Use of the Valve Visualization on Echocardiography Grade Tool Improves Sensitivity and Negative Predictive Value of Transthoracic Echocardiogram for Exclusion of Native Valvular Vegetation.

BACKGROUND: Transesophageal echocardiography (TEE) remains the preferred test to rule out infective endocarditis (IE) but is resource intensive and carries risk. Multiple studies report low sensitivity of transthoracic echocardiography (TTE) for detection of IE; however, these studies did not account for TTE quality. We test the validity of a simple valve visualization grading tool to stratify TTEs by quality and determine whether a high-quality TTE may be used to exclude valvular vegetation and forgo the need for TEE. METHODS: The Valve Visualization on Echocardiography Grade (VEG) tool scores the TTE from 0 to 10 based on leaflet visualization and valve leaflet clarity. The tool was retrospectively applied to 309 sequential patients who underwent both TTE and TEE at an academic teaching hospital between 2011 and 2015. The TEE report was the gold standard for presence or absence of vegetation. Patients with prosthetic valves and pacemaker wires were excluded. Sensitivity of TTE for detecting vegetation was calculated at each VEG score, and the optimal cutoff was identified. RESULTS: A total of 309 patients were included in the analysis. Among the 216 negative TTEs, 19 (9%) had a positive TEE. The median VEG score was 4. A VEG score cutoff >6 provided optimal sensitivity and was used as the cutoff. Overall, 75 (25%) patients had a VEG score >6, and 234 (75%) had a score ≤6. Sensitivity and negative predictive value for IE were higher in the VEG >6 versus VEG ≤6 group (sensitivity 96% vs 66%, negative predictive value 97.5% vs 90%; P < .05). The false-negative rate was lower (2.5% vs 10%; P = .04) in VEG > 6 versus VEG ≤ 6 groups, respectively. CONCLUSIONS: Leaflet visualization and valve leaflet clarity are important components in the TTE evaluation of patients with suspected IE. This study demonstrates that the better the valve leaflets are visualized on TTE (as represented in this population by a score >6), the higher the confidence one can have that the TTE will not be falsely negative for vegetation(s) when vegetation(s) are not noted on these TTEs. If validated in future prospective studies, this may reduce the need to perform an invasive TEE in selected patients undergoing evaluation for native valve IE.

Echocardiographic Assessment of Young Male Draft-Eligible Elite Hockey Players Invited to the Medical and Fitness Combine by the National Hockey League.

The "athletic heart" is characterized by hypertrophy and dilation of the heart, in addition to functional and electrical remodeling. The aim of this study was to provide reference 2-dimensional (2DE) and 3-dimensional (3DE) echocardiographic measurements in a large database on draft-eligible elite ice hockey players and to determine the frequency of occult cardiac anomalies in this cohort of athletes. In this prospective cohort study, we performed a comprehensive cardiac assessment of the 100 top draft picks selected by the National Hockey League. Complete 2DE and 3DE examinations were performed to obtain comprehensive measurements of cardiac structure and function at rest, which were compared with nonathlete controls. A total of 592 athletes were evaluated (mean age 18 ± 0.5 years) from 2009 to 2014 at the National Hockey League combine. 2DE and 3DE ventricular, atrial dimensions, and left ventricular mass were significantly greater in the athletes compared with controls. Abnormalities were identified in 15 hockey players (2.5%) consisting of a bicuspid aortic valve in 10 (1.7%), patent ductus arteriosus in 1 (0.2%), low normal left ventricular systolic function in 2 (0.3%), an idiopathic pericardial effusion in 1 (0.2%), and posterior mitral valve prolapse in 1 (0.2%). In conclusion, intense ice hockey training is associated with typical myocardial adaptations and the frequency of cardiac anomalies found in this cohort of young elite hockey players is low and does not differ significantly from the reported incidences in the general population.

Development of an Educational Strategy and Decision Support Tool to Enhance Appropriate Use of Stress Echocardiography at a Large Academic Medical Center: A Prospective, Pre- and Postintervention Analysis.

BACKGROUND: Despite previous studies demonstrating suboptimal appropriate use of stress echocardiography (SE), few interventions have been demonstrated to improve its appropriate use. The aim of this study was to develop a novel mechanism to improve the appropriateness of SE by implementing a point-of-care decision support tool and ordering requisition coupled with an educational strategy. METHODS: A prospective pre- and postintervention analysis was conducted. The intervention included education and the development and implementation of novel ordering requisition coupled with a decision support tool that integrated appropriate use criteria (AUC) for SE. RESULTS: In the baseline period, 256 consecutive stress echocardiographic studies were evaluated, and 97% were classifiable by the 2011 AUC. During the intervention period, 159 studies were evaluated (98% classifiable). The intervention resulted in an increase in the appropriate proportion from 65% to 76% and a reduction in the rarely appropriate proportion from 31% to 19% (P = .017). After adjustment for physician specialty, the postintervention period had lower odds of rarely appropriate testing (0.54; 95% CI, 0.3-0.95; P = .04). Cardiology had significant lower odds of rarely appropriate testing (0.23; 95% CI, 0.11-0.50; P < .001) compared with family practice (the reference standard). Vascular surgery had the highest odds (5.76; 95% CI, 2.18-21.52; P = .002) of rarely appropriate testing. CONCLUSION: AUC have not previously been applied to SE in a single-payer, publicly funded health system. The development of an educational intervention involving a new requisition and decision support tool that integrated AUC resulted in a significantly reduced proportion of rarely appropriate SE. Cardiologists ordered the highest proportion of appropriate SE. Further study is needed to determine the generalizability of the results.

Lack of difference in T wave variability between patients at risk of sudden cardiac death and healthy subjects.

BACKGROUND: T wave variability (Tvar) is a proposed method to predict sudden cardiac death (SCD). The purpose of this trial was to evaluate the reproducibility of Tvar measurements over time and demonstrate a difference in Tvar between patient populations at risk for ventricular arrhythmias and healthy subjects. METHODS: Sixty subjects were enrolled in into 3 groups: healthy subjects (Population I), patients at high risk of SCD (Population II), and patients with a recent ventricular tachyarrhythmia event (Population III). Recording and analysis of T wave amplitude variance (TAV) as a measure of Tvar was performed at baseline and 3 months. RESULTS: TAV could not be interpreted in 12 of 43 patients in Populations II and III due to PVCs or noise. No subject had a TAV value suggestive of high risk of SCD as per a previously defined cutoff of >59 µV. Median (range) values of TAV in µV at baseline for Populations I, II and III were 26 (15-39), 21 (13-43), and 24 (18-41), respectively (p = 0.39). TAV was reproducible within population's from baseline to 3 months (p = 0.27, 0.53, 0.17 for Populations I, II and III, respectively). There was no significant difference between TAV values of high risk patients and healthy subjects. CONCLUSION: Tvar was reproducible primarily in patients with left ventricular dysfunction. However, the role of Tvar as a risk stratifying tool remains inconclusive.

Predictors of normal coronary arteries at coronary angiography.

BACKGROUND: Coronary angiograms are important in the diagnostic workup of patients with suspected coronary artery disease. However, little is known about the clinical predictors of normal angiograms and whether this rate varies across different cardiac centers in Ontario. METHODS: We conducted a study using the Cardiac Care Network Variations in Revascularization Practice in Ontario database of 2,718 patients undergoing an index cardiac catheterization for an indication of stable angina between April 2006 and March 2007 at one of 17 cardiac hospitals in Ontario. We determined predictors of normal coronary angiograms (0% coronary stenosis) and compared rates of patients with normal catheterizations across centers. RESULTS: Overall, 41.9% of patients with stable angina had a normal catheterization. A multivariate model demonstrated female gender to be the strongest predictor of a normal angiogram (odds ratio 3.55, 95% CI 2.93-4.28). In addition, atypical ischemic symptoms or no symptoms, the absence of diabetes, hyperlipidemia, smoking history, peripheral vascular disease, and angiography performed at a nonteaching site were associated with higher rates of normal catheterization. The rate of normal angiograms studied varied from 18.4% to 76.9% across hospitals and was more common in community compared with academic settings (47.1% vs 35.4%, P < .001). CONCLUSIONS: The absence of traditional cardiac risk factors, female gender, and lack of typical angina symptoms are all associated with a higher frequency of normal cardiac catheterizations. The wide variation in Ontario in the frequency of normal angiograms in patients with stable angina suggests that there are opportunities to improve patient case selection.

Angiotensin converting enzyme-2 confers endothelial protection and attenuates atherosclerosis.

The endothelium plays a central role in the maintenance of vascular homeostasis. One of the main effectors of endothelial dysfunction is ANG II, and pharmacological approaches to limit ANG II bioactivity remain the cornerstone of cardiovascular therapeutics. Angiotensin converting enzyme-2 (ACE2) has been identified as a critical negative modulator of ANG II bioactivity, counterbalancing the effects of ACE in determining net tissue ANG II levels; however, the role of ACE2 in the vasculature remains unknown. In the present study, we hypothesized that ACE2 is a novel target to limit endothelial dysfunction and atherosclerosis. To this aim, we performed in vitro gain and loss of function experiments in endothelial cells and evaluated in vivo angiogenesis and atherosclerosis in apolipoprotein E-knockout mice treated with AdACE2. ACE2-deficient mice exhibited impaired endothelium-dependent relaxation. Overexpression of ACE2 in human endothelial cells stimulated endothelial cell migration and tube formation, and limited monocyte and cellular adhesion molecule expression; effects that were reversed in ACE2 gene silenced and endothelial cells isolated from ACE2-deficient animals. ACE2 attenuated ANG II-induced reactive oxygen species production in part through decreasing the expression of p22phox. The effects of ACE2 on endothelial activation were attenuated by pharmacological blockade of ANG-(1-7) with A779. ACE2 promoted capillary formation and neovessel maturation in vivo and reduced atherosclerosis in apolipoprotein E-knockout mice These data indicate that ACE2, in an ANG-(1-7)-dependent fashion, functions to improve endothelial homeostasis via a mechanism that may involve attenuation of NADPHox-induced reactive oxygen species production. ACE2-based treatment approaches may be a novel approach to limit aberrant vascular responses and atherothrombosis.