Serial assessment of focal myocardial function after percutaneous coronary intervention for ST-elevation myocardial infarction: Value of layer-specific speckle tracking echocardiography.

BACKGROUND: Ischemia-reperfusion injury (IRI) frequently follows successful PCI for STEMI and is recognized by multiple modalities. Multilayer speckle tracking echocardiography (STE) has the potential of detecting myocardial dysfunction in different myocardial layers. Our objective was to describe the changes in layer-specific myocardial function over the 24 hours after successful PCI for ST-elevation myocardial infarction (STEMI). METHODS: Patients (n = 120) with STEMI and no prior myocardial infarction underwent echocardiography prior to PCI, immediately after and at 3- and 24-hours post-PCI. Worsening focal dysfunction (WFD) was defined as an immediate reduction, compared to the pre-PCI value, in the amplitude of endo-myocardial longitudinal strain (endo-MLS) within the infarction territory. RESULTS: Patients with WFD (52%) had further reductions in endo-MLS, mid-MLS, and epi-MLS in the infarction region immediately post-PCI; at 3 hours strain began to improve and continued to improve at 24 hours. Reductions of endo-MLS strain were more evident than those of global, mid-MLS, and epi-MLS. This same pattern was seen in each of the ischemic territories of the anterior descending, circumflex, and right coronary arteries. Immediate improvement in endo-MLS following PCI was seen in 48% of patients. The time from symptom onset to balloon time was markedly longer in those with WFD (P < .0001). CONCLUSIONS: Multilayer SPE is a sensitive method that identifies serial alterations in focal myocardial function following successful PCI for STEMI. Layer-specific reductions in endo-MLS appeared more evident than decreases in global LV strain. Prolonged total ischemic time prior to PCI was directly related to the incidence of WFD.

Echocardiographic assessment of simultaneously measured left ventricular filling pressures in patients with normal left ventricular ejection fraction.

BACKGROUND: Assessment of left ventricular (LV) diastolic function is part of routine echocardiographic examinations. Accuracy of the 2016 ASE/EACVI algorithm to detect LV diastolic dysfunction in patients with a normal LV ejection fraction (LVEF) has been examined but simultaneous measurements of LV pressures and echocardiographic parameters of diastolic function are sparse. METHODS: The accuracy of multiple echo parameters of diastolic dynamics and the 2016 guidelines were assessed by simultaneous transthoracic echocardiography and LV pressure recordings in 120 patients (derivation cohort) and 60 patients (validation cohort) with suspected coronary artery disease and normal LVEF. Receiver-operating characteristic (ROC) curves defined optimal cut points for each echocardiographic parameter. A new algorithm was proposed to estimate LV diastolic pressures using 5 parameters based on ROC data: tricuspid regurgitation velocity >280cm/s, average e' <9 cm/s, average E/e' ratio >13, velocity of pulmonary vein A-wave reversal >32 cm/s, and left atrial volume index >32 mL/m2 . Performances of the 2016 guidelines and a proposed algorithm were examined for detecting a LV pre-A >12 and LV end-diastolic pressure (LVEDP) >15 mm Hg. RESULTS: In the derivation cohort, the 2016 algorithm identified an elevated LVEDP >15 mm Hg with an accuracy of 74.2% (63.8-82.9); the modified algorithm improved accuracy to 86.0% (77.6-92.1), P < .05. In the validation cohort, the proposed algorithm improved sensitivities with accuracies remaining like the 2016 algorithm. CONCLUSIONS: LV diastolic pressures in patients with normal LVEF were reliably assessed by the 2016 guidelines. The proposed algorithm improved sensitivities and may improve the accuracies for detecting abnormal LV filling pressures.

Echocardiographic strain in hypertrophic cardiomyopathy and hypertensive left ventricular hypertrophy.

BACKGROUND: The myocardial structure differs between secondary left ventricular hypertrophy (LVH) and hypertrophic cardiomyopathy (HCM). We investigated left ventricular function of these two types of hypertrophy using multilayer strain analysis with two-dimensional echocardiography. METHODS: Transthoracic echocardiography (Vivid-E9) was performed in 240 patients with preserved left ventricular ejection fraction (LVEF ≥50%) and with either HCM (n = 80, 63 men, age 49.8 ± 14.1 years), hypertensive LVH (n = 80, 63 men, age 51.4 ± 13.3 years) or normal blood pressure and left ventricular structure (n = 80, 63 men, 50.8 ± 12.4 years). Quantitative multilayer longitudinal strain (LS), circumferential strain (CS), and radial strain (RS) were analyzed. The ratio of endo-/epi-myocardial strain was calculated. RESULTS: Longitudinal strain was significantly (P < 0.001) lower in HCM patients than normal controls (15.2 ± 4.2% vs 23.1 ± 2.7%), especially in hypertrophic segments (14.5 ± 4.4% vs 17.2 ± 3.2% in nonhypertrophic segments, P < 0.01). LS was lower in patients with hypertensive LVH, similarly in all left ventricular segments (20.7 ± 3.7%, P < 0.001 vs controls). CS was lower in the mid- and epicardium (P < 0.01), but not endocardium in HCM (P = 0.4), and preserved in all myocardial layers in hypertensive LVH. The endo-/epi-myocardial ratios of both LS and CS were higher in HCM than hypertensive LVH (P < 0.01). RS was higher (P < 0.01) in HCM than hypertensive LVH and controls. Endocardial CS and global RS were correlated with LVEF (r ≥ 0.32, P < 0.01). CONCLUSIONS: Hypertrophic cardiomyopathy patients had marked reductions in LS and CS, whereas patients with hypertensive LVH had less reduction in LS and preserved CS. The increased endo-/epi-myocardial ratios of LS and CS may be useful in differentiating HCM from hypertensive LVH.

Subclinical left ventricular systolic dysfunction detected by two-dimensional speckle tracking echocardiography in patients with pheochromocytoma and paraganglioma and preserved ejection fraction.

BACKGROUND: Excessive catecholamine leads to pressure overload and left ventricular (LV) remodeling. The goal of this study was to explore subclinical LV systolic dysfunction and the mechanism of preserved left ventricular ejection fraction (LVEF) in patients with pheochromocytoma and paraganglioma using two-dimensional speckle tracking echocardiography. METHODS: A total of 48 patients with pheochromocytoma and paraganglioma and preserved LVEF and 38 age- and gender-matched volunteers were studied. Echocardiographic parameters including LVEF, and global peak longitudinal and circumferential strains were measured. The correlation between echocardiographic parameters and blood pressure as well as biochemical parameters was analyzed. RESULTS: LVEF was similar between patients with pheochromocytoma and paraganglioma and controls. The amplitude of LV longitudinal strain was decreased, and the amplitude of LV circumferential strain was increased in the pheochromocytoma and paraganglioma group (P = .003 and P = .009). LV mass index and blood pressure were positively correlated with 24-hour urinary norepinephrine (r = .696, P < .0001; r = .470, P = .0007). The amplitude of LV longitudinal strain reduced with increase in blood pressure, 24-hour urinary norepinephrine and LV mass index (r = -.305, P = .035; r = -.506, P = .0002; r = -.680, P < .0001). CONCLUSIONS: This study revealed that excessive norepinephrine in pheochromocytoma and paraganglioma was associated with increased blood pressure and LV mass. The LV longitudinal strain was decreasing with increase in blood pressure and LV mass index. The enhanced LV circumferential strain might be the mechanism of compensation to maintain the normal LVEF in these patients.

Quantitative analysis of mitral valve morphology in mitral valve prolapse with real-time 3-dimensional echocardiography: importance of annular saddle shape in the pathogenesis of mitral regurgitation.

BACKGROUND: Few data exist on the relation of the 3-dimensional morphology of mitral valve and degree of mitral regurgitation (MR) in mitral valve prolapse. METHODS AND RESULTS: Real-time 3-dimensional transesophageal echocardiography of the mitral valve was acquired in 112 subjects, including 36 patients with mitral valve prolapse and significant MR (≥3+; MR+ group), 32 patients with mitral valve prolapse but no or mild MR (≤2+; MR- group), 12 patients with significant MR resulting from nonprolapse pathologies (nonprolapse group), and 32 control subjects. The 3-dimensional geometry of mitral valve apparatus was measured with dedicated quantification software. Compared with the normal and MR- groups, the MR+ group had more dilated mitral annulus (P<0.0001), a reduced annular height to commissural width ratio (AHCWR) (P<0.0001) indicating flattening of annular saddle shape, redundant leaflet surfaces (P<0.0001), greater leaflet billow volume (P<0.0001) and billow height (P<0.0001), longer lengths from papillary muscles to coaptation (P<0.0001), and more frequent chordal rupture (P<0.0001). Prevalence of chordal rupture increased progressively with annulus flattening (7% versus 24% versus 42% for AHCWR >20%, 15%-20%, and <15%, respectively; P=0.004). Leaflet billow volume increased exponentially with decreasing AHCWR in patients without chordal rupture (r(2)=0.66, P<0.0001). MR severity correlated strongly with leaflet billow volume (r(2)=0.74, P<0.0001) and inversely with AHCWR (r(2)=0.44, P<0.0001). In contrast, annulus dilatation but not flattening occurred in nonprolapse MR patients. An AHCWR <15% (odds ratio=7.1; P=0.0004) was strongly associated with significant MR in mitral valve prolapse. CONCLUSION: Flattening of the annular saddle shape is associated with progressive leaflet billowing and increased frequencies of chordal rupture and may be important in the pathogenesis of MR in mitral valve prolapse.

Quantification of mitral valve morphology with three-dimensional echocardiography--can measurement lead to better management?

The mitral valve (MV) has complex 3-dimensional (3D) morphology and motion. Advance in real-time 3D echocardiography (RT3DE) has revolutionized clinical imaging of the MV by providing clinicians with realistic visualization of the valve. Thus far, RT3DE of the MV structure and dynamics has adopted an approach that depends largely on subjective and qualitative interpretation of the 3D images of the valve, rather than objective and reproducible measurement. RT3DE combined with image-processing computer techniques provides precise segmentation and reliable quantification of the complex 3D morphology and rapid motion of the MV. This new approach to imaging may provide additional quantitative descriptions that are useful in diagnostic and therapeutic decision-making. Quantitative analysis of the MV using RT3DE has increased our understanding of the pathologic mechanism of degenerative, ischemic, functional, and rheumatic MV disease. Most recently, 3D morphologic quantification has entered into clinical use to provide more accurate diagnosis of MV disease and for planning surgery and transcatheter interventions. Current limitations of this quantitative approach to MV imaging include labor-intensiveness during image segmentation and lack of a clear definition of the clinical significance of many of the morphologic parameters. This review summarizes the current development and applications of quantitative analysis of the MV morphology using RT3DE.

Do baseline diastolic echocardiographic parameters predict outcome after resynchronization therapy? Results from the PROSPECT trial.

INTRODUCTION: Cardiac resynchronization therapy (CRT) can improve clinical and cardiac structural status in heart failure patients. The role of baseline diastolic echocardiographic parameters to characterize the likelihood of positive outcomes is not well known. We explored relationships between diastolic parameters and outcomes 6 months after CRT implant in the Predictors of Response to CRT (PROSPECT) Trial. HYPOTHESIS: We hypothesized that diastolic echocardiographic parameters were associated with clinical and structural outcomes in CRT patients. METHODS: For 426 patients in PROSPECT, a prospective observational trial of CRT, baseline E/A ratio, left atrial (LA) area, isovolumic relaxation time, left ventricular inflow deceleration time, E' velocity, and E/E' ratio were evaluated and related to 6-month clinical composite score (CCS) and left ventricular end-systolic volume (LVESV) reduction using Spearman rank-order correlations. Parameters associated with outcomes were analyzed further by discrete categorization. RESULTS: As continuous variables, only E/A ratio and LA area correlated with CCSs (P = 0.017, P = 0.045, respectively) and relative change in LVESV at 6 months (P < 0.0001, P = 0.001, respectively). As discrete variables, E/A ratio and LA area also correlated with CCSs and LVESV. CONCLUSION: Diastolic echo parameters E/A ratio and LA area were associated with clinical and structural outcomes in CRT patients at 6 months.

Dyssynchronous ventricular contraction in Wolff-Parkinson-White syndrome: a risk factor for the development of dilated cardiomyopathy.

UNLABELLED: Emerging evidence suggests that significant left ventricular dysfunction may arise in right-sided septal or paraseptal accessory pathways (APs) with Wolff-Parkinson-White syndrome, even in the absence of recurrent or incessant tachycardia. During 1 year and 9 months, we identified four consecutive female children with median age of 8 years diagnosed as having dilated cardiomyopathy (DCM) combined with overt right-sided APs several years ago. Incessant or recurrent tachycardia as the cause of DCM could be excluded. Anti-heart failure chemotherapy did not produce satisfactory effects. The patients underwent radiofrequency ablations (RFCAs). This report describes the clinical and echocardiographic characteristics of the cases before and after the ablation. Dyssynchronous ventricular contraction was observed in all patients. The locations of the APs were the right-sided anteroseptum and the free wall (n = 2 each). All patients received successful RFCAs. Their physical activities and growth improved greatly, and the echocardiographic data demonstrated that their left ventricular (LV) contraction recovered to synchrony shortly after the ablation and that their LV function recovered to normal gradually during the follow-up. CONCLUSIONS: A causal relationship between overt ventricular preexcitation and the development of DCM is supported by the complete recovery of LV function and reversed LV remodeling after the loss of ventricular preexcitation. Preexcitation-related dyssynchrony was probably the crucial mechanism. Not only right-sided septal or paraseptal but also free wall overt APs may induce LV dysfunction and even DCM. AP-induced DCM is an indication for ablation with a good prognosis.

Tumor-derived endomucin promotes colorectal cancer proliferation and metastasis.

BACKGROUND: Endomucin (EMCN) is a type I transmembrane glycoprotein and a mucin-like component of the endothelial cell glycocalyx. The mechanism of EMCN action in colorectal cancer (CRC) remains unclear. AIMS: Our aim was to explore the role of EMCN in the progression of CRC. MATERIALS & METHODS: We examined EMCN expression in CRC tissues and normal para-carcinoma tissues. The function and mechanisms of EMCN were checked in CRC cell lines and in mouse xenograft. Additionally, we used co-immunoprecipitation and mass spectrometry to identify the potential EMCN-binding proteins. Functional annotation analysis showed where these genes were enriched. RESULTS: We found that EMCN was overexpressed in tumor tissues compared with that in normal para-carcinoma tissues. We also found that overexpression of EMCN induced CRC proliferation and metastasis both in vitro and in vivo. EMCN knockdown prevents epithelial-mesenchymal transition in vitro. We identified 178 potential EMCN-binding partners. Furthermore, functional annotation analysis indicated that these genes were considerably enriched in carcinogenic-related functions and pathways. Collectively, the identification of EMCN-binding partners enhanced our understanding of the mechanism of EMCN-mediated malignant phenotypes, and this research may provide valuable insights into the molecular mechanisms underlying CRC. CONCLUSION: Tumor-derived endomucin promotes colorectal cancer proliferation and metastasis. We identified 178 EMCN-binding proteins and initially screened three potential EMCN-interacting proteins: NALCN, and TPM2, ANKK1. Our study provides valuable insights into the molecular mechanisms underlying CRC development.

Cardiac function evaluated by two-dimensional speckle tracking imaging in fetuses with congenital heart disease of ventricular afterload increase.

AIMS: To study myocardial deformation in fetuses with ventricular afterload increase compared with gestational age-matched controls using speckle tracking echocardiography. METHODS AND RESULTS: Eighty-nine fetuses were retrospectively selected from the pregnancy screen by echocardiography. There are 41 fetuses with gestational age-matched normal heart served as the control group, 25 fetuses with congenital heart disease (CHD) leading to left ventricular (LV) afterload increase as group LVA and 23 fetuses with CHD leading to right ventricular(RV) afterload increases as group RVA. LV and RV fractional shortening (FS) were measured by conventional methods. The longitudinal strain (LS) and strain rate (LSr) were analyzed by EchoPac software. Group LVA and RVA compared with control group, the LV FS was no significant difference, but LS and LSr values of LV were lower in fetuses with LVA compared to the control group (LS:-15.97(-12.50,-22.52)vs -27.53(-24.33,-29.16) %, p < .01; systolic strain rate (SRs):-1.34(-1.12,-2.16) vs -2.55(-2.28,-2.92) 1/sec, p < .01; early diastolic strain rate (SRe):1.70 ± 0.57 vs 2.46 ± 0.61 1/sec, p < 0.01; late diastolic strain rate (SRa):1.62 ± 0.82 vs 2.39 ± 0.81 1/sec, p < .01). LS and LSr values of LV or RV were lower in fetuses with RVA compared to the control group (LV: LS:-21.52 ± 6.68 vs -26.79 ± 3.22%, p < .01; SRs:-2.11 ± 0.78 vs -2.56 ± 0.43 1/sec; p = .02; RV: LS:-17.64 ± 7.58 vs -26.38 ± 3.97%, p < .01; SRs:-1.62 ± 0.67 vs -2.37 ± 0.44 1/sec; p < .01). CONCLUSION: The results of this study showed that the ventricular LS, LSr, SRs, SRe, SRa values were lower in fetuses with LV or RV afterload increasing CHD estimated by speckle tracking imaging but LV and RV FS were normal,which indicated the strain imaging is feasible in evaluating cardiac function of fetus, and may be more sensitive.

Increase in ventricular-arterial stiffness in patients with psoriatic arthritis.

OBJECTIVES: Ventricular and arterial stiffness is an accepted cause of myocardial diastolic dysfunction. The aim of this study is to determine whether there is increased ventricular and arterial stiffness in patients with PsA and any relationship with disease-related risk factors. METHODS: Seventy-three patients with PsA were divided into two subgroups based on the absence or presence of hypertension and/or left ventricular (LV) hypertrophy. Fifty healthy controls were enrolled for comparison. All participants underwent non-invasive assessments including conventional echocardiography with tissue Doppler imaging and pulse wave analysis. Ventricular stiffness was measured by ventricular end-systolic and diastolic elastance, whereas arterial stiffness was measured by total arterial compliance and aortic augmentation index. RESULTS: There was significantly increased ventricular and arterial stiffness in patients with PsA (P < 0.001), even in those without hypertension and/or LV hypertrophy. Based on the cut-off points derived from the controls, 38.4% of PsA patients had increased LV stiffness including 31.5% in diastole and 17.8% in systole, and 15.1% had increased arterial stiffness. Multivariable logistic regression analysis showed that long PsA disease duration (>10 years) (odds ratio = 6.55, P = 0.001) was an independent risk factor for increased LV diastolic elastance after adjusting for age, gender and hypertension. CONCLUSION: Patients with PsA may have increased ventricular and arterial stiffness even without evidence of LV remodelling, and those with long disease duration may be at a higher risk. Therefore, prolonged inflammatory burden may be an important cause of early cardiovascular disease in patients with PsA.

Results of the Predictors of Response to CRT (PROSPECT) trial.

BACKGROUND: Data from single-center studies suggest that echocardiographic parameters of mechanical dyssynchrony may improve patient selection for cardiac resynchronization therapy (CRT). In a prospective, multicenter setting, the Predictors of Response to CRT (PROSPECT) study tested the performance of these parameters to predict CRT response. METHODS AND RESULTS: Fifty-three centers in Europe, Hong Kong, and the United States enrolled 498 patients with standard CRT indications (New York Heart Association class III or IV heart failure, left ventricular ejection fraction < or = 35%, QRS > or = 130 ms, stable medical regimen). Twelve echocardiographic parameters of dyssynchrony, based on both conventional and tissue Doppler-based methods, were evaluated after site training in acquisition methods and blinded core laboratory analysis. Indicators of positive CRT response were improved clinical composite score and > or = 15% reduction in left ventricular end-systolic volume at 6 months. Clinical composite score was improved in 69% of 426 patients, whereas left ventricular end-systolic volume decreased > or = 15% in 56% of 286 patients with paired data. The ability of the 12 echocardiographic parameters to predict clinical composite score response varied widely, with sensitivity ranging from 6% to 74% and specificity ranging from 35% to 91%; for predicting left ventricular end-systolic volume response, sensitivity ranged from 9% to 77% and specificity from 31% to 93%. For all the parameters, the area under the receiver-operating characteristics curve for positive clinical or volume response to CRT was < or = 0.62. There was large variability in the analysis of the dyssynchrony parameters. CONCLUSIONS: Given the modest sensitivity and specificity in this multicenter setting despite training and central analysis, no single echocardiographic measure of dyssynchrony may be recommended to improve patient selection for CRT beyond current guidelines. Efforts aimed at reducing variability arising from technical and interpretative factors may improve the predictive power of these echocardiographic parameters in a broad clinical setting.

Shorter AV delays provide improved echocardiographic hemodynamics during exercise in patients receiving cardiac resynchronization therapy.

BACKGROUND: Although atrial ventricular (AV) intervals are often optimized at rest in patients receiving cardiac resynchronization therapy (CRT), there are limited data on the impact of exercise on optimal AV interval. METHODS: In 15 patients with CRT, AV intervals were serially programmed while patients were supine and at rest, and during exercise with heart rates that averaged 20 and 40 beats per minute above their resting rates. Echocardiographic Doppler images were acquired at each programmed AV interval and each rate. Three independent echocardiographic criteria were retrospectively used to determine each patient's optimal AV interval as a function of exercise-induced increased heart rates: the duration of left ventricular filling, stroke volume, and a clinical assessment of left ventricular function. RESULTS: A negative correlation between the optimal AV interval and heart rate was observed across all patients using all three independent criterion: the maximum left ventricular filling time (slope =-0.77, intercept = 151.9, r = 0.55, P < 0.001), maximum stroke volume (slope =-0.93, intercept = 183.3, r = 0.50, P = 0.002), or the subjective clinical assessment (slope =-1.06, intercept = 182.0, r = 0.72, P < 0.001). Consistent trends were observed between all three parameters for 12 out of the 15 patients. CONCLUSIONS: These results suggest that in patients indicated for CRT, rate-adaptive functions may be useful to shorten AV intervals with increased rate, in order to maximize left ventricular filling, stroke volume, and clinical left ventricular function. Further studies are necessary to determine the clinical impact of these rate-adaptive algorithms.

Junior medical student performed focused cardiac ultrasound after brief training to detect significant valvular heart disease.

BACKGROUND: Focused cardiac ultrasound (FOCUS) examination using a portable device is increasingly used for bedside diagnosis of cardiovascular diseases. This is a 4-week pilot project aiming to teach medical students to perform FOCUS to detect valvular heart lesions. METHODS: Patients undergoing routine transthoracic echocardiography (TTE) were recruited by third year medical students who performed physical examination (PE) and FOCUS after 6-hour training to detect significant (moderate-to-severe) valvular lesions. Performance of FOCUS and PE was compared to TTE as reference using kappa statistics. RESULTS: 10 medical students performed 212 PE and FOCUS on 107 patients with mean age 63.7 ±â€¯14.9 years. TTE detected 126 significant valvular lesions of which FOCUS correctly identified 54 lesions (κ = 0.45) compared to 32 lesions by PE (κ = 0.28, p < 0.01). FOCUS was better than PE in identifying mitral stenosis (κ = 0.51 vs. 0.17), aortic stenosis (κ = 0.45 vs. 0.16) and tricuspid regurgitation (κ = 0.39 vs. 0.09, all p < 0.01). Students became more proficient in performing FOCUS examination with time. CONCLUSIONS: Teaching junior medical students to perform and interpret FOCUS was feasible after brief training and better than PE in detecting significant valvular lesions. Further studies are warranted to determine the utility of incorporating this new technology into mainstream medical training.

Prognostic value of acoustic cardiography in patients with chronic heart failure.

BACKGROUND: Rapid risk stratification in patients with heart failure is critically important but challenging. The aim of our study is to ascertain whether acoustic cardiography can identify heart failure (HF) patients at high risk for mortality. METHODS: A total of 474 HF patients were enrolled into our study (76±11years old). Acoustic cardiographic parameters included S3 score (ie, third heart sound exists) and systolic dysfunction index (SDI) (correlated closely with left ventricular systolic dysfunction). The event-free survival curves were plotted by Kaplan-Meier method. Cox regression analysis was used to identify independent predictors for all-cause mortality. RESULTS: During a mean follow-up of 484days, 169 (35.7%) patients died and 126 (26.6%) were due to cardiac causes. After controlling for age, systolic blood pressure, hemoglobin, blood urea nitrogen, albumin, as well as ACEI and beta-blocker treatment in multivariate Cox regression analysis, SDI ≥5 and S3 score ≥4 were both independent predictors for all-cause mortality. Kaplan-Meier analysis showed that HF patients with SDI ≥5 or S3 score ≥4 had a significantly lower survival (52.2% vs. 69.2%, Log-rank χ(2)=18.07, P<0.001; 56.8% vs. 68.6%, Log-rank χ(2)=10.58, P=0.001, respectively) than those with lower SDI or S3 score. CONCLUSIONS: Acoustic cardiography could serve as a cost-effective and time-efficient tool to identify HF patients at high risk for mortality who might benefit from aggressive monitoring and intervention. It may improve assessment and initial disposition decisions in HF management.