Inducible Wall Motion Abnormalities Research Articles

High resting coronary flow velocity and reduced coronary flow velocity reserve independently predict worse survival in diabetic patients without inducible ischemia and normal left ventricular function

Abstract Background High resting coronary flow velocity (CFV) in the mid-distal left anterior descending coronary artery (LAD) can be easily assessed with transthoracic echocardiography (TTE) and is a predictor of worse survival. Purpose In this study, we sought to assess the relationship between resting CFV, coronary flow velocity reserve (CFVR), and outcome in patients without inducible regional wall motion abnormality during stress echo (SE). Methods In a prospective multicenter study design, we enrolled 6,887 patients (age 65±11 years, 3,838 men, 1,963 diabetics), with left ventricular ejection fraction (LVEF) ≥50% referred for SE. Recruitment (years 2004-2022) involved 7 accredited laboratories, with inter-observer variability <10% for CFV measurement at study entry. Baseline peak diastolic CFV (abnormal value >32 cm/s) was obtained by pulsed-wave Doppler in mid-distal LAD. Coronary flow velocity reserve (CFVR, abnormal value ≤2.0) was assessed with dipyridamole. All-cause death was the only end-point. Results The mean CFV of LAD was 30±11 cm/s. The mean CFVR was 2.37±0.58. During a median follow-up of 6.0±4.2, 1,015 (15%) patients died. At Cox analysis, resting CFV >32 cm/s independently predicted mortality together with CFVR <2, age, diabetes, previous myocardial infarction, history of coronary surgery and LVEF. Resting CFV allowed effective risk stratification either in diabetics and nondiabetics although the difference in survival based on resting CFV was more marked in the former (Figure). In addition, it added significant (p<0.0001) prognostic information to CFVR result in the diabetic, but not in the non-diabetic population (Figure). Conclusion High resting CFV with TTE in mid-distal LAD predicts worse survival in patients without inducible ischemia. The value is independent and additive to CFVR in diabetic patients. The combination of high resting CFV-low CFVR is associated with worse survival.

Association between fractional flow reserve and CMR-derived exercise capacity

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): NMRC Open-Fund Young Individual Research Grant, Singapore. NMRC Open-Fund Individual Research Grant, Singapore. Background In-scanner exercise stress cardiac magnetic resonance (ExCMR) imaging using supine cycling ergometer offers assessment of perfusion defects, inducible regional wall motion abnormalities, viability and exercise capacity in a single examination (EMPIRE Trial). Aim We aim to investigate the role of CMR-derived exercise capacity to assess the physiological stenosis severity, measured by invasive fractional flow reserve (FFR). Methods 107 patients (60±8 years, 80 males) with suspected coronary artery disease (CAD) underwent ExCMR (Siemens 1.5T) and invasive coronary angiogram with FFR measurement (PressureWireTMX Guidewire – Abbott Laboratories) followed previously published trial protocol [1]. Exercise capacity was derived as age- and sex-specific percentile of peak cardiac index, according to the reference range previously established [2]. Results Exercise capacity remains the only predictor of FFR values (beta 0.005, P<0.001) with backward multivariate regression of clinical variables (age, sex, BMI, presence of hyperlipidema, blood pressure, presence of diabetes mellitus) and quantitative CMR parameters (LV mass, extracellular volume, LV stroke volume at rest and exercise capacity). Patients with haemodynamically significant CAD (FFR<0.8) had significantly lower exercise capacity (median 14 [IQR 4–20] vs 5 [IQR 1–10] age- and sex-specific percentile of peak cardiac index, P<0.001) Conclusion In addition to perfusion defects, regional wall motion abnormalities and viability assessment to detect coronary artery disease, exercise capacity predicts the physiological stenosis severity.

Cardiac exercise imaging using a 3-tesla magnetic resonance-conditional pedal ergometer: Preliminary results in healthy volunteers and patients with known or suspected coronary artery disease.

Cardiac magnetic resonance imaging (CMR) remains underutilized as an exercise imaging modality, mostly because of the limited availability of MR-compatible exercise equipment. This study prospectively evaluates the clinical feasibility of a newly developed MR-conditional pedal ergometer for exercise CMR METHODS: Ten healthy volunteers (mean age 44 ± 16 years) and 11 patients (mean age 60 ± 9 years) with known or suspected coronary artery disease (CAD) underwent rest and post-exercise cinematic 3T CMR. Visual analysis of wall motion abnormalities (WMA) was rated by 2 experienced radiologists, and volumes and ejection fractions (EF) were determined. Image quality was assessed by a 4-point Likert scale for visibility of endocardial borders. Median subjective image quality of real-time cine at rest was 1 (interquartile range [IQR] 1-2) and 2 (IQR 2-2.5) for post-exercise real-time cine (p = 0.001). Exercise induced a significant increase in heart rate (62 [62-73] to 111 [104-143] bpm, p < 0.0001). Stroke volume and cardiac index increased from resting to post-exercise conditions (85 ± 21 to 101 ± 19 mL and 2.9 ± 0.7 to 6.6 ± 1.9 L/min/m2, respectively; both p < 0.0001), driven by a reduction in end-systolic volume (55 ± 20 to 42 ± 21 mL, p < 0.0001). Patients (2/11) with inducible regional WMA at high-resolution postexercise cine imaging revealed significant coronary artery stenosis in subsequently performed invasive coronary angiography. Exercise-CMR using our newly developed 3T MR-conditional pedal ergometer is clinically feasible. Imaging of both cardiac response and myocardial ischemia, triggered by dynamic stress, is rapidly conducted while the patient is near their peak heart rate.

Association between severity of ischemia evaluated by stress CMR and Syntax score in patients with stable coronary artery disease

Abstract Dipiridamol stress cardiac magnetic resonance (CMR) had proved to be useful to evaluate the benefit of revascularization in stable coronary artery disease [1]. Nevertheless the association between stress CMR imaging parameters and coronary Syntax score has not yet be fully evaluated. Objective To analyze the association of the extent and transmurality of ischemia and necrosis analyzed by vasodilators stress CMR with the severity and prognosis of coronary artery disease assessed by the Syntax score. Methods A retrospective cohort study including consecutive patients with stable coronary artery disease with inducible ischaemia in vasodilators stress CMR who underwent post-study catheterization was performed. The CMR protocol includes a functional study with b-SSFP sequences, first-pass perfusion with b-SSFP sequences obtained after administration of 0.84mg/kg of dipyridamole and during administration of gadolinium chelates and also IR-FGE viability sequences. A post-stress perfusion (PSP) and viability (V) score was developed scoring each segment from 0 to 2 according to transmurality. The number of segments with induced wall motion abnormalities (NSIWA) were also analyzed. The Syntax I and II scores were calculated using data from coronary angiography and computerized medical records. Results 208 patients were included, mean age 65±13 years, 44% women, 109 of them revascularized after stress CMR, 13 of them by surgery. Univariate analysis showed a significant correlation of the PSP, NSIWA and V scores with the Syntax I and Syntax 2. Using a multivariate regression models, NSIWA and V scores were independent predictors for Syntax I while NSIWA and PSP were independent predictors for Syntax 2. Conclusions – CMR stress test in patients with stable coronary artery disease allows an integrative assessment of V, PSP and PSWA and all of this parameters were associated with the severity of coronary artery disease and the prognosis after revascularization estimated by the Syntax I and 2. – NSIWA and V independently predict the severity of coronary artery disease estimated using Syntax I. – NSIWA and PSP independently predict prognosis after revascularization estimated for surgery using Syntax 2. Funding Acknowledgement Type of funding sources: None.

Prognostic value of coronary flow and heart rate reserve in emergency department chest pain

Abstract Aims To estimate the prognostic value of stress echo (SE) with the assessment of coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) in patients admitted for chest pain with non-diagnostic EKG, negative troponin, and without inducible regional wall motion abnormalities (RWMA). Methods 658 patients (age 67±12 years) admitted to our Emergency Department with chest pain, non-diagnostic EKG, and negative serial troponin underwent dipyridamole (0.84 mg/kg in 6') SE with simultaneous assessment of RWMA, CFVR in the left anterior descending artery, and HRR as peak/rest heart rate. The outcome measure was all-cause mortality. Results Of the 658 patients initially enrolled, 20 (3%) showed RWMA during SE and were referred to ischemia-driven revascularization. In the remaining 638, CFVR was abnormal (&amp;lt;2.0) in 148 patients (23%). HRR was abnormal (&amp;lt;1.22 in patients in sinus rhythm, or &amp;lt;1.17 in patients with permanent atrial fibrillation) in 196 patients (31%). The main clinical and echocardiographic characteristics according to CFVR and HRR response are shown in Table 1. During a follow-up of 7.3±4.3 years, 151 (24%) patients died. Survival at 8 years was 93% in patients with normal CFVR and HRR, 76% in patients with abnormal CFVR only, 73% in patients with abnormal HRR only, and 38% in those with abnormal CFVR and HRR (p&amp;lt;0.0001) (Figure 1). At multivariable analysis, abnormal CFVR (HR 1.49, 95% CI 1.05–2.10, p=0.02) and abnormal HRR (HR 2.01, 95% CI 1.43–2.84, p&amp;lt;0.0001) were independent predictors of survival. Conclusions In admitted patients with non-ischemic EKG, negative serial troponin, and whitout RWMA during dipyridamole SE, a reduced CFVR and blunted HRR independently identify a subset with worse survival in the long-term. Funding Acknowledgement Type of funding sources: None.

Reduced coronary flow velocity reserve and blunted heart rate reserve identify a higher risk group in patients with chest pain and negative emergency department evaluation.

To estimate the prognostic value of stress echo (SE) with the assessment of coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) in patients admitted for chest pain with non-diagnostic EKG, negative troponin, and without inducible regional wall motion abnormalities (RWMA). 658 patients (age 67 ± 12years) admitted to our Emergency Department with chest pain, non-diagnostic EKG, and negative serial troponin underwent dipyridamole (0.84mg/kg in 6') SE with simultaneous assessment of RWMA, CFVR in the left anterior descending artery, and HRR as peak/rest heart rate. The outcome measure was all-cause mortality. Of the 658 patients initially enrolled, 20 (3%) showed RWMA during SE and were referred to ischemia-driven revascularization. In the remaining 638, CFVR was abnormal (≤ 2.0) in 148 patients (23%). HRR was abnormal (≤ 1.22 in patients in sinus rhythm, or ≤ 1.17 in patients with permanent atrial fibrillation) in 196 patients (31%). During a follow-up of 7.3 ± 4.3years, 151 (24%) patients died. Survival at 8years was 93% in patients with normal CFVR and HRR, 76% in patients with abnormal CFVR only, 73% in patients with abnormal HRR only, and 38% in those with abnormal CFVR and HRR (p < 0.0001). At multivariable analysis, abnormal CFVR (HR 1.49, 95% CI 1.05-2.10, p = 0.02) and abnormal HRR (HR 2.01, 95% CI 1.43-2.84, p < 0.0001) were independent predictors of survival. In admitted patients with non-ischemic EKG, negative serial troponin, and without RWMA during dipyridamole SE, a reduced CFVR and blunted HRR independently identify a subset with worse survival in the long term. Upper panel: Color and pulsed-wave Doppler with the electrocardiographic lead tracing of Four different response patterns (from left to right): normal CFVR and HRR; normal CFVR, abnormal HRR; abnormal CFVR, normal HRR; abnormal CFVR and HRR. Lower panel: The annualized death rate for each of the four groups with negative SE for RWMA and stratified according to the presence of CFVR and HRR: none, one, or two abnormalities.

Safety and reliability of dobutamine stress echocardiography in pediatric and young adult patients with coronary arteries abnormalities

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This study was conducted with the support of Regione Marche, Italy Background Risk stratification in coronary arteries abnormalities (CAA), both anomalous aortic origin of a coronary artery (AAOCA) and myocardial bridges (MBs), is still challenging. A reliable method to detect myocardial ischemia is missing in these anomalies. We studied the safety and feasibility of dobutamine stress echocardiography (DSE), compared with exercise stress echocardiography (ESE), in pediatric and young adult patients with CAA. Methods In 2019-21, N = 27 CAA [median age 16 years (Q1–Q3: 11, 22)] (n= 23 AAOCA, n = 4 MBs) were assessed. ESE was performed 1-2 days before the DSE examination, double-blinded for examiners and patients. Hemodynamic response and major (cardiac arrest, myocardial infarction, ventricular arrhythmia) and minor [hypertension (≥ 200/120 mmHg), paradoxical bradycardia, chest pain, nausea/vomiting, skin rash, anxiety, dizziness, dyspnea] events were recorded. Differences between rest/stress and DSE/ESE for wall motion abnormalities (WMA) and global longitudinal strain (GLS) were evaluated. Inter-observer agreement was also tested using the kappa (k) coefficient. Results Heart rate and blood pressure increased significantly from baseline (p &amp;lt; 0.001) in both DSE and ESE exams. Only DSE tests reached a heart rate ≥ 150 bpm (p &amp;lt; 0.001), while younger patients barely reached the heart rate target and frequently showed less compliance to the test. No patient had major events, while 5 (18.5%) had minor events, the majority during DSE. Inducible WMA were observed only at DSE examinations. Inter-observer agreement for WMA and GLS changes was good for both examinations (95%, k = 0.85, p &amp;lt; 0.001). Conclusions DSE is feasible in pediatric and young adult patients with AAOCA and MBs to assess inducible WMA and GLS rest/stress changes. It can be performed safely with a low incidence of major/minor events, with a better performance when compared to ESE. DSE is potentially a valuable test for detecting myocardial ischemia and probably helpful in managing CAA patients.

Left ventricular contractile reserve, coronary flow reserve, and heart rate reserve during dipyridamole stress echocardiography predict survival in non-ischemic heart failure

Abstract Background Left ventricular contractile reserve (LVCR), coronary flow velocity reserve (CFVR), and heart rate reserve (HRR) have recognized independent impact on outcome in heart failure (HF). They all can be simultaneously measured during dipyridamole stress echocardiography (DSE). Aim To assess the value of comprehensive DSE in patients with non-ischemic heart failure. Methods We evaluated 613 patients with HF, no history of coronary artery disease and no inducible regional wall motion abnormalities: 270 patients with preserved (≥50%) ejection fraction; 147 with mid-range (40–49%) ejection fraction; 196 with HF and reduced (&amp;lt;40%) ejection fraction. All underwent DSE (0.84 mg/kg in 6') in 5 accredited laboratories. We measured LVCR (abnormal value ≤1.1), CFVR in left anterior descending artery (abnormal value ≤2.0), and HRR (peak/rest heart rate, abnormal value ≤1.22). All patients were followed-up. Results Abnormal CFVR, LVCR and HRR occurred in 29%, 44% and 46% of patients, respectively. After a median follow-up time of 20 months (interquartile range 12–32 months), 41 patients died. Annual mortality rate was lowest in patients (n=200) with normal response, and &amp;gt;10-fold higher in patients (n=96) with 3 abnormal criteria: see figure. At multivariable analysis, a reduced HRR (Hazard Ratio = 3.402, 95% Confidence Intervals 1.530–7.565, p=0.003) was the strongest SE independent predictor of all-cause death. Conclusion Abnormal LVCR, CFVR and HRR can be frequently observed during vasodilator SE in HF patients. They target different pathophysiological vulnerabilities (myocardial function, coronary microcirculation and cardiac autonomic system) and are useful for outcome prediction. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Consiglio nazionale delle ricerche - Institute of Clinical Physiology Figure 1

Coronary Flow, Left Ventricular Contractile and Heart Rate Reserve in Non-Ischemic Heart Failure.

Background: Left ventricular contractile reserve (LVCR), coronary flow velocity reserve (CFVR), and heart rate reserve (HRR) affect outcome in heart failure (HF). They can be simultaneously measured during dipyridamole stress echocardiography (DSE). Aim: To assess the value of comprehensive DSE in patients with non-ischemic HF. Methods: We evaluated 610 patients with HF, no history of coronary artery disease, and no inducible regional wall motion abnormalities: 270 patients with preserved ejection fraction (≥50%), 146 patients with mid-range ejection fraction (40–49%), and 194 patients with reduced ejection fraction (<40%). All underwent DSE (0.84 mg/kg in 6′) in 7 accredited laboratories. We measured LVCR (abnormal value ≤ 1.1), CFVR in left anterior descending artery (abnormal value: ≤2.0), and HRR (peak/rest heart rate; abnormal value: ≤1.22). All patients were followed up. Results: Abnormal CFVR, LVCR, and HRR occurred in 29%, 45%, and 47% of patients, respectively (p < 0.001). After a median follow-up time of 20 months (interquartile range: 12–32 months), 113 hard events occurred in 105 patients with 41 deaths, 8 myocardial infarctions, 61 admissions for acute HF, and 3 strokes. The annual mortality rates were 0.8% in 200 patients with none abnormal criteria, 1.8% in 184 patients with 1 abnormal criterion, 7.1% in 130 patients with 2 abnormal criteria, 7.5% in 96 patients with 3 abnormal criteria. Conclusions: Abnormal LVCR, CFVR, and HRR were frequent during DSE in non-ischemic HF patients. They target different pathophysiological vulnerabilities (myocardial function, coronary microcirculation, and cardiac autonomic balance) and are useful for outcome prediction.

Prognostic relevance of exercise testing in hypertrophic cardiomyopathy. A systematic review

BackgroundCardiopulmonary exercise test (CPET) is indicated as part of the assessment in hypertrophic cardiomyopathy (HCM) patients and stress echocardiography is often used to assess symptoms. However, the role of exercise testing for prognostic stratification in HCM is still not established. AimsTo systematically review the evidence on the role of exercise testing for prognostic stratification in hypertrophic cardiomyopathy. MethodsA systematic review was conducted for eligible publications, between 2010 and 2020, that included evaluation of outcomes and prognosis. In these studies, patients underwent exercise echocardiography and/or cardiopulmonary exercise testing, performed according to predefined protocols. Diverse parameters were assessed in order to determine which were relevant for the prognosis. Analyzed outcomes included death from any cause, sudden cardiac death (SCD) and equivalents, cardiovascular death, heart failure requiring hospitalization or progression to New York Heart Association classes III or IV, cardiac transplantation, non-sustained ventricular tachycardia, stroke, myocardial infarction and invasive septal reduction therapy. ResultsEighteen publications were included, corresponding to a total of 7525 patients. The mean follow-up period varied between 1 and 8 years. The main findings of these studies revealed that the major predictors of outcomes were abnormal heart rate recovery, abnormal blood pressure response exercise induced wall motion abnormalities, lower peak VO2, higher VE/VCO2, and pulmonary hypertension/exercise-induced pulmonary hypertension. ConclusionAlthough most studies concluded that exercise test results are useful to determine prognosis in HCM, further investigation is needed regarding whether it adds independent value to the current risk stratification strategies.

Natural History of Patients With Ischemia and No Obstructive Coronary Artery Disease

Ischemia with no obstructive coronary artery disease (INOCA) is common and has an adverse prognosis. We set out to describe the natural history of symptoms and ischemia in INOCA. CIAO-ISCHEMIA (Changes in Ischemia and Angina over One Year in ISCHEMIA Trial Screen Failures With INOCA) was an international cohort study conducted from 2014 to 2019 involving angina assessments (Seattle Angina Questionnaire) and stress echocardiograms 1 year apart. This was an ancillary study that included patients with a history of angina who were not randomly assigned in the ISCHEMIA trial. Stress-induced wall motion abnormalities were determined by an echocardiographic core laboratory blinded to symptoms, coronary artery disease status, and test timing. Medical therapy was at the discretion of treating physicians. The primary outcome was the correlation between the changes in the Seattle Angina Questionnaire angina frequency score and changes in echocardiographic ischemia. We also analyzed predictors of 1-year changes in both angina and ischemia, and we compared CIAO participants with ISCHEMIA participants with obstructive coronary artery disease who had stress echocardiography before enrollment, as CIAO participants did. INOCA participants in CIAO were more often female (66% of 208 versus 26% of 865 ISCHEMIA participants with obstructive coronary artery disease, P<0.001), but the magnitude of ischemia was similar (median 4 ischemic segments [interquartile range, 3-5] both groups). Ischemia and angina were not significantly correlated at enrollment in CIAO (P=0.46) or ISCHEMIA stress echocardiography participants (P=0.35). At 1 year, the stress echocardiogram was normal in half of CIAO participants, and 23% had moderate or severe ischemia (≥3 ischemic segments). Angina improved in 43% and worsened in 14%. Change in ischemia over 1 year was not significantly correlated with change in angina (ρ=0.029). Improvement in ischemia and angina were common in INOCA but not correlated. Our INOCA cohort had a degree of inducible wall motion abnormalities similar to concurrently enrolled ISCHEMIA participants with obstructive coronary artery disease. Our results highlight the complex nature of INOCA pathophysiology and the multifactorial nature of angina. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02347215.

Dobutamine stress cardiac MRI is safe and feasible in pediatric patients with anomalous aortic origin of a coronary artery (AAOCA)

BackgroundRisk stratification in anomalous aortic origin of a coronary artery (AAOCA) is challenged by the lack of a reliable method to detect myocardial ischemia. We prospectively studied the safety and feasibility of Dobutamine stress-cardiac magnetic resonance (DSCMR), a test with excellent performance in adults, in pediatric patients with AAOCA. MethodsConsecutive DSCMR from 06/2014–12/2019 in patients≤20 years old with AAOCA were included. Hemodynamic response and major/minor events were recorded. Image quality and spatial/temporal resolution were evaluated. Rest and stress first-pass perfusion and wall motion abnormalities (WMA) were assessed. Inter-observer agreement was assessed using kappa coefficient. ResultsA total of 224 DSCMR were performed in 182 patients with AAOCA at a median age of 14 years (IQR 12, 16) and median weight of 58.0 kg (IQR 43.3, 73.0). Examinations were completed in 221/224 (98.9%), all studies were diagnostic. Heart rate and blood pressure increased significantly from baseline (p < 0.001). No patient had major events and 28 (12.5%) had minor events. Inducible hypoperfusion was noted in 31/221 (14%), associated with WMA in 13/31 (42%). Inter-observer agreement for inducible hypoperfusion was very good (Κ = 0.87). Asymptomatic patients with inducible hypoperfusion are considered high-risk and those with a negative test are of standard risk. ConclusionsDSCMR is feasible in pediatric patients with AAOCA to assess for inducible hypoperfusion and WMA. It can be performed safely with low incidence of major/minor events. Thus, DSCMR is potentially a valuable test for detection of myocardial ischemia and helpful in the management of this patient population.

Multiparametric exercise stress cardiovascular magnetic resonance in the diagnosis of coronary artery disease: the EMPIRE trial

BackgroundStress cardiovascular magnetic resonance (CMR) offers assessment of ventricular function, myocardial perfusion and viability in a single examination to detect coronary artery disease (CAD).We developed an in-scanner exercise stress CMR (ExCMR) protocol using supine cycle ergometer and aimed to examine the diagnostic value of a multiparametric approach in patients with suspected CAD, compared with invasive fractional flow reserve (FFR) as the reference gold standard.MethodsIn this single-centre prospective study, patients who had symptoms of angina and at least one cardiovascular disease risk factor underwent both ExCMR and invasive angiography with FFR. Rest-based left ventricular function (ejection fraction, regional wall motion abnormalities), tissue characteristics and exercise stress-derived (perfusion defects, inducible regional wall motion abnormalities and peak exercise cardiac index percentile-rank) CMR parameters were evaluated in the study.ResultsIn the 60 recruited patients with intermediate CAD risk, 50% had haemodynamically significant CAD based on FFR. Of all the CMR parameters assessed, the late gadolinium enhancement, stress-inducible regional wall motion abnormalities, perfusion defects and peak exercise cardiac index percentile-rank were independently associated with FFR-positive CAD. Indeed, this multiparametric approach offered the highest incremental diagnostic value compared to a clinical risk model (χ2 for the diagnosis of FFR-positive increased from 7.6 to 55.9; P < 0.001) and excellent performance [c-statistic area under the curve 0.97 (95% CI: 0.94–1.00)] in discriminating between FFR-normal and FFR-positive patients.ConclusionThe study demonstrates the clinical potential of using in-scanner multiparametric ExCMR to accurately diagnose CAD.Trial registration: ClinicalTrials.gov, NCT03217227, Registered 11 July 2017–Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT03217227?id=NCT03217227&draw=2&rank=1&load=cart

The obesity paradox in the stress echo lab: fat is better for hearts with ischemia or coronary microvascular dysfunction.

Obesity is an independent risk factor for coronary artery disease (CAD), but once CAD has developed it has been associated with improved survival ("obesity paradox"). To assess how obesity affects prognosis in patients with or without inducible ischemic regional wall motion abnormalities (RWMA) and/or abnormal coronary flow velocity reserve (CFVR) during stress echocardiography (SE). In an observational retrospective two- center study design, we analyzed 3249 consecutive patients (1907 men; age 66 ± 12 years; body mass index, BMI, 26.9 ± 4.1 kg/m2) with known (n = 1306) or suspected (n = 1943) CAD who underwent dipyridamole SE with simultaneous evaluation of RWMA and CFVR. All-cause death was the outcome end-point. 1075 patients were lean (BMI 18.5-24.9 kg/m2), 1523 overweight (BMI 25.0-29.9 kg/m2), and 651 obese (≥30.0 kg/m2). Ischemic test result for RWMA occurred in 28 (3%) lean, 69 (4%) overweight, and 28 (4%) obese patients (p = 0.03). An abnormal CFVR (≤2.0) was found in 281 (26%) lean, 402 (26%) overweight and 170 (26%) obese patients (p = 0.99). During 68 ± 44 months of follow-up, 496 (15%) patients died. At multivariable Cox analysis, BMI ≥ 30 was an independent predictor of reduced mortality in the 878 patients with stress-induced (≥2 segments) RWMA and/or CFVR abnormality (HR 0.58, 95% CI 0.40-0.84; p = 0.003), while showed no effect at univariate analysis in the 2371 patients with no RWMA and normal CFVR (HR 1.04, 95% CI 0.74-1.46; p = 0.84). Obesity exerts a "paradoxical" protective effect in patients with stress-induced ischemia and/ or coronary microvascular dysfunction, and shows a neutral effect in patients with normal CFVR and no stress-induced RWMA.

Impaired global longitudinal strain in elderly patients with preserved ejection fraction is associated with raised post-exercise left ventricular filling pressure.

The purpose of this study was to evaluate whether impaired resting global longitudinal strain (GLS) in elderly patients with preserved left ventricular (LV) ejection fraction (EF) is associated with raised post-exercise LV filling pressure estimated by the ratio of early diastolic transmitral flow velocity to annulus velocity (E/e'). Seventy elderly patients (age = 74 ± 6years, male 40 patients) who underwent treadmill stress echocardiography were studied. All patients had normal sinus rhythm, normal LV wall motion at rest, and had preserved LVEF ≥ 50%. Patients with exercise induced wall motion abnormality were not included. GLS at rest was measured using automated functional imaging. Twenty-four of the 70 patients had raised post-exercise LV filling pressure indicated by septal E/e' ≥ 15.0. Patients with raised post-exercise LV filling pressure had smaller resting GLS than that in patients without it (-16.9 ± 1.8 vs. -19.6 ± 2.5%, respectively, p < 0.0001). Downward stepwise multivariate logistic regression analysis demonstrated that resting GLS was one of independent predictors of raised post-exercise E/e'. Receiver operating characteristic (ROC) curve analysis had demonstrated that optimal cutoff point for resting GLS to predict raised post-exercise E/e' was -17.8% (sensitivity 83.3%, specificity 80.4%, respectively), and the area under the ROC curve was 0.820. In elderly patients with preserved LVEF and without obvious myocardial ischemia, impaired resting GLS at rest is associated with raised post-exercise LV filling pressure estimated by E/e' ≥ 15.0.

Role of adjuvant carotid ultrasound in women undergoing stress echocardiography for the assessment of suspected coronary artery disease.

ObjectiveDue to the low prevalence of obstructive coronary artery disease (CAD) in women, stress testing has a relatively low predictive value for this. Additionally, conventional cardiovascular risk scores underestimate risk in women. This study sought to evaluate the role of atherosclerosis assessment using carotid ultrasound (CU) in women attending for stress echocardiography (SE).MethodsThis was a prospective study in which consecutive women with recent-onset suspected angina, who were referred for clinically indicated SE, underwent CU.Results415 women (mean age 61±10 years, 29% diabetes mellitus, mean body mass index 28) attending for SE underwent CU. 47 women (11%) had inducible wall motion abnormalities, and carotid disease (CD) was present in 46% (carotid plaque in 41%, carotid intima-media thickness >75th percentile in 15%). Women with CD were older (65 vs 58 years, p<0.001), and more likely to have diabetes (41% vs 21%, p=0.001), hypertension (67% vs 36%, p<0.01) and a higher pretest probability of CAD (59% vs 41%, p<0.001). 40% of women classified as low Framingham risk were found to have evidence of CD.The positive predictive value of SE for flow-limiting CAD was 51%, but with the presence of carotid plaque, this was 71% (p<0.01). Carotid plaque (p=0.004) and ischaemia (p=0.01) were the only independent predictors of >70% angiographic stenosis. In women with ischaemia on SE and no carotid plaque, the negative predictive value for flow-limiting disease was 88%.During a follow-up of 1058±234 days, there were 15 events (defined as all-cause mortality, non-fatal myocardial infarction, heart failure admissions and late coronary revascularisation). Age (HR 1.07 (1.00–1.15), p=0.04), carotid plaque burden (HR 1.65 (1.36–2.00), p<0.001) and ischaemic burden (HR 1.41 (1.18–1.68), p<0.001) were associated with outcome. There was a stepwise increase in events/year from 0.3% when there were no ischaemia and atherosclerosis, 1.1% when there was atherosclerosis and no ischaemia, 2.2% when there was ischaemia and no atherosclerosis and 10% when there were both ischaemia and atherosclerosis (p<0.001).ConclusionCU significantly improves the accuracy of SE alone for identifying flow-limiting disease on coronary angiography, and improves risk stratification in women attending for SE, as well identifying a subset of women who may benefit from primary preventative measures.

Prognostic value of heart rate reserve is additive to coronary flow velocity reserve during dipyridamole stress echocardiography

During dipyridamole stress echocardiography (SE), a blunted heart rate reserve (HRR) is a prognostically unfavourable sign of cardiac autonomic dysfunction. To assess the prognostic meaning of HRR and coronary flow velocity reserve (CFVR). The study group comprised 2149 patients (1236 men; mean age 66±12 years) with suspected (n=1280) or known (n=869) coronary artery disease and without inducible regional wall motion abnormalities (RWMA) during dipyridamole SE (0.84mg/kg in 6min). We assessed CFVR of the left anterior descending artery with pulsed-wave Doppler as the ratio between hyperaemic peak and basal peak diastolic flow velocities (abnormal value≤2.0). HRR was calculated as the peak/resting ratio of heart rate from a 12-lead electrocardiogram (abnormal value≤1.22). All patients were followed up. CFVR and HRR were abnormal in 520 (24%) and 670 (31%) patients, respectively. There was a positive linear correlation between CFVR and HRR (r=0.30; P<0.0001). During a median follow-up of 22 months (1st quartile 12 months, 3rd quartile 35 months), 75 (6%) patients died. The annual mortality was 1.6% in the overall population, 0.5% in the 1224 (57%) patients with normal CFVR and HRR, 1.7% in the 405 (19%) patients with abnormal HRR only, 3.6% in the 255 (12%) patients with abnormal CFVR only, and 6.2% in the 265 (12%) patients with abnormal CFVR and HRR. HRR is weakly related to CFVR, and a blunted HRR usefully complements RWMA and CFVR for prediction of outcome with dipyridamole SE. The patient without inducible RWMA is still at intermediate risk, but the risk is low with concomitant preserved CFVR, and very low with concomitant normal HRR.

419 The use of ST/HR Hysteresis as a Diagnostic Tool During Treadmill Exercise Stress Echo

Exercise stress test limitations including relatively low reported sensitivity has prompted research into analysis methods beyond traditional ST-segment depression criteria. ST/HR hysteresis has demonstrated relatively higher diagnostic accuracy as acknowledged by the American Heart Association Scientific Statement (2013). The aim of the present study is to assess the sensitivity and specificity of ST/HR Hysteresis for identifying CAD within a large tertiary referral centre. Data from Exercise Stress Echo (ESE) reports performed at a large tertiary referral centre between October 2017 and May 2018 (n=318) analysed retrospectively. Uninterpretable ECGs (n=24), bundle branch blocks (n=40) , and those with “non-diagnostic” ESE reports (n=33) excluded. ST/HR Hysteresis values calculated via GE-CASE Stress System (leads aVL, aVR, V1 excluded). Positive hysteresis was based on a partition value of ≥0.015mV and compared against a reference test of stress echo to determine sensitivity and specificity. Identification of ‘CAD’ for the purpose of analysis was based upon a positive ESE displaying a new inducible wall-motion abnormality. 225 tests remained after exclusions (24 positive, 201 negative) Both positive ESE and hysteresis occurred in 18 cases (sensitivity-=75%). Of 201 negative tests, 123 displayed negative hysteresis (specificity=62%). ST/HR hysteresis used during ESE does not display superior sensitivity and specificity within this population compared to that of traditional ST-segment criteria reference values. Further research is required using ECG-only based EST, ideally with coronary angiography as the reference test, to explore the potential utility of ST/HR Hysteresis as a diagnostic tool.

P1507Role of adjuvant carotid ultrasound in women undergoing stress echocardiography for the assessment of suspected angina with no previous history of coronary artery disease

Abstract Introduction Traditional risk assessment tools classify the majority of women at low risk despite cardiovascular disease remaining the leading cause of death in women. Additionally conventional stress testing techniques have poor predictive value in women, due to unique pathophysiological mechanisms causing ischaemia in women, and the lower prevalence of obstructive CAD. The study sought to evaluate the role of adjuvant carotid ultrasound (CU) in women attending for stress echocardiography (SE). Methods and results 415 women (Mean age 62±10 years, 28% Diabetes Mellitus, Mean BMI 28) attending for SE prospectively underwent CU, to assess Carotid Intima-media thickness (CIMT) and the presence of plaque. 47 women (11%) had inducible wall motion abnormalities, and carotid disease (CD) was present in 46% (Carotid plaque in 41%, 15% CIMT &gt;75th percentile). Women with CD were older (65 vs 58 years, p&lt;0.0001), more likely to have Diabetes (41% vs 21%, p=0.0001) and hypertension (67% vs 36%, p&lt;0.01), and had higher pretest probability of CAD (59% vs 41%, p&lt;0.0001). 40% of women classified as low Framingham, were found to have evidence of CD. Conversely, only 40% of women classified as high Framingham risk, had CD. The positive predictive value of SE for flow-limiting CAD was 51%, but the presence of carotid plaque improved this to 71% (p&lt;0.01). Of all clinical and test parameters, carotid plaque (p=0.001) and SE result (p=0.01) were the only independent predictors of &gt;70% angiographic. Conclusion CU significantly improves the accuracy of SE alone for identifying flow-limiting disease on coronary angiography. Non-invasive assessment of subclinical atherosclerosis using CU offers an individualized disease-guided approach in women, where conventional scoring systems offer modest risk stratification.

P4982Blunted heart rate reserve as an imaging-independent prognostic predictor during dipyridamole-echocardiography test

Abstract Background A blunted heart rate (HR) response during dipyridamole myocardial perfusion imaging have been associated with a poor outcome. Aim To assess the value of HR response in patients undergoing high dose dipyridamole stress echocardiography (SE). Methods We retrospectively selected a consecutive sample of 1,622 patients (none with pacemakers or atrial fibrillation), mean age 66±12 years, 431 (27%) on beta-blockers. All underwent high dose (0.84 mg/kg) dipyridamole SE for known or suspected coronary artery disease and/or heart failure from January 1988 to January 2018 in our Cardiology Division. HR (with 12-lead ECG) was obtained each minute and recorded at rest and peak stress. HR reserve (HRR) was calculated as the peak/rest HR ratio. All patients were followed-up. The composite end-point was made of all cause-death, non-fatal myocardial infarction and late (&gt;3 months) symptoms-driven myocardial revascularizations. Results SE was positive for regional wall motion abnormalities (RWMA) in 192 patients (12%). HR increased (rest=70±11 beats/min vs stress= 92±17 beats/min, p&lt;0.0001). During a median follow-up time of 904 days, 462 events occurred: 73 deaths, 57 non-fatal myocardial infarctions, 332 myocardial revascularizations. Receiver operating curve analysis identified a HRR ≤1.27 as the best cutoff. At multivariate analysis a reduced HRR was a significant predictor of hard events (Hazard Ratio, HR=2.02, 95% Confidence Intervals, CI, 1.38–2.95, P&lt;0.0001), additive to ischemic regional wall motion abnormalities (HR=2.11, 95% CI 1.28–3.48, P=0.004), resting RWMA (HR =1.88, 95% CI 1.31–2.72, P&lt;0.001), age (HR =1.06, 95% CI 1.04–1.08, P&lt;0.001) and beta-blockers at the time of testing (HR =1.55, 95% CI 1.06–2.29, P=0.03). Five-year hard event-free survival increased from 6% to 26% from the highest to the lowest HRR quartile: see figure. Survival curve Conclusion A blunted HRR is a useful non-imaging predictor of adverse events during high dose dipyridamole-SE. It is additive over resting or inducible regional wall motion abnormalities, and unmasks a prognostically meaningful autonomic unbalance. Chronotropic incompetence during dipyridamole SE is a negative prognostic finding, equally important than RWMA.