Clinical Research in Cardiology最新文献

Background: In acute heart failure (AHF) patients, non-invasive estimation of left ventricular filling pressures (LVFPs) appears crucial to guide management. Although poorly investigated, left atrial (LA) mechanics play a pivotal role in this setting. This report sought to assess the correlation of echocardiographic LA stiffness index with invasive LVFPs and its diagnostic accuracy as compared to other parameters used in clinical practice.

Methods: In this observational, prospective study, 104 patients with suspected acute coronary syndrome and signs/symptoms of AHF were enrolled. Available invasive estimation of LVFPs was required. Comprehensive echocardiography was performed for all patients, including LA reservoir strain (LARS). LA stiffness index was derived by speckle-tracking analysis and Tissue Doppler imaging as early diastolic transmitral inflow velocity/mitral annulus early diastolic velocity [E/e']/LARS.

Results: Invasively measured LVFPs showed a strong correlation with LA stiffness index (Spearman ρ = 0.773, p < 0.0001), as well as with LARS and E/e'. Receiver operating characteristic (ROC) curve analysis was used to demonstrate better accuracy performed by LA stiffness index than average E/e', LA volume or LARS alone, in predicting high LVFPs. Guideline-recommended assessment of diastolic function was finally compared to LARS and LA stiffness index performances in an independent population group; we were hence able to obtain a LA stiffness threshold of 0.48 with a positive predictive value of 91.7% and a negative predictive value of 88.9% in identifying patients with high LVFPs.

Conclusions: For the first time, diagnostic performance of LA stiffness index has been investigated in a heterogeneous AHF population, providing correlations with invasively measured LVFPs and comparisons with established diastolic function metrics.

Background: The electrocardiogram (ECG) is routinely used in patients with suspected infiltrative cardiomyopathies; heart diseases characterized by the abnormal deposition of pathological substances in the myocardium. This study presents a review of ECG features attributable to various infiltrative cardiomyopathies and analyzes the prevalence and overlap of electrocardiographic abnormalities in patients with adjudicated CHF.

Results: The study included 573 consecutive CHF patients without severe aortic stenosis, further stratified by LV hypertrophy (LVH) and preserved or decreased LV ejection fraction. Comprehensive ECG analysis revealed at least one ECG abnormality typically associated with infiltrative cardiomyopathies in 95% of patients, and more than one ECG abnormality in 70%. An average number of ECG abnormalities was 2.2 ± 1.2 per patient. There was substantial overlap in ECG abnormalities in individual patients, particularly those attributable to Fabry's disease and hemochromatosis (51.5%) or cardiac amyloidosis (46.1%), and hemochromatosis and cardiac amyloidosis (44.2%). Prevalence of various ECG abnormalities was similar across various patient demographics and co-morbidities, including LVH status and/or history of CAD which did not increase the number of ECG abnormalities (2.155 ± 1.238 vs. 2.228 ± 1.192 in patients without CAD history, p = 0.969). Patients with reduced LV ejection fraction had a higher prevalence of widened QRS and premature ventricular complexes.

Conclusion: ECG abnormalities attributable to infiltrative cardiomyopathies are common in heart failure patients, with a significant overlap in findings classically attributed to various infiltrative cardiomyopathies. The presence of LVH and decreased LV ejection fraction do not significantly affect the prevalence of ECG abnormalities.

Background: Risk prediction in patients with severe, symptomatic aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) remains an unsolved issue. In addition to classical risk scoring systems, novel circulating biomarkers like mid-regional pro-adrenomedullin (MR-proADM) and growth differentiation factor 15 (GDF-15) may be of value in assessing risk.

Methods: Consecutive patients undergoing elective transfemoral TAVI were included in this prospective observational study. Baseline information, imaging findings, blood samples, and clinical outcomes were collected. Blood levels of the classical biomarkers interleukin-6 (IL-6) and high-sensitivity C-reactive peptide (hsCRP) and of the novel biomarkers MR-proADM and GDF-15 were measured and their predictive utility for mortality assessed.

Results: The study cohort consisted of 92 patients undergoing TAVI. The median age was 80.7 years [IQR 77.2;83.3], and 48 (52.2%) were male. Analysis of the area under the curve (AUC) of the receiver-operating characteristics showed that the hsCRP levels discriminated poorly (AUC 0.66, 95% CI [0.52;0.8], p = 0.027), whereas all other biomarkers reached a higher level of discrimination (IL-6: AUC 0.76, 95% CI [0.66;0.86], p < 0.001; MR-proADM: AUC 0.73, 95% CI [0.61;0.85], p = 0.002; GDF-15: AUC 0.73, 95% CI [0.61;0.85], p = 0.002). Kaplan-Meier analysis in conjunction with Youden J-statistics yielded the optimal cutoff points for each biomarker to predict survival: IL-6 4.65 pg/mL, hsCRP 12.9 mg/L, MR-proADM 1.02 nmol/L, and GDF-15 2400.1 pg/mL.

Conclusion: Novel circulating biomarkers like MR-proADM and GDF-15 may provide additional value in predicting survival after TAVI.

Background: Despite scarce data, invasive mechanical ventilation (MV) is widely suggested as first-line ventilatory support in cardiogenic shock (CS) patients. We assessed the real-life use of different ventilation strategies in CS and their influence on short and mid-term prognosis.

Methods: FRENSHOCK was a prospective registry including 772 CS patients from 49 centers in France. Patients were categorized into three groups according to the ventilatory supports during hospitalization: no mechanical ventilation group (NV), non-invasive ventilation alone group (NIV), and invasive mechanical ventilation group (MV). We compared clinical characteristics, management, and occurrence of death and major adverse event (MAE) (death, heart transplantation or ventricular assist device) at 30 days and 1 year between the three groups.

Results: Seven hundred sixty-eight patients were included in this analysis. Mean age was 66 years and 71% were men. Among them, 359 did not receive any ventilatory support (46.7%), 118 only NIV (15.4%), and 291 MV (37.9%). MV patients presented more severe CS with more skin mottling, higher lactate levels, and higher use of vasoactive drugs and mechanical circulatory support. MV was associated with higher mortality and MAE at 30 days (HR 1.41 [1.05-1.90] and 1.52 [1.16-1.99] vs NV). No difference in mortality (HR 0.79 [0.49-1.26]) or MAE (HR 0.83 [0.54-1.27]) was found between NIV patients and NV patients. Similar results were found at 1-year follow-up.

Conclusions: Our study suggests that using NIV is safe in selected patients with less profound CS and no other MV indication. NCT02703038.

Background: Ultrasound renal sympathetic denervation (uRDN) reduces blood pressure (BP) in the absence and presence of antihypertensive treatment at 2 months. Beyond 3 years, there is a lack of follow-up data. This study investigated the long-term safety and efficacy of uRDN.

Methods: This prospective observational study recruited patients previously included in the international multicenter ACHIEVE study, with office systolic blood pressure (SBP) ≥160 mmHg, 24 h ambulatory SBP ≥130 mmHg, ≥3 antihypertensive drugs and estimated Glomerular Filtration Rate (eGFR) ≥45 ml/min/1.73m² undergoing uRDN. The primary efficacy outcome was 24 h ambulatory SBP, adjusted for the number of defined daily dosages (DDD) of antihypertensive drugs. Statistical analyses were performed using linear mixed-effects models and inverse probability weighting.

Results: A total of 27 out of the initially enrolled 96 patients underwent prospective follow-up at a median of 8.2 [7.6-8.9] years. Mean age was 62.6±9.3 years (37.0% female). Preprocedural 24 h ambulatory BP was 151.9/84.1±11.5/11.1 mmHg and the median number of DDDs was 5.0 [4.3-7.0]. At 8 years after uRDN, the change in 24 h ambulatory SBP was -19.5 [95%CI -26.7,-12.4] mmHg (p<0.001). The 8-year change in the number of DDDs was -1.7 [-2.8,-0.6] (p = 0.003). The 8-year decline in eGFR was -8.9 [-13.2,-4.7] ml/min/1.73m² (p<0.001). Clinical event data were available for all 96 patients (median follow-up 3.5 [1.0-8.0] years). Renal failure occurred in one patient and no cases of renal artery stenosis were detected.

Conclusions: A significant BP reduction was observed up until 8 years following uRDN in parallel to a decrease in drug burden over time, in the absence of procedure-related adverse events.

Background: Planning noncardiac surgery after transcatheter aortic valve implantation (TAVI) is challenging. We evaluated the incidence, characteristics, and outcome of noncardiac surgeries in patients who underwent TAVI.

Methods: We retrieved data from the Prospective Segeberg TAVI registry of all patients who received TAVI between 2007 and 2020. Type, timing, urgency, and risk of noncardiac surgery were assessed. We evaluated the patients' clinical outcomes within 30 days following noncardiac surgery that included death, myocardial infarction, bleeding, stroke, and acute heart failure. A composite outcome of all adverse events was proposed to independently predict 30 day adverse events.

Results: Among 1602 patients, 104 patients (mean age, 79.9 ± 7.14 years; 61 (58.7%) females) underwent 148 noncardiac surgeries after TAVI. More than half of the noncardiac surgeries were considered elective (n = 84, 56.7%). Procedures were categorized into low-risk (n = 27, 18.2%), intermediate-risk (n = 102, 68.9%), and high-risk (n = 19, 12.8%) surgery. The composite outcome of adverse events occurred after 57 noncardiac surgeries (38.5% of all procedures) and after more than half of the surgeries in the high-risk group (n = 11, 57.9%). Major or life-threatening bleeding occurred in 24 noncardiac surgeries (19.1%) and was more frequent in high-risk surgeries than in low- and intermediate-risk surgeries (36.8%, p < 0.047). High-risk category of surgery was independently associated with increased risk of the composite outcome (adjusted OR, 3.99; 95% CI 1.12-14.23; p = 0.033).

Conclusion: Noncardiac surgery after TAVI was performed in 6.5% patient of our study cohort. High-risk noncardiac surgeries were associated with increased risk of adverse events.

Background: Intravenous iron improves symptoms in heart failure (HF) with iron deficiency (ID) but failed to consistently show a benefit in cardiovascular outcomes. The ID definition used may influence the response to intravenous iron. The aim of this meta-analysis is to assess the influence of ID definition on the intravenous iron effect in HF.

Methods/results: We performed a random-effects meta-analysis of randomized controlled trials (RCT) on intravenous iron (vs. placebo or standard of care) in patients with HF and ID that provided data on transferrin saturation (TSAT) and ferritin subgroups on the composite outcome of cardiovascular death (CVD) or HF hospitalizations (HFH). The risk ratio (RR) and 95% confidence intervals (95% CI) were extracted on the TSAT (< 20% and ≥ 20%) and ferritin (< 100 ng/mL and ≥ 100 ng/mL) subgroups. Data from four major RCT was collected including a total of more than 5500 patients. In patients with a TSAT < 20%, intravenous iron reduced the composite outcome of CVD or HFH: RR 0.81, 95%CI 0.69-0.94, while in patients with a TSAT ≥ 20% the effect was neutral: RR 0.98, 95%CI 0.79-1.21, interaction, P = 0.05. On the other hand, ferritin levels did not modify the effect of IV iron: ferritin ≥ 100 ng/mL RR 0.84, 95%CI 0.65-1.09, and ferritin < 100 ng/mL RR 0.85, 95%CI 0.74-0.97; interaction, P = 0.96.

Conclusions: Our meta-analysis suggests that the benefit of intravenous iron may be restricted to patients with TSAT < 20% regardless of ferritin levels and supports the single use of TSAT < 20% to identify patients with ID who may benefit from intravenous iron therapy.

Background: A routine echocardiogram aims at identifying only regional wall motion abnormality (RWMA) or left ventricle diastolic dysfunction (LVDD) for coronary artery disease (CAD). When absent, a study is often labeled "normal." This creates an unmet need to identify and add subtle markers of CAD to the routine echocardiogram to increase the diagnostic yield.

Methods: Left ventricle (LV) systolic and diastolic parameters, along with left atrium (LA) strain parameters, were assessed using echocardiography in one hundred three patients of stable angina undergoing coronary angiography and compared with their SYNTAX score-II (SS-II).

Results: The left ventricle global longitudinal strain (LV-GLS) and LA Volume indexed (LAVi) did not correlate significantly with the SS-II. The LA filling pressures reflected by the ratio of early mitral inflow velocity with early mitral annular velocity (E/e`), however, increased significantly with SS-II, with a cut-off value >10.39 for significant CAD (pvalue <0.001). The LA reservoir function parameters, peak atrial longitudinal strain (PALS), and peak global systolic strain rate (LAsSR) decreased significantly with increasing SS-II (p values of 0.011 and 0.001, respectively). The values < 23.56 for PALS and less than 1.15 for LAsSR, showed a significant association with CAD. The LA conduit function parameter, peak global early diastolic strain rate (LAeSR), also increased significantly with increasing SS-II (p-value <0.001), with values > 1.09 having a good correlation with CAD.

Conclusion: Besides RWMA and LV-GLS, the LV diastolic and LA strain parameters can be potential echocardiographic markers for CAD in stable angina patients.