Decrease In Left Ventricular Systolic Function Research Articles

Left ventricular noncompaction in Duchenne muscular dystrophy.

BackgroundLeft ventricular noncompaction (LVNC) describes deep trabeculations in the left ventricular (LV) endocardium and a thinned epicardium. LVNC is seen both as a primary cardiomyopathy and as a secondary finding in other syndromes affecting the myocardium such as neuromuscular disorders. The objective of this study is to define the prevalence of LVNC in the Duchenne Muscular Dystrophy (DMD) population and characterize its relationship to global LV function.MethodsCardiac magnetic resonance (CMR) was used to assess ventricular morphology and function in 151 subjects: DMD with ejection fraction (EF) > 55% (n = 66), DMD with EF < 55% (n = 30), primary LVNC (n = 15) and normal controls (n = 40). The non-compacted to compacted (NC/C) ratio was measured in each of the 16 standard myocardial segments. LVNC was defined as a diastolic NC/C ratio > 2.3 for any segment.ResultsLVNC criteria were met by 27/96 DMD patients (prevalence of 28%): 11 had an EF > 55% (prevalence of 16.7%), and 16 had an EF < 55% (prevalence of 53.3%). The median maximum NC/C ratio was 1.8 for DMD with EF > 55%, 2.46 for DMD with EF < 55%, 1.54 for the normal subjects, and 3.69 for primary LVNC patients. Longitudinal data for 78 of the DMD boys demonstrated a mean rate of change in NC/C ratio per year of +0.36.ConclusionThe high prevalence of LVNC in DMD is associated with decreased LV systolic function that develops over time and may represent muscular degeneration versus compensatory remodeling.

Identification of high-risk chronic heart failure patients in clinical practice: role of changes in left ventricular function.

Left ventricular (LV) dysfunction and remodeling are key pathophysiological features underlying disease progression in chronic heart failure (CHF). To describe the course of LV dysfunction and identify predictors and prognostic impact of changes in LV volumes and function in stable CHF patients under optimal therapy. There were 318 consecutive CHF outpatients who underwent a repeated echocardiographic evaluation at baseline and at 1 year and subsequently followed-up for at least 12 months. The end point of the study was all-cause mortality. Mean LV ejection fraction (LVEF) was 33 ± 7% at baseline and 36 ± 9% at follow-up. Twenty-four percent of patients had an improvement of LVEF >5 absolute points (group 1); 58% remained stable (group 2), 17% worsened at >5 absolute points (group 3). Age, New York Heart Association class, diuretic dose, renal function, and baseline LVEF were independent predictors of LVEF improvement at 1 year. At the Cox analysis, patients in group 3 had a 4-fold higher risk of death when compared with group 1 (hazard ratio: 3.99, 95% confidence interval: 1.6-9.9, P = 0.002), independently of age, etiology, and symptoms severity. In stable CHF outpatients, LV function improves in 24% of cases; a modest decrease in LV systolic function is associated with a significantly higher risk of all-cause mortality, independent of other markers of disease severity.

Incidence, determinants and consequences of left atrial remodelling after a first anterior myocardial infarction

Left atrial (LA) volume is an important predictor of mortality and morbidity after myocardial infarction (MI). However, the process of LA remodelling has not been extensively investigated. Our purpose was to analyse the incidence, determinants and consequences of LA remodelling in a cohort of patients with a first anterior MI enrolled in the modern era of MI management. We used data from 246 patients with a first anterior MI who were included in a prospective study on left ventricular (LV) remodelling (REVE-2). Serial echocardiographic studies were performed before discharge and at 3 months and 1 year after MI. LA volume increased from 20.5±5.9 mL/m2 at baseline to 24.6±7.4 mL/m2 at 3 months (P<0.0001 versus baseline) and 25.4±7.6 mL/m2 at 1 year (P<0.0001 versus baseline). Patients with high LA volumes at baseline had higher LV volumes, decreased LV systolic function, increased E/Ea (early transmitral velocity/mitral annular early diastolic velocity ratio) and increased B-type natriuretic peptide concentration. By multivariable analysis, the sole independent predictor of change in LA volume from baseline to 1 year was peak creatine kinase concentration (P<0.0001). Patients with higher LA volumes at baseline were at higher risk of cardiovascular death or rehospitalization for heart failure during follow-up (P=0.015). Despite modern therapeutic management, LA remodelling is common during the first 3 months after anterior MI. Patients with larger infarct size are at greater risk of LA remodelling after discharge.

First reported case of recurrent tachycardia-induced cardiomyopathy due to atrial flutter

The patient is a 61-year-old Caucasian male with a history of hypertension and hyperlipidemia who presented in 2010 with 3 days of progressively worsening palpitations, chest tightness and shortness of breath. There was no history of paroxysmal nocturnal dyspnea, orthopnea or syncope. The remainder of the review of symptoms was unremarkable. There is no family history of premature sudden death. His medications were Aspirin, Metoprolol succinate, Lisinopril, Amlodipine and Atorvastatin. He first presented with an arrhythmia in 2007 with a 3-day history of palpitations and light-headedness and he was diagnosed with atrial flutter with 2:1 heart block and a heart rate of 150 beats/min. Transesophageal echocardiography (TEE) revealed normal left ventricular (LV) size with moderately decreased LV systolic function, global hypokinesia and an ejection fraction (EF) of 35% (Fig. 1). There was no left atrial thrombus, hence, he received direct current cardioversion (DCCV) and was converted back to sinus rhythm. His baseline laboratories including thyroid function tests were within normal limits. The follow-up echocardiogram 2 months later revealed normal LV size and systolic function. He was therefore felt to have a resolved Tachycardia-Induced Cardiomyopathy (TIC) at that time and was treated with beta-blockers and aspirin after 1 month of warfarin. Figure 1. EF at presentation of each episode of tachyarrhythmia at 0, 10th and 40th month and subsequent recovery of EF after correction of each episode in 2nd, 14th and 42nd months, respectively. He had another episode of sustained …

Correlation between hemoglobin level and left ventricular systolic functions and dimensions in children with chronic severe anemia

Background Chronic severe anemia is a connnon disease. Cardiac output may increase when the hemoglobin (Hb) level decreases to &lt; 7 g/dL for 3 months or more. Alteration of left ventricular (LV) function occurs frequently in children 'With chronic severe anemia, in the {onn of concentric LV hypertrophy, LV dilatation with or v.ithout LV hypertrophy, or systolic dysfunction. Objective To examine the correlation between Hb level and alteration of LV systolic function in children with chronic severe anemia. Methods We conducted a cross-sectional study in Adam Malik Hospital from October to December 2009. Subjects were chronic severely anemic children. Left ventricular systolic function (ejection fraction/EF, fractional shortening/FS) and dimensions (left ventricular end diastolic diameter/LVEDD and left ventricular end systolic diameter/LVESD) were measured using Hitachi EUB 5500 echocardiography unit. Univariate analysis and Pearson correlation were performed.Results Thirty children were enrolled in the study. The mean of age was 113.5 months (SD 53.24). Hb values ranged from 2.1 to 6.9 g/dL with mean value of 4.6 g/dL (SD 1.44). Mean duration of anemia was 3.9 months (SD 0.70). Chronic severe anemia was not associated \\lith decreased LV systolic function [EF 62.2% (SD 9.16), r =0.296, P=0.112; FS 33.8% (SD 7.26), r =0.115, P=0.545], nor LV dimension changes [LVEDD 40.2 mm (SD 6.85), r = -0.192, P=0.308; LVESD 26.2 mm (SD 4.98), r=-0.266, P=0.156]. Conclusion There was no correlation between Hb level in chronically anemic children and changes in LV systolic function or dimension.

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Can We Predict and Prevent the Onset of Acute Decompensated Heart Failure?

Watch the disease in time: For when, within the dropsy rages, and extends the skin, in vain for helebore the patient cries, and sees the doctor, but too late is wise: Too late for cure, he proffers half his wealth; ten thousand doctors cannot give him health. — —Benjamin Franklin, Poor Richard’s Almanack, 1749 This rather pessimistic representation of heart failure (dropsy) in the 18th century has some relevance to the presentation of acute decompensation in patients with chronic heart failure in our current century, despite the availability of various therapies that prolong survival and decrease the morbidity of this disorder. In 2006, >1 million hospitalizations for acute decompensated heart failure (ADHF) occurred, and the number of heart failure hospitalizations have increased 175% since 1979.1 The vast majority of these patients, 75.6%, had a history of heart failure,2 and the in-hospital mortality was 3.2%. Patients with preserved left ventricular (LV) systolic function have a slightly lower in-hospital mortality (2.9%) compared with those with an LV ejection fraction ≤40% (3.9%); however, the 3-month mortalities were similar at 9.5% to 9.8%.3 Rehospitalization rates remain high at 29% to 30% for patients with both preserved and decreased LV systolic function, and rehospitalization is an independent predictor of 1-year mortality, especially in elderly patients.4 In addition, patients with ADHF are at greater risk for death and morbidity than those with stable chronic heart failure.5 Thus, the natural history of heart failure may be altered by repeated episodes of decompensation requiring hospitalization. Finally, a tremendous financial burden is involved in the treatment of ADHF. Of the $30.2 billion spent on heart failure care in 2006, $17.8 billion (59%) was related to in-hospital care, an increase of $2.4 billion over the previous year.1 Article p 1549 The development of ADHF …

Electromechanical effects of cardiac resynchronization therapy during rest and stress in patients with heart failure

Haemodynamic and functional effects of cardiac resynchronization therapy (CRT) have been studied mostly at rest. CRT effects on left ventricular (LV) dyssynchrony and function during stress have not been evaluated in detail. We studied the electromechanical effects of CRT at rest and during Dobutamine stress echocardiography (DSE), during active and withheld CRT. Twenty-one responders to CRT (62+/-12 yr) were assessed by walking test, quality of life, and BNP with active CRT ("on") and 2 weeks after pacing withdrawal ("off"). DSE (10 microg/kg/min) was performed both at "on" and "off" to evaluate dyssynchrony parameters, systolic and diastolic function. At rest, CRT withdrawal was associated with an increased interventricular mechanical delay (IVMD, from 21+/-18 ms to 49+/-24 ms, p<0.001) and impaired intraventricular synchrony. There was a significant decrease in LV systolic function and LV filling time. Dobutamine infusion had no impact on inter- and intraventricular synchrony. During stress, there was an improvement in LV performance both at "on" and "off". However, LV dp/dt, aortic VTI, cardiac output, mean systolic peak velocities and LV filling time during dobutamine stress were significantly greater with CRT "on". In long-term responders, CRT improves LV performance both at rest and during dobutamine stress. This is attributable to an improvement in LV synchrony, which is maintained during stress.

Correlation of echocardiography parameters with cardiac magnetic resonance imaging in transfusion‐dependent thalassaemia major

Heart iron load (cardiac Fe) can be indirectly quantified by cardiac magnetic resonance (CMR) T2*. CMR accessibility is limited, whereas echocardiography (Echo) is relatively inexpensive and readily available. The objective was to find Echo parameters that may be useful for predicting cardiac Fe. We compared a number of parameters derived from Echo to cardiac Fe in 142 thalassaemia major patients who had undergone a CMR study. All patients with decreased left ventricular (LV) function had cardiac Fe. After removing those patients from the analysis, the total diameter index (Tdi) >5.57 cms/m2, left atrial diameter index >2.41 cm/m2, and the diastolic parameter E/A > 1.96 were highly specific (91.4%, 97.1% and 96.9% respectively) but had low sensitivity (31.8%, 20.45% and 21.8%) in predicting iron load. A right ventricular index >1.47 cm/m2, LV systolic index >2.26 cm/m2 or Tdi >6.26 cm/m2 discriminated between patients with no, or mild to moderate cardiac Fe from those with heavy load, with specificity of 91%, 98.5%, and 98.5%, respectively, but with low sensitivity. Echo parameters for cardiac Fe prediction have restricted value, whereas CMR is essential to assess cardiac Fe. However, patients with decreased LV systolic function should be considered a priori as having cardiac Fe, and chelation therapy should be intensified. This also applies to patients who have the above-described Echo criterion values, even if CMR is not available. Once a patient is found by CMR to have cardiac Fe, then the above Echo criterion values may be useful for ongoing monitoring.

Magnesium attenuates isoproterenol-induced acute cardiac dysfunction and β-adrenergic desensitization

Sympathetic nervous activation is a crucial compensatory mechanism in heart failure. However, excess catecholamine may induce cardiac dysfunction and beta-adrenergic desensitization. Although magnesium is known to be a cardioprotective agent, its beneficial effects on acute cardiac dysfunction remain to be elucidated. We examined the effects of magnesium on left ventricular (LV) dysfunction induced by a large dose of isoproterenol in dogs. Sixteen anesthetized dogs underwent a continuous infusion of isoproterenol (1 micro g.kg(-1).min(-1)) with or without a magnesium infusion (1 mg.kg(-1).min(-1)). The dose response to small doses of isoproterenol (0.025-0.2 micro g.kg(-1).min(-1)) was tested hourly. A large dose of isoproterenol decreased LV systolic function, increased the time constant of LV isovolumic relaxation, and suppressed the dose response to small doses of isoproterenol in a time-dependent manner. Magnesium significantly attenuated isoproterenol-induced LV systolic and diastolic dysfunction and preserved the dose response to isoproterenol. Serum-ionized calcium significantly decreased with a large dose of isoproterenol but was fully maintained at baseline level with magnesium. A large dose of isoproterenol increased serum lipid peroxide levels and serological markers of myocardial damage, which were significantly suppressed by magnesium. In conclusion, magnesium significantly attenuated excess isoproterenol-induced acute cardiac dysfunction and beta-adrenergic desensitization.

Ischemia-Modified Albumin Predicts Mortality in ESRD

The primary study aim is to determine whether ischemia-modified albumin (IMA) levels predict mortality in patients with end-stage renal disease (ESRD). The secondary aim is to determine characteristics of patients with elevated IMA levels. A prospective observational study of 114 renal transplantation candidates was performed. All underwent coronary angiography and dobutamine stress echocardiography. The primary end point is total mortality. During a follow-up period of 2.25 +/- 0.71 years, there were 18 deaths; 10 were cardiac related. Diabetes, severe coronary artery disease, positive dobutamine stress echocardiography result, cardiac troponin T (cTnT) level, IMA level, left ventricular (LV) end-systolic diameter, LV ejection fraction, left atrial size, and mitral peak velocity of early filling (E)/early diastolic velocity (Ea) ratio all predicted mortality. The receiver operating characteristic area under the curve for mortality prediction was similar for IMA and cTnT levels. An IMA level of 95 KU/L or greater (n = 46) predicted mortality with a sensitivity of 76% and specificity of 74%. cTnT level of 0.06 ng/mL or greater (> or = 0.06 microg/L; n = 51) predicted mortality with a sensitivity of 75% and specificity of 72%. Thirty-eight patients (33%) had both IMA and cTnT levels elevated. With multivariate analysis, a positive dobutamine stress echocardiography result (P = 0.003), combined elevated IMA and cTnT levels (P = 0.005), and E/Ea ratio (P = 0.009) were independent prognostic factors. IMA and cTnT levels alone were not independent predictors of mortality. Patients with an elevated IMA level had a significantly larger LV size, decreased LV systolic function, and greater E/Ea ratio compared with those without an increased level. IMA level predicts mortality in patients with ESRD. Patients with elevated levels have larger LV size, decreased systolic function, and greater estimated LV filling pressures.

Relation of Pericardial Effusion to Degree of Fractional Shortening

The prevalence of significant pericardial effusion in patients with left ventricular (LV) dysfunction has not been reported. The goal of this study was to evaluate the prevalence and severity of pericardial effusion in patients with decreased fractional shortening (FS) using a large echocardiographic database. A retrospective analysis of 24,265 echocardiograms performed at our institution from 1984 to 1998 was undertaken. FS was measured in 18,015 of the echocardiograms. The occurrence of pericardial effusion was correlated with the degree of FS, and FS was stratified into 4 groups: (1) >25%, (2) 17.5% to 25%, (3) 10% to 17.5%, and (4) <10%. On the basis of visual estimation, effusion was divided into 3 groups: mild, moderate, and severe. Pericardial effusion was present in 1,632 of the echocardiograms in which FS was measured. Pericardial effusion was significantly more common in patients with FS <25% and was correlated with the severity of decreased FS (group 1: 8.4%; group 2: 12.8%; group 3: 13.2%; group 4: 14.4%; p <0.0001). However, when categorizing pericardial effusion by severity, only mild pericardial effusion was correlated with decreased FS (group 1: 6.6%; group 2: 11.0%; group 3: 11.1%; group 4: 14.0%; p <0000.1). Our results indicate that the occurrence of moderate to severe pericardial effusion cannot be explained by a decrease in LV systolic function.

Characteristics of Left Ventricular Diastolic Function in Patients with Systolic Heart Failure: A Doppler Tissue Imaging Study

Our aim was to characterize myocardial velocity profiles in different types of diastolic dysfunction for patients with severely decreased left ventricular (LV) systolic function. A total of 126 patients with congestive heart failure and an LV ejection fraction of 35% or less were included. Patients underwent an echocardiographic Doppler examination, with measurement of the transmitral inflow pattern, and Doppler tissue imaging of the mitral annulus. Compared with age-matched control subjects, the patients had decreased systolic (9.5 vs 4.9 cm/s, P < .001) and early diastolic (11.6 vs 5.6 cm/s, P < .001) mitral annular velocities. According to the transmitral inflow pattern, 56 patients had signs of a LV restrictive pattern, 36 had a pseudonormalization pattern, and 34 had an abnormal relaxation pattern. The peak systolic and early diastolic mitral annular velocities were quite similarly reduced in different diastolic groups (systolic velocities of 4.6, 5.0, and 5.3 cm/s, and early diastolic velocities of 5.7, 5.8, and 5.1 cm/s at restrictive, pseudonormal, and abnormal relaxation, respectively). The ratio of the transmitral early wave and mitral annular early velocity, an expression of LV filling pressure, was highest in the restrictive group compared with other groups (17.0, 14.6, and 11.7 in the above 3 groups, respectively, P < .001 among groups). The ratio of the transmitral early wave and mitral annular early velocity was also higher in the pseudonormal group than in a control group of patients with ejection fraction of 35% or more with signs of a normal/pseudonormal pattern (14.6 vs 9.0, P < .001). Doppler tissue imaging may enhance the estimates of diastolic dysfunction in patients with decreased LV systolic function, and help to disclose abnormal diastolic function especially in a pseudonormal group.

The Effect of Preload Reduction on a New Parameter to Evaluate Left Ventricular Diastolic Function

Background and Objectives：The time interval between the onset of the mitral inflow and the mitral annulus velocity (TE’-E) has been proposed as a new index for representing the left ventricular (LV) relaxation and this is related to the LV filling pressure. This index has been reported to be a preload independent parameter in an experimental canine model. However, the impact of the preload on this index has not been studied in humans. Subjects and Methods：Forty-five patients (29 men, mean age: 51±14 years old) who had end-stage renal disease underwent echocardiography immediately before and after hemodialysis (HD). The two-dimensional and Doppler parameters were measured, including the peak early (E) and late (A) transmitral inflow velocity. The mitral annulus velocity (E’) at the septal, lateral, anterior and inferior corners of the mitral annulus, as accessed by Doppler tissue imaging (DTI), and the flow propagation velocity (Vp), as accessed by color M-mode, were also measured. The time intervals between the peak of the R wave and the onset of the mitral E velocity and also between the peak R wave and the onset of E’ at the four corners of the mitral annulus were measured. Results：The mean ejection fraction was 62±16%. The average weight reduction by the HD was 2.9±1.1 kg. The dimensions of the LV end-diastole, left atrium and inferior vena cava were significantly reduced. After the HD, the peak E, A and E/A ratio, the average peak E’ and the Vp were significantly decreased. The TE’-E did not change significantly after the HD regardless of the LV systolic function. Conclusion：A new parameter for the diastolic function, i.e., the time interval between the onset of mitral inflow and the mitral annulus velocity, appears to be preload-independent in the patients with a normal or decreased LV systolic function. (Korean Circulation J 2005;35:827-833)

Right ventricular long-axis function in relation to left ventricular systolic function.

A decrease in left ventricular (LV) systolic function is accompanied by a decrease in maximal relaxation velocity in LV long-axis direction, but is it also accompanied by a decrease in right ventricular (RV) long-axis function? To study this 35 consecutive patients were examined by echocardiography. Ejection fraction (LVEF) and mitral annulus motion (MAM) were used as indices of LV systolic function and tricuspid annulus motion (TAM), that is the systolic shortening in RV long-axis direction, was used as an index of RV systolic long-axis function. In the same way the maximal relaxation velocity in LV long-axis direction, that is the maximal diastolic velocity of MAM (MDV MAM), has been suggested as an index of LV diastolic function the maximal diastolic velocity of TAM (MDV TAM) can be supposed to be an index of RV diastolic function measuring the maximal relaxation velocity in the RV long-axis direction. A significant positive correlation was found between MDV TAM and MAM (r = 0.64, P<0001) and LVEF (r = 0.54, P = 0.001) and between TAM and the two studied indices of LV systolic function, with the highest correlation to MAM (r = 0.68, P<0.001) and the lowest to LVEF (r = 0.57, P<0.001). Thus, a decrease in LV systolic function is accompanied by a decrease in both systolic and diastolic RV long-axis function, findings that probably are due to the close anatomical connection between the ventricles and to changes that occur in afterload of the RV secondary to LV systolic dysfunction.

Glycation end-product cross-link breaker reduces collagen and improves cardiac function in aging diabetic heart

Aging and diabetes mellitus (DM) both affect the structure and function of the myocardium, resulting in increased collagen in the heart and reduced cardiac function. As part of this process, hyperglycemia is a stimulus for the production of advanced glycation end products (AGEs), which covalently modify proteins and impair cell function. The goals of this study were first to examine the combined effects of aging and DM on hemodynamics and collagen types in the myocardium in 12 dogs, 9-12 yr old, and second to examine the effects of the AGE cross-link breaker phenyl-4,5-dimethylthazolium chloride (ALT-711) on myocardial collagen protein content, aortic stiffness, and left ventricular (LV) function in the aged diabetic heart. The alloxan model of DM was utilized to study the effects of DM on the aging heart. DM induced in the aging heart decreased LV systolic function (LV ejection fraction fell by 25%), increased aortic stiffness, and increased collagen type I and type III protein content. ALT-711 restored LV ejection fraction, reduced aortic stiffness and LV mass with no reduction in blood glucose level (199 +/- 17 mg/dl), and reversed the upregulation of collagen type I and type III. Myocardial LV collagen solubility (%) increased significantly after treatment with ALT-711. These data suggest that an AGE cross-link breaker may have a therapeutic role in aged patients with DM.

Collagen accumulation after myocardial infarction: effects of ETA receptor blockade and implications for early remodeling.

Endothelin A (ETA) receptor blockade started early after myocardial infarction (MI) promotes adverse left ventricular (LV) dilatation. We tested the hypothesis that inhibition of ETA receptors during the early phase of healing affects collagen synthesis and accumulation, and induces expansion of infarcted myocardium. Starting 3 h after coronary ligation, female Wistar rats were treated with the selective ETA receptor antagonist LU 135252 (30 mg/kg body wt/day) or placebo. A period of 7 days after MI, hemodynamic, morphometric and biochemical studies were performed. ET(A) receptor blockade enhanced infarct expansion index and decreased LV systolic function. Infarct scar of LU 135252-treated rats displayed decreased gene expression of fibrillar type I/III collagens and of transforming growth factor-beta(1) (TGF-beta(1)). Collagen content in the infarct scar and border regions was lower after ETA inhibition. In addition, Western blot analysis revealed, after ETA receptor blockade, enhanced matrix metalloproteinases MMP-13, and MMP-2 expression in the infarcted LV myocardium. These data demonstrate that endothelin stimulates collagen accumulation at the site of infarction. Decreased collagen and TGF-beta(1) gene expression, associated with enhanced infarct expansion and MMP up-regulation likely contributes to ETA receptor blockade-mediated deleterious effects on ventricular remodeling after infarction.

Clinical presentation, hospital length of stay, and readmission rate in patients with heart failure with preserved and decreased left ventricular systolic function

Congestive heart failure is the leading cause of hospital admissions for adults in the United States. To our knowledge, there are limited data comparing the clinical presentation, hospital length of stay, and readmission in patients with preserved and decreased left ventricular (LV) systolic function. The goal of the study was to determine whether there are differences in clinical presentation, hospital length of stay, and readmission in patients with preserved (> or = 50%) and reduced (< 50%) systolic function. We prospectively evaluated 187 patients admitted with congestive heart failure confirmed by the presence of pulmonary vascular congestion on chest x-ray, and with recent (< 6 months) documentation of LV systolic function by two-dimensional echocardiography. History and physical examination findings, patient demographics, comorbidities, discharge medications, and length of hospital stay data were documented. Readmission rate over a 6-month follow-up period was also documented. Of the 187 patients, 130 (70%) patients had an ejection fraction (EF) <50%, and 57 (30%) patients had an EF > or = 50%. Patients with EF < 50% were more likely to be men (54 vs. 37%, p = 0.03). African Americans (79 vs. 60%, p = 0.007), had a higher prevalence of previous stroke (17 vs. 5%, p = 0.03), and were more likely to carry no medical insurance at the time of admission (14 vs. 2%, p = 0.01) and to be discharged on digoxin (60 vs.30%, p<0.001). There were no significant differences in symptoms (exertional dyspnea, rest dyspnea, orthopnea, or paroxysmal nocturnal dyspnea), or in physical examination findings (S3, S4, elevated jugular venous pressure, rales, or peripheral edema). According to chest x-ray, patients with EF <50% had more frequent cardiomegaly (88 vs. 72% p = 0.008), but there were no differences in the presence of pleural effusion or pulmonary vascular congestion (p = NS). The mean length of stay was 5.9 and 5.2 days, respectively (p = 0.34). During the 6-month follow-up period, the readmission rates were 33% (43 patients) and 26% (15 patients), respectively (p = 0.36). The clinical presentation, hospital length of stay, and readmission rate for congestive heart failure are similar in patients with preserved and decreased LV systolic function.

Predictors of congestive heart failure in the elderly: the cardiovascular health study

OBJECTIVESWe sought to characterize the predictors of incident congestive heart failure (CHF), as determined by central adjudication, in a community-based elderly population.BACKGROUNDThe elderly constitute a growing proportion of patients admitted to the hospital with CHF, and CHF is a leading source of morbidity and mortality in this group. Elderly patients differ from younger individuals diagnosed with CHF in terms of biologic characteristics.METHODSWe analyzed data from the Cardiovascular Health Study, a prospective population-based study of 5,888 elderly people >65 years old (average 73 ± 5, range 65 to 100) at four locations. Multiple laboratory measures of cardiovascular structure and function, blood chemistries and functional assessments were obtained.RESULTSDuring an average follow-up of 5.5 years (median 6.3), 597 participants developed incident CHF (rate 19.3/1,000 person-years). The incidence of CHF increased progressively across age groups and was greater in men than in women. On multivariate analysis, other independent predictors included prevalent coronary heart disease, stroke or transient ischemic attack at baseline, diabetes, systolic blood pressure (BP), forced expiratory volume 1 s, creatinine >1.4 mg/dl, C-reactive protein, ankle-arm index <0.9, atrial fibrillation, electrocardiographic (ECG) left ventricular (LV) mass, ECG ST-T segment abnormality, internal carotid artery wall thickness and decreased LV systolic function. Population-attributable risk, determined from predictors of risk and prevalence, was relatively high for prevalent coronary heart disease (13.1%), systolic BP ≥140 mm Hg (12.8%) and a high level of C-reactive protein (9.7%), but was low for subnormal LV function (4.1%) and atrial fibrillation (2.2%).CONCLUSIONSThe incidence of CHF is high in the elderly and is related mainly to age, gender, clinical and subclinical coronary heart disease, systolic BP and inflammation. Despite the high relative risk of subnormal systolic LV function and atrial fibrillation, the actual population risk of these for CHF is small because of their relatively low prevalence in community-dwelling elderly people.

A prolonged QRS duration on surface electrocardiogram is a specific indicator of left ventricular dysfunction

Objective. We sought to determine whether a prolonged QRS interval duration is associated with decreased left ventricular (LV) systolic function.Background. The 12-lead electrocardiogram (ECG) is a routine test for suspected cardiac disease. Although several scoring systems have been devised to estimate LV systolic function, no studies have examined the direct relationship between QRS duration alone and LV systolic function.Methods. We analyzed the standard 12-lead surface ECG of 270 consecutive patients, referred for radionuclide ventriculography. Patients (n = 44) with bundle branch blocks, atrial flutter or fibrillation, pacemaker rhythm, recent myocardial infarction or bypass surgery, and patients on antiarrhythmic drugs were excluded. In the remaining patients (n = 226), we correlated the QRS duration on standard resting ECG, and the resting LV ejection fraction (EF), end-systolic and end-diastolic counts (ESC and EDC, respectively; LV volume indices), as obtained by radionuclide angiography. We used a multivariate analysis to identify independent predictors of reduced ventricular function entering QRS duration, the previously described R-wave score and clinical variables in our model.Results. The QRS duration in the abnormal EF group was significantly longer than in the normal EF group (0.102 vs. 0.091 s, p < 0.0001). A QRS duration >0.10 s was highly specific (83.6%), but modestly sensitive (43.8%), for the prediction of abnormal EF. Furthermore, an abnormal EF was predicted with incrementally increased specificity (83.6% to 99.3%) and a corresponding decrease in sensitivity (43.8% to 13.8%) for each 0.01-s increase in the definition of prolonged QRS (from >0.10 to >0.12 s). Accordingly, the positive likelihood ratio for the prediction of decreased LV function was increased from 2.67 to 19.7 as the definition of prolonged QRS duration was increased from >0.10 to >0.12 s. In the multivariate analysis, a prolonged QRS duration and a low R-wave score were the only independent predictors of decreased LV systolic function.Conclusions. Prolonged QRS duration (>0.10 s) obtained from a standard resting 12-lead ECG is a specific, but relatively insensitive indicator of decreased LV systolic function. Further prolongation of the QRS had a higher specificity for decreased LV EF and a higher positive likelihood ratio for predicting abnormal LV EF.