Diagnosis Of Left Ventricular Systolic Dysfunction Research Articles

Prognostic Relevance of Left Ventricular Global Longitudinal Strain in Patients With Heart Failure and Reduced Ejection Fraction

Patients with heart failure (HF) and reduced ejection fraction (HFrEF) are complex patients who often have a high prevalence of co-morbidities and risk factors. In the present study, we investigated the prognostic significance of left ventricular (LV) global longitudinal strain (GLS) along with importantclinical and echocardiographic variables in patients with HFrEF. Patients who had a first echocardiographic diagnosis of LV systolic dysfunction, defined as LV ejection fraction ≤45%, were selected. The study population was subdivided into 2 groups based on a spline curve analysis derived optimal threshold value of LV GLS (≤10%). The primary end point was occurrence of worsening HF, whereas the composite of worsening HF and all-cause death was chosen for the secondary end point. A total of 1,873 patients (mean age 63±12years, 75% men) were analyzed. During a median follow-up of 60months (interquartile range 27 to 60months), 256 patients (14%) experienced worsening HF and the composite end point of worsening HF and all-cause mortality occurred in 573 patients (31%). The 5-year event-free survival rates for the primary and secondary end point were significantly lower in the LV GLS ≤10% group compared with the LV GLS >10% group. After adjustment for important clinical and echocardiographic variables, baseline LV GLS remained independently associated with a higher risk of worsening HF (hazard ratio0.95, 95% confidence interval 0.90 to 0.99, p=0.032) and the composite of worsening HF and all-cause mortality (hazard ratio0.94, 95% confidence interval 0.90 to 0.97, p=0.001). In conclusion, baseline LV GLS is associated with long-term prognosis in patients with HFrEF, independent of various clinical and echocardiographic predictors.

Influence of sex on cardiovascular outcomes in RBM20 variant carriers

Abstract Background Variants in the RBM20 gene cause dilated cardiomyopathy and may be associated with a poor prognosis. Objectives To determine disease penetrance, the risk of adverse events and the influence of sex on outcomes in RBM20 variant carriers. Methods Consecutive probands and relatives carrying pathogenic or likely pathogenic RBM20 variants were retrospectively recruited from 12 cardiomyopathy units. The primary endpoint was a composite of malignant ventricular arrhythmia (MVA) and end-stage heart failure (ESHF). MVA and ESHF endpoints were also analysed separately and males and females compared. Results Longitudinal follow-up data were available for 163 RBM20 variant carriers (82 male, median age 36.5 years, median follow-up 77.6 months). 10/163 had an MVA event at baseline. 30/153 without baseline MVA (19.6%) reached the primary endpoint with a trend towards worse outcomes in males (p=0.08). 16/153 (10.5%) had new MVA with no difference between males and females (p=0.92). 20/163 (12.2%) developed ESHF (17 males and 3 females; p<0.001). By the end of follow-up, 114 patients (70%) had either left ventricular systolic dysfunction (LVSD) or had experienced MVA. 22 patients received a first diagnosis of LVSD during follow-up. Disease penetrance in individuals over 40 years of age was 78.5% by last evaluation. Eleven patients that reached the MVA endpoint had a left ventricular ejection fraction (LVEF) available within 6 months of the event. Median [IQR] contemporary LVEF was 30% [23.75, 40%]. 5/11 patients had a contemporary LVEF >35%. 1/11 had a contemporary LVEF >45% (a female, 1st degree relative presenting with sustained ventricular tachycardia and an LVEF of 65%). Conclusions RBM20 variants are highly penetrant. The risk of MVA in male and female RBM20 variant carriers is similar but male sex is strongly associated with ESHF. MVA events occur in patients with LVEF >35%. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): British Heart Foundation Clinical Research Training Fellowship

Prognostic relevance of left ventricular global longitudinal strain in patients with heart failure and reduced ejection fraction

Abstract Background Patients with heart failure (HF) and reduced ejection fraction (HFrEF) are complex patients who often have a high prevalence of comorbidities and cardiovascular risk factors. However, risk stratification and treatment decision in these patients mainly depend on simple measurements of left ventricular (LV) ejection fraction (EF). In the present study, we investigated the prognostic significance of LV global longitudinal strain (GLS) along with important clinical and echocardiographic risk factors in patients with HFrEF. Methods Patients who had a first echocardiographic diagnosis of LV systolic dysfunction, defined as LVEF ≤45%, were identified. LV GLS was measured with speckle-tracking echocardiography and represented by a positive value. To divide the study population into 2 groups, spline curve analysis was used to derive the optimal threshold value of LV GLS (i.e. where the predicted hazard ratio for the endpoint was ≥1) (Figure 1). Patients were followed up for worsening HF, as well as the composite endpoint of worsening HF and all-cause mortality. Results A total of 2394 patients (mean age 63±12 years, 75% men) were analyzed. During a median follow-up of 60 months (interquartile range [IQR] 31–60 months), 306 patients (13%) experienced worsening HF and the composite endpoint of worsening HF and all-cause mortality occurred in 673 patients (28%). The 5-year event-free survival rates for the primary and secondary endpoint were significantly lower in the patients who had LV GLS ≤10% compared to the patients who had LV GLS >10% (Figure 2A for worsening HF and Figure 2B for the composite endpoint of worsening HF and all-cause mortality). After adjustment for important clinical and echocardiographic risk factors, including HF treatments and baseline LVEF, baseline LV GLS remained independently associated with a higher risk of worsening HF (HR=0.95, 95% CI 0.90–0.99, p=0.029) and the composite of worsening HF and all-cause mortality (HR=0.94, 95% CI 0.90–0.97, p=0.001). Conclusions Baseline LV GLS is associated with long-term prognosis in patients with HFrEF, independently from various clinical and echocardiographic risk factors. Funding Acknowledgement Type of funding sources: None.

Inverse association of mortality and body mass index in patients with left ventricular systolic dysfunction of both ischemic and non-ischemic etiologies.

BackgroundObesity is a worldwide epidemic that has been associated with poor outcomes. Previous studies have demonstrated an inverse relationship between body mass index (BMI) and outcomes, the 'obesity paradox', in several diseases.HypothesisWe sought to evaluate whether the obesity paradox is present in patients with left ventricular systolic dysfunction (LVSD) of all etiologies, using all‐cause mortality as the primary endpoint and hospitalization as the secondary endpoint.MethodsWe conducted a retrospective cohort study of LVSD patients (n = 18 003) seen within the University of Pittsburgh Medical Center network between January 2011 and December 2017. Patients were divided into four BMI categories (underweight, normal weight, overweight, and obese) and stratified by left ventricular ejection fraction (LVEF): <20%, 20–35%, and 35–50%.ResultsOver a median follow‐up of 2.28 years, higher BMI (mean 28.9 ± 6.8) was associated with better survival for the overall cohort and within LVEF strata (p < .0001). The most common cause of hospitalization was subendocardial infarction among underweight and normal weight patients and heart failure among overweight and obese patients. Cox proportional hazards model showed that BMI, age, and comorbid conditions of diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and prior myocardial infarction are independent predictors of death.ConclusionsOur results support the existence of an obesity paradox impacting all‐cause mortality in patients with LVSD of ischemic and non‐ischemic etiologies even after adjusting for LVEF and comorbidities. Additional research is needed to understand the effect of weight loss on survival once a diagnosis of LVSD is established.

Comorbidity and polypharmacy in chronic heart failure: a large cross-sectional study in primary care

Comorbidity is common in heart failure, but previous prevalence estimates have been based on a limited number of conditions using mainly non-primary care data sources. To compare prevalence rates of comorbidity and polypharmacy in those with and without chronic heart failure due to left ventricular systolic dysfunction (LVSD). A cross-sectional study of 1.4 million patients in primary care in Scotland. Data on the presence of LVSD, 31 other physical, and seven mental health comorbidities, and prescriptions were extracted from a database of 1 424 378 adults. Comorbidity prevalence was compared in patients with and without LVSD, standardised by age, sex, and deprivation. Pharmacology data were also compared between the two groups. There were 17 285 patients (1.2%) who had a diagnosis of LVSD. Compared with standardised controls, the LVSD group had greater comorbidity, with the biggest difference found for seven or more conditions (odds ratio [OR] 4.10; 95% confidence interval (CI] = 3.90 to 4.32). Twenty-five physical conditions and six mental health conditions were significantly more prevalent in those with LVSD relative to standardised controls. Polypharmacy was higher in the LVSD group compared with controls, with the biggest difference found for ≥11 repeat prescriptions (OR 4.81; 95% CI = 4.60 to 5.04). However, these differences in polypharmacy were attenuated after controlling for the number of morbidities, indicating that much of the additional prescribing was accounted for by multimorbidity rather than LVSD per se. Extreme comorbidity and polypharmacy is significantly more common in patients with chronic heart failure due to LVSD. The efficient management of such complexity requires the integration of general and specialist expertise.

Noninvasive Detection of Left-Ventricular Systolic Dysfunction by Acoustic Cardiography in Atrial Fibrillation

Objectives. Assessment of left ventricular (LV) systolic function in patients with atrial fibrillation can be difficult. Acoustic cardiography provides several parameters for quantifying LV systolic function. We evaluated the ability of acoustic cardiography to detect LV systolic dysfunction in patients with and without atrial fibrillation. Design. We studied 194 patients who underwent acoustic cardiography and cardiac catheterization including measurement of angiographic ejection fraction (EF) and maximum LV dP/dt. LV systolic dysfunction was defined as LV maximum dP/dt <1600 mmHg/s. Acoustic cardiographic parameters included electromechanical activation time (EMAT) and the systolic dysfunction index (SDI). Results. Acoustic cardiography detected systolic dysfunction with high specificity and moderate sensitivity with similar performance to EF (sensitivity/specificity without afib: EMAT 30/96, SDI 40/90, EF at 35% 30/96; sensitivity/specificity with afib: EMAT 64/82, SDI 59/100, EF at 35% 45/82). Conclusions. Acoustic cardiography can be used for diagnosis of LV systolic dysfunction in atrial fibrillation.

The accuracy of symptoms, signs and diagnostic tests in the diagnosis of left ventricular dysfunction in primary care: A diagnostic accuracy systematic review

BackgroundTo assess the accuracy of findings from the clinical history, symptoms, signs and diagnostic tests (ECG, CXR and natriuretic peptides) in relation to the diagnosis of left ventricular systolic dysfunction (LVSD) in a primary care setting.MethodsDiagnostic accuracy systematic review, we searched Medline (1966 to March 2008), EMBASE (1988 to March 2008), Central, Cochrane and ZETOC using a diagnostic accuracy search filter. We included cross-sectional or cohort studies that assess the diagnostic utility of clinical history, symptoms, signs and diagnostic tests, against a reference standard of echocardiography. We calculated pooled positive and negative likelihood ratios and assessed heterogeneity using the I2 index.Results24 studies incorporating 10,710 patients were included. The median prevalence of LVSD was 29.9% (inter-quartile range 14% to 37%). No item from the clinical history or symptoms provided sufficient diagnostic information to "rule in" or "rule out" LVSD. Displaced apex beat shows a convincing diagnostic effect with a pooled positive likelihood ratio of 16.0 (8.2–30.9) but this finding occurs infrequently in patients. ECG was the most widely studied diagnostic test, the negative likelihood ratio ranging from 0.06 to 0.6. Natriuretic peptide results were strongly heterogeneous, with negative likelihood ratios ranging from 0.02 to 0.80.ConclusionFindings from the clinical history and examination are insufficient to "rule in" or "rule out" a diagnosis of LVSD in primary care settings. BNP and ECG measurement appear to have similar diagnostic utility and are most useful in "ruling out" LVSD with a normal test result when the probability of LVSD is in the intermediate range.

Identification of contractility abnormalities in intensive care unit patients with sepsis using tissue Doppler imaging

Tissue Doppler imaging (TDI), as a more recent ultrasound technique, is a precious diagnostic tool revealing earlier left ventricular (LV) contractility abnormalities as compared with the conventional echocardiography. This study aimed at assessing the contribution of TDI to the early diagnosis of LV systolic dysfunction in ICU septic patients maintaining a normal ejection fraction (EF).

The prognostic value of N-terminal proB-type natriuretic peptide

The heart is not only a pump, but also it is an endocrine organ. Cardiac stretch and overload stimulate the secretion of natriuretic peptides, which have a variety of beneficial actions, such as vasodilation and natriuresis. Cardiac-derived natriuretic peptides, especially B-type natriuretic peptide (BNP), have emerged as useful biomarkers for the diagnosis, and potentially the treatment, of heart failure patients. The inactive amino-terminal fragment of the BNP prohormone (NT-proBNP), which is more stable than mature BNP, has also been recognized as an aid in the diagnosis of left-ventricular systolic dysfunction. Furthermore, elevated NT-proBNP concentrations have been shown to be predictive of poor prognosis in a variety of cardiovascular diseases, suggesting that it could be useful for risk stratification of patients. This review summarizes current literature that has addressed the issue of NT-proBNP as a prognostic tool in heart failure, acute coronary syndromes and other conditions.

Diagnostic value of troponin T for alterations in left ventricular mass and function in dialysis patients

Cardiac troponin T (cTnT) is related to left ventricular (LV) mass in patients with end-stage renal disease (ESRD). Furthermore, cTnT reflects the severity of systolic dysfunction in patients with heart diseases. We tested the diagnostic value of cTnT for left ventricular hypertrophy (LVH) and LV systolic dysfunction in a large group of clinically stable hemodialysis patients without heart failure. CTnT was significantly (P < 0.001) higher in patients with LVH than in those with normal LV mass. In a multiple logistic regression model, adjusting for potential confounders (including cardiac ischemia), systolic pressure and cTnT (both P = 0.003) were the strongest correlates of LVH. Similarly, cTnT was significantly higher (P = 0.005) in patients with systolic dysfunction than in those with normal LV function and in a multiple logistic regression model cTnT ranked as the second independent correlate of this alteration after male sex. Serum cTnT had a high positive prediction value for the diagnosis of LVH (87%) but its negative prediction value was relatively low (44%). The positive predictive value of cTnT for LV dysfunction was low (25%) while its negative predictive value was high (93%). A combined analysis including systolic pressure (for the diagnosis of LVH) and sex (for the diagnosis of LV systolic dysfunction) augmented the diagnostic estimates to an important extent (95% positive prediction value for LVH and 98% negative prediction value for LV systolic dysfunction). CTnT has a fairly good diagnostic potential for the identification of LVH and for the exclusion of LV systolic dysfunction in patients with ESRD without heart failure. This marker may be useful for the screening of alterations in LV mass and function in clinically stable hemodialysis patients.