The aim of this study was to assess whether serial quantitative assessment of right ventricular (RV) function by speckle-based strain imaging is affected by pulmonary hypertension–specific therapies ...and whether there is a correlation between serial changes in RV strain and clinical status. RV longitudinal systolic function was assessed using speckle-tracking echocardiography in 50 patients with pulmonary arterial hypertension (PAH) before and after the initiation of therapy. The mean interval to follow-up was 6 ± 2 months. Subsequent survival was assessed over 4 years. Patients demonstrated a mean increase in RV systolic strain from −15 ± 5 before to −20 ± 7% (p = 0.0001) after PAH treatment. Persistence of or progression to a severe reduction in free wall systolic strain (<−12.5%) at 6 months was associated with greater disease severity (100% were in functional class III or IV vs 42%, p = 0.005), greater diuretic use (86% vs 40%, p = 0.02), higher mean pulmonary artery pressure (67 ± 20 vs 46 ± 17 mm Hg, p = 0.006), and poorer survival (4-year mortality 43% vs 23%, p = 0.002). After adjusting for age, functional class, and RV strain at baseline, patients with ≥5% improvement in RV free wall systolic strain had a greater than sevenfold lower mortality risk at 4 years (hazard ratio 0.13, 95% confidence interval 0.03 to 0.50, p = 0.003). In conclusion, serial echocardiographic assessment of RV longitudinal systolic function by quantitative strain imaging independently predicts clinical deterioration and mortality in patients with PAH after the institution of medical therapy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background Pulmonary arterial hypertension (PAH) is a devastating illness of pulmonary vascular remodeling, right-sided heart failure, and limited survival. Whether strain-based measures of right ...ventricular (RV) systolic function predict future right-sided heart failure and/or death is untested. Methods RV longitudinal systolic strain and strain rate were evaluated by echocardiography in 80 patients with World Health Organization group 1 pulmonary hypertension (PH) (72% were functional class FC III or IV). Survival status was assessed over 4 years. Results All patients had a depressed RV systolic strain (−15% ± 5%) and strain rate (−0.80 ± 0.29 s−1 ). Of the parameters assessed, average RV free wall systolic strain worse than −12.5% identified a cohort with greater severity of disease (82% were FC III/IV), greater RV systolic dysfunction (RV stroke volume index 26 ± 9 mL/m2 ), and higher right atrial pressure (12 ± 5 mm Hg). Patients with an RV free wall strain worse than −12.5% were associated with a greater degree of disease progression within 6 months, a greater requirement for loop diuretics, and/or a greater degree of lower extremity edema, and it also predicted 1-, 2-, 3-, and 4-year mortality (unadjusted 1-year hazard ratio, 6.2; 2.1–22.3). After adjusting for age, sex, PH cause, and FC, patients had a 2.9-fold higher rate of death per 5% absolute decline in RV free wall strain at 1 year. Conclusions Noninvasive assessment of RV longitudinal systolic strain and strain rate independently predicts future right-sided heart failure, clinical deterioration, and mortality in patients with PAH.
Application of Appropriateness Criteria to Stress Single-Photon Emission Computed Tomography Sestamibi Studies and Stress Echocardiograms in an Academic Medical Center Raymond J. Gibbons, Todd D. ...Miller, David Hodge, Lynn Urban, Philip A. Araoz, Patricia Pellikka, Robert B. McCully We retrospectively examined 284 patients who underwent stress single-photon emission computed tomography (SPECT) myocardial perfusion imaging and 298 patients who underwent stress echocardiography using published appropriateness criteria for SPECT. Similar percentages of each imaging modality were assigned to the 3 appropriateness categories: 64% of stress SPECT and 64% of stress echo studies were classified appropriate; 11% of stress SPECT and 9% of stress echo studies were of uncertain appropriateness; 14% of stress SPECT and 18% of stress echo studies were inappropriate. Quality improvement efforts directed at reducing the number of these inappropriate studies may improve efficiency in the health care system.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
It has been suggested that lipoprotein abnormalities may contribute to the pulmonary arteriolar dysfunction observed in pulmonary arterial hypertension (PAH). High-density lipoprotein cholesterol ...(HDL) has vasodilatory, anti-inflammatory, and endothelial protective properties. We hypothesized that a higher serum HDL level may be advantageous for survival in PAH and that the serum HDL level at diagnosis would be an independent predictor of survival in PAH and be additive to previously validated predictors of survival. This study included all patients with PAH seen at the Mayo Clinic Pulmonary Hypertension Clinic from January 1, 1995, to December 31, 2009, who had a baseline HDL measurement. Mortality was analyzed over 5 years using the Kaplan–Meier method. Univariate and multivariable Cox proportional hazards ratios were calculated to evaluate the relation between baseline HDL level and survival. HDL levels were available for 227 patients. Higher HDL levels were associated with significantly lower mortality. Patients with an HDL >54 mg/dl at diagnosis had a 5-year survival of 59%. By comparison those with an HDL <34 mg/dl had a 5-year survival of 30%. On multivariate analysis, higher HDL was associated with an age-adjusted risk ratio for death of 0.78 (CI 0.67 to 0.91; p <0.01) per 10 mg/dl increase. In conclusion, HDL was an independent predictor of survival in PAH.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
To evaluate the impact of screening stress testing for coronary artery disease in asymptomatic patients with diabetes in a community-based population.
This observational study included 3146 patients ...from Olmsted County, Minnesota, with no history of coronary artery disease or cardiac symptoms in whom diabetes was newly diagnosed from January 1, 1992, through December 31, 2008. With combined all-cause mortality and myocardial infarction as the primary outcome, weighted Cox proportional hazards regression was performed with screening stress testing within 2 years of diabetes diagnosis as the time-dependent covariate. For descriptive analysis, participants were classified by their clinical experience during the first 2 years postdiagnosis as screened (asymptomatic, underwent stress test), unscreened (asymptomatic, no stress test), or symptomatic (experienced symptoms or event).
Among the screened and unscreened participants, 54% (1358 of 2538) were men; the mean (SD) age at diabetes diagnosis was 55 years (13.8 years), and 97% (2442 of 2520) had type 2 diabetes. In event-free survival analysis, 292 patients comprised the screened cohort and 2246 patients comprised the unscreened cohort. Death or myocardial infarction occurred in 454 patients (32 patients in the screened cohort and 422 in the unscreened cohort 5-year rate, 1.9% and 5.3%, respectively) during median (interquartile range) follow-up of 9.1 years (5.3-12.5 years). Screening stress testing was associated with improved event-free survival (hazard ratio, 0.61; P=.004), independent of cardiac risk factors. However, while stress test results were abnormal in 47 of the 292 screened patients (16%), only 6 (2%) underwent coronary revascularization.
Although screening cardiac stress testing in asymptomatic patients with diabetes in this community-based population was associated with improvement in long-term event-free survival, this result does not appear to occur by coronary revascularization alone.
Guidelines suggest that an abnormal blood potassium level is a relative contraindication to performing dobutamine stress echocardiography (DSE). However, this has not been previously studied.
We ...reviewed a consecutive series of patients who had potassium testing within 48 hours of undergoing DSE for the evaluation of myocardial ischemia over a 10-year period (N = 13,198). Normal potassium range in our laboratory is 3.6-5.2 mmol/L. Hemolyzed samples were not included. The association of potassium levels with the development of supraventricular and ventricular arrhythmias was assessed.
The incidence of clinically significant arrhythmias was very low (supraventricular tachycardia/atrial fibrillation, 4.9%; nonsustained ventricular tachycardia, 2.9%; sustained ventricular tachycardia or ventricular fibrillation, 0.1%), confirming the overall safety of DSE. Most arrhythmias (88%) occurred in patients with normal potassium levels, and arrhythmia rates remained low in patients with potassium abnormalities. Patients with hyperkalemia had a lower risk of developing mild (odds ratio OR, 0.39; 95% CI, 0.22-0.71) and severe (OR, 0.13; 95% CI, 0.01-0.68) supraventricular arrhythmias as well as mild ventricular arrhythmias (OR, 0.58; 95% CI, 0.40-0.83). Even though events were rare, patients with severe hypokalemia (potassium levels ≤ 3.1 mmol/L) had an increased risk of supraventricular arrhythmia and ventricular ectopy.
DSE is safe even in the setting of abnormalities in blood potassium concentrations, and hence cancellation of DSE in patients with potassium abnormalities does not appear warranted. Elevated potassium levels are associated with lower rates of clinically significant supraventricular and ventricular arrhythmias. While remaining at relatively low risk, patients with very low potassium levels (≤3.1 mmol/L) at the time of DSE have a modestly increased risk of arrhythmia. Consideration could be given to correcting severe hypokalemia prior to DSE.
The objective of the present study was to determine whether diastolic dysfunction (DD) is associated with outcomes in the absence of myocardial ischemia. We studied 2,835 patients undergoing exercise ...echocardiography from January 2006 through December 2006 who had normal systolic function (ejection fraction ≥50%) and an absence of exercise-induced wall motion abnormalities. Diastolic function was graded as normal, mild DD, or moderate to severe DD. Medical records review and patient contact were undertaken to determine mortality, cardiovascular events (i.e., death, myocardial infarction, or stroke), incident heart failure (HF), and hospitalization. The mean ± SD age was 58.9 ± 12.8 years, and 54.0% were women. DD was present in 40.0% of the participants, with mild DD in 28.2% and moderate to severe DD in 11.8%. During a median follow-up of 4.4 years, 81 deaths and 114 cardiovascular events occurred, and DD was associated with greater rates of mortality, cardiovascular events, and HF events or hospitalizations (all p <0.001). On multivariate analysis, mild or moderate to severe DD (referent, normal function) was associated with HF or hospitalization (hazard ratio 1.45, 95% confidence interval 1.18 to 1.78, p <0.001 for mild DD; hazard ratio 1.75, 95% confidence interval 1.37 to 2.24, p <0.001 for moderate to severe DD) but was not independently associated with death or cardiovascular events. The diastolic index of filling pressure (E/e′) was independently associated with mortality, cardiovascular events, and HF or hospitalization. In conclusion, among patients without demonstrable myocardial ischemia, left ventricular DD was associated with greater event rates during long-term follow up but did not independently predict hard end points other than HF or hospitalization. E/e′ was independently associated with the clinical outcomes and might be an important echocardiographically derived parameter to identify in patients undergoing exercise echocardiography.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Objective To determine the frequency and prognostic significance of abnormal exercise echocardiographic results for patients achieving a workload of 10 or more metabolic equivalents during ...treadmill exercise echocardiography. Patients and Methods Patients who underwent treadmill exercise echocardiography from November 1, 2003, through December 31, 2008, and exercised for 9 or more minutes using the Bruce protocol (N=7236) were included. Clinical and exercise echocardiographic characteristics and outcomes were evaluated. Variables associated with abnormal exercise echocardiographic results and mortality were identified. Results Exercise echocardiographic results were positive for ischemia in 862 patients (12%). Extensive ischemia developed in 265 patients (4%). For patients with normal exercise echocardiographic results, all-cause and cardiovascular mortality rates were 0.30% and 0.05% per person-year of follow-up, respectively. For patients who had extensive ischemia, all-cause and cardiovascular mortality rates were 0.84% and 0.25% per person-year of follow-up, respectively. Patients at highest risk were those who had extensive and severe regional wall motion abnormalities at rest (n=58), and their all-cause and cardiovascular mortality rates were 2.65% and 0.76% per person-year of follow-up. Exercise echocardiographic variables did not identify sizable patient subgroups at risk for death and did not provide incremental prognostic information (C statistic was 0.74 compared with 0.73 for the clinical plus exercise electrocardiography model). Conclusion Patients achieving a workload of 10 or more metabolic equivalents during treadmill exercise testing do not often have extensive ischemic abnormalities on exercise echocardiography. Although exercise echocardiographic results provide some prognostic information, it is not of incremental value for these patients, whose short-term and medium-term prognosis is excellent.
Abnormal cardiac stress imaging findings are not always associated with angiographically significant coronary artery disease. The outcomes of patients with such false-positive findings have not been ...extensively examined. The aim of this retrospective study was to describe the characteristics and outcomes of patients with abnormal stress echocardiographic findings who had false-positive results compared with those who had true-positive results.
Of 1,477 consecutive patients (mean age, 66 +/- 12 years; 61% men) with abnormal stress echocardiographic findings who underwent coronary arteriography within 30 days, death from any cause was ascertained.
At coronary arteriography, 997 patients (67.5%) had true-positive results, defined by the presence of angiographically significant coronary artery disease (> or = 50% stenoses), and 480 (32.5%) had false-positive results, defined by <50% stenoses or normal coronary arteries. Of the subgroup of patients with markedly abnormal stress echocardiographic findings (n = 605), 28% had <50% stenoses or normal coronary arteries. During an average follow-up period of 2.4 +/- 1.0 years, there were 140 deaths. The adjusted likelihood of subsequent death for patients with <50% stenoses compared to patients with > or = 50% stenoses after abnormal stress echocardiography was 1.05 (95% confidence interval, 0.86-1.31; P = .62).
A sizable proportion of patients with abnormal stress echocardiographic results who are referred for coronary angiography have false-positive findings. The outcomes of patients with false-positive results were similar to those of patients with true-positive results. This finding suggests that patients with false-positive results on stress echocardiography should still receive intensive risk factor management and careful clinical follow-up.
Unraveling the RV Ejection Doppler Envelope Takahama, Hiroko, MD; McCully, Robert B., MD; Frantz, Robert P., MD ...
JACC. Cardiovascular imaging,
October 2017, Volume:
10, Issue:
10
Journal Article
Peer reviewed
Open access
Abstract Objectives The purpose of this study was to characterize the profiles of right ventricular outflow tract (RVOT) Doppler flow velocity envelopes in patients with pulmonary arterial ...hypertension (PAH) and to establish whether changes in the RVOT flow profile related to patient outcome. Background The RVOT systolic flow profile is frequently abnormal, with findings of a mid-systolic flow deceleration and notching, previously proposed as an indicator of elevated pulmonary vascular resistance (PVR). Methods We reviewed RVOT systolic flow profiles recorded by pulsed-wave Doppler from 159 consecutive patients with PAH and measured deceleration time (DT) of mid-systolic deceleration slope (mid-systolic DT) and the peak velocity of pre- and post-notching flow. Concurrent right-heart catheterization was available in all (41 of 41) incident patients and in 39 of 118 established patients. Outcomes, defined as time to all-cause mortality or need for lung transplantation, were assessed during 3 years of follow-up. Results Notched envelopes were identified in 150 of 159 patients. The presence of a notched pattern and a decrease in the mid-systolic DT were associated with higher PA pressures; higher PVR; and, at a threshold of a mid-systolic DT of <120 ms, worse outcome. Those patients with a shorter DT were further subdivided based on the post-notch systolic flow velocity. In these patients, a decline in the post-notch flow velocity to less than 62% of the pre-notch flow velocity defined a cohort with a marked reduction in systolic function and the worst outcome. Conclusions In PAH, the notched profile of RVOT Doppler flow velocity envelope appears to integrate indicators of pulmonary vascular load and RV function and serves as a marker for adverse outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
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