Asymptomatic Left Ventricular Dysfunction Research Articles

Transition from asymptomatic to symptomatic systolic chronic heart failure: rationale and design of TransitionCHF.

Chronic systolic heart failure (CHF) is a major health burden. A relevant number of patients shows asymptomatic left ventricular dysfunction (ALVSD) before symptomatic CHF or becomes asymptomatic after initiating heart failure therapy. Clinical course, prognosis, and response to pharmacological and device-based treatment are largely unknown in these two distinct groups of patients. Current pharmacological and interventional therapies do neither properly address the underlying pathophysiology nor prevent malignant loss of function. New therapeutic paradigms are needed to stop the progression from asymptomatic to symptomatic heart failure. Key questions are what causes progression of clinically asymptomatic New York Heart Association (NYHA) I heart failure to overt heart failure (>NYHA I) in some but not all patients and the underlying reasons for this transition. This requires the identification of disease mechanisms and biomarkers that predict outcome in well-defined cohorts for innovative preclinical and clinical trials. TransitionCHF is a prospective, multicentre, longitudinal pathophysiological evaluation cohort study in patients with asymptomatic systolic dysfunction NYHA I and left ventricular ejection fraction ≤40%. The cohort comprises both incidental findings and patients who had become asymptomatic after a previous symptomatic event. TransitionCHF has recruited 1000 patients with ALVSD caused by various aetiologies in 20 university heart failure clinics across Germany. Both patients with and without comorbidities at study entry will be recruited. Patients will be systematically investigated and followed up annually over the course of the study. The primary composite endpoint is time to hospitalization for heart failure and cardiovascular death. The secondary endpoints assess time to all-cause mortality, to cardiovascular mortality, to heart failure mortality, to all-cause hospitalization, to heart failure hospitalization, and to recurrent heart failure hospitalizations, as well as time to assist device implantation/transplantation. Additional investigations focusing on biomarkers, comorbidities, gender aspects, nutrition, and functional parameters including quality of life will be performed. TransitionCHF will provide a more thorough pathophysiological understanding of the progression of asymptomatic systolic dysfunction into symptomatic heart failure that will help develop therapies tailored to prevent progressive heart failure.

Use of the energy waveform electrocardiogram to detect subclinical left ventricular dysfunction in patients with type 2 diabetes mellitus

BackgroundRecent guidelines propose N-terminal pro-B-type natriuretic peptide (NT-proBNP) for recognition of asymptomatic left ventricular (LV) dysfunction (Stage B Heart Failure, SBHF) in type 2 diabetes mellitus (T2DM). Wavelet Transform based signal-processing transforms electrocardiogram (ECG) waveforms into an energy distribution waveform (ew)ECG, providing frequency and energy features that machine learning can use as additional inputs to improve the identification of SBHF. Accordingly, we sought whether machine learning model based on ewECG features was superior to NT-proBNP, as well as a conventional screening tool—the Atherosclerosis Risk in Communities (ARIC) HF risk score, in SBHF screening among patients with T2DM.MethodsParticipants in two clinical trials of SBHF (defined as diastolic dysfunction [DD], reduced global longitudinal strain [GLS ≤ 18%] or LV hypertrophy [LVH]) in T2DM underwent 12-lead ECG with additional ewECG feature and echocardiography. Supervised machine learning was adopted to identify the optimal combination of ewECG extracted features for SBHF screening in 178 participants in one trial and tested in 97 participants in the other trial. The accuracy of the ewECG model in SBHF screening was compared with NT-proBNP and ARIC HF.ResultsSBHF was identified in 128 (72%) participants in the training dataset (median 72 years, 41% female) and 64 (66%) in the validation dataset (median 70 years, 43% female). Fifteen ewECG features showed an area under the curve (AUC) of 0.81 (95% CI 0.787–0.794) in identifying SBHF, significantly better than both NT-proBNP (AUC 0.56, 95% CI 0.44–0.68, p < 0.001) and ARIC HF (AUC 0.67, 95%CI 0.56–0.79, p = 0.002). ewECG features were also led to robust models screening for DD (AUC 0.74, 95% CI 0.73–0.74), reduced GLS (AUC 0.76, 95% CI 0.73–0.74) and LVH (AUC 0.90, 95% CI 0.88–0.89).ConclusionsMachine learning based modelling using additional ewECG extracted features are superior to NT-proBNP and ARIC HF in SBHF screening among patients with T2DM, providing an alternative HF screening strategy for asymptomatic patients and potentially act as a guidance tool to determine those who required echocardiogram to confirm diagnosis.Trial registration LEAVE-DM, ACTRN 12619001393145 and Vic-ELF, ACTRN 12617000116325

Prognostic value of left ventricular systolic function before vascular surgery: a systematic review.

Vascular surgery carries a high risk of post-operative cardiac complications. Recent studies have shown an association between asymptomatic left ventricular systolic dysfunction and increased risk of major adverse cardiovascular events (MACE). This systematic review aims to evaluate the prognostic value of left ventricular function as determined by left ventricular ejection fraction (LVEF) measured by resting echocardiography before vascular surgery. This review conformed to PRISMA and MOOSE guidelines. PubMed, OVID Medline and Cochrane databases were searched from inception to 27 October 2022. Eligible studies assessed vascular surgery patients, with multivariable-adjusted or propensity-matched observational studies measuring LVEF via resting echocardiography and providing risk estimates for outcomes. The primary outcomes measures were all-cause mortality and congestive heart failure at 30 days. Secondary outcome included the composite outcome MACE. Ten observational studies were included (4872 vascular surgery patients). Studies varied widely in degree of left ventricular systolic dysfunction, symptom status, and outcome reporting, precluding reliable meta-analysis. Available data demonstrated a trend towards increased incidence of all-cause mortality, congestive heart failure and MACE in patients with pre-operative LVEF <50%. Methodological quality of the included studies was found to be of moderate quality according to the Newcastle Ottawa Checklist. The evidence surrounding the prognostic value of LVEF measurement before vascular surgery is currently weak and inconclusive. Larger scale, prospective studies are required to further refine cardiac risk prediction before vascular surgery.

Opportunistic Screening for Asymptomatic Left Ventricular Dysfunction With the Use of Electrocardiographic Artificial Intelligence: A Cost-Effectiveness Approach

BackgroundThe burden of asymptomatic left ventricular dysfunction (LVD) is greater than that of heart failure; however, a cost-effective tool for asymptomatic LVD screening has not been well validated. We aimed to prospectively validate an artificial intelligence (AI)–enabled electrocardiography (ECG) algorithm for asymptomatic LVD detection and evaluate its cost-effectiveness for opportunistic screening. MethodsIn this prospective observational study, patients undergoing ECG at outpatient clinics or health check-ups were enrolled in 2 hospitals in Taiwan. Patients were stratified into LVD (left ventricular ejection fraction ≤ 40%) risk groups according to a previously developed ECG algorithm. The performance of AI-ECG was used to conduct a cost-effectiveness analysis of LVD screening compared with no screening. Incremental cost-effectiveness ratio (ICER) and sensitivity analyses were used to examine the cost-effectiveness and robustness of the results. ResultsAmong the 29,137 patients, the algorithm demonstrated areas under the receiver operating characteristic curves of 0.984 and 0.945 for detecting LVD within 28 days in the 2 hospital cohorts. For patients not initially scheduled for ECG, the algorithm predicted future echocardiograms (high-risk, 46.2%; medium-risk, 31.4%; low-risk, 14.6%) and LVD (high-risk, 26.2%; medium-risk, 3.4%; low-risk, 0.1%) at 12 months. Opportunistic screening with AI-ECG could result in a negative ICER of −$7,439 for patients aged 65 years, with consistent cost-savings across age groups and particularly in men. Approximately 91.5% of the cases were found to be cost-effective at the willingness-to-pay threshold of $30,000 in the probabilistic analysis. ConclusionsThe use of AI-ECG for asymptomatic LVD risk stratification is promising, and opportunistic screening in outpatient clinics has the potential to reduce costs.

Outcomes of asymptomatic left ventricular dysfunction in the patient with or without type 2 diabetic Mellitus

Abstract Background Type 2 diabetes mellitus (T2DM) has been related to ventricular systolic and diastolic dysfunction and subsequent heart failure. [1] The study aimed to investigate the prevalence of asymptomatic left ventricular dysfunction (aLVD) in subjects with T2DM, and its predisposing factors. Method Subjects without existed cardiovascular disease were eligible for this study. Left ventricular ejection fraction (LVEF), mitral E/A ratio, peak mitral annulus tissue velocity (e’), left atrial dimension (LAD), peak tricuspid regurgitation velocity (TR Vmax) were obtained by a standard echocardiographic study. Asymptomatic left ventricular diastolic dysfunction (ALVSD) was defined as LVEF &amp;lt; 50% and the asymptomatic left ventricular diastolic dysfunction (ALVDD) was defined as having three or more of the four parameters: septal e' &amp;lt; 7, septal E/e’&amp;gt;15, LAD &amp;gt; 40mm, and TR Vmax &amp;gt; 2.8 m/s. [2] All-cause mortality up to 2 years was obtained by linking to the National Death Registry. Result A total of 27684 subjects (59.6±17.4 years, 46.2% men, 17.7% diabetes) were included in this study(Table 1). The ALVSD patients were older, male dominant, more prevalent with hypertension, diabetes mellitus and coronary artery disease, and had higher BMI, lower hemoglobin, and estimated glomerular filtration rate. ALVSD and ALVDD was more prevalent in patients with T2DM than those without (4.9% vs 8.2%, P&amp;lt;0.001)(15.4% v.s. 32.1%) (Figure 1). Age (odds ratio and 95% confidence interval: 1.04, 1.03–1.04), male gender(2.24, 1.99-2.52), T2DM (1.28, 1.11-1.46), coronary artery disease (1.38, 1.14-1.68), hemoglobin (0.95, 0.91-1.00), CKD stage 3(2.02, 1.63-2.50), and CKD stage 4-5(3.95, 3.06-5.09) were all independently correlated to ALVSD(Table 2a). On the other hand age (odds ratio and 95% confidence interval: 1.07, 1.07–1.08), BMI (1.12, 1.11-1.13), T2DM (1.34, 1.24-1.46), hypertension (1.31, 1.20-1.43), hemoglobin (0.88, 0.85-0.91), and CKD stage 4-5(3.11, 2.58-3.76) were independently correlated to ALVDD(Table 2b). During a mean follow-up of 5.3 ± 3.6 years, there were 2625 deaths (9.5%). The Kaplan–Meier curve analysis revealed diabetic subjects with were associated with the worst survival rate than those with either T2DM or ALVSD/ALVDD (Figure 2). The Cox regression analysis revealed the ALVDD and ALVSD was related to mortality, independent of age, gender, body mass index, hypertension, coronary artery disease, hemoglobulin, estimated glomerular filtration rate, and medication [hazard ratio and 95% confidence interval of mortality(ALVSD/ALVDD): 1.78 (1.40–2.25)/1.31(1.15-1.49)]. Conclusion ALVD has a high disease burden in patients without established cardiovascular disease, and its prevalence is higher in patients with T2DM, which was associated with an excessive mortality rate. Therefore, early screening and intervention should be considered in diabetic patients.

Improved heart failure screening and prevention in type 2 diabetes mellitus by cardiologist in rural areas

Abstract Purpose Guidelines recommend screening in type 2 diabetes mellitus (T2DM) for unrecognised asymptomatic left ventricular systolic dysfunction (LVSD), reduced (HFrEF), mid-range (HFmrEF) or preserved (HFpEF) heart failure (HF) with periodic evaluation of natriuretic peptides (NTproBNP) or echocardiography (echo). Tissue doppler and speckle-tracking echo may be needed to facilitate HF diagnosis at earlier, more treatable stage. Methods 2185 consecutive asymptomatic T2DM (age 62 ±4 years, 62% women) patients (pts) were referred from January 2015 by rural diabetologists (dia) to echolab with elevated NTproBNP (&amp;gt;125 pg/mL) or 5-year HF risk score WATCH-DM ≥14 points. After exclusion of abnormal electrocardiogram or chest x-ray and significant valvular heart disease was compared continued usual care by diabetologist with randomly assigned prospective follow-up by regional cardiologist. Results At referral in both groups were similar baseline characteristics, 20% pts were treated with ACE-inhibitor (ACEi), 2% beta-blockers (BB). After cardiologist consultation ACEi and BB use increased significantly to 96% and 84% in both groups (all p &amp;lt;0.001). Global LVSD (EF≤50%) was detected in 8% at baseline and 29% pts after 5 years in diabetologist group, respectively 9% at baseline and 13% after 5 years in cardiologist group (p &amp;lt;0.001). Systolic dysfunction (S’≤6.0 cm/s) occured in 20% at baseline and 41% pts after 5 years in dia group, respectively 19% at baseline and 24% after 5 years in cardiologist group (p &amp;lt;0.001). Reduced global longitudinal (GLS&amp;lt;16%) observed in 26% at baseline and 59% pts after 5 years in dia group, respectively 26% at baseline and 36% after 5 years in cardiologist group (p &amp;lt;0.001). At baseline we found 1% pts with new-onset HF in both groups (only HFmrEF). After mean follow-up of 54 ±7 months in cardiologist group developed new HF in 4% pts (2% HFmrEF, 2% HFpEF) compared with 25% pts (3% HFrEF, 7% HFmrEF, 15% HFpEF) in diabetologist group (p &amp;lt;0.001). Significant (p &amp;lt;0.001) predictors of incident HFmrEF were systolic dysfunction (S’≤6.0 cm/s), hazard ratio (HR) 3.6, 95% CI 2.96-4.2) and reduced GLS (HR 4.6, 95% CI 3.8-5.2), all p &amp;lt;0.01. The strongest (p &amp;lt;0.001) predictors of incident HFpEF were new-onset atrial fibrillation (HR 2.5, 95% CI 1.2-3.7) and echo-detected left ventricular hypertrophy (septal and posterior wall thickness ≥13 mm, HR 1.7, 95% CI 1.2-2.1), all p &amp;lt;0.01. Conclusions For preventing HF progression is required additional research focused on cooperative care between diabetologists and specialised HF outpatient clinic.

Asymptomatic left ventricular systolic dysfunction in hypertensive patients with disturbed ventriculo arterial coupling

Abstract Funding Acknowledgements Type of funding sources: None. Background Left ventricular (LV) ejection fraction (LVEF) is most commonly used validated echocardiographic parameter of systolic function estimation, but left ventricular (LV) global longitudinal strain (GLS) is an early indicator of subclinical cardiac dysfunction, even when LVEF is normal. Purpose To investigate ventriculo – arterial coupling (VAC) and LV function in asymptomatic hypertensive patients without target organ damage to compare different echocardiographic parameters for systolic function. Methods A total 110 patients (56 ± 14 years) with hypertension, were separated in two groups: 32(men, ( 59 %)) patients with normal AE/Ees ratio (Arterial elastance (AE) and ventricular elastance (Ees)) and 78 (men, ( 64%)) hypertensive patients with decrease AE/Ees ratio, marker for ventriculo – arterial coupling. All patients underwent standard two – dimentional echocardiography with Speckle tracking analysis for LV - GLS. End – systolic pressure was determined from the brachial pulse wave. Arterial elastance (AE) and ventricular elastance (Ees) were calculated as and – systolic pressure/stroke volume and end – systolic pressure/end – systolic volume. Results Patients with disturbed VAC had concentric hypertrophy whereas patients with normal VAC had concentric remodeling. There were no significant differences in EF, but GLS in all patients was reduced. There were no statistically significant differences in LV diastolic function parameters. Statistically significant differences in echocardiographic parameters were found in patients with normal VAC in comparison with disturbed VAC (TABL. 1), There are negative correlation between LV - GLS and AE/Ees (r = -0.327, p = 0.001) and positive with Ees (r=0.250, p = 0.015). Conclusion LV - GLS is a more sensitive parameter of LV systolic function than LVEF, when LV concentric hypertrophy is present in hypertensive patients. Further investigation are needed to confirm the superiority of GLS over LVEF in LV systolic function estimation and its implementation in clinical practice.

Left ventricular function in type 2 diabetics

Diabetic cardiomyopathy has been proposed as an independent cardiovascular disease and many mechanisms, such as microvascular disease, autonomic dysfunction, metabolic disorders, and interstitial fibrosis, have been suggested as causative factors. However, the exact causes and mechanisms of diabetic cardiomyopathy remain unclear. Several studies have demonstrated evidence for preclinical left ventricular (LV) diastolic dysfunction in patients with diabetes mellitus (DM) independent of coronary disease or hypertension. The prevalence of diastolic dysfunction in asymptomatic patients with type 2 diabetes mellitus or its relation with other diabetic complications (nephropathy, retinopathy, and neuropathy) is not well defined and data are controversial. A case series study of ninety patients with type 2 diabetes mellitus was designed to determine the frequency of asymptomatic left ventricular diastolic dysfunction in type 2 diabetes patients and its relation to patients’ duration, control of diabetes and other factors, the setting was at Diabetes Clinic, Echocardiography Unit and wards of Ibn Sina Teaching Hospital. During the period from the 1st of July to 31st of December 2011, eighty seven consecutive normotensive diabetic patients type 2 (mean age 51.35+8.21 years) and having no coronary artery disease on non invasive testing, were studied for assessment of left ventricular diastolic function using pulsed Doppler at the tip of mitral valve, the peak late (atrial) transmitral flow velocity (A wave), the peak early transmitral flow velocity (E wave),the (E wave) deceleration time and the ratio between (E wave) and (A wave) were assessed. Tissue Doppler was also used to assess the basal septal (medial) mitral valve annular velocities, the peak early basal annular velocity ( E` wave ) and the peak late basal annular velocity (A` wave) in addition E/E` ratio was assessed, left ventricular diastolic function was classified as left ventricular diastolic dysfunction positive and left ventricular diastolic dysfunction negative, further classification in to normal, impaired relaxation and Pseudonormal groups was made, age gender duration of diabetes, atherogenic index, obesity were studied in relation to left ventricular diastolic dysfunction using Chi square and Fissures exact tests, T-tests and ANOVA were used to calculate means and to compare them.

Early and late onset cardiotoxicity following anthracycline-based chemotherapy in breast cancer patients: Incidence and predictors

IntroductionCardiotoxicity represents a major limitation for the use of anthracyclines or trastuzumab in breast cancer patients. Data on longitudinal studies about early and late onset cardiotoxicity in this group of patients is scarce. The objective of the present study was to assess predictors of early and late onset cardiotoxicity in patients with breast cancer treated with A. Methods100 consecutive patients receiving anthracycline-based chemotherapy (CHT) to treat breast cancer were included in this prospective study. All patients underwent evaluation at baseline, at the end of CHT, 3 months after the end of CHT and 1 and 4 years after the beginning of CHT. Clinical data, systolic and diastolic echo parameters and cardiac biomarkers including high sensitivity Troponin T (TnT), N-terminal pro-brain natriuretic peptide (NT-proBNP) and Heart-type fatty acid binding protein (H-FABP) were assessed. ResultsMean doxorubicin dose was 243 mg/m2. Mean follow-up was 51.8 ± 8.2 months. At one-year incidence of anthracycline related-cardiotoxicity (AR-CT) was 4% and at the end of follow-up was 18% (15 patients asymptomatic left ventricular systolic dysfunction, 1 patients heart failure and 2 patients a sudden cardiac death). Forty-nine patients developed diastolic dysfunction (DD) during first year. In the univariate analysis DD during first year was the only parameter associated with AR-CT (Table 1). In the logistic regression model DD was independently related with the development of AR-CT, with an odds ratio value of 7.5 (95% CI 1.59–35.3). ConclusionsIncidence of late-onset cardiotoxicity is high but mostly subclinical. Diastolic dysfunction early after chemotherapy is a strong predictor of anthracycline cardiotoxicity.

Utility of an Artificial Intelligence Enabled Electrocardiogram for Risk Assessment in Liver Transplant Candidates.

Post-operative cardiac complications occur infrequently but contribute to mortality after liver transplantation (LT). Artificial intelligence-based algorithms based on electrocardiogram (AI-ECG) are attractive for use during pre-operative evaluation to screen for risk of post-operative cardiac complications, but their use for this purpose is unknown. The aim of this study was to evaluate the performance of an AI-ECG algorithm in predicting cardiac factors such as asymptomatic left ventricular systolic dysfunction or potential for developing post-operative atrial fibrillation (AF) in cohorts of patients with end-stage liver disease either undergoing evaluation for transplant or receiving a liver transplant. A retrospective study was performed in two consecutive adult cohorts of patients who were either evaluated for LT or underwent LT at a single center between 2017 and 2019. ECG were analyzed using an AI-ECG trained to recognize patterns from a standard 12-lead ECG which could identify the presence of left ventricular systolic dysfunction (LVEF < 50%) or subsequent atrial fibrillation. The performance of AI-ECG in patients undergoing LT evaluation is similar to that in a general population but was lower in the presence of prolonged QTc. AI-ECG analysis on ECG in sinus rhythm had an AUROC of 0.69 for prediction of de novo post-transplant AF. Although post-transplant cardiac dysfunction occurred in only 2.3% of patients in the study cohorts, AI-ECG had an AUROC of 0.69 for prediction of subsequent low left ventricular ejection fraction. A positive screen for low EF or AF on AI-ECG can alert to risk of post-operative cardiac dysfunction or predict new onset atrial fibrillation after LT. The use of an AI-ECG can be a useful adjunct in persons undergoing transplant evaluation that can be readily implemented in clinical practice.

Speckle tracking echocardiography: principles and clinical applications

Speckle Tracking Echocardiography is a relatively new, non-invasive ultrasound technique that allows an objective and quantitative evaluation of global and regional myocardial function. There is a lot of evidence that global longitudinal strain is more sensitive than the left ventricular ejection fraction for the assessment of left ventricular dysfunction, is used to follow-up cancer therapeutic-related cardiac dysfunction, stratify risks, classify and determine treatment in the asymptomatic left ventricular dysfunction. Thus, this technique can help identify ventricular function and subclinical cardiac dysfunction, even when the ejection fraction is normal. Currently, speckle tracking echocardiography has been standardized and applied to evaluate left ventricular function, right ventricular function and left atrial function according to the consensus of American Society Echocardiography and European Association of Cardiovascular Imaging. Key words: Speckle Tracking Echocardiography, left ventricular ejection fraction, global longitudinal strain

Artificial intelligence applied to the electrocardiogram, or is there really a needle in a haystack?

Artificial intelligence applied to the standard Ecg (Ai-Ecg) is able to enormously enhance the performance of a diagnostic test that has been in use for over 100 years. The tool can in fact identify diseases, cardiac and non-cardiac, hidden or foreseeable, often asymptomatic, previously undetectable. Here we describe some of the main applications in cardiology: sub-clinical atrial fibrillation and asymptomatic left ventricular dysfunction. However, the Ai-Ecg still needs validation in non-experimental contexts: only in that case can its potential be considered verified and therefore usable in clinical practice.

Significance of standard and speckle-tracking echocardiography for early diagnosis of asymptomatic left ventricular dysfunction in type 2 diabetes

Aim. To study the relationship between echocardiographic parameters of left ventricular (LV) function and carbohydrate metabolism indicators, as well as to evaluate value of speckle-tracking echocardiography (STE) in the early diagnosis of subclinical LV dysfunction in type 2 diabetes (T2D) in individuals without clinical manifestations of cardiovascular disease (CVD).Material and methods. The study included 120 people of both sexes aged 45 to 75 years. Patients were divided into three following groups: 1 — with T2D (n=53), 2 — with prediabetes (n=20), 3 — control, without carbohydrate metabolism disorders (n=47). All participants underwent transthoracic two-dimensional echocardiography with an assessment of standard systolic and diastolic parameters, as well as quantitative STE indicators. In addition, all participants underwent laboratory diagnostics of carbohydrate metabolism disorders, which included the determination of blood fasting glucose, glycated hemoglobin (HbA1c), insulin, and C-peptide, as well as insulin resistance index estimation.Results. In patients with T2D, in comparison with the control group, diastolic function parameters were significantly different as follows: a lower value of early to late diastolic transmitral flow velocity (E/A) ratio, the ratio of early transmitral flow velocity to early diastolic mitral annulus velocity (E/e'), mitral annular velocity (e') and higher isovolumic relaxation time (IVRT), as well as early diastolic flow deceleration time (DT). According to multivariate analysis, not only T2D, but also prediabetes was an independent predictor of diastolic dysfunction. The Simpson's LV ejection fraction was preserved in all study participants. In patients with T2D, in comparison with the control, according to STE, a decrease in global longitudinal strain (GLS), an increase in apical rotation, and also LV twist were revealed. In a multivariate regression analysis, the HbA1c level had an inverse relationship with GLS and was an independent predictor of its decrease, and the T2D duration was a significant predictor of twisting changes, apical and basal rotation. At the same time, GLS and LV twist had a high sensitivity in determining the decrease in E/A, e'/a', e', as well as the increase in IVRT.Conclusion. In patients with T2D without CVD manifestations, sub-clinical signs of diastolic dysfunction were revealed, such as delayed LV relaxation; systolic dysfunction with preserved ejection fraction was manifested by a decrease in GLS, as well as an increase in apical rotation and LV twisting, identified by STE. The severity of asymptomatic LV systolic-diastolic dysfunction was associated with the severity of glucose metabolism disorders and T2D duration.

Can Global Longitudinal Strain Assess Asymptomatic Subtle Left Ventricular Dysfunction in Recovered COVID-19 Patients?

Coronavirus disease 2019 (COVID-19) might be associated with cardiac injury as a part of multisystem affection in response to cytokine storms. However, left ventricular (LV) function appears preserved in most of the cases, whereas subtle LV dysfunction might happen in others. Hence, we tried to detect subtle LV dysfunction in patients with COVID-19 using global longitudinal strain (GLS). We performed a single-center observational study on 90 stable patients who were recently recovered from mild to moderate COVID-19 infections. A transthoracic echocardiographic examination was done for all patients, and GLS assessment was used as an indicator of LV function. The population age ranged from 27 to 66 years, and the majority of patients were males (54, 73.3%). Besides, 46.7% of the included patients were smokers, 33.3% had hypertension, and 23.3% were diabetics. All the patients had normal LV internal dimensions and ejection fractions. However, 33.3% of them had subclinical LV dysfunction as expressed by reduced GLS. There was no statistically significant correlation between GLS and age, gender, or other risk factors, whereas troponin and C-reactive protein significantly correlated with GLS. Recovered patients from recent mild to moderate COVID-19 infections might show subtle LV dysfunction as manifested by reduced GLS.

Diagnostic and prognostic value of the electrocardiogram in stable outpatients with type 2 diabetes

Aims . The European Society of Cardiology guidelines on diabetes and cardiovascular disease (CVD) recommend an electrocardiogram (ECG) in patients with diabetes and hypertension or with suspected CVD. We investigated whether ECG abnormalities can be used as a diagnostic and prognostic marker of heart failure (HF) in patients with type-2 diabetes (T2D) in secondary care diabetes-clinics. Methods . We included 722 patients with T2D in sinus rhythm. HF with preserved ejection fraction (HFpEF) was defined according to the European Society of Cardiology guidelines. Heart failure with mid-range ejection fraction (HFmrEF) was patients with dyspnoea and an LVEF 41–49%. Heart failure with reduced ejection fraction (HFrEF) or asymptomatic left ventricular systolic dysfunction (ALVSD) was defined as a LVEF ≤40%. Results . Overall, 24% patients had ECG abnormalities. A total of 15% had HF whereof 48% had ECG abnormalities. A normal ECG had a 99.3% negative predictive value (NPV) of ruling out HFrEF/ALVSD. In a sub-group with 0-1 simple clinical risk markers, the ECG ruled out both HFrEF/ALVSD, HFmrEF, and HFpEF with an NPV of 96.6%. The hazard-ratio (HR) of incident CVD or death in patients with HF and a normal ECG compared with patients without HF was 1.85 [95%CI 1.01–3.39], p = .05, while an abnormal ECG increased the HR to 3.84 [2.33–6.33], p < .001. Conclusion . HFrEF/ALVSD and HFmrEF were rare and HFpEF was frequent in this T2D population. A normal ECG ruled out HFrEF/ALVSD and in a sub-population with 0–1 simple clinical risk markers also both HFrEF/ALVSD, HFmrEF, and HFpEF. Key messages What is already known about this subject? In early studies of unselected patients from primary care with suspected chronic heart failure, the presence of a normal ECG was found be useful to rule out heart failure with reduced ejection fraction. What does this study add? This study confirms that a standard electrocardiogram when normal in 722 stable outpatients with type 2 diabetes can be used to rule out HFrEF/ALVSD. Further, it adds knowledge about the risk of incident cardiovascular disease or death as a pathologic electrocardiogram increases the hazard ratio. How might this implicate clinical practice? With this study clinicians in secondary diabetes care clinics can use an electrocardiogram to select patients to undergo echocardiography when suspecting heart failure with reduced ejection fraction, as a normal electrocardiogram will rule out this diagnosis with a negative predictive value of >99%.

Association of Neurohormonal Antagonists on Incident Cardiotoxicity in Patients With Breast Cancer

Cardiovascular disease is the leading cause of mortality among breast cancer survivors. Anthracyclines and trastuzumab have been associated with an increased risk of cardiotoxicity, requiring close follow-up for signs of clinical heart failure or asymptomatic left ventricular systolic dysfunction. Whether neurohormonal antagonism with angiotensin-converting enzyme inhibitor (ACE-I), angiotensin receptor blockers (ARBs), or β-blockers can prevent the development of chemotherapy-induced cardiomyopathy in this population remains unknown. We studied 459 women who were diagnosed with breast cancer at our medical center from January 2014 to December 2021 and evaluated baseline characteristics, oncologic treatment, and outcomes. The primary end point was the development of cardiotoxicity, defined as symptomatic decline in ejection fraction of ≥5% below 55% or an asymptomatic decline of ≥10% after treatment with chemotherapy. Patients who were exposed to neurohormonal antagonists were more likely to have hypertension, hyperlipidemia, and diabetes. There was an increased risk of cardiotoxicity noted for patients who were older (hazard ratio [HR] 1.04, 95% confidence interval [CI] 1.01 to 1.1), smokers within the past 10years (HR 2.54, 95% CI 1.41 to 4.6), or who received a combination of both trastuzumab and anthracycline therapy (HR 2.52, 95% CI 1.01 to 6.3). Over a median follow-up of 12months, there were no significant protective benefits noted for patients who were taking ACE-I/ARBs (HR 0.49, 95% CI 0.17 to 1.4), β-blockers (HR 0.50, 95% CI 0.16 to 1.6), or both (HR 1.30, 95% CI 0.44 to 3.9). In conclusion, previous use of ACE-I/ARBs and β-blockers, separately or in combination, was not associated with a reduction in the development of cardiotoxicity in patients receiving anthracycline or trastuzumab therapies. Older age, smoking, and combination chemotherapy were found to be associated with an increased risk.

Abstract 12121: Integrating Ketone Bodies in Multi-Marker Risk Prediction of Incident Heart Failure in the Multi-Ethnic Study of Atherosclerosis (MESA)

Introduction: The Universal Definition of Heart Failure (HF) has incorporated N-terminal proB-type natriuretic peptide (NT-proBNP) and high-sensitivity troponin (hs-cTnT) as markers to identify “stage B” HF (asymptomatic left ventricular dysfunction). Plasma ketone bodies (KB) have demonstrated an association with disease severity in HF patients. A multi-biomarker risk score may improve risk stratification of incident HF in the community. Methods: Participants free of CVD from the Multiethnic Study of Atherosclerosis (MESA) at the baseline visit were included. A multi-biomarker score was developed incorporating NT-proBNP ≥ 125 pg/mL, hs-cTnT ≥ 14 ng/L, and total KB ≥ 75 th percentile (316 μmol/L), with 1 point allocated for each abnormal marker. A multivariable Cox model was used to assess the association between multi-biomarker risk score categories and the risk of incident HF. The 5- year Kaplan Meier estimates for incident HF was determined for each biomarker score. Results: Among 6748 participants there were 383 incident HF events over a median follow-up of 15.7 yrs. Total KB displayed a poor correlation with other biomarkers (r&lt;0.06 for all). The addition of KB to the current standard of care to identify pre-HF (either elevation in NT-proBNP and/or hs-cTnT) improved risk prediction (C-statistic 0.70 vs. 0.73). The 3-biomarker score demonstrated good discrimination for predicting 5-year HF risk [C-statistic 0.74 (95%CI 0.70-0.78)]. A graded association was observed between biomarker score groups and the risk of HF independent of established clinical factors ( Figure ). 8% of participants with biomarker score ≥2 developed HF within 5 yrs, while those with biomarker scores≤1 faced very low risk (≤2% over 5 yrs). Conclusions: The addition of plasma KB to a clinical risk score using routinely collected biomarkers of cardiac injury and stress may further personalize risk estimation and reduce misclassification of those at risk of incident HF.

Primary care screening and prevention of heart failure coordinated by cardiologist in rural areas

Abstract Purpose Current guidelines do not support community-wide screening for undetected asymptomatic left ventricular systolic dysfunction (LVSD), reduced (HFrEF), mid-range (HFmrEF) or preserved (HFpEF) heart failure (HF), either with natriuretic peptides (NTproBNP) or open access echocardiography (echo). Universal access to NTproBNP testing (with reimbursement in primary care) before referral for tissue doppler and speckle-tracking echo may be needed to facilitate HF diagnosis at earlier, more treatable stage. Methods 4376 consecutive patients (pts) were referred from January 2015 by general practitioners (GP) to echolab with suspected HF symptoms (unexplained breathlessness or ankle swelling). After confirmation elevated NTproBNP (&amp;gt;400 pg/mL) and MESA (Multi-Ethnic Study of Atherosclerosis) 5-year HF risk score ≥10 points and after exclusion significant valvular disease and abnormal electrocardiogram or chest x-ray in subgroup of randomly selected 829 asymptomatic elderly (≥65 years) pts (age 71±4 years, 48% women) with continued usual care by GP was compared with randomly selected 833 asymptomatic elderly pts from 5 GP practices in rural areas with prospective follow-up by regional cardiologist. Results At referral in both groups were similar baseline characteristics, 14% pts were treated with ACE-inhibitor (ACEi), 5% beta-blockers (BB) and 39% loop-diuretics. After cardiologist consultation loop-diuretics withdrawn in 90% pts, ACEi and BB use increased significantly to 98% and 82% in both groups (all p&amp;lt;0.001). Global LVSD (EF≤50%) was detected in 5% at baseline and 23% pts after 5 years in GP group, respectively 5.4% at baseline and 7% after 5 years in cardiologist group (p&amp;lt;0.001). Systolic dysfunction (S'≤6.0 cm/s) occurred in 14% at baseline and 38% pts after 5 years in GP group, respectively 15% at baseline and 21% after 5 years in cardiologist group (all p&amp;lt;0.001). Reduced global longitudinal (GLS&amp;lt;16%) observed in 20% at baseline and 51% pts after 5 years in GP group, respectively 21% at baseline and 29% after 5 years in cardiologist group (all p&amp;lt;0.001). At baseline we found 0.5% pts with new-onset HF in both groups (only HFmrEF). After mean follow-up of 54±4 months in cardiologist group developed new HF in 3% pts (1% HFmrEF, 2% HFpEF) compared with 19% pts (3% HFrEF, 7% HFmrEF, 9% HFpEF) in GP group (p&amp;lt;0.001). Significant (p&amp;lt;0.001) predictors of incident HFmrEF were systolic dysfunction (S'≤6.0 cm/s), hazard ratio (HR) 2.2, 95% CI 1.82–2.9) and reduced GLS (HR 3.5, 95% CI 3.1–3.9), all p&amp;lt;0.01. The strongest (p&amp;lt;0.001) predictors of incident HFpEF were new-onset atrial fibrillation (HR 1.9, 95% CI 0.9–3.9) and echo-detected left ventricular hypertrophy (septal and posterior wall thickness ≥13 mm, HR 1.52, 95% CI 1.22–1.89), all p&amp;lt;0.01. Conclusions For preventing HF progression is required additional research focused on cooperative care between GP and specialised HF outpatient clinic. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Supported by grant from the Slovak Society of Cardiology 2015 Selective screening of heart failure stages in regional settings

High prevalence of asymptomatic left ventricular diastolic dysfunction and its detection among South Asian patients with Type 2 Diabetes Mellitus compared with White Europeans

Abstract Background Heart failure (HF) is an important manifestation of Type 2 Diabetes (T2D). The development of HF in T2D may be preceded by Stage B HF. Asymptomatic left ventricular impairment, especially left ventricular diastolic dysfunction (LVDD), is a defining early feature of Stage B HF. Detection of Stage B HF is crucial as it provides an opportune target for intervention with cardio-protective therapy to prevent the development of symptomatic HF in T2D. The risk of T2DM is higher in South Asian populations resulting in increased risk of macrovascular and microvascular complications. The prevalence of Stage B HF in South Asian patients with T2DM is not known. Purpose (i) To compare the prevalence of Stage B HF in South Asians in India compared with White Europeans in Scotland; (ii) To test the role of NT-proBNP in identifying Stage B HF Methods This study involved the comparison between two independently conducted, cross-sectional studies. The patients were asymptomatic patients with T2DM with no prior history of cardiovascular disease from Chennai, India (n=246) and Tayside, Scotland (n=246). All patients underwent transthoracic echocardiogram (echo) examination to detect the presence of structural and functional echo features of Stage B HF: left atrial enlargement (LAE), left ventricular hypertrophy (LVH), LVDD and LV systolic dysfunction (LVSD). Receiver operating curves (ROC) were used to determine the predictive ability of NT-proBNP to predict LAE/LVDD/LVD/LVSD. Results The prevalence of Stage B HF was high in South-Asian patients with T2DM (median age of 55 [49, 62] with a high prevalence of LVDD (5% had LVH, 7.3% had LAE, 70% had LVDD and 0% had LVSD (Figure 1B). 10% of the South Asian patients had at least 2 factors contributing to Stage B HF and these patients had higher NT-proBNP titres (703.4 [500.0, 949.2] vs 423.7 [35.0, 754.2], p&amp;lt;0.001). ROC curves show that NT-proBNP can predict these participants with 2 or more echo features [Figure 2B, AUC: 0.7043 (0.6159, 0.7928) p&amp;lt;0.05]. The prevalence of Stage B HF among White Europeans (median age of 67 [61, 72].) was lower compared with South Asian patients: 15% had LVH, 13% had LAE, 19% had LVDD and 2% had LVSD (Figure 1A). 8% of White Europeans had at least 2 factors contributing to Stage B HF and these had higher NT-proBNP titres (368.9 [154.6, 1087.8] vs 186.8 [79.7, 411.5], p=0.02). ROC curves show that NT-proBNP can predict participants with 2 or more factors [Figure 2A, AUC: 0.6399 (0.5122, 0.7676) p&amp;lt;0.05]. Conclusion Our study has shown that South Asian patients with T2DM have a high prevalence of Stage B HF compared with White Europeans and that the predominant Stage B HF feature is LVDD. We also found that NTproBNP could potentially be used to detect Stage B HF and help identify at-risk patients for cardio-protective therapy such as SGLT2 inhibitor therapy that has been shown to prevent the development of future HF events. Funding Acknowledgement Type of funding sources: None.

Nomogram based on multimodal echocardiography for assessing the evolution of diabetic cardiomyopathy in diabetic patients with normal cardiac function.

BackgroundDiabetic cardiomyopathy (DCM) remains asymptomatic for many years until progression to asymptomatic left ventricular diastolic dysfunction (ALVDD), a subclinical cardiac abnormality present in early-stage DCM. Because LV function in patients with type 2 diabetes mellitus (T2DM) may be subtly altered long before the onset of ALVDD, quantitative assessment of the risk of progression to early-stage DCM in T2DM patients with normal hearts is critical for delaying or even reversing DCM.ObjectiveThis study aimed to establish a nomogram with the aid of DCM characteristics revealed by multimodal echocardiography to assess the likelihood of the progression to early-stage DCM in T2DM patients with normal cardiac function.MethodsOf the 423 T2DM patients enrolled, 302 were included in the training cohort and 121 in the validation cohort. The clinical characteristics, biochemical data, and multimodal echocardiographic parameters were collected. In the training cohort, the screened correlates of ALVDD were utilized to develop a nomogram for estimating the risk coefficient for early-stage DCM. This model was validated both in the training and validation cohorts.ResultsALVDD was independently correlated with the number of comorbidities [with one comorbidity: odds ratio (OR) = 3.009; with two comorbidities: OR = 4.026], HbA1c (OR = 1.773), myocardial blood flow (OR = 0.841), and global longitudinal strain (OR = 0.856) (all P < 0.05). They constituted a nomogram to visualize the likelihood of DCM development in T2DM patients with normal cardiac function. The model was validated to present strong discrimination and calibration, and obtained clinical net benefits both in the training and validation cohorts.ConclusionWe constructed and validated a nomogram to estimate the likelihood of developing early-stage DCM in T2DM patients with normal cardiac function. The alteration of the nomogram-predicted risk coefficient is expected to be proposed as a therapeutic target to slow or stop DCM progression.