrated robustness of our models. Conclusion: A combination of ECG biomarkers and clinical variables were able to predict LVH defined by CMR. Our findings provide support for the ECG as an inexpensive screening tool to risk stratify patients with LVH as a prelude to advanced imaging.
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AIMS: We evaluated the associations of left atrial (LA) structure and function with prevalent and incident cardiovascular disease (CVD), independent of left ventricular (LV) metrics, in 25 896 UK Biobank participants. METHODS AND RESULTS: We estimated the association of cardiovascular magnetic resonance (CMR) metrics [LA maximum volume (LAV), LA ejection fraction (LAEF), LV mass : LV end-diastolic volume ratio (LVM : LVEDV), global longitudinal strain, and LV global function index (LVGFI)] with vascular risk factors (hypertension, diabetes, high cholesterol, and smoking), prevalent and incident CVDs [atrial fibrillation (AF), stroke, ischaemic heart disease (IHD), myocardial infarction], all-cause mortality, and CVD mortality. We created uncorrelated CMR variables using orthogonal principal component analysis rotation. All five CMR metrics were simultaneously entered into multivariable regression models adjusted for sex, age, ethnicity, deprivation, education, body size, and physical activity. Lower LAEF was associated with diabetes, smoking, and all the prevalent and incident CVDs. Diabetes, smoking, and high cholesterol were associated with smaller LAV. Hypertension, IHD, AF (incident and prevalent), incident stroke, and CVD mortality were associated with larger LAV. LV and LA metrics were both independently informative in associations with prevalent disease, however LAEF showed the most consistent associations with incident CVDs. Lower LVGFI was associated with greater all-cause and CVD mortality. In secondary analyses, compared with LVGFI, LV ejection fraction showed similar but less consistent disease associations. CONCLUSION: LA structure and function measures (LAEF and LAV) demonstrate significant associations with key prevalent and incident cardiovascular outcomes, independent of LV metrics. These measures have potential clinical utility for disease discrimination and outcome prediction.
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Fibrilação Atrial , Diabetes Mellitus , Hipertensão , Acidente Vascular Cerebral , Bancos de Espécimes Biológicos , Colesterol , Átrios do Coração , Humanos , Valor Preditivo dos Testes , Reino Unido/epidemiologia , Função Ventricular EsquerdaRESUMO
BACKGROUND: Infective endocarditis (IE) is challenging to manage in the COVID-19 lockdown period, in part given its reliance on echocardiography for diagnosis and management and the associated virus transmission risks to patients and healthcare workers. This study assesses utilisation of the endocarditis team (ET) in limiting routine echocardiography, especially transoesophageal echocardiography (TOE), in patients with suspected IE, and explores the effect on clinical outcomes. METHODS: All patients discussed at the ET meeting at Imperial College Healthcare NHS Trust during the first lockdown in the UK (23 March to 8 July 2020) were prospectively included and analysed in this observational study. RESULTS: In total, 38 patients were referred for ET review (71% male, median age 54 [interquartile range 48, 65.5] years). At the time of ET discussion, 21% had no echo imaging, 16% had point-of-care ultrasound only, and 63% had formal TTE. In total, only 16% underwent TOE. The ability of echocardiography, in those where it was performed, to affect IE diagnosis according to the Modified Duke Criteria was significant (p=0.0099); however, sensitivity was not affected. All-cause mortality was 17% at 30 days and 25% at 12 months from ET discussion in those with confirmed IE. CONCLUSION: Limiting echocardiography in patients with a low pretest probability (not probable or definite IE according to the Modified Duke Criteria) did not affect the diagnostic ability of the Modified Duke Criteria to rule out IE in this small study. Moreover, restricting nonessential echocardiography, and importantly TOE, in patients with suspected IE through use of the ET did not impact all-cause mortality.
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Função do Átrio Esquerdo , Fibrose , Insuficiência Cardíaca , Miocárdio , Valor Preditivo dos Testes , Função Ventricular Esquerda , Humanos , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/etiologia , Miocárdio/patologia , Masculino , Feminino , Fatores de Risco , Idoso , Pessoa de Meia-Idade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/etiologia , Incidência , Medição de Risco , Fatores de Tempo , Prognóstico , Átrios do Coração/fisiopatologia , Átrios do Coração/diagnóstico por imagem , Cardiomiopatias/fisiopatologia , Cardiomiopatias/diagnóstico por imagem , Cardiomiopatias/etiologiaRESUMO
AIMS: South Asian (SA) patients are known to have an increased incidence of acute cardiovascular events compared with Caucasians. The aim of this observational study was to compare the prevalence of coronary stenoses, the amount and composition of coronary atherosclerosis in a cohort of Caucasian and SA patients with stable chest pain, in non-acute settings. METHODS AND RESULTS: The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki. In 963 consecutive Caucasian and SA patients undergoing coronary computed tomography angiography, atherosclerotic plaques were quantified using a semi-automated algorithm. The vessel per cent diameter and area stenosis were measured. Plaque composition was examined from the measurement of calcified, non-calcified, and total plaque burden. There were 420 Caucasian (238 males) and 543 SA (297 males) patients. Caucasian patients were older than SA patients (54.39 ± 11.65 vs. 49.83 ± 11.03 years) and had lower prevalence of diabetes (13.13 vs. 32.41%) and hyperlipidaemia (56.90 vs. 68.51%) (all P-values <0.001). After adjusting for differences in cardiovascular risk factors, there were no differences in per cent diameter and area stenosis, and no difference in the proportions of patients with one-, two-, or three-vessel disease. There was no difference in total plaque burden; however, the per cent non-calcified plaque composition was lower in Caucasians compared with SA (80.95 vs. 90.42%; P-value <0.001). CONCLUSION: This study conducted in non-acute settings showed an ethnic difference in composition of coronary atherosclerotic plaque with lower non-calcified composition in Caucasian patients compared with SA patients, which was independent of age, diabetes, hyperlipidaemia, and the other available cardiovascular risk factors.