Left atrioventricular coupling index assessed using cardiac CT as a prognostic marker of cardiovascular death.

PURPOSE: The purpose of this study was to investigate the prognostic value of left atrioventricular coupling index (LACI) assessed by cardiac computed tomography (CT), to predict cardiovascular death in consecutive patients referred for cardiac CT with coronary analysis. MATERIALS AND METHODS: Between 2010 and 2020, we conducted a single-centre study with all consecutive patients without known cardiovascular disease referred for cardiac CT. LACI was defined as the ratio of left atrial to left ventricle end-diastolic volumes. The primary outcome was cardiovascular death. Cox regressions were used to evaluate the association between LACI and primary outcome after adjustment for traditional risk factors and cardiac CT angiography findings. RESULTS: In 1,444 patients (mean age, 70 ± 12 [standard deviation] years; 43% men), 67 (4.3%) patients experienced cardiovascular death after a median follow-up of 6.8 (Q1, Q3: 5.9, 9.1) years. After adjustment, LACI was positively associated with the occurrence of cardiovascular death (adjusted hazard ratio [HR], 1.07 [95% CI: 1.05-1.09] per 1% increment; P < 0.001), and all-cause death (adjusted HR, 1.05 [95% CI: 1.03-1.07] per 1% increment; P <0.001). After adjustment, a LACI ≥ 25% showed the best improvement in model discrimination and reclassification for predicting cardiovascular death above traditional risk factors and cardiac CT findings (C-statistic improvement: 0.27; Nnet reclassification improvement = 0.826; Integrative discrimination index =0.209, all P < 0.001; likelihood-ratio-test, P < 0.001). CONCLUSION: LACI measured by cardiac CT is independently associated with cardiovascular death and all-cause death in patients without known cardiovascular disease referred for cardiac CT, with an incremental prognostic value over traditional risk factors and cardiac CT findings.

Sequencing and titrating approach of therapy in heart failure with reduced ejection fraction following the 2021 European Society of Cardiology guidelines: an international cardiology survey.

AIMS: In symptomatic patients with heart failure and reduced ejection fraction (HFrEF), recent international guidelines recommend initiating four major therapeutic classes rather than sequential initiation. It remains unclear how this change in guidelines is perceived by practicing cardiologists versus heart failure (HF) specialists. METHODS AND RESULTS: An independent academic web-based survey was designed by a group of HF specialists and posted by email and through various social networks to a broad community of cardiologists worldwide 1 year after the publication of the latest European HF guidelines. Overall, 615 cardiologists (38 [32-47] years old, 63% male) completed the survey, of which 58% were working in a university hospital and 26% were HF specialists. The threshold to define HFrEF was ≤40% for 61% of the physicians. Preferred drug prescription for the sequential approach was angiotensin-converting enzyme inhibitors or angiotensin receptor-neprilysin inhibitors first (74%), beta-blockers second (55%), mineralocorticoid receptor antagonists third (52%), and sodium-glucose cotransporter 2 inhibitors (53%) fourth. Eighty-four percent of participants felt that starting all four classes was feasible within the initial hospitalization, and 58% felt that titration is less important than introducing a new class. Age, status in training, and specialization in HF field were the principal characteristics that significantly impacted the answers. CONCLUSION: In a broad international cardiology community, the 'historical approach' to HFrEF therapies remains the preferred sequencing approach. However, accelerated introduction and uptitration are also major treatment goals. Strategy trials in treatment guidance are needed to further change practices.

Coronary Computed Tomography Angiography Analysis of Calcium Content to Identify Non-culprit Vulnerable Plaques in Patients With Acute Coronary Syndrome.

Background: Aside from the culprit plaque, the presence of vulnerable plaques in patients with acute coronary syndrome (ACS) may be associated with future cardiac events. A link between calcification and plaque rupture has been previously described. Aim: To assess whether analysis of the calcium component of coronary plaques using CT angiography, coronary computed tomographic angiography (CCTA) can help to detect additional vulnerable plaques in patients with non-ST elevation myocardial infarction (NSTEMI). Materials And Methods: Cross sectional study of consecutive patients referred for NSTEMI from 30 July to 30 August 2018 with CCTA performed before coronary angiography with systematic optical coherence tomography (OCT) analysis of all coronary arteries within 24 h of clinical onset of NSTEMI. Three types of plaques were defined: culprit plaques defined by angiography (vulnerable culprit plaques-VCP) - plaques with a fibrous cap thickness < 65 microns or thrombus in OCT (vulnerable non-culprit plaque-VNCP) - plaques with a fibrous cap thickness ≥ 65 microns in OCT (stable plaque-SP). Results: A total of 134 calcified plaques were identified in 29 patients (73% male, 59 ± 14 years) with 29(22%) VCP, 28(21%) VNCP and 77(57%) SP. Using CCTA analysis of the calcium component, factors associated with vulnerable plaques were longer calcification length, larger calcification volume, lower calcium mass, higher Agatston score plaque-specific (ASp), presence of spotty calcifications and an intimal position in the wall. In multivariate analysis, ASp, calcification length and spotty calcifications were independently associated to vulnerable plaques. There was no difference between VCP and VNCP. Conclusions: CCTA analysis of calcium component of the plaque could help to identify additional vulnerable plaques in NSTEMI patients.

Prescription, Compliance, and Burden Associated with Salt-Restricted Diets in Heart Failure Patients: Results from the French National OFICSel Observatory.

(1) Background: There is much debate about the use of salt-restricted diet for managing heart failure (HF). Dietary guidelines are inconsistent and lack evidence. (2) Method: The OFICSel observatory collected data about adults hospitalised for HF. The data, collected using study-specific surveys, were used to describe HF management, including diets, from the cardiologists' and patients' perspectives. Cardiologists provided the patients' clinical, biological, echocardiography, and treatment data, while the patients provided dietary, medical history, sociodemographic, morphometric, quality of life, and burden data (burden scale in restricted diets (BIRD) questionnaire). The differences between the diet recommended by the cardiologist, understood by the patient, and the estimated salt intake (by the patient) and diet burden were assessed. (3) Results: Between March and June 2017, 300 cardiologists enrolled 2822 patients. Most patients (90%) were recommended diets with <6 g of salt/day. Mean daily salt consumption was 4.7 g (standard deviation (SD): 2.4). Only 33% of patients complied with their recommended diet, 34% over-complied, and 19% under-complied (14% unknown). Dietary restrictions in HF patients were associated with increased burden (mean BIRD score of 8.1/48 [SD: 8.8]). (4) Conclusion: Healthcare professionals do not always follow dietary recommendations, and their patients do not always understand and comply with diets recommended. Restrictive diets in HF patients are associated with increased burden. An evidence-based approach to developing and recommending HF-specific diets is required.

Early and short-term intensive management after discharge for patients hospitalized with acute heart failure: a randomized study (ECAD-HF).

AIMS: Hospitalization for acute heart failure (HF) is followed by a vulnerable time with increased risk of readmission or death, thus requiring particular attention after discharge. In this study, we examined the impact of intensive, early follow-up among patients at high readmission risk at discharge after treatment for acute HF. METHODS AND RESULTS: Hospitalized acute HF patients were included with at least one of the following: previous acute HF < 6 months, systolic blood pressure ≤ 110 mmHg, creatininaemia ≥ 180 µmol/L, or B-type natriuretic peptide ≥ 350 pg/mL or N-terminal pro B-type natriuretic peptide ≥ 2200 pg/mL. Patients were randomized to either optimized care and education with serial consultations with HF specialist and dietician during the first 2-3 weeks, or to standard post-discharge care according to guidelines. The primary endpoint was all-cause death or first unplanned hospitalization during 6-month follow-up. Among 482 randomized patients (median age 77 and median left ventricular ejection fraction 35%), 224 were hospitalized or died. In the intensive group, loop diuretics (46%), beta-blockers (49%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (39%) and mineralocorticoid receptor antagonists (47%) were titrated. No difference was observed between groups for the primary endpoint (hazard ratio 0.97; 95% confidence interval 0.74-1.26), nor for mortality at 6 or 12 months or unplanned HF rehospitalization. Additionally, no difference between groups according to age, previous HF and left ventricular ejection fraction was found. CONCLUSIONS: In high-risk HF, intensive follow-up early post-discharge did not improve outcomes. This vulnerable post-discharge time requires further studies to clarify useful transitional care services.

First symptoms and health care pathways in hospitalized patients with acute heart failure: ICPS2 survey. A report from the Heart Failure Working Group (GICC) of the French Society of Cardiology.

BACKGROUND: Acute heart failure (AHF) is a common serious condition that contributes to about 5% of all emergency hospital admissions in Europe. HYPOTHESIS: To assess the type and chronology of the first AHF symptoms before hospitalization and to examine the French healthcare system pathways before, during and after hospitalization. MATERIAL AND METHODS: A retrospective observational study including patients hospitalized for AHF RESULTS: 793 patients were included, 59.0% were men, 45.6% identified heart failure (HF) as the main cause of hospitalization; 36.0% were unaware of their HF. Mean age was 72.9 ± 14.5 years. The symptoms occurring the most before hospitalization were dyspnea (64.7%) and lower limb edema (27.7%). Prior to hospitalization, 47% had already experienced symptoms for 15 days; 32% of them for 2 months. Referral to hospital was made by the emergency medical assistance service (SAMU, 41.6%), a general practitioner (GP, 22.3%), a cardiologist (19.5%), or the patient (16.6%). The modality of referral depended more on symptom acuteness than on type of symptoms. A sudden onset of AHF symptoms led to making an emergency call or to spontaneously attending an emergency room (ER), whereas cardiologists were consulted when symptoms had already been present for over 15 days. Cardiologists referred more patients to cardiology departments and fewer patients to the ER than general practitioners or the SAMU. CONCLUSION: This study described the French healthcare system pathways before, during and after hospitalization AHF. AHF clinic network should be developed to provide adequate care for all HF patients and create awareness regarding AHF symptoms.

Epidemiological characteristics and therapeutic management of patients with chronic heart failure who use smartphones: Potential impact of a dedicated smartphone application (report from the OFICSel study).

BACKGROUND: The effectiveness of transitional care services for patients discharged from hospital after acute heart failure is challenging, especially in terms of reducing subsequent heart failure hospitalizations. The increased adoption of smartphone applications in society offers a new opportunity to interact with patients to avoid rehospitalization. Thus, electronic health (e-health) can enhance the impact of existing therapeutic education programmes. AIMS: To determine the prevalence of smartphone use among patients with chronic heart failure, and to assess the epidemiological characteristics and therapeutic management of these patients, with a broader aim of developing smartphone-based therapeutic education programmes for patients. METHODS: The French Observatoire français de l'insuffisance cardiaque et du sel (OFICSel) registry was conducted in 2017 by 300 cardiologists, and included both inpatients and outpatients who had been hospitalized for heart failure at least once in the previous 5 years. Data collection included demographic and heart failure-related variables, which were provided by the cardiologist and by the patient via a questionnaire. RESULTS: Among the 2822 patients included, 2517 completed the questionnaire. Of this total, 907 patients (36%) were smartphone users. Compared with non-users, smartphone users were younger, were more frequently men, more frequently lived in cities, had a higher educational level and were more frequently professionally active. Smartphone users less frequently had diabetes, hypertension, atrial fibrillation or ischaemic cardiopathy. Only 22% of patients were actively participating in a therapeutic education programme. CONCLUSION: Smartphones were used by more than one-third of patients with heart failure in France in 2017, underscoring the feasibility of developing a smartphone application to deliver therapeutic education to the population with chronic heart failure.

Characterization of non-response to cardiac resynchronization therapy by post-procedural computed tomography.

INTRODUCTION: Causes of non-response to cardiac resynchronization therapy (CRT) include mechanical dyssynchrony, myocardial scar, and suboptimal left ventricular (LV) lead location. We aimed to assess the utility of Late Iodine Enhancement Computed Tomography (LIE-CT) with image subtraction in characterizing CRT non-response. METHODS: CRT response was defined as a decrease in LV end-systolic volume > 15% at 6 months. LIE-CT was performed after 6 months, and analyzed global and segmental dyssynchrony, myocardial scar, coronary venous anatomy, and position of LV lead relative to scar and segment of latest mechanical contraction. RESULTS: We evaluated 29 patients (age 71 ± 12 years; 72% men) including 18 (62%) responders. All metrics evaluating residual dyssynchrony such as wall motion index and wall thickness index were worse in non-responders. There was no difference in presence and extent of scar between responders and non-responders. However, in non-responders, the LV lead was more often over an akinetic/dyskinetic area (72% vs. 22%, p = .007), a fibrotic area (64% vs. 8%, p = .0007), an area with myocardial thickness < 6 mm (82% vs. 22%, p = .002), and less often concordant with the region of maximal wall thickness (9% vs. 72%, p = .001). Among the 11 non-responders, eight had at least another coronary venous branch visualized by CT, including three (27%) coursing over a potentially interesting myocardial area (free of scar, with normal wall motion, and with a myocardial thickness ≥6 mm). CONCLUSION: LIE-CT with image subtraction allows a comprehensive characterization of patients after CRT and may provide clues for management of non-responders.

Physical activity for patients with heart failure: Position paper from the heart failure (GICC) and cardiac rehabilitation (GERS-P) Working Groups of the French Society of Cardiology.

Physical activity is important in heart failure to improve functional capacity, quality of life and prognosis, and is a class IA recommendation in the European Society of Cardiology guidelines (Ponikowski et al., 2016). The benefits of exercise training are widely recognized. Cardiac rehabilitation centres offer tailored exercise training to patients with heart failure, as part of specialized multidisciplinary care, alongside pharmacological treatment optimization and patient education. After cardiac rehabilitation, maintenance of regular physical activity long term is essential, as the benefits of exercise training vanish within a few weeks. Unfortunately, only 10% of patients benefit from a cardiac rehabilitation programme after hospitalization for acute heart failure, and the majority of patients do not pursue long-term physical activity. In this paper, two Working Groups of the French Society of Cardiology (the heart failure group [Groupe Insuffisance Cardiaque et Cardiomyopathies; GICC] and the cardiac rehabilitation group [Groupe Exercice Réadaptation Sport et Prévention; GERS-P]) discuss the obstacles to broader access to cardiac rehabilitation centres, and propose ways to improve the diffusion of cardiac rehabilitation programmes and encourage long-term adherence to physical activity.

Extracorporeal membrane oxygenation support in acute circulatory failure: A plea for regulation and better organization.

Emergent implantation of temporary mechanical circulatory support using venoarterial ECMO (ECLS for extracorporeal Life Support) is increasingly adopted in various indications of acute circulatory failure refractory to optimal medical treatment. To implant such devices, but also to provide appropriate daily management, expertise and adapted technical platform are required. Organization, coordination and regulation of such program are not clearly established in our country. We propose a dedicated territorial organization to improve and facilitate management of these specific and most severe patients.

Effects of sacubitril/valsartan on neprilysin targets and the metabolism of natriuretic peptides in chronic heart failure: a mechanistic clinical study.

AIM: This study aimed at evaluating the effects of sacubitril/valsartan on neprilysin (NEP), and the metabolism of natriuretic peptides in heart failure (HF) and providing additional mechanistic information on the mode of action of the drug. METHODS AND RESULTS: We enrolled 73 chronic HF patients who were switched from angiotensin-converting enzyme inhibitor or angiotensin receptor blocker to sacubitril/valsartan. In addition to clinical and echocardiographic assessment, plasma biomarkers were measured at baseline, day 30 and day 90 after initiation of treatment. Sacubitril/valsartan led to decrease in New York Heart Association class and improvement of echocardiographic parameters, as well as a dose-dependent decrease in soluble NEP (sNEP) activity, while sNEP concentration remained unchanged. Neprilysin inhibition translated into an increase in its substrates such as atrial natriuretic peptide (ANP), substance P, and glucagon-like peptide 1, the latter translating into a decrease in fructosamine. Cardiac troponin and soluble ST2 levels, biomarkers of HF severity unrelated to NEP metabolism also decreased. While there was a ∼4-fold increase in ANP, we observed no change in plasma brain natriuretic peptide (BNP) and plasma BNP activity, and a mild decrease in N-terminal proBNP (NT-proBNP) concentrations. Finally, we found a progressive increase in the relationship between BNP and NT-proBNP, which strongly correlated with an increase in T71 proBNP glycosylation (R2 = 0.94). CONCLUSION: Sacubitril/valsartan rapidly and strongly reduced sNEP activity, leading to an increase in levels of NEP substrates. These data suggest a pleiotropic favourable impact of sacubitril/valsartan on the metabolism of HF patients with ANP rather than BNP as major effectors amongst natriuretic peptides.

Effects of a cardiac rehabilitation programme on plasma cardiac biomarkers in patients with chronic heart failure.

Background Cardiac rehabilitation (CR) improves the symptoms, exercise capacity and quality of life of chronic heart failure (CHF) patients. Its effects on new plasma biomarkers of prognostic importance are unknown. The present study aimed at analysing the effects of a structured CR programme on plasma cardiac biomarkers in a large population of patients with CHF and reduced left ventricular ejection fraction (LVEF). Methods We enrolled 107 consecutive CHF patients with LVEF ≤ 45% in an ambulatory CR programme. Peak VO2 and plasma levels of Galectin-3, mid-regional proANP (MR-proADM), soluble suppressor of tumorigenicity 2 (sST2) and mid-regional pro-adrenomedullin (MR-proANP) were assessed at inclusion and at the end of CR. Twenty-four unenrolled patients were managed with standard medical care and evaluated over the same period (no-CR group). Results Galectin-3, sST2, MR-proADM and MR-proANP plasma levels decreased after CR, with respective median reductions of 6.3% for Galectin 3 ( p < 0.001), 7.4% for sST2 ( p = 0.036), 6.4% for MR-proADM ( p = 0.001) and 16% for MR-proANP ( p < 0.001). MR-proADM was negatively correlated with peak VO2 (ρ = -0.529, 95% confidence interval [CI] -0.654 to -0.375, p < 0.001), and so were their relative variations along the course of CR (ρ = -0.357, 95% CI -0.518 to -0.172, p < 0.001). No change occurred in terms of biomarkers in the no-CR group. Conclusions Plasma cardiac biomarkers such as Galectin-3, MR-proADM, sST2 and MR-proANP all decreased after CR in CHF patients, suggesting an overall improvement in the neuro-hormonal profile.

Baseline subendocardial viability ratio influences left ventricular systolic improvement with cardiac rehabilitation.

OBJECTIVE: Subendocardial viability ratio (SEVR), defined as diastolic to systolic pressure-time integral ratio, is a useful tool reflecting the balance between coronary perfusion and arterial load. Suboptimal SEVR creating a supply-demand imbalance may limit favorable cardiac response to cardiac rehabilitation (CR). To explore this hypothesis, we designed a study to analyze the relationship between baseline SEVR and response to CR in patients with coronary artery disease (CAD). METHODS: In this prospectively study, after baseline arterial tonometry, echocardiography, and cardiopulmonary exercise tests (CPETs), patients undergone 20 sessions of CR. Post-CR echocardiographic and CPET measurements were obtained for comparison. RESULTS: Final study population was comprised of fifty subjects. Study population was divided into two subgroups by median SEVR value (1.45, interquartile range 0.38). Although both groups showed significant improvements in peak VO2, significant improvements in oxygen pulse (πO2) (from 16.1±3.4 to 19.1±4.8 mL O2.kg-1.beat-1; p<0.001) and stroke volume index (from 31±5 to 35±6 mL; p=0.008) were observed in only the patients in the above-median subgroup. The change in πO2 was also significantly higher in the above-median SEVR subgroup (2.9±3.3 vs. 0.5±2.4; p=0.007). CONCLUSION: Our study shows that baseline supply-demand imbalance may limit systolic improvement response to CR in patients with CAD.

Value of Baseline Cardiovascular Mechanics in Predicting Exercise Training Success.

PURPOSE: Despite being repeatedly shown that exercise training (ET) increases exercise capacity and decreases mortality in many cardiac conditions, not all patients enjoy the benefits of ET programs. We hypothesized that baseline cardiovascular mechanic properties, including cardiac systolic and diastolic functions, arterial mechanics and ventriculoarterial interaction, may have a role in predicting response to ET. METHODS: Full left ventricular pressure-volume loops were constructed and arterial mechanics were evaluated using echocardiographic and tonometric measurements. A cardiopulmonary exercise (CPX) test was performed before and after the ET program. RESULTS: Sixty of the 75 patients with coronary artery disease or heart failure diagnoses completed the study. All of the CPX parameters showed a significant improvement with ET. The change in oxygen uptake correlated only with arterial parameters, such as compliance (r = 0.399, P = .002), end-systolic arterial elastance (r = -0.293, P = .02), aortic pulse pressure (r = -0.302, P = .02), and brachial pulse pressure (r = -0.312, P = .01). Receiver-operating characteristics analysis demonstrated that baseline arterial compliance and brachial pulse pressure predicted a significantly positive ET result with reasonable sensitivity and specificity. CONCLUSIONS: Patients with a more compliant arterial system improved their exercise capacity more with ET. Evaluation of baseline arterial compliance may facilitate proper patient selection and may define patients who need optimizing measures for the arterial system before commencing ET. Even a simple blood pressure measurement may give clues in this regard.

Association between baseline cardiovascular mechanics and exercise capacity in patients with coronary artery disease.

OBJECTIVE: Functional capacity is one of the cardinal determinants of morbidity and mortality in patients with coronary artery disease (CAD). We hypothesized that baseline cardiovascular mechanics, including cardiac systolic and diastolic functions, arterial mechanics, and ventriculoarterial interaction, may play a role in predicting exercise capacity in patients with CAD. METHODS: Fifty consecutive patients with CAD who were referred to cardiac rehabilitation were prospectively included in the study. Patients with non-sinus rhythms or severe valvular disease were excluded. Full left ventricular pressure-volume loops were constructed and arterial mechanics was evaluated using echocardiographic and tonometric measurements. Cardiopulmonary exercise tests were performed to measure exercise capacity. RESULTS: Fifty patients were enrolled in the study. Ventriculo-arterial coupling showed a moderate correlation with peak oxygen consumption (VO2) (r=0.410, p=0.04) in patients with reduced left ventricular ejection fraction (LVEF). Only left ventricular volume at 15 mm Hg (r=0.514, p<0.01) in diastolic parameters (stiffness constant, p=0.75; ventricular compliance, p=0.17) and arterial compliance (r=0.467, p=0.01) in arterial parameters [arterial elastance, p=0.27; systemic vascular resistance, p=0.45; augmentation pressure, p=0.85; augmentation index (AIx), p=0.63; heart rate-corrected AIx, p=0.68] emerged as significant factors correlated with peak VO2 in patients with normal LVEF. CONCLUSION: Comprehensive evaluation of resting cardiovascular mechanics can give clues about exercise-recruited reserves of the cardiovascular system. Optimization of ventriculo-arterial coupling in patients with reduced LVEF and arterial compliance in patients with normal LVEF should be the main target in patients with CAD and limited functional capacity.

HypnosIS to faciLitate trans-Esophageal echocardiograPhy Tolerance: The I-SLEPT study.

BACKGROUND: Trans-oesophageal echocardiography (TOE) is one of the major diagnostic tests in cardiovascular medicine, but the procedure is associated with some discomfort for the patient. AIM: To determine the additive value of hypnosis as a means of improving patient comfort during TOE. METHODS: We randomly assigned 98 patients with non-emergency indications for TOE to a 30-minute hypnosis session combined with topical oropharyngeal anaesthesia (HYP group) or topical oropharyngeal anaesthesia only (CTRL group) before the procedure. The primary efficacy endpoint was the level of patient discomfort assessed using a visual analogue scale (VAS). RESULTS: The VAS score was significantly reduced in the HYP group compared with the CTRL group (6 [5; 8] vs. 7 [5; 9]; P=0.046). No statistically significant differences were observed in terms of procedure failure (HYP group 2.2% vs. CTRL group 3.9%; P=1.00) and procedure length (HYP group 7 [5; 11] minutes vs. CTRL group 8 [7; 11] minutes; P=0.29). However, the patients' subjective estimations of the length of the procedure were significantly shorter in the HYP group than in the CTRL group (8 [5; 10] vs. 10 [10; 20] minutes; P<0.0001). There were no major adverse events in either group. The reported minor events rate was lower in the HYP group (36% vs. 57%; P=0.04). CONCLUSION: Hypnosis is an efficient alternative or complementary method for improving patient comfort during TOE.

Effects of Cardiopulmonary Exercise Rehabilitation on Left Ventricular Mechanical Efficiency and Ventricular-Arterial Coupling in Patients With Systolic Heart Failure.

BACKGROUND: Success of cardiac rehabilitation (CR) is generally assessed by the objective improvement in peak volume of inhaled oxygen (VO2) measured by cardiopulmonary exercise test (CPX). However, cardiac mechanical efficiency and ventricular-arterial coupling (VAC) are the other important dimensions of the heart failure pathophysiology, which are not included in CPX-derived data. The effect of cardiac rehabilitation on left ventricular (LV) efficiency or VAC in unselected heart failure patients has not been studied thus far. METHODS AND RESULTS: Thirty patients with an ejection fraction of ≤45% were recruited for 20 sessions of exercise-based CR. Noninvasive LV pressure-volume loops were constructed and VAC was calculated with the help of applanation tonometry and echocardiography before and after CR. VAC showed an improved mechanical efficiency profile and increased significantly from 0.56±0.18 to 0.67±0.21 (P=0.02). LV mechanical efficiency improved from 43.9±9.1% to 48.8±9.1% (P=0.01). The change in peak VO2 was not in a significant correlation with the change in VAC (r=-0.18; P=0.31), mechanical efficiency (r=-0.16, P=0.39), or the change in ejection fraction (r=-0.07; P=0.68). CONCLUSIONS: CR is associated with an improvement in VAC and LV mechanical efficiency in heart failure patients. Further studies are needed to determine the incremental value of VAC and mechanical efficiency over CPX-derived data in predicting clinical outcomes.

Effects of exercise on postexercise ventricular-arterial coupling and pulsatile efficiency in patients with systolic dysfunction.

BACKGROUND: A suboptimal ventricular-arterial (VA) interaction may have a prolonged depressing effect on the failing heart after functional reserves forced to their limits under stress conditions such as exercise. The continuation of excessive load in the postexercise period may be more important than the load during exercise, because the sum of postexercise periods generally exceeds exercise time itself. We sought that exercise-induced changes in postexercise VA coupling and pulsatile efficiency in patients with heart failure (HF). METHODS: Thirty consecutive HF with reduced ejection fraction (EF) and thirty age-, sex- and peak VO2 -matched subjects with preserved EF were enrolled. Pre- and postexercise echocardiographic and tonometric measurements were taken to calculate left ventricular and arterial elastances, arterial compliance and wave reflections, and steady and pulsatile power. RESULTS: VA coupling significantly deteriorated in HF group (from 1·50 ± 0·47 to 2·00 ± 0·75 mmHg/mL, P < 0·01), but control group maintained basal favourable coupling status after exercise (from 1·04 ± 0·29 to 1·03 ± 0·24 mmHg/mL, P = 0·77). Pulsatile percentage of total power significantly increased with exercise in HF group, whereas it showed a significant decrease in control group. The change in pulsatile power fraction was correlated with the change in augmentation pressure (r = 0·41, ß = 3·00, P < 0·01) and inversely correlated with the change in total arterial compliance (r = -0·29, ß = -8·52, P = 0·02). CONCLUSION: Our data indicate that exercise-induced VA decoupling and pulsatile inefficiency extend into postexercise phase in patients with systolic dysfunction. The exact duration of these derangements requires further studies.

Greater prognostic value of peak VO2 after exercise training program completion in heart failure patients.

BACKGROUND: Exercise capacity, best reflected by peak exercise oxygen consumption (peak VO(2)), is a powerful prognostic factor in patients with chronic heart failure (CHF). However, the optimal time to assess exercise capacity for prognosis remains unclear and whether an exercise training program (ETP) to improve exercise capacity alters the prognostic value of cardiopulmonary exercise (CPX) testing variables in CHF is unknown. METHODS AND RESULTS: CHF patients who underwent an ETP in two cardiac rehabilitation centers between 2004 and 2009 were prospectively included, and CPX testing was performed before and after ETP completion. We included 285 consecutive patients who underwent an ETP (19.4 ± 8.7 training sessions in 4 to 10 weeks), including segmental gymnastics and cycling sessions. During follow-up (12 months), 14 patients died, 6 underwent cardiac transplantation and 15 were hospitalized for acute heart failure. Univariate analysis and receiver operating characteristic (ROC) curve analysis showed that CPX variables, especially peak oxygen consumption and circulatory power (product of peak VO(2) × peak systolic blood pressure) before and after ETP completion predicted prognosis. However, CPX data obtained after ETP completion had the best prognostic value (area under the ROC curve = 0.79 ± 0.03 for peak VO(2) after ETP completion vs 0.64 ± 0.04 before ETP completion, p < 0.0001). The results did not change even when considering only deaths. CONCLUSION: In patients with stable CHF who can exercise, the prognostic value of CPX data seems greater after versus before completion of a hospital-based ETP. Therefore, CPX capacity for prognostic purposes should at best be assessed after cardiac rehabilitation.