Anthracycline therapy (ANT) is associated with cancer therapy-related cardiac dysfunction. Coronary flow velocity reserve (CFVR) has shown prognostic utility in non-cancer cohorts, but no data have ...been obtained in a cardio-oncology setting. We investigated the acute effect of ANT on CFVR in breast cancer patients. A total of 12 female breast cancer patients undergoing ANT had pre- and post-ANT CFVR assessment. A significant decline in CFVR occurred (baseline: 2.66 ± 0.41 vs post-ANT: 2.47 ± 0.37, P = 0.016). This prospective study is the first to identify ANT-related coronary physiology changes in humans. Further studies are required to determine their clinical significance.
Le traitement par l’anthracycline est associé à une dysfonction cardiaque liée au traitement anticancéreux. La réserve de débit coronaire a démontré son utilité pronostique dans les cohortes sans cancer, mais aucune donnée n’a été obtenue dans un contexte de cardio-oncologie. Nous avons étudié l’effet aigu de l’anthracycline sur la réserve de débit coronaire chez des patientes atteintes d’un cancer du sein. La réserve de débit coronaire a été évaluée avant et après le traitement par l’anthracycline chez un total de 12 femmes atteintes d’un cancer du sein. Un déclin important de la réserve de débit coronaire est survenu (valeur initiale de 2,66 ± 0,41 par rapport à 2,47 ± 0,37 après le traitement par l’anthracycline, p = 0,016). Cette étude prospective est la première à déceler des changements dans la physiologie coronarienne liés à l’anthracycline chez les humains. D’autres études sont nécessaires pour en déterminer la portée clinique.
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Summary Background Syndecan-4 is a transmembrane heparan sulfate-carrying glycoprotein that mediates signal transduction pathways activated by growth factors and cell surface receptors, thereby ...modulating tissue regeneration, angiogenesis, and focal adhesion. The aim of the present study was to determine the clinical use of serum syndecan-4 concentration for diagnosis of heart failure. Methods Concentration of serum syndecan-4 and other biomarkers of heart failure was measured in 45 patients with heart failure and 21 healthy subjects. Clinical and echocardiographic parameters of cardiac function were recorded. Results Serum syndecan-4 concentration significantly increased in proportion to the decrease in ejection fraction ( r = −0.599, p < 0.001) and increase in the left ventricular (LV) mass index ( r = 0.315, p < 0.05). Serum syndecan-4 concentration was significantly correlated with LV geometrical parameters (i.e. LV mass index, LV end-diastolic volume, and LV dimension), while B-type natriuretic peptide (BNP) was significantly correlated with pressure-related parameters i.e. early transmitral flow velocity/early diastolic velocity of the mitral valve annulus ( E / e ′), right ventricular systolic pressure, and left atrial volume index. Syndecan-4 concentration did not significantly correlate with plasma BNP, transforming growth factor-1, matrix metalloproteinase-2, and tenascin-C concentrations. Serum syndecan-4 concentration could predict cardiac death and re-hospitalization due to heart failure (area under curve, 0.706, p < 0.05). Conclusion Serum syndecan-4 concentration shows promise as a novel diagnostic and prognostic biomarker for heart failure. Since syndecan-4 correlated with LV geometrical rather than hemodynamic parameters, serum syndecan-4 may represent a biomarker of LV remodeling in the failing heart.
Heart failure (HF) readmissions are a common and serious problem of heterogeneous etiology. Left ventricular (LV) ejection fraction has not been found to be a consistent risk marker. However, LV ...strain has been shown to predict outcomes in other settings, so the aim of this study was to determine the association of LV strain with 30-day HF readmission, independent of and incremental to clinical and basic echocardiographic parameters.
A total of 468 patients who underwent echocardiography at the time of the first admission for HF from July 2009 to June 2012 were retrospectively studied. Clinical parameters were comprehensively assessed, and standard echocardiographic parameters and two strain parameters (global longitudinal strain GLS and global circumferential strain) were measured using speckle-tracking. Patients were followed for all-cause 30-day hospital readmission or death after discharge, and the associations of parameters with outcome were assessed using Cox proportional hazards models.
Readmission within 30 days (n = 92 patients 20%) was associated with greater impairment of LV GLS (-8.6% interquartile range, -10.9% to -5.9% vs -11.1% interquartile range, -14.6% to -7.7%, P < .01). The association of GLS with readmission (hazard ratio, 1.13; 95% confidence interval, 1.07-1.19; P < .01) was independent of age, male gender, systolic blood pressure, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker use, and comorbidity, as well as renal function, sodium, hematocrit, LV mass, left atrial size, and mitral regurgitation. Global circumferential strain was associated with outcome but not was independent after adjustment with echocardiographic parameters. In sequential models for 30-day outcome, GLS added incremental information to clinical parameters and LV ejection fraction and significantly improved reclassification (categorical net reclassification improvement, 0.34; P = .04) when LV ejection fraction was >50%.
GLS is associated with HF readmission, independent of and incremental to clinical and basic echocardiographic parameters.
Left atrial (LA) strain imaging enables the quantitative assessment of LA function. The clinical relevance of these measurements is dependent on the provision of information incremental to the left ...ventricular (LV) evaluation. The aim of this study was to test the hypothesis that LA pump function but not reservoir function is independent of measurement of LV mechanics.
Echocardiography was undertaken in a community-based study of 576 participants ≥65 years of age with one or more risk factors (e.g., hypertension, diabetes mellitus, obesity). Strain analysis was conducted using a dedicated software package, using R-R gating. LV function was classified as normal in the presence of global longitudinal strain (GLS) (≤-18%) or global circumferential strain (GCS) (≤-22%). The associations between GLS or GCS and LA reservoir, conduit, and pump strain were assessed using univariate and multivariate linear regression.
Patients (mean age 71 ± 5 years, 54% women) with reduced GLS had higher blood pressure and rates of diabetes and obesity (P < .05). LA reservoir strain and conduit strain were lower in the group with impaired GLS (38.2 ± 7.3% vs 39.9 ± 6.4% P = .004 and 18.7 ± 5.7% vs 20.5 ± 5.1% P < .001, respectively), but there was no difference in LA pump strain (19.5 ± 5.5% vs 19.3 ± 4.6%, P = .72). GLS was independently associated with LA reservoir and conduit strain (P < .05) but not independently associated with LA pump strain (P = .91). Reduced GCS was associated with a larger body mass index, male sex, and diabetes (P < .05). There were no differences in LA reservoir, conduit, and pump strain in patients with normal and abnormal GCS (P > .05).
The application of LA strain is specific to the component measured. LA pump strain is independent of LV mechanics.
Background Appropriate use criteria (AUC) for stress single-photon emission computed tomography (SPECT) are only one step in appropriate use of imaging. Other steps include pretest clinical risk ...evaluation and optimal management responses. We sought to understand the link between AUC, risk evaluation, management, and outcome. Methods We used AUC to classify 1,199 consecutive patients (63.8 ± 12.5 years, 56% male) undergoing SPECT as inappropriate, uncertain, and appropriate. Framingham score for asymptomatic patients and Bethesda angina score for symptomatic patients were used to classify patients into high (≥5%/y), intermediate, and low (≤1%/y) risk. Subsequent patient management was defined as appropriate or inappropriate based on the concordance between management decisions and the SPECT result. Patients were followed up for a median of 4.8 years, and cause of death was obtained from the social security death registry. Results Overall, 62% of SPECTs were appropriate, 18% inappropriate, and 20% uncertain (only 5 were unclassified). Of 324 low-risk studies, 108 (33%) were inappropriate, compared with 94 (15%) of 621 intermediate-risk and 1 (1%) of 160 high-risk studies ( P < .001). There were 79 events, with outcomes of inappropriate patients better than uncertain and appropriate patients. Management was appropriate in 986 (89%), and appropriateness of patient management was unrelated to AUC ( P = .65). Conclusion Pretest clinical risk evaluation may be helpful in appropriateness assessment because very few high-risk patients are inappropriate, but almost half of low-risk patients are inappropriate or uncertain. Appropriate patient management is independent of appropriateness of testing.
Abstract Papillary fibroelastoma (PFE) is a well-known primary cardiac tumor, but multiple PFEs are rare. We report an interesting case with multiple PFEs that were clearly demonstrated and evaluated ...with real time three-dimensional (RT3D) transesophageal echocardiography (TEE). A 77-year-old woman was referred to our institution with a diagnosis of osteoarthritis of the hip. Transthoracic echocardiography showed an abnormal structure on the aortic valve. Although two-dimensional TEE revealed typical characteristics of multiple PFE, RT3D TEE clearly demonstrated their number and location on the right and non-coronary cusp of the aortic valve. These results were subsequently confirmed by surgery and pathological findings. RT3D TEE is an exceptionally useful tool for pre-surgical evaluation of PFE. < Learning objective: PFE is a well-known primary cardiac tumor, but multiple PFEs are rare. We report an interesting case with multiple PFEs that was clearly demonstrated and evaluated with RT3D TEE. RT3D TEE is an exceptionally useful tool for pre-surgical evaluation of PFE.>
Temporal Changes in Appropriateness of Cardiac Imaging Fonseca, Ricardo, MD; Negishi, Kazuaki, MD, PhD; Otahal, Petr, GDipSc ...
Journal of the American College of Cardiology,
03/2015, Letnik:
65, Številka:
8
Journal Article
Recenzirano
Odprti dostop
Abstract Background Appropriate use criteria (AUC) for cardiac imaging have been available for almost 10 years. The extent to which there has been a reported improvement in appropriate use is ...undefined. Objectives This study systematically reviewed published evidence to identify whether the promulgation of AUC has led to an improvement in the proportion of appropriate cardiac imaging requests. Methods Electronic databases were systematically searched for English-language papers related to AUC and cardiovascular imaging. We found 59 reports involving 103,567 tests that were published from 2000 to 2012. The rate of appropriate testing over time was analyzed in a meta-regression. Results New AUC were associated with apparent improvements in appropriateness for transthoracic echocardiography (TTE) (80% 95% confidence interval (CI): 0.75 to 0.84 vs. 85% 95% CI: 0.81 to 0.89), transesophageal echocardiography (TEE) (89% 95% CI: 0.81 to 0.94 vs. 95% 95% CI: 0.93 to 0.96) and computed tomography angiography (CTA) (37% 95% CI: 0.21 to 0.55 vs. 55% 95% CI: 0.44 to 0.65) but not stress echocardiography (53% 95% CI: 0.45 to 0.61 vs. 52% 95% CI: 0.42 to 0.61) or single-photon emission computed tomography (72% 95% CI: 0.66 to 0.77 vs. 68% 95% CI: 0.60 to 0.74). Although there were no correlations between the proportion of appropriate TTEs and published year (p = 0.36) for 2007 AUC, there was a positive correlation between proportion of appropriateness and the year of publication (p = 0.01) for 2011 AUC. There was a significant decrease in the proportion of appropriateness over time using the 2007 TEE AUC (p = 0.03) and 2006 CT AUC (p = 0.02). There were no meaningful associations between appropriateness and publication year for stress echocardiography, CTA, or single-photon emission computed tomography. Conclusions Rates of reported appropriate use in imaging show improvements for TTE and CTA but not for stress imaging and TEE. The observed reductions in imaging studies are not matched by reported rates of appropriate use.
Left atrial (LA) remodeling and dysfunction reflect chronic exposure to elevated left ventricular (LV) filling pressures. The aim of this longitudinal cohort study was to define the effect of ...reducing LV filling pressures on reverse remodeling of LA volume (LAV) and function.
This retrospective cohort included 195 patients (52% men; mean age, 64 ± 14 years) in sinus rhythm with LA dilatation and sequential echocardiograms (median interval, 1 year; interquartile range, 0.5-2.0 years). One hundred seventy-four patients underwent medical therapy (82 with reduced E/e' ratios), and 21 underwent surgery for valvular heart disease. Biplane LAV (normal value, ≤ 68 mL for men, ≤ 62 mL for women), LA strain (ε) (normal value, >32%) and LV filling pressures (assessed as E/e' ratio; normal value, <13) were measured.
Although LAV at baseline and follow-up were 88 ± 27 and 81 ± 24 mL, LA ε and E/e' ratio remained stable at 26 ± 11% and 14 ± 7, respectively. Changes in E/e' ratio were associated with changes in LAV (r = 0.37, P < .001) and LA ε (r = -0.51 P < .001). Although reduced E/e' ratio or improved LA ε at follow-up occurred in about 50% of the patients, only 26% (51 of 195) had normalized LAV. Compared with surgery, successful reduction of E/e' with medical therapy was less effective in reducing LAV (P < .001) but produced similar improvement in LA ε. Having normal or improved E/e' ratio at follow-up was not associated with normalization of LAV (relative risk, 1.29 P = .326 and 1.22 P = .421, respectively) but was associated with normalized LA ε (relative risk, 2.04 P = .011 and 1.86 P = .017, respectively) independently of LAV.
Reduction in LV filling pressures reduces but rarely normalizes LAV. The strong association of reduced LV filling pressure with improved LA function indicated by LA longitudinal ε supports the increasing interest of LA ε measurement.
Global longitudinal strain (GLS) is well validated and has important applications in contemporary clinical practice. The aim of this analysis was to evaluate the accuracy of resting peak GLS in the ...diagnosis of obstructive coronary artery disease (CAD).
A systematic literature search was performed through July 2015 using four databases. Data were extracted independently by two authors and correlated before analyses. Using a random-effect model, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and summary area under the curve for GLS were estimated with their respective 95% CIs.
Screening of 1,669 articles yielded 10 studies with 1,385 patients appropriate for inclusion in the analysis. The mean age and left ventricular ejection fraction were 59.9 years and 61.1%. On the whole, 54.9% and 20.9% of the patients had hypertension and diabetes, respectively. Overall, abnormal GLS detected moderate to severe CAD with a pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of 74.4%, 72.1%, 2.9, and 0.35 respectively. The area under the curve and diagnostic odds ratio were 0.81 and 8.5. The mean values of GLS for those with and without CAD were -16.5% (95% CI, -15.8% to -17.3%) and -19.7% (95% CI, -18.8% to -20.7%), respectively. Subgroup analyses for patients with severe CAD and normal left ventricular ejection fractions yielded similar results.
Current evidence supports the use of GLS in the detection of moderate to severe obstructive CAD in symptomatic patients. GLS may complement existing diagnostic algorithms and act as an early adjunctive marker of cardiac ischemia.
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