Abstract
The aim of study was to compare efficacy of therapy with ramipril (R, 10 mg) + spironolacton (S, 25 mg), valsartatan (V, 320 mg) + S, sacubitril/valsartan (S/V, 97/103 mg), and S/V+S on ...prognosis, left (LV) and right ventricular (RV) and atrial (LA) and (RA) functional parameters, NT-pro-BNP (pg/ml), transforming growth factor-beta (TGF-β) and hsCRP (ng/ml) levels in patients (pts) with III NYHA FC heart failure in relation to reduced (HFrEF), mid-ranged (HFmEF) or preserved (HFpEF) ejection fraction (EF).
Methods
122 pts (age 58.4) with HFrEF (EF<50), 108 pts (age 59.9) with HFmEF (40≤EF<50) and 104 pts (age 63.1) with HFpEF (EF≥50) in sinus rhythm were randomly assigned to groups, receiving R+S (n=32; 28; 27), V+S (n=30; 27; 26) and S/V (n=31; 27; 26) and S/V+S (n=29; 26; 25) in addition to diuretics and beta-blockers.
Results
1-year mor-tality and hospitalization (%) were, 40.6 and 73.3; 39.3 and 57.1; 33.3 and 55.5 in R+S; 43.3 and 76.7; 40.7 and 59.3; 38.5 and 57.7 in V+S; 32.3 and 58.1; 29.6 and 48.1 and 30.1 and 42.3 in S/V and 31 and 55.2; 30.8 and 42.3 and 32 and 40 in S/V+S receiving groups with HFrEF, HFmEF and HFpEF, respectively.
Survival analysis revealed RR reduction of 1-year mortality at 20.7 and 23.6; 25.4 and 28.4 and hospitalization at 20.7 and 24.3; 24.7 and 29.3 in HFrEF pts, treated by S/V and S/V+S, compared to R+S and V+S, respectively (p<0.05). Similarly, 1-year mortality and hospitalization were reduced at 24.7 and 21.6; 27.3 and 24.3 in HFmEF pts. Significant reduction of 1-year hospitalization at 23.8 and 23.7; 27.9 and 30.7 (p<0.05), but not mortality was revealed in V/S and V/S+S treatment group with HFpEF. 1-year S/V and S/V+S treatment significantly (at % from baseline, p<0.01) decreased levels of TGF-β at 32.3 and 34.5; 31.3 and 33.3, NT-pro-BNP at 40.3 and 42.3 and 38.9 and 40.1, e' at 30.6 and 31.5; 30.2 and 30.6,Ar-A at 56.6 and 58.8; 55.1 and 57.2, RAFI at 34.3 and 35.1; 32.9 and 33.6, LAFI at 35.7 and 36.6; 34.9 and 35.2, LV EF at 23.1 and 24.2; 22.1 and 23.4 in pts with HFrEF and HFmEF, and significant changes of hsCRP at 34.6 and 35.2, levels of TGF-β at 30.2 and 31.2, TAPSE at 42.2 and 43.4, e' at 26.2 and 28.2, PA ET at 19.8 and 20.3 in pts with HFpEF, compared to R+S and V+S, respectively.
Conclusions
1) S/V and S/V+S treatment associated with significant reduction of morbidity and mortality in pts with HFrEF and HFmEF, and hospitalization in HFpEF compared to use of R+S and V+S. 2) Changes of NT-pro-BNP, Ar-A, RAFI and LAFI, e' ≥40%, TGF-β ≥30% identified pts with cardiovascular risk reduction in HFrEF and HFmEF groups, while changes of TGF-β, hsCRP≥30%; PAET ≥30% revealed pts with improvement of morbidity in pts with HFpEF. 3) Prognostic improvement in pts treated by S/V and S/V+S has related to improvement of TGF-β, LV systolic and diastolic functional parameters, LA and RA functional parameters in HFrEF and HFmEF and to TGF-β, hsCRP, LV diastolic and RV functional parameters changes in HFpEF.
Abstract
Preclinical diastolic disfunction (PDD) often progresses to heart failure and distinct clinical predictors for this transformation are yet to be defined. Since deterioration of longitudinal ...strain (LS) can occur before the changes of more conventional parameters, we assumed that right ventricular free wall longitudinal strain (RVLS) might start deteriorating before the pulmonary hypertension can be established.
Methods
We followed up 243 patients (143 female) 67±9 years with PDD for 3 years. All patients had an impaired relaxation or pseudo normal transmitral patterns and E/e' 8–13 at rest, normal NT-proBNP values, and systolic pulmonary artery pressure (sPAP) ≤30 mm Hg. PDD was diagnosed by stress echocardiography (SE) if E/e' ≥13, transmittal E wave deceleration time reduction >50ms, systolic pulmonary artery pressure (sPAP) <30 mmHg, and patients remained asymptomatic during SE. RVLS as average of RV free wall 3 segments values, left atrial peak reservoir LS (LALS) as average of two LA basal segments in four chamber view and left ventricular peak systolic global LS (LVGLS) were measured by speckle tracking (ST). ST and SE was performed with 6 months intervals. 35 healthy subject served as controls.
Results
Patients with PDD had higher RVLS, LVGLS, and lower LALS compared with controls (RVLS –23.2±4.2% vs –27.3±5.1%, p<0.001; LVGLS –17.8±5.2% vs –21.9±2.8%, p<0.001; LALS 39.7±3.7% vs 44.1±4.9%, p<0.002). 76 (31.3%) patients developed sPAP increase >30 mmHg at rest or SE during follow up of which 34 (44.7%) had dyspnea. Patients with increased sPAP had higher RVLS and lower LALS values at baseline compared with the rest of PDD patients without significant differences in other parameters (RVLS –17.9±2.8% vs –24.8±3.6%, p<0.002; LALS 37.7±2.3% vs 41.5±3.6%, p<0.003; LVGLS –17.4±4.8% vs –18.2±5.1%, p>0.05). Both LALS and RVLS correlated with LA end diastolic volume index (LALS r=0.51, p<0.01; RVLS r=0.54, p<0.01). Additionally RVLS was an independent predictor of sPAP rise (OR=2.7; 95% CI=2.43–6.92; p<0.01).
Conclusion
RVLS is an independent predictor of sPAP increase in patients with PDD.
Abstract
Mitral regurgitation (MR) leads to subclinical changes that often cannot be detected by low sensitive conventional parameters and early predictors of deterioration could suggest a better ...timing for intervention.
Methods
We follow up 175 asymptomatic patients 56±13 years (79 female) with severe primary MR in sinus rhythm and without diabetes mellitus and renal disease for 2 years. Global longitudinal strain (LS) of left ventricle (LVGLS), right ventricular (RV) free wall LS (RVLS), and left atrial (LA) peak reservoir LS as average of two basal segments in 4 chamber view were measured by speckle tracking along with indexes of LV end-systolic and end-diastolic volumes, LV ejection fraction (EF), left atrial end-systolic volume index (LAVi) every 6 months. Normal reference values of LS were obtained from age and sex matched 40 healthy controls.
Results
Patients with MR had higher LV ejection fraction (EF), LVGLS, LALS and lower values of RVLS compared with controls (EF 67.4±5% vs 59.3±4%, p<0.05; LVGLS –25.2±2.3% vs –21.2±1.9%, p<0.03; LALS 46.2±5.1% vs 42.4±3.7%, p<0.04; RVLS –23.4±5.1% vs –27.3±2.8%, p<0.03). 53 (30%) patients developed symptoms at exercise during follow up. Symptomatic patients at baseline had higher values of RVLS compared with patients who remained asymptomatic during follow up without significant differences in EF, LVGLS, LALS (RVLS –21.4±2.6% vs –25.8±3.2%, p<0.02; EF 66.8±2.4% vs 68.1±3.1%, p>0.05; LVGLS –24.8±2.1% vs –25.3±2.3%, p>0.05; LALS 45.7±4.1% vs 46.5±4.4%, p>0.05). RVLS correlated with LAVi (r=0.53, p<0.01) and LALS (r=0.57, p<0.01). Regression analysis defined RVLS as an independent predictor of symptoms development (OR=3.2; 95% CI=1.37–7.63; p<0.01).
Conclusion
RV longitudinal strain predicts symptoms in patients with chronic primary mitral regurgitation.
Abstract
Left atrial (LA) dimensions, wall composition and function strongly depend on left ventricular (LV) diastolic function and impaired in patients with preclinical diastolic disfunction (PDD), ...which increases the likelihood of atrial fibrillation (AF) occurrence. LA longitudinal strain (LALS) is a sensitive parameter of subclinical myocardial changes and its reduction might be predictive for AF.
Methods
168 patients (90 female) 68±9 years with arterial hypertension in sinus rhythm with preserved systolic function (LVEF>50%) and PDD and without renal or valvular disease and 45 age and sex matched healthy controls were followed up for 2 years. PDD was diagnosed at stress echocardiography (SE) if E/e' ≥13, transmittal E wave deceleration time reduction >50ms, systolic pulmonary artery pressure (sPAP) >30 mmHg, and patients remained asymptomatic. LALS was measured by speckle tracking echocardiography as average value of two basal segments in 4 chamber view along with LA end-systolic volume index (LAVi), LA EF, LV mass index (LVMi), and LVLS. 72 hours Holter monitoring was performed every 6 months.
Results
Patients with PDD had larger LAVi, less LALS, higher LVLS and bigger LVMi compared with controls (LAVi 30.5±4.9 ml/m2 vs 23.1±4.8 ml/m2, p<0.001; LALS 34.7±6.9% vs 45±4.3%, p<0.001; LVLS –17.4±2.4% vs –20.8±2.1%, p<0.002; LVMi 81.8±12.3 g/m2 vs 68±9.2 g/m2, p<0.001). AF was registered in 42 (25%) patients with PDD. LAVi, LVLS and LVMi did not significantly differ in PDD patients with or without incidents of AF however LALS was significantly less in patients with AF (26.8±7.5% vs 37.2±8.1%, p<0.01). Multivariate analysis defined LALS as an independent predictor of AF development (OR=2.4; 95% CI=2.41–5.96; p<0.01) with the cut-off value of 28.9%.
Conclusion
LA peak reservoir LS is an independent predictor of AF development in patients with PDD.
Abstract
Accurate surgical timing for significant primary mitral regurgitation (PMR) still remains an issue despite of several ways of left ventricular (LV) hidden disfunction detection, including ...LV global longitudinal strain (GLS). Since novel modalities such as myocardial work (MW) or area strain (AS) are currently available we assumed that they might predict surgical timing beyond known parameters.
Methods
58 patients (31 female) 63±8 years, asymptomatic and with pulmonary systolic pressure (PSP) ≤45 mmHg on exercise echo test (ET), with PMR, in sinus rhythm, with ejection fraction (EF) ≥65% and GLS <−19.5% were enrolled into the study along with 23 healthy subjects matched by age and sex and followed up for 1 year. Comprehensive echocardiography (EchoCG) was performed with offline analysis including MW and AS by one experienced specialist. GW index (GWI) was obtained from pressure-strain loops derived from speckle tracking analysis multiplied by brachial systolic blood pressure.Global constructive work (GCW) as the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation, global wasted work (GWW) aa energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation, and GW efficiency (GWE) as the percentage ratio of constructive work to the sum of constructive work and wasted work were obtained by the dedicated software.
Results
13 (22%) patients with PMR became symptomatic or increase PSP >50 mmHg on ET in 1 year follow up. EF, GLS, AS and GWI did not differ between symptomatic patients and those who remained asymptomatic during follow up, however these patients had significantly lower values of GCW, and higher values of GWW (EF 68.3±6.1% vs 69.2±6.5%, p=NS; GLS –22.4±2.3% vs 23.1±3.2%, p=NS, GWI 2452±161 mmHg% vs 2479±147 mmHg%, p=NS; GCW 1875±119 mmHg% vs 2321±124 mmHg%, p<0.01; GWW 118±9 mmHg% vs 88±7 mmHg%, p<0.03; GWE 93±8% vs 96±9%, p=NS; AS −32.5±5.4% vs −34.3±6.1%, p=NS;). Patients with subsequent symptoms development had significantly lower values of GCW and higher values of GWW. Among all parameters GCW was the predictor of MR clinical course worsening (AUC 0.769).
Conclusion
MR GCW is able to predict clinical course of patients with PMR beyond known conventional parameters.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): City Hall resources
Abstract
Background
Despite advances in treatment of heart failure with preserved ejection fraction (HFpEF) its management remains challenging. SGLT2 inhibitors benefits across the full range of ...ejection fraction, and sacubitril/valsartan benefits up to the lower end of preserved EF <57% implies that in some patients with HFpEF some pathophysiological mechanisms of HFrEF might co-exist, and some subset of HFpEF patients might benefit from proven treatment of HFrEF, particularly those with EF deterioration over time. We aimed to found out predictors of EF deterioration in HFpEF patients assuming that we can start treating them earlier with therapies of HFrEF, preventing further deterioration.
Methods
We studied 215 patients (63% women) 73±8 years with HFpEF. All patients had records of comorbidity Charlson index (CI), glomerular filtration rate (GFR). Echocardiography (EchoCG) was performed with offline analysis, including calculations of myocardial work (MW), global longitudinal (LS), radial (RS), circumferential (SS) and area strain (AS) by one experienced specialist. GW index was obtained from pressure-strain loops derived from speckle tracking analysis multiplied by brachial systolic blood pressure. Global constructive work (GCW) as the sum of positive work due to myocardial shortening during systole and negative work due to lengthening during isovolumic relaxation, global wasted work as energy loss by myocardial lengthening in systole and shortening in isovolumic relaxation, and GW efficiency as the percentage ratio of constructive work to the sum of constructive work and wasted work were obtained. RS, SS and AS were calculated in 3D by dedicated software. Patients followed up for 3 years.
Results
5 patients developed myocardial infarction and were excluded from the study. Baseline EF was higher in women (61,2±3,1 vs 56,4±2,7; P<0.002), in patients >70 years (62,4±2,1 vs 57,1±2,3; p<0.005), and with end-diastolic volume index <60 ml/m2 (56,1±3,2 vs 63,4±2,3; p<0.001). Overall decline in EF compare to baseline was −7.3±1.6%, p<0.01. Reduction in EF was more prominent in patients >70 years (−6,9±1,8 vs −5,7±1,7; P<0,002), and in patients with coronary artery disease (CAD) (−7,2±1,9 vs −5,8±1,6; P<0,001) and did not relate to sex, LV size, CI, and GFR. During follow up 58 (27%) patients had EF <50%. We observed significant worsening in AS (−27.9±8.5% vs −24.7±5.3%, p<0.003), LS (−19.7±2.4% vs −17.1±1.6%, p<0.005), and GCW (GCW 2378±117 vs 2107±102 mmHg%, p<0.002). Patients with EF <50% at the end of the study had significantly less AS and GCW baseline values compared with patients with EF>50% (22.4±7.2% vs −27.6±8.1%, p<0.002; 2081±92 vs 2489±127 mmHg%, p<0.001). GCW was the predictor of EF deterioration (area under curve 0,875).
Conclusion
GCW predicts reduction of EF in patients with HFpEF which may help earlier identify the subset of HFpEF patients who may benefit from proven therapies for HFrEF and prevent upcoming deterioration.
Funding Acknowledgement
Type of funding sources: None.
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