Asymptomatic Left Ventricular Dysfunction Research Articles

Cardiac power output associated with hospitalization and mortality in coronary artery disease patients at stage B heart failure

BackgroundCardiac power output (CPO) predicts outcomes in advanced heart failure (HF) and cardiogenic shock, but its role in early HF stages is unclear. This study assessed the prognostic value of CPO in coronary artery disease patients with asymptomatic left ventricular systolic dysfunction (ALVSD) at stage B HF. MethodsWe conducted a retrospective analysis of coronary artery disease patients who underwent coronary and pulmonary artery catheterization between 2006 and 2016. Stage B HF with ALVSD was defined as left ventricular ejection fraction < 50 %, without HF symptoms, signs, or prior HF hospitalization. CPO was derived from invasive hemodynamic parameters. Endpoints included HF hospitalization, cardiovascular mortality, and all-cause mortality over a 5-year follow-up. ResultsA total of 783 coronary artery disease patients with ALVSD at stage B HF were enrolled. Incidence rates (per 1000 person-years) were 13.9 for HF hospitalization, 14.5 for cardiovascular mortality, and 23.7 for all-cause mortality.Multivariate analysis adjusting for covariates demonstrated that CPO was independent associated with all endpoints. Patients with a low CPO (<0.97 Watts) were at significantly higher risk for HF hospitalization (adjusted hazard ratio [HR]: 4.04; 95 % CI: 1.53 – 10.6; p = 0.005), cardiovascular mortality (adjusted HR: 2.73; 95 % CI: 1.19 – 6.27; p = 0.018), and all-cause mortality (adjusted HR: 1.86; 95 % CI: 1.05 – 3.30; p = 0.035) compared to those with higher CPO, regardless of subgroup classification. ConclusionResting CPO in patients with ALVSD is significantly associated with adverse events, including HF hospitalization and mortality, highlighting its value in early-stage HF management.

Prevalence and associations of asymptomatic left ventricular systolic dysfunction in Lebanese patients with type 2 diabetes mellitus.

Diabetes Mellitus is a prevalent disease with a growing impact on individuals worldwide. Evaluating the prevalence of subclinical left ventricular dysfunction and understanding its associations with microvascular complications, uncontrolled glycemia, diabetes duration, and patient age is crucial. Our aim is to determine the utility of screening for this condition. We conducted a retrospective cohort study involving 159 asymptomatic individuals with type 2 diabetes. Bivariate analysis was employed to assess potential factors and their associations with subclinical left ventricular dysfunction. Patients with a history of cardiac disease or interventions were excluded. The average age of our sample was 61.5 years. Almost half of the patients exhibited an HbA1c exceeding 7% (50.3%), and approximately half had an ejection fraction (EF) of less than 55% (50.9%). In the bivariate analysis, a notable difference in microvascular diabetic complications was observed among different EF groups. Specifically, nephropathy (62%), neuropathy (57.5%), and retinopathy (74.4%) were significantly more prevalent among patients with an EF < 55%. We also identified a significant age difference between groups, with a higher mean diabetes duration (14.1 ± 7.7 years) in the lower EF group. Notably, 63.7% of patients with an HbA1c exceeding 7% exhibited an EF < 55%. Older patients were associated with a lower EF, with an adjusted odds ratio (aOR) of 0.94. An HbA1c of 7% or less was linked to a higher likelihood of an EF > 55%. We established a correlation between subclinical left ventricular systolic dysfunction and microvascular complications. However, further extensive prospective research is necessary to deepen our understanding of these associations and their clinical implications.

Use of EMPAgliflozin in the prevention of CARDiotoxicity: the EMPACARD – PILOT trial

BackgroundAnthracycline-based chemotherapy represents a cornerstone treatment for a number of common cancers, including breast cancer, lymphoma, and sarcoma. However, anthracycline-induced cardiotoxicity remains a significant concern, often presenting as a decline in cardiac function which can ultimately lead to heart failure (HF) or asymptomatic left ventricular dysfunction, in up to 10–15% of patients.Sodium-glucose transport protein 2 inhibitor (SGLT2i) therapies have been demonstrated to reduce the incidence of HF in high-risk non-cancer patients. Preliminary retrospective data suggest their role in mitigating the incidence of HF during or after anthracycline treatmentMethodsThe EMPACARD-PILOT trial was a prospective case‒control study involving breast cancer patients scheduled to undergo anthracycline-based chemotherapy in a 4-cycle protocol of 60 mg/m2 doxorubicin. We used the HFA/ICOS risk score to identify patients at high or very high risk of cardiotoxicity. Patients with diabetes mellitus or stable heart failure with preserved ejection fraction (HFpEF) were prescribed empagliflozin (10 mg per day), starting seven days before the administration of anthracyclines and continuing for a period of six months. Those not meeting these criteria served as controls. The primary endpoint was cancer therapy-related cardiac dysfunction (CTRCD) incidence. CTRCD was defined as either a decrease in left ventricular ejection fraction (LVEF) of at least 10% to a final value below 50% or a reduction in global longitudinal strain (GLS) of at least 15% from baseline at any point during the study. The secondary endpoints included mortality and hospitalization due to cardiovascular causes or clinical heart failure. Exploratory endpoints included increases in serum troponin and NT-proBNP levels and a decrease in the glomerular filtration rate (GFR). The safety endpoints tracked includedketoacidosis, hypoglycemia, sepsis, neutropenic fever, and urinary tract infections.ResultsDuring the enrollment period, 785 breast cancer patients were analysed. Of these, 107 met the inclusion criteria, and 76 subsequently provided informed consent. The study was conducted with comparable adherence rates of 81.5% in both the empagliflozin group (n = 38) and the control group (n = 38). The follow-up data from 62 patients revealed a significant reduction in the primary outcome within 6 months for the empagliflozin group compared with the control group (6.5% vs. 35.5%, p = 0.005), with a relative risk of 0.18 (95% CI: 0.04–0.75). Compared with the control treatment, treatment with empagliflozin also significantly preserved the ejection fraction at 6 months follow-up (56.8% ± 5.8% vs. 53.7% ± 6.7, p = 0.029). However, there were no significant differences between the groups in terms of NT-proBNP, cTnI, clinical heart failure, GFR, or mortality/hospitalization due to heart failure.ConclusionEmpagliflozin is associated with reduced incidence of CTRCD in high-risk patients treated with anthracyclines. These data should serve as the foundation for a clinical trial to test whether SGLT2 inhibitors can reduce the incidence of heart failure in this patient group.

Changes in Mitochondrial Function and Cell Death Patterns in Peripheral Blood Mononuclear Cells during Trastuzumab Treatment Following Doxorubicin Chemotherapy.

Trastuzumab, a monoclonal antibody which works against human epidermal growth factor receptor 2 (HER2), possibly causes cardiotoxicity through mitochondrial dysfunction. The usefulness of isolated peripheral blood mononuclear cells (PBMCs) in the assessment of trastuzumab-induced cardiotoxicity remains uncertain. This study aimed to determine the temporal changes in mitochondrial function, oxidative stress, and cell death in the isolated PBMCs of HER2-positive breast cancer patients during breast cancer treatment and to compare the changes with HER2-negative breast cancer patients who did not receive trastuzumab therapy. Eighteen newly diagnosed HER2-positive breast cancer women who received sequential doxorubicin and trastuzumab were consecutively recruited. Age- and gender-matched controls with HER2-negative breast cancer were selected. Echocardiography was carried out, and blood samples for the study of cardiac biomarkers and PBMCs were collected periodically during treatment. Only one patient in our cohort developed asymptomatic left ventricular dysfunction during trastuzumab treatment. However, trastuzumab following doxorubicin aggravated subclinical cardiac injury, determined by cardiac troponin and echocardiography. Cellular and mitochondrial oxidative stress in isolated PBMCs remained unchanged throughout breast cancer treatment. Regarding mitochondrial respiration, the maximal respiration and spare respiration capacity was significantly increased in controls after doxorubicin treatment but not in patients who received trastuzumab therapy. Moreover, the percentage of apoptosis and necroptosis in isolated PBMCs was dramatically decreased in the control, compared to patients with trastuzumab treatment. In conclusion, trastuzumab caused subtle myocardial injury and impaired mitochondrial respiration and cell viability in isolated PBMCs.

Factors associated with risk analysis for asymptomatic left ventricular diastolic dysfunction in nondialysis patients with chronic kidney disease

Heart failure (HF) constitutes a major determinant of outcome in chronic kidney disease (CKD) patients. The main pattern of HF in CKD patients is preserved ejection fraction (HFpEF), and left ventricular diastolic dysfunction (LVDD) is a frequent pathophysiological mechanism and specific preclinical manifestation of HFpEF. Therefore, exploring and intervention of the factors associated with risk for LVDD is of great importance in reducing the morbidity and mortality of cardiovascular disease (CVD) complications in CKD patients. We designed this retrospective cross-sectional study to collect clinical and echocardiographic data from 339 nondialysis CKD patients without obvious symptoms of HF to analyze the proportion of asymptomatic left ventricular diastolic dysfunction (ALVDD) and its related factors associated with risk by multivariate logistic regression analysis. Among the 339 nondialysis CKD patients, 92.04% had ALVDD. With the progression of CKD stage, the proportion of ALVDD gradually increased. The multivariate logistic regression analysis revealed that increased age (OR 1.237; 95% confidence interval (CI) 1.108–1.381, per year), diabetic nephropathy (DN) and hypertensive nephropathy (HTN) (OR 25.000; 95% CI 1.355–48.645, DN and HTN vs chronic interstitial nephritis), progression of CKD stage (OR 2.785; 95% CI 1.228–6.315, per stage), increased mean arterial pressure (OR 1.154; 95% CI 1.051–1.268, per mmHg), increased urinary protein (OR 2.825; 95% CI 1.484–5.405, per g/24 h), and low blood calcium (OR 0.072; 95% CI 0.006–0.859, per mmol/L) were factors associated with risk for ALVDD in nondialysis CKD patients after adjusting for other confounding factors. Therefore, dynamic monitoring of these factors associated with risk, timely diagnosis and treatment of ALVDD can delay the progression to symptomatic HF, which is of great importance for reducing CVD mortality, and improving the prognosis and quality of life in CKD patients.

#2406 Echocardiographic characteristics of autosomal dominant polycystic kidney disease

Abstract Background and Aims Cardiovascular complications in patients with autosomal dominant polycystic kidney disease (ADPKD) are one of the most frequently investigated extrarenal manifestations. The results are many times contradictory. This is caused by a limited size of studied populations and high inter- and intrafamilial heterogeneity of ADPKD. Expanding knowledge of populations of patients from different regions and cohorts is crucial for improving the understanding and treatment of cardiovascular morbidity and mortality. This study aims to explore the prevalence of cardiovascular abnormalities in echocardiography and to analyze their relationships with clinical characteristics across different stages of CKD progression in patients with ADPKD. Method Sixty-eight patients were included in the study. All patients underwent transthoracic echocardiography with the use of GE Vingmed Ultrasound (GE Norway Health Tech, Oslo, Norway). Information about demography, prior medical history and taking antihypertension drugs was recorded. The results of creatinine, lipids and haemoglobin were collected. To diagnose the rapid progression of CKD, creatinine was sampled twice, in a one-year interval. Results Using different indicators of left ventricular hypertrophy (LVH), we found it in above 40% of ADPKD patients. A single associate of left ventricular mass was eGFR decline after one year of observation. Other highly prevalent findings were asymptomatic left ventricular diastolic dysfunction (ALVDD) (39%), left atrium (LA) enlargement (39%) and mild valvular regurgitations (80%). Ejection fraction, aortic root dimension, tricuspid annular plane systolic excursion (TAPSE) and prevalence of mitral valve prolapse were not importantly increased. Apart from age, the strong determinant of ALVDD diagnosis was the treatment with beta-blockers. Cardiac indices were not different across the eGFR stages. Conclusion LVH, LA enlargement, ALVDD and valvular regurgitations are characteristics of cardiac phenotype in ADPKD. Cardiac indices were not different across different stages of CKD pointing towards the diagnosis of ADPKD being main drive of their occurrence.

Association of N-terminal Pro B-type Natriuretic Peptide with Asymptomatic Left Ventricular Dysfunction in Patients of Type 2 Diabetes Mellitus

Abstract Objectives: Patients with type 2 diabetes mellitus (T2DM) are known to have an increased risk of developing cardiovascular disease. Increased circulating N-terminal pro B-type natriuretic peptide (NT-proBNP) levels in patients with asymptomatic and symptomatic ventricular dysfunction are demonstrated and therefore can be used as a potential marker for early diagnosis and treatment. Hence, this study was undertaken to determine serum NT-proBNP levels and to explore the association of serum NT-proBNP levels with asymptomatic left ventricular dysfunction (ALVD) in patients of T2DM. Materials and Methods: This hospital-based cross-sectional study was carried out in a total of 85 patients of T2DM without any overt heart disease. Serum NT-proBNP was measured by electrochemiluminescence method. Echocardiography was performed to assess the left ventricular (LV) function in all the study participants. All statistical procedures were performed using SPSS software. Results: Out of the 85 type 2 diabetic participants, 15 (17.6%) were diagnosed with ALVD. Serum NT-proBNP levels in type 2 diabetic patients with ALVD were significantly higher than in T2DM patients with normal LV function (P = 0.001). The area under the receiver operating characteristic curve for NT-proBNP to separate normal versus abnormal ventricular function was 0.95 in Type 2 diabetic patients. Serum NT-proBNP at a cutoff point of 127.65 pg/ml showed 86.7% sensitivity and 97.1% specificity for the detection of ALVD in T2DM patients. Conclusion: Secretion of NT-proBNP is found to be increased in T2DM patients with ALVD and therefore may be a simple screening tool to select diabetic patients with ALVD requiring further examination with echocardiography.

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.

A Comparative Study of Plasma N-Terminal Pro- Brain Natriuretic Peptide to Assess Asymptomatic Cardiovascular Disease in Type 2 Diabetic Patients

Background: This study aimed to assess NT-pro BNP level in patients of T2DM without overt cardiovascular disease to determine presence of Asymptomatic Left Ventricular Dysfunction (ALVD) compared with matched control group. Methods: This study conducted at SMS Hospital, Jaipur by selecting 60 patients of type 2 diabetes mellitus and 60 control of non-diabetic population. Information regarding demographic data, clinical symptoms, past medical history, laboratory parameters, NT pro-BNP and 2D Echocardiography collected from selected sample population for comparative analysis among both groups. Results: Patients of T2DM have significantly higher value of NT pro-BNP, blood sugar and HbA1c with proportionally increased diastolic dysfunction as compared to matched non-diabetic population (P&lt;0.05). Absolute value of NT pro-BNP in patients of T2DM is directly correlated with age, duration of diabetes, Blood pressure, blood sugar level, HbA1c level, creatinine, total cholesterol and urine protein (positive correlation coefficient with P-value&lt;0.05). Left ventricular ejection fractions were found statistically similar among both groups. Conclusion: Heart failure in patients with T2DM is a most crucial diabetic complication for diagnosis as well as management. Level of NT-pro BNP in blood stream is an important tool for early diagnosis of heart failure especially HFpEF. This study suggests that the secretion of NT-pro BNP is increased in patients with T2DM compared with control subject without overt heart disease. Therefore, measurement of NT-pro BNP paired might be a simple screening tool to identify patients with diabetes at risk for ventricular dysfunction requiring further examination with echocardiography.

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.