[Prognostic value of serial measurements of left ventricular function and exercise performance in chronic heart failure]. / Valor pronóstico de las medidas seriadas de la función ventricular izquierda y del rendimiento en el ejercicio en la insuficiencia cardiaca crónica.

INTRODUCTION AND OBJECTIVES: The prognostic value of a single measurement of ejection fraction and peak oxygen uptake in chronic heart failure has been extensively investigated. The aim of our study was to evaluate the prognostic significance of serial changes in ejection fraction and exercise performance in moderate to severe chronic heart failure. METHODS: 182 patients (156 men, 53 [47-58] years) underwent echocardiography and cardiopulmonary exercise testing at baseline and after 10 [8-12] months. Most patients had idiopathic dilated cardiomyopathy (69%) and all patients presented left ventricular ejection fraction <45%. Median follow-up was 21 [14-34] months; cardiac death and heart transplantation were the end-points. Hazard ratio (HR, per unit) is presented with its 95% confidence interval (CI). RESULTS: During follow-up 18 patients (9.9%) died and 14 (7.7%) underwent heart transplantation. Baseline ejection fraction (HR, 0.94, 95% CI, 0.89-0.98 P=.006) and mitral regurgitation (HR, 4.22, 95% CI, 1.63-10.92, P=.003), and delta (second examination-baseline) ejection fraction (HR, 0.93, 95% CI, 0.88-0.98, P=.01) were the only significant variables at univariate analysis. Both ejection fraction and delta ejection fraction remained independently associated with events at multivariate analysis. The prognostic power significantly increased between a model including ejection fraction alone and another one including ejection fraction plus delta ejection fraction. CONCLUSIONS: In clinically stable patients with chronic heart failure, ejection fraction and its changes were independently associated with outcome; on the contrary, serial cardiopulmonary exercise testing did not provide significant prognostic value. Baseline plus changes in ejection fraction showed better prognostic performance than baseline ejection fraction alone.

Valor pronóstico de las medidas seriadas de la función ventricular izquierda y del rendimiento en el ejercicio en la insuficiencia cardiaca crónica / Prognostic value of serial measurements of left ventricular function and exercise performance in chronic heart failure

No disponibleIntroducción y objetivos. Se ha investigado extensamente el valor pronóstico de una determinación aislada de la fracción de eyección y del consumo máximo de oxígeno en la insuficiencia cardiaca crónica. El objetivo del presente estudio fue valorar el significado pronóstico de los cambios seriados en la fracción de eyección y en el rendimiento del ejercicio en la insuficiencia cardiaca crónica moderada o severa. Métodos. En la situación basal y después de 10 (8-12) meses, se realizaron una ecocardiografía y pruebas de esfuerzo cardiopulmonar a 182 pacientes (156 varones, 53 [47-58] años de edad). La mayor parte de los pacientes presentaba una miocardiopatía dilatada idiopática (69%), y todos tenían una fracción de eyección inferior al 45%. La mediana del seguimiento fue de 21 (14-34) meses; los criterios principales de valoración fueron la muerte cardiaca y la necesidad de trasplante cardiaco. Se presenta el cociente de riesgo (CR, por unidad) con sus intervalos de confianza (IC) del 95%. Resultados. Durante el seguimiento fallecieron 18 pacientes (9,9%) y 14 (7,7%) recibieron un trasplante cardiaco. En el análisis univariado las únicas variables significativamente asociadas con la evolución fueron la fracción de eyección basal (CR = 0,94; IC del 95%, 0,89-0,98; p = 0,006), la regurgitación mitral (CR = 4,22; IC del 95%, 1,63-10,92; p = 0,003), y el cambio de la fracción de eyección (segundo examen basal) (CR = 0,93; IC del 95%; 0,88-0,98; p = 0,01). En el análisis multivariado la fracción de eyección y el cambio de la fracción de eyección siguieron asociándose independientemente con los acontecimientos adversos en el seguimiento. La potencia pronóstica aumentó significativamente entre el modelo que sólo incluyó la fracción de eyección y otro modelo que incluyó la fracción de eyección más el cambio de la fracción de eyección. Conclusiones. En pacientes con insuficiencia cardiaca crónica estables desde un punto de vista clínico, la fracción de eyección y sus cambios se asociaron independientemente con el pronóstico. Por el contrario, las pruebas de esfuerzo cardiopulmonar seriadas no tuvieron un valor pronóstico significativo. La fracción de eyección aislada más sus cambios demostraron un mayor rendimiento pronóstico que la fracción de eyección aislada determinada en el período basal (AU)

Introduction and objectives. The prognostic value of a single measurement of ejection fraction and peak oxygen uptake in chronic heart failure has been extensively investigated. The aim of our study was to evaluate the prognostic significance of serial changes in ejection fraction and exercise performance in moderate to severe chronic heart failure. Methods. 182 patients (156 men, 53 [47-58] years) underwent echocardiography and cardiopulmonary exercise testing at baseline and after 10 [8-12] months. Most patients had idiopathic dilated cardiomyopathy (69%) and all patients presented left ventricular ejection fraction <45%. Median follow-up was 21 [14-34] months; cardiac death and heart transplantation were the end-points. Hazard ratio (HR, per unit) is presented with its 95% confidence interval (CI). Results. During follow-up 18 patients (9.9%) died and 14 (7.7%) underwent heart transplantation. Baseline ejection fraction (HR, 0.94, 95% CI, 0.89-0.98 P=.006) and mitral regurgitation (HR, 4.22, 95% CI, 1.63-10.92, P=.003), and delta (second examination-baseline) ejection fraction (HR, 0.93, 95% CI, 0.88-0.98, P=.01) were the only significant variables at univariate analysis. Both ejection fraction and delta ejection fraction remained independently associated with events at multivariate analysis. The prognostic power significantly increased between a model including ejection fraction alone and another one including ejection fraction plus delta ejection fraction. Conclusions. In clinically stable patients with chronic heart failure, ejection fraction and its changes were independently associated with outcome; on the contrary, serial cardiopulmonary exercise testing did not provide significant prognostic value. Baseline plus changes in ejection fraction showed better prognostic performance than baseline ejection fraction alone (AU)

Prognostic value of contractile response during high-dose dipyridamole echocardiography test in heart transplant recipients.

BACKGROUND: Coronary allograft vasculopathy (CAV) remains a main factor limiting long-term survival after heart transplantation (HTX). The diagnosis of CAV is still based on serial coronary angiography. In this study, we evaluated the prognostic value of high-dose dipyridamole echocardiography in HTX. METHODS: Sixty-eight patients underwent dipyridamole echocardiography within 48 hours of their scheduled annual coronary angiography. Coronary allograft vasculopathy was defined as CAV 1 (focal or diffuse stenosis <50%) or CAV 2 (focal or diffuse stenosis >or=50%). Wall-motion score index (WMSI) was evaluated at rest and after dipyridamole administration. RESULTS: Results of coronary angiography were normal in 43 patients (63%), showed CAV 1 in 11 (16%), and showed CAV 2 in 14 (21%). Rest wall motion was normal in 39 patients and abnormal in 29. After dipyridamole administration, wall motion remained normal in all 39 (Group 1, no CAV in 34 and CAV 1 in 5). Of 29 patients with rest wall-motion abnormalities, all reversed to normal after dipyridamole in 8 patients (Group 2, no CAV in 7 and CAV 1 in 1) and remained or worsened in 21 (Group 3, CAV 2 in 14 and no CAV or CAV 1 in 7). During follow-up (6 +/- 3 years), 15 patients had major cardiac events: 11 occurred in Group 3, whereas 4 occurred in Groups 1 and 2. Wall motion at rest and after dipyridamole administration and CAV were independent predictors for cardiac events; only dipyridamole WMSI >1 remained significant (p < 0.0001) at multivariate analysis. CONCLUSIONS: Dipyridamole echocardiography is a simple, non-invasive test that after HTX may identify patients with altered wall motion who deserve stricter surveillance.

Resting echocardiographic assessment of regional wall motion, thickness and reflectivity in chronic ischemic cardiomyopathy: an alternative to the viability test?

BACKGROUND: A resting echo showing a regional end-diastolic wall thickness < or = 6 mm with a hyperechoic texture is pathognomonic of scar tissue and of non-viable myocardium. The aim of this study was to assess the prognostic value of the resting echo scar texture in patients with chronic ischemic cardiomyopathy evaluated prior to coronary artery bypass surgery. METHODS: The preoperative clinical and echocardiographic data of 70 patients with a mean ejection fraction of 29.8 +/- 4% scheduled for coronary revascularization were correlated to the cardiac events observed during a mean follow-up of 24 +/- 12 months after surgery. Akinetic segments of the left ventricular wall with a reduced diastolic thickness and increased echoreflectivity were judged scarred. RESULTS: Sixty-eight patients were discharged alive from hospital. On the basis of ROC analysis, we identified: group A (27 patients) with > 5 and group B (41 patients) with < or = 5 scarred segments. There were 10 events (3 deaths, 4 heart transplants and 3 refractory heart failures), 8 in group A (29%) and 2 in group B (5%). At multivariate analysis the only independent predictor of the clinical outcome after revascularization was whether the patient was included in group A or B (Wald 6.3, p < 0.012). One year after surgery, the ejection fraction improved only in group B patients (p < 0.03). CONCLUSIONS: The extent of scarred myocardial tissue as assessed at resting echocardiography predicted the benefit of revascularization in patients with chronic ischemic left ventricular dysfunction. This simple and straightforward echo parameter should be taken into consideration when assessing the instrumental value of more technologically demanding and costly viability testing.