Abstract
Background. Left ventricular mechanical dyssynchrony (LVMD), left ventricular hypertrophy, and impaired cardiac sympathetic innervation are closely related to the development of heart failure (HF) and unfavorable outcomes. Methods and Results. A total of 705 consecutive HF patients with reduced left ventricular ejection fraction (EF) < 50% were registered in our hospital HF database. LVMD and left ventricular mass index (LVMI) were evaluated three-dimensionally by gated myocardial perfusion SPECT. LVMD was measured as a heterogeneity index (phase SD) of the regional contraction phase angles calculated by Fourier analysis. Cardiac sympathetic innervation was quantified as a normalized heart-to-mediastinum ratio (HMR) of the 123I-metaiodobenzylguanidine (MIBG) activity. The patients were followed up with a primary end point of lethal cardiac events (CEs) for 42 months. CEs were documented in 246 of the HF patients who had a greater phase SD, greater LVMI, and lower MIBG HMR than those in HF patients without CEs. In the overall multivariate analysis, phase SD, LVMI, and MIBG HMR were identified as significant CE determinants. The three biomarkers were incrementally related to increases in CE risks. Conclusions. Assessment of cardiac sympathetic innervation can further stratify patients with systolic heart failure at increased cardiac risk identified by left ventricular hypertrophy and mechanical dyssynchrony.
Highlights
Management of patients with heart failure (HF) is becoming a critical concern to be resolved due to rapid increases in the number of elderly patients, and the increase in expenditure for life-saving measures and subsequent long-term medical care [1,2]
A total of 705 patients were consecutively and prospectively registered in our hospital HF database between April 2011 and December 2016 using the following entry criteria: symptomatic HF established by typical symptoms and signs based on the Framingham criteria including palpitation, dyspnea/orthopnea, neck vein distension, peripheral and/or lung congestion S3/S4 gallop, chest radiographic findings of congestive heart failure, echocardiographic left ventricular ejection fraction (LVEF) less than 50% at admission, and a significant increase in brain natriuretic peptide (BNP)
Case 2 had markedly reduced LVEF (28%) and heart-to-mediastinum ratio (HMR) (1.48), had increased left ventricular mass index (LVMI) (178 g/m2) and phase standard deviation (SD) (40 degrees), and the patient died of progression of HF (Figure 1, Case 2)
Summary
Management of patients with heart failure (HF) is becoming a critical concern to be resolved due to rapid increases in the number of elderly patients, and the increase in expenditure for life-saving measures and subsequent long-term medical care [1,2]. Among the known prognostic clinical variables, left ventricular hypertrophy (LVH) is a classical but still important variable, but has been conventionally assessed by electrocardiography or two-dimensional echocardiography. Attention has recently been given to left ventricular mechanical dyssynchrony (LVMD) in relation to prognostic implications, and to the clinical indication of cardiac re-synchronization treatment (CRT). Besides technical issues of device implantation, this is probably because of the limited assessment using an electrical and/or two-dimensional echo data, resulting in an ineffective CRT rate of nearly 30% [9,10]. Left ventricular mechanical dyssynchrony (LVMD), left ventricular hypertrophy, and impaired cardiac sympathetic innervation are closely related to the development of heart failure (HF) and unfavorable outcomes. Assessment of cardiac sympathetic innervation can further stratify patients with systolic heart failure at increased cardiac risk identified by left ventricular hypertrophy and mechanical dyssynchrony
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