Global longitudinal systolic strain (GLS) is often reduced in aortic stenosis despite normal ejection fraction. The importance of reduced preoperative GLS on long-term outcome after aortic valve ...replacement is unknown.
A total of 125 patients with severe aortic stenosis and ejection fraction >40% scheduled for aortic valve replacement were evaluated preoperatively and divided into 4 groups according to GLS quartiles. Patients were followed up for 4 years. The primary end points were major adverse cardiac events (MACEs) defined as cardiovascular mortality and cardiac hospitalization because of worsening of heart failure; the secondary end point was cardiovascular mortality. MACE and cardiac mortality were significantly increased in patients with lower GLS. Estimated 5-year MACE was increased: first quartile 19% (n=6) / second quartile 20% (n=6) / third quartile 35% (n=11) / fourth quartile 49% (n=15); P=0.04. Patients with increased age, left ventricular hypertrophy, and left atrial dilatation were at increased risk. In Cox regression analysis, after correcting for standard risk factors and ejection fraction, GLS was found to be significantly associated with cardiac morbidity and mortality. In a stepwise Cox model with forward selection, GLS was the sole independent predictor: hazard ratio=1.13 (95% confidence interval, 1.02-1.25), P=0.04. Comparing the overall log likelihood χ(2) of the predictive power of the multivariable model containing GLS was statistically superior to models based on EuroScore, history with ischemic heart disease, and ejection fraction.
In patients with symptomatic severe aortic stenosis undergoing aortic valve replacement, reduced GLS provides important prognostic information beyond standard risk factors.
We aimed to describe characteristics and outcomes in a nationwide population of patients with acute type A and type B aortic dissection.
All patients in Denmark with a first-time diagnosis of acute ...aortic dissection between 2006 and 2015 were identified by national registries. The main outcomes were in-hospital mortality and long-term survival in hospital survivors.
The study population comprised 1157 (68%) patients with type A aortic dissection and 556 (32%) patients with type B aortic dissection, median age of 66 (57-74) years and 70 (61-79) years, respectively. Men accounted for 64%. Median follow-up was 8.9 (6.8-11.5) years. Of patients with type A aortic dissection, 74% were managed surgically, whereas 22% of the patients with type B aortic dissection were managed with surgery or endovascular technique. In-hospital mortality was 27% for type A aortic dissection overall (surgery, 18%; no surgery, 52%) and 16% for type B aortic dissection (surgery or endovascular treatment, 13%; conservative treatment, 17%; P < .001, type A vs type B). Of patients discharged alive, survival was persistently better for type A aortic dissection than for type B aortic dissection (P < .001). Unadjusted 1- and 3-year survival of patients with type A aortic dissection discharged alive was 96% and 91%, respectively, for surgically managed and 88% and 78% without surgery. For type B aortic dissection, the numbers were 89% and 83% for endovascular/surgically managed and 89% and 77% for conservatively managed.
We found higher in-hospital mortality for type A and type B aortic dissection than is reported from referral center registries. Type A aortic dissection had the highest mortality rate during the acute phase, whereas for patients who were discharged alive, the mortality rate was higher for patients with type B aortic dissection.
Aims
Anthracycline‐based chemotherapy improves survival in breast cancer patients but is associated with increased risk of heart failure (HF). However, the risk of late‐onset HF is debatable and ...mainly based on observational studies. The aim of this study was to evaluate the effect of anthracycline‐based chemotherapy on long‐term risk of clinical HF.
Methods and results
Between 1990 and 1998 the Danish Breast Cancer Cooperative Group (DBCG) 89D trial randomized 980 Danish women with early breast cancer to adjuvant cyclophosphamide, epirubicin, and fluorouracil or cyclophosphamide, methotrexate, and fluorouracil. Incident HF was the primary endpoint obtained from Danish administrative registries. Follow‐up ended at December 2014. The risk of HF was evaluated in a cumulative incidence analysis and a Fine–Gray proportional hazards model. Median follow‐up time was 16.9 years interquartile range (IQR) 3.7–20.9. In the epirubicin treatment group, 23 new cases of HF were identified vs. 9 in the non‐epirubicin group corresponding to incidence rates per 1000 patient‐years of 3.7 95% confidence interval (CI) 2.5–5.6 vs. 1.4 (95% CI 0.7–2.7). The cumulative incidence of HF was higher in the epirubicin treatment group compared with the non‐epirubicin group (P < 0.01), yielding a hazard ratio of 3.00 (95% CI 1.39–6.49, P < 0.01) for HF associated with epirubicin. The median dose of epirubicin was 451.9 mg/m2 (IQR 400.0–523.5).
Conclusions
Anthracycline‐based chemotherapy is associated with a three‐fold increased risk of late‐onset clinical HF relative to non‐anthracycline chemotherapy in this randomized clinical trial, but overall risk is low.
The study sought to determine the prognostic importance of left atrial (LA) dilation in patients with type 2 diabetes mellitus (T2DM) and no history of cardiovascular disease (CVD).
T2DM is ...associated with the development of CVD, and morphological changes in the heart may appear before symptoms arise.
A total of 305 T2DM patients without known CVD referred to a diabetes clinic were included consecutively (age 58.6 ± 11.3 years, diabetes duration 2.0 interquartile range: 0 to 6.0 years). Each patient underwent a comprehensive echocardiogram and a myocardial perfusion scintigraphy (MPS) at inclusion. Patients were divided according to left atrial volume index (LAVi) ≥32 ml/m(2). Patients were followed for median of 5.6 (interquartile range: 5.1 to 6.1) years for the occurrence of major cardiac events and death.
LAVi ≥32 ml/m(2) was found in 105 patients (34%). During follow-up, 60 patients (20%) experienced the composite endpoint, of whom 28 (9%) died. Patients with LAVi ≥32 ml/m(2) had a significantly higher cardiac event rate and death rate (p < 0.001 and p = 0.002, respectively). Univariate predictors of the composite endpoint were age, hypertension, left ventricular diastolic function, E/e'septum-ratio and LAVi ≥32 ml/m(2); however, myocardial ischemia on MPS was not a predictor. When adjusting for age and hypertension, only LAVi ≥32 ml/m(2) was a predictor of the composite endpoint (hazard ratio: 1.82 95% confidence interval: 1.08 to 3.07, p = 0.024).
Increased LAVi was an independent and incremental predictor of cardiovascular morbidity and mortality in T2DM patients with no history of CVD. (Presence of Macrovascular Disease in Type 2 Diabetes Mellitus; NCT00298844).
Aims
A hallmark of heart failure with preserved ejection fraction (HFpEF) is impaired exercise capacity of varying severity. The main determinant of exercise capacity is cardiac output (CO), however ...little information is available about the relation between the constituents of CO – heart rate and stroke volume – and exercise capacity in HFpEF. We sought to determine if a heterogeneity in heart rate and stroke volume response to exercise exists in patients with HFpEF and describe possible clinical phenotypes associated with differences in these responses.
Methods and results
Data from two prospective trials of HFpEF (n = 108) and a study of healthy participants (n = 42) with invasive haemodynamic measurements during exercise were utilized. Differences in central haemodynamic responses were analysed with regression models. Chronotropic incompetence was present in 39–56% of patients with HFpEF and 3–56% of healthy participants depending on the definition used, but some (n = 47, 44%) had an increase in heart rate similar to that of healthy controls. Patients with HFpEF had a smaller increase in their stroke volume index (SVI) (HFpEF: +4 ± 10 mL/m2, healthy participants: +24 ± 12 mL/m2, P < 0.0001), indeed, SVI fell in 28% of patients at peak exercise. Higher body mass index and lower SVI at rest were associated with smaller increases in heart rate during exercise, whereas higher resting heart rate, and angiotensin‐converting enzyme inhibitor/angiotensin II receptor blocker use were associated with a greater increase in SVI in patients with HFpEF.
Conclusion
The haemodynamic response to exercise was very heterogeneous among patients with HFpEF, with chronotropic incompetence observed in up to 56%, and 28% had impaired increase in SVI. This suggests that haemodynamic exercise testing may be useful to identify which HFpEF patients may benefit from interventions targeting stroke volume and chronotropic response.
Determinants and consequences of heart rate (HR) and stroke volume (SV) response to exercise in patients with heart failure and preserved ejection fraction (HFpEF). ACEi, angiotensin‐converting enzyme inhibitor; ARB, angiotensin II receptor blocker; GFR, glomerular filtration rate.
Aims
Mechanical circulatory support devices (MCS) are potentially effective treatments for cardiogenic shock (CS) and are thus evaluated in several randomised controlled trials (RCTs). However, it is ...not clear how enrolment criteria of these RCTs apply to a real‐world CS population. This study aimed to shed light on eligibility to these trials.
Methods and results
Pragmatic enrolment criteria for the IABP‐SHOCK II, the DanGer‐SHOCK, the ECLS‐SHOCK and the EURO‐SHOCK trials were retrospectively applied to 1305 CS patients admitted to a tertiary care hospital between 2009 and 2019. Based on this, major enrolment criteria were identified and outcome between eligible and ineligible patients was assessed. In this study, 415 (31.8%) patients were eligible for any study. Lowest eligibility was observed for DanGer‐SHOCK (11.9%) and the highest for IABP‐SHOCK II (26.9%). Over all trials, inclusion criteria were more restrictive than exclusion criteria and absence of CS caused by acute myocardial infarction (AMI) was the primary reason for non‐eligibility. However, even in CS caused by AMI, enrolment criteria were only met in 65.4% of patients. Importantly, 30‐day mortality was high across all patients/trials, irrespective of eligibility or non‐eligibility.
Conclusion
The present study highlights that current and past RCTs only reflect about a third of the overall CS population. While enrolment criteria are a necessary aspect of RCTs, their application limits generalisability of the trials' findings. More trials on CS sub‐populations not represented by current or past trials, e.g. CS not caused by AMI, are needed, especially as mortality is high irrespective of eligibility status.
Objective One of the hemodynamic consequences of aortic valve stenosis is pressure overload leading to left atrial dilatation. Left atrial size is a known risk factor providing prognostic information ...in several cardiac conditions. It is not known if this is also the case in patients with aortic valve stenosis after aortic valve replacement. Methods A total of 119 patients with severe aortic valve stenosis scheduled for aortic valve replacement were evaluated preoperatively and divided into 2 groups according to left atrial volume index (≥40 mL/m2 ). Echocardiography was repeated 12 months after surgery. Patients were followed up for 24 months. The primary end point was the composite end point overall mortality and hospitalization due to congestive heart failure. Results Preoperative left atrial dilation was associated with left ventricular hypertrophy and increased filling pressure. Preoperative left atrial volume index was associated with persistent abnormalities in left ventricular filling pressure and left ventricular mass index at 1 year after surgery. Event-free survival in patients with left atrial volume index of 40 mL/m2 or more at 1 year was 71% compared with 88% in patients with left atrial volume index less than 40 mL/m2 ( P = .002). Patients with preoperative increased E/e’ ratio and left ventricular hypertrophy were at increased risk. In Cox regression analysis after correcting for standard risk factors, left atrial volume index was found to be the only significant predictor of the composite end point. In a forward conditional multivariable model, left atrial volume index 40 mL/m2 or greater (hazard ratio, 4.2 1.6–10.7; P = .003) remained an independent predictor, whereas E/e’ was borderline significant ( P = .06). Conclusions In patients with symptomatic severe aortic valve stenosis undergoing aortic valve replacement, left atrial volume provides important prognostic information beyond standard risk factors.
The aim of this study was to assess the prognostic value of a noninvasive measure of left ventricular diastolic pressure (LVDP) early after acute myocardial infarction (MI).
The early diastolic ...velocity of the mitral valve annulus (e′) reflects the rate of myocardial relaxation. When combined with measurement of the early transmitral flow velocity (E), the resultant ratio (E/e′) correlates well with mean LVDP. In particular, an E/e′ ratio >15 is an excellent predictor of an elevated mean LVDP. We hypothesized that an E/e′ ratio >15 would predict poorer survival after acute MI.
Echocardiograms were obtained in 250 unselected patients 1.6 days after admission for MI. Patients were followed for a median of 13 months. The end point was all-cause mortality.
Seventy-three patients (29%) had an E/e′ >15. This was associated with excess mortality (log-rank statistic 21.3, p < 0.0001) and was the most powerful independent predictor of survival (risk ratio 4.8, 95% confidence interval 2.1 to 10.8, p = 0.0002). The addition of E/e′ >15 improved the prognostic utility of a model containing clinical variables and conventional echocardiographic indexes of left ventricular systolic and diastolic function (p = 0.001).
E/e′ is a powerful predictor of survival after acute MI. An E/e′ ratio >15 is superior, in this respect, to other clinical or echocardiographic features. Furthermore, it provides prognostic information incremental to these parameters.
Diastolic dysfunction in acute myocardial infarction (MI) is associated with adverse outcome. Recently, the ratio of early mitral inflow velocity (E) to global diastolic strain rate (e'sr) has been ...proposed as a marker of elevated LV filling pressure. However, the prognostic value of this measure has not been demonstrated in a large-scale setting when existing parameters of diastolic function are known. We hypothesized that the E/e'sr ratio would be independently associated with an adverse outcome in patients with MI.
We prospectively included patients with MI and performed echocardiography with comprehensive diastolic evaluation including E/e'sr. The relationship between E/e'sr and the primary composite endpoint (all-cause mortality, hospitalization for heart failure (HF), stroke, and new onset atrial fibrillation) was analysed with Cox models. A total of 1048 patients (mean age 63 ± 12, 73% male) were included and 142 patients (13.5%) reached the primary endpoint (median follow-up 29 months). A significant prognostic value was found for E/e'sr hazard ratio (HR) per 1 unit change: 2.36, 95% confidence interval (CI): 2.02-2.75, P < 0.0001. After multivariable adjustment E/e'sr remained independently related to the combined endpoint (HR per 1 unit change, 1.50; CI: 1.05-2.13, P = 0.02). The prognostic value of E/e'sr was driven by mortality (HR per 1 unit change, 2.52; CI: 2.09-3.04, P < 0.0001) and HF admissions (HR per 1 unit change, 2.79; CI: 2.23-3.48, P < 0.0001).
Deformation-based E/e'sr contributes important information about global myocardial relaxation superior to velocity-based analysis and is independently associated with the outcome in acute MI.
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