Assessment Of Left Ventricular Ejection Fraction Research Articles

Depression and anxiety at time of implantable cardioverter defibrillator implantation and the biological link with cardiovascular disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Psychological distress, such as symptoms of anxiety and depression, are frequently present in patients receiving an implantable cardioverter defibrillator (ICD) and they are associated with adverse outcomes. Multiple pathophysiological mechanisms may explain the link between psychological distress and cardiovascular disease, such as autonomic dysfunction, neuro-endocrine alterations and chronic inflammation. Purpose The present study aims to examine the prevalence of psychological distress at time of ICD implantation and evaluates the complex interplay between psychological distress, autonomic function, neuro-endocrine alterations and inflammatory status in ICD patients. Methods We conducted a prospective study that included ICD patients receiving an ICD for primary and secondary prevention of sudden cardiac death. Prior to implantation, patients underwent extensive psychological evaluation, including validated questionnaires for depression, anxiety and personality traits. Cardiac status was evaluated by left ventricular ejection fraction (LVEF) assessment, New York Heart Association (NYHA) functional class evaluation, 6-minute walk test (6MWT), and 24-hour Holter monitoring for heart rate variability (HRV). Thyroid function, catecholamine levels and inflammatory status were also evaluated. Results Of 178 patients included (age 64 ± 12, 79% male, LVEF 35 ± 13%), 35% had symptoms of depression and 32% had symptoms of anxiety. Symptoms of depression and anxiety increased significantly with higher NYHA functional class (P < 0.001). Depressive symptoms were associated with a reduced 6MWT (411 ± 128 m versus 488 ± 89 m, P < 0.001), lower LVEF (29 ± 9% versus 36 ± 13%, P = 0.03), higher heart rate (74 ± 13 bpm versus 70 ± 13 bpm, P = 0.02), higher thyroid stimulating hormone levels (1.8 [1.3-2.8] mU/L versus 1.5 [1.0-2.2] mU/L, P = 0.04) and multiple HRV parameters, indicating reduced HRV. Anxiety symptoms were only associated with a reduced 6MWT (433 ± 112 m versus 477 ± 102, P = 0.02). Symptoms of depression or anxiety were not correlated with c-reactive protein, NT-proBNP or catecholamine levels. Conclusion A substantial part of ICD patients has symptoms of depression and anxiety at time of ICD implantation. Depression was correlated with a higher NYHA class, reduced exercise capacity, reduced LV-function and alterations in autonomic function, suggesting a biological link between depression and cardiac status. Whether depression and anxiety leads to an increase in ventricular arrhythmias will be determined during further follow-up. Abstract Figure. NYHA class and psychological distress

Pre-anthracycline left ventricular ejection fraction (LVEF) assessment and long-term cardiovascular (CV) outcomes in adolescent and young adult (AYA) lymphoma survivors.

e24060 Background: Anthracyclines are known to cause long-term cardiotoxicity. There are no specific guidelines for CV screening and follow-up of AYA patients treated with anthracyclines. Pediatric guidelines focus on long-term imaging surveillance, while for adults, LVEF assessment prior to anthracyclines is recommended. Multiple studies have demonstrated LVEF assessment rarely impacts treatment decisions, especially in the absence of CV symptoms/risk factors, adds to unnecessary costs and delays treatment initiation. Our study aimed to determine the pre-treatment LVEF assessment practices in AYA lymphoma patients treated with anthracyclines and its association with long-term cardiotoxicity. Methods: AYA survivors diagnosed with lymphoma > 5 years ago and treated with anthracyclines at age 15-39 years were identified in a retrospective single institution registry. To ensure adequate follow-up, at least 2 follow-up visits during 2015-19 were required. Data abstracted on eligible subjects included documentation of pre-treatment LVEF evaluation, clinical rationale and treatment regimen. CV risk factors and events were collected pre-treatment and during follow-up. Descriptive statistics were used to summarize data. Results: 64/115 (56%) of AYA lymphoma patients underwent pre-treatment LVEF assessment. Rationale for/against LVEF assessment was rarely documented: low CV risk was recorded as rationale for no LVEF assessment in 2 subjects. Among AYAs who underwent pre-treatment LVEF assessment, no significant abnormalities were detected and no changes in subsequent treatment plans were found. During median follow-up of 6.7 (inter-quartile range 5.4-9.5) years, 6/115 (5%) experienced CV events. Only 2 (1.7%) survivors experienced potential anthracycline-related CV events: 1 moderate cardiomyopathy at 9 years, 1 peri-partum cardiomyopathy and atrial fibrillation due to post-radiation SVC occlusion at 15 years post-treatment. Both these AYAs (aged 38 and 31 years at time of CV events) also had other CV risk factors- family history, smoking, obesity, and hyperlipidemia. Four (3.5%) survivors’ experienced CV events (1 sinus tachyarrhythmia, 1 junctional rhythm, 2 acute/asymptomatic drop in LVEF) unrelated to anthracyclines with clear alternative etiology e.g. sepsis/symptom burden. There was no correlation between having pre-treatment LVEF assessment and occurrence of CV events. 13/115 (11.3%) developed new CV risk factors: 4 hypertension, 6 hyperlipidemia, 3 diabetes. Conclusions: Pre-treatment LVEF assessment is done inconsistently in AYA lymphoma patients but does not impact initial treatment or predict late cardiotoxicity. CV events in long-term AYA lymphoma survivors are rare but evaluation of CV risk factors, early detection and management may be more important than focusing on LVEF assessment.

Cardiac safety of dual anti-HER2 blockade with pertuzumab plus trastuzumab (P+T) in the APHINITY trial.

510 Background: Trastuzumab (T) increases the incidence of cardiac events (CEs) in patients (pts) with early breast cancer (BC). Dual blockade with P+T improves BC outcomes and is the standard of care for high-risk HER2-positive BC pts following the phase 3 APHINITY trial that evaluated the addition of P or placebo (Pla) to T and chemotherapy (CT). We analyzed the cardiac safety of P+T in APHINITY. Methods: APHINITY eligibility required a left ventricular ejection fraction (LVEF) ≥55% at study entry. LVEF assessment was performed every 3 months (mos) during treatment, every 6 mos up to month 36, and yearly thereafter. Primary CE was defined as heart failure (HF) class III/IV and a significant decrease in LVEF of at least 10 percentage points from baseline and to <50%, or cardiac death. Secondary CE was defined as a confirmed significant decrease in LVEF or CEs confirmed by the cardiac advisory board. Results: The safety analysis population consists of 4,769 pts. With 74 mos median follow-up (FU), CEs were observed in 159 pts (3.3%): 83 (3.5%) in the P+T and 76 (3.2%) in Pla+T arms, respectively. Most CEs occurred during anti-HER2 therapy: 123/159 (77.4%) and were asymptomatic or mildly symptomatic LVEF decrease (133/159; 83.6%) (Table 1). There were 2 cardiac deaths in each arm (0.1%). More CEs occurred in pts receiving an anthracycline-based CT compared to those receiving non-anthracycline CT (139 vs. 20 CEs, respectively). Acute recovery from a CE based on subsequent LVEF values was observed in 127/155 pts (81.9%). Conclusions: Dual blockade with P+T does not increase the risk of CE compared to Pla+T alone. The use of anthracycline-based CT increases the risk of a CE; hence non-anthracycline CT may be considered particularly in pts with other cardiovascular risk factors. Clinical trial information: NCT01358877. [Table: see text]

Cardiac function in patients receiving dual anti-Her2 antibodies (trastuzumab and pertuzumab) combined with chemotherapy for breast cancer in routine practice.

e13009 Background: Chemotherapy regimens (C) containing a combination of anti-Her2 antibodies are associated with a risk of cardiac toxicity in landmark clinical trials. We evaluate the cardiac function of patients with Her2 over-expressed (Her2OE) breast cancer (BC) receiving C combined with trastuzumab (T) and pertuzumab (P) in routine clinical practice setting. Methods: The initial cohort of patients who started C in combination with TP (CTP) in standard doses and schedules before September 2019 in 4 cancer units were included. All patients had regular measurement of left ventricular ejection fraction (LVEF) by Doppler ultrasound studies. Data was collected retrospectively and was limited to the first 24 months after initiation of CTP treatment. The paired sample T-test was used to test the significance of the difference in LVEF. Results: Sixty seven patients were identified. CTP treatment was administered in the neoadjuvant and palliative settings in 28 (41.8%) and 39 (58.2%) respectively. None of the patients received concomitant anthracycline with TP. All patients underwent LVEF assessment prior to starting CTP treatment and at 3 and 6 months later. Subsequently LVEF was measured at 9, 12, 15, 18, 21 and 24 months as long as patients are still receiving CTP treatment (table). LVEF was measured in 11 patients for 24 months. Compared to baseline, mean LVEF was not significantly different at any of the subsequent time points (range; decrease by -0.936% to increase by 1.087%) (Table). Dual anti-Her2 antibodies (TP) administration was omitted temporarily once for 2 patients due to clinically suspected cardiac toxicity which was excluded on further investigations. Conclusions: In this cohort describing our limited initial experience, dual anti-Her2 antibodies (T&P) combined with chemotherapy is not associated with significant cardiac toxicity when LVEF is measured every 3 months. Further studies investigating less frequent LVEF monitoring (e.g. every 5-6 months) may be warranted.[Table: see text]

Electronic Health Records-Based Cardio-Oncology Registry for Care Gap Identification and Pragmatic Research: Procedure and Observational Study.

BackgroundProfessional society guidelines are emerging for cardiovascular care in cancer patients. However, it is not yet clear how effectively the cancer survivor population is screened and treated for cardiomyopathy in contemporary clinical practice. As electronic health records (EHRs) are now widely used in clinical practice, we tested the hypothesis that an EHR-based cardio-oncology registry can address these questions.ObjectiveThe aim of this study was to develop an EHR-based pragmatic cardio-oncology registry and, as proof of principle, to investigate care gaps in the cardiovascular care of cancer patients.MethodsWe generated a programmatically deidentified, real-time EHR-based cardio-oncology registry from all patients in our institutional Cancer Population Registry (N=8275, 2011-2017). We investigated: (1) left ventricular ejection fraction (LVEF) assessment before and after treatment with potentially cardiotoxic agents; and (2) guideline-directed medical therapy (GDMT) for left ventricular dysfunction (LVD), defined as LVEF<50%, and symptomatic heart failure with reduced LVEF (HFrEF), defined as LVEF<50% and Problem List documentation of systolic congestive heart failure or dilated cardiomyopathy.ResultsRapid development of an EHR-based cardio-oncology registry was feasible. Identification of tests and outcomes was similar using the EHR-based cardio-oncology registry and manual chart abstraction (100% sensitivity and 83% specificity for LVD). LVEF was documented prior to initiation of cancer therapy in 19.8% of patients. Prevalence of postchemotherapy LVD and HFrEF was relatively low (9.4% and 2.5%, respectively). Among patients with postchemotherapy LVD or HFrEF, those referred to cardiology had a significantly higher prescription rate of a GDMT.ConclusionsEHR data can efficiently populate a real-time, pragmatic cardio-oncology registry as a byproduct of clinical care for health care delivery investigations.

New Hybrid Method for Left Ventricular Ejection Fraction Assessment from Radionuclide Ventriculography Images.

In this paper, we propose a new efficient method of radionuclide ventriculography image segmentation to estimate the left ventricular ejection fraction. This parameter is an important prognostic factor for diagnosing abnormal cardiac function. The proposed method combines the Chan-Vese and the mathematical morphology algorithms. It was applied to diastolic and systolic images obtained from the Nuclear Medicine Department of Salah AZAIEZ Institute. In order to validate our proposed method, we compare the obtained results to those of two methods present in the literature. The first one is based on mathematical morphology, while the second one uses the basic Chan-Vese algorithm. To evaluate the quality of segmentation, we compute accuracy, positive predictive value and area under the ROC curve. We also compare the left ventricle ejection fraction estimated by our method to that of the reference given by the software of the gamma-camera and validated by the expert, using Pearson's correlation coefficient, ANOVA test and linear regression. Static results show that the proposed method is very efficient for the detection of the left ventricle. The accuracy was 98.60%, higher than that of the other two methods (95.52% and 98.50%). Likewise, the positive predictive value was the highest (86.40% vs. 83.63% 71.82%). The area under the ROC curve was also the most important (0.998% vs. 0.926% 0.919%). On the other hand, Pearson's correlation coefficient was the highest (99% vs. 98% 37%). The correlation was significantly positive (p<0.001).

Monitoring for Chemotherapy-Related Cardiotoxicity in the Form of Left Ventricular Systolic Dysfunction: A Review of Current Recommendations.

Cardiotoxicity is a well-established complication of multiple cancer therapeutics, and the one of the most prominent effects that limits the use of these agents is in the form of left ventricular dysfunction, otherwise known as chemotherapy-induced cardiomyopathy (CIMP). Because CIMP can worsen patient outcomes and interfere with a patient's life-saving cancer treatments, it is important to implement a monitoring strategy for patients undergoing potentially cardiotoxic treatments. Efforts have been made by multiple societies to provide recommendations for screening and monitoring for CIMP in at-risk patients, with slight variations between guideline documents and expert consensuses. Most of the recommendations for monitoring for CIMP are specific to anthracyclines and the human epidermal growth factor receptor 2-antagonist trastuzumab, with very limited guidance for other cardiotoxic agents such as Tyr kinase inhibitors and proteasome inhibitors, which we cover in this article. Echocardiography remains the mainstay for imaging surveillance because of its safety profile and widespread availability, but the accuracy of cardiac magnetic resonance imaging (CMR) makes it an important modality when there are discrepancies in left ventricular ejection fraction assessment. Subclinical cardiotoxicity may be detected using laboratory biomarkers such as cardiac troponin and brain natriuretic peptide as well as myocardial deformation (strain) imaging by echocardiography or CMR. Specific recommendations for timing and frequency of laboratory biomarker assessment remain up for debate, but myocardial deformation imaging should be performed with every echocardiogram or CMR assessment. Future studies are needed to evaluate the efficacy of established surveillance recommendations and to develop specific recommendations for novel cancer therapeutics.

Association of Left Ventricular Systolic Function With Incident Heart Failure in Late Life

Limited data exist regarding the association of subtle subclinical systolic dysfunction and incident heart failure (HF) in late life. To assess the independent associations of subclinical impairments in systolic performance with incident HF in late life. This study was a time-to-event analysis of participants without heart failure in the Atherosclerosis Risk in Communities (ARIC) study, a prospective, community-based cohort study, who underwent protocol echocardiography at the fifth study visit (January 1, 2011, to December 31, 2013). Findings were validated independently in participants in the Copenhagen City Heart Study (CCHS). Data analysis was performed from June 1, 2018, to February 28, 2020. Left ventricular ejection fraction (LVEF), longitudinal strain (LS), and circumferential strain (CS) measured by 2-dimensional and strain echocardiography. Main outcomes were incident adjudicated HF and HF with preserved and reduced LVEF at a median follow-up of 5.5 years (interquartile range, 5.0-5.8 years). Cox proportional hazards regression models adjusted for demographics, hypertension, diabetes, obesity, smoking, coronary disease, estimated glomerular filtration rate, LV mass index, e', E/e', and left atrial volume index. Lower 10th percentile limits were determined in 374 participants free of cardiovascular disease or risk factors. Among 4960 ARIC participants (mean [SD] age, 75 [5] years; 2933 [59.0%] female; 965 [19%] Black), LVEF was less than 50% in only 76 (1.5%). In the 3552 participants with complete assessment of LVEF, LS, and CS, 983 (27.7%) had 1 or more of the following findings: LVEF less than 60%, LS less than 16.0%, or CS less than 23.7%. Modeled continuously or dichotomized, worse LVEF, LS, and CS were each independently associated with incident HF. The adjusted hazard ratio (HR) per SD decrease in LVEF was 1.41 (95% CI, 1.29-1.55); the HR for LVEF less than 60% was 2.59 (95% CI, 1.99-3.37). Similar findings were observed for continuous LS (HR, 1.37; 95% CI, 1.22-1.53) and dichotomized LS (HR, 1.93; 95% CI, 1.46-2.55) and for continuous CS (HR, 1.39; 95% CI, 1.22-1.57) and dichotomized CS (HR, 2.30; 95% CI, 1.64-3.22). Although the magnitude of risk for incident HF or death associated with impaired LVEF was greater using guideline (HR, 2.99; 95% CI, 2.19-4.09) compared with ARIC-based limits (HR, 1.88; 95% CI, 1.58-2.25), the number of participants classified as impaired was less (104 [2.1%] based on guideline thresholds compared with 692 [13.9%] based on LVEF <60%). The population-attributable risk associated with LVEF less than 60% was 11% compared with 5% using guideline-based limits, a finding replicated in 908 participants in the CCHS. These findings suggest that relatively subtle impairments of systolic function (detected based on LVEF or strain) are independently associated with incident HF and HF with reduced LVEF in late life. Current recommended assessments of LV function may substantially underestimate the prevalence of prognostically important impairments in systolic function in this population.

Cardiotoxic Effect of Modern Anthracycline Dosing on Left Ventricular Ejection Fraction: A Systematic Review and Meta-Analysis of Placebo Arms From Randomized Controlled Trials.

BackgroundAnthracyclines are a key chemotherapeutic agent used against hematological and solid organ malignancies. However, their benefits in cancer survival are limited by cumulative, dose‐related cardiotoxicity. The impact of anthracyclines on left ventricular ejection fraction (LVEF), in the era of modern chemotherapy regimens, remains unclear.Methods and ResultsThree databases (CENTRAL, MEDLINE, and SCOPUS) were systematically searched for randomized trials evaluating cardioprotective agents against placebo, in preventing cardiotoxicity. Echocardiography or magnetic resonance measured LVEF pre‐ and post‐anthracycline‐based chemotherapy was abstracted from placebo trial arms. The key terms included “anthracycline,” “cardiotoxicity” and “randomized.” A doxorubicin equivalent anthracycline dose metric was calculated to compare different anthracyclines. A random‐effects model was used to pool mean difference in LVEF after anthracycline. Meta‐regressions were calculated to identify variation sources. We included 660 patients from 19 trials. The weighted mean baseline LVEF across studies was 62.6%, and follow‐up LVEF assessment was performed at 6 months. The pooled mean decline in LVEF among placebo arms was 5.4% (95% CI, 3.5%–7.3%) with a doxorubicin equivalent anthracycline dose of 385 mg/m2. Meta‐regression analysis showed no significant difference in LVEF against doxorubicin equivalent anthracycline dose as continuous (P=0.29) or against published cut‐offs for cardiotoxicity (250 mg/m2, P=0.21; 360 mg/m2, P=0.40; and 400 mg/m2, P=0.66). The differences in mean LVEF were not associated with sex, adjunct chemotherapy, or cancer type.ConclusionsThe magnitude of LVEF impairment post‐anthracycline therapy appears less than previously described with modern dosing regimens. This may improve the accuracy of power calculation for future clinical trials assessing the role of cardioprotective therapy.

Prognostic value of cardiovascular magnetic resonance left ventricular volumetry and geometry in patients receiving an implantable cardioverter defibrillator

BackgroundCurrent indications for implantable cardioverter defibrillator (ICD) implantation for sudden cardiac death prevention rely primarily on left ventricular (LV) ejection fraction (LVEF). Currently, two different contouring methods by cardiovascular magnetic resonance (CMR) are used for LVEF calculation. We evaluated the comparative prognostic value of these two methods in the ICD population, and if measures of LV geometry added predictive value.MethodsIn this retrospective, 2-center observational cohort study, patients underwent CMR prior to ICD implantation for primary or secondary prevention from January 2005 to December 2018. Two readers, blinded to all clinical and outcome data assessed CMR studies by: (a) including the LV trabeculae and papillary muscles (TPM) (trabeculated endocardial contours), and (b) excluding LV TPM (rounded endocardial contours) from the total LV mass for calculation of LVEF, LV volumes and mass. LV sphericity and sphere-volume indices were also calculated. The primary outcome was a composite of appropriate ICD shocks or death.ResultsOf the 372 consecutive eligible patients, 129 patients (34.7%) had appropriate ICD shock, and 65 (17.5%) died over a median duration follow-up of 61 months (IQR 38–103). LVEF was higher when including TPM versus excluding TPM (36% vs. 31%, p < 0.001). The rate of appropriate ICD shock or all-cause death was higher among patients with lower LVEF both including and excluding TPM (p for trend = 0.019 and 0.004, respectively). In multivariable models adjusting for age, primary prevention, ischemic heart disease and late gadolinium enhancement, both LVEF (HR per 10% including TPM 0.814 [95%CI 0.688–0.962] p = 0.016, vs. HR per 10% excluding TPM 0.780 [95%CI 0.639–0.951] p = 0.014) and LV mass index (HR per 10 g/m2 including TPM 1.099 [95%CI 1.027–1.175] p = 0.006; HR per 10 g/m2 excluding TPM 1.126 [95%CI 1.032–1.228] p = 0.008) had independent prognostic value. Higher LV end-systolic volumes and LV sphericity were significantly associated with increased mortality but showed no added prognostic value.ConclusionBoth CMR post-processing methods showed similar prognostic value and can be used for LVEF assessment. LVEF and indexed LV mass are independent predictors for appropriate ICD shocks and all-cause mortality in the ICD population.

Association of early versus delayed normalisation of left ventricular ejection fraction with mortality in ischemic cardiomyopathy

ObjectiveIn patients with non-ischaemic cardiomyopathy and reduced left ventricular ejection fraction (LVEF), normalisation of LVEF is associated with improved outcomes. However, data on patients with ischaemic cardiomyopathy and recovered LVEF...

Racial and Socioeconomic Disparities in Cardiotoxicity Among Women With HER2-Positive Breast Cancer

Breast cancer and cardiovascular-specific mortality are higher among blacks compared with whites, but disparities in cancer therapy-related adverse cardiovascular outcomes have not been well studied. We assessed for the contribution of race and socioeconomic status on cardiotoxicity among women with HER2-positive breast cancer. This retrospective cohort analysis studied women diagnosed with stage I-III HER2-positive breast cancer from 2004-2013. All underwent left ventricular ejection fraction assessment at baseline and at least one follow-up after beginning trastuzumab. Multivariable logistic regression was used to assess the association between race and socioeconomic status (SES) on cardiotoxicity, defined by clinical heart failure (New York Heart Association class III or IV) or asymptomatic left ventricular ejection fraction decline (absolute decrease ≥ 10% to < 53%, or ≥ 16%). Blacks had the highest prevalence of hypertension, diabetes, and increased BMI. Neighborhood-level SES measures including household income and educational attainment were lower for blacks compared with whites and others. The unadjusted cardiotoxicity risk was significantly higher in black compared with white women (OR, 2.10; 95% CI, 1.42 to 3.10). In a multivariable analysis, this disparity persisted after controlling for relevant cardiovascular risk factors (adjusted OR, 1.88; 95% CI, 1.25 to 2.84). Additional models adjusting for SES factors of income, educational attainment, and insurance status did not significantly alter the association between race and cardiotoxicity. In conclusion, black women are at increased risk of cardiotoxicity during HER2-targeted breast cancer therapy. Future etiologic analyses, particularly studies exploring biologic or genetic mechanisms, are needed to further elucidate and reduce racial disparities in cardiotoxicity.

Does automated left ventricular ejection fraction assessment available on handheld ultrasound devices represent improvement in the diagnostic accuracy?

Abstract Funding Acknowledgements Type of funding sources: None. Purpose To assess the accuracy of an algorithm for automated measurement of the left ventricular ejection fraction (LVEF) available on handheld ultrasound device (HUD). Methods 112 patients admitted to the cardiology department, who were referred for the conventional echocardiographic examination, underwent additional assessment performed with HUD (Vscan Extend, GE Vingmed Ultrasound, Horten, Norway). In each case 4 – chamber apical view was obtained and LVEF was calculated by means of the LVivo software. Imaging quality was assessed in a 4-grade scale. Subsequently, during the examination performed with the use of the stationary echocardiograph the three-dimensional (3D) measurement of LVEF was recorded. Results Ultimately 96 (53 men, mean age 63 ± 11) patients were enrolled into the study group In the remaining 16 cases (14%) 3D image quality was not sufficient to allow the calculation of the LVEF. LVivo software was unsuccessful in calculating LVEF in all these 16 patients and in additional 20 patients, who remained in the study group due to satisfactory 3D image quality. The quality of images acquired with the use of HUD was assessed as optimal in 25 (26%) patients, good in 37 (39%), acceptable in 24 (25%), poor in 10 (10%). The average LVEF value was 46%±14 with the 3D LVQ measurements and 48%±14 using the LVivo software. The correlation coefficient between the LVEF values obtained with the two methods was r = 0,92; (P &amp;lt; 0,0001). Using paired samples t-test we found that the difference between these two techniques was not significant (mean difference 4,5± 3,4%; P = 0,35). LVivo software EF assessment is based on a single apical view and for this reason we have assumed that the differences in EF can be larger in patients with regional wall motion abnormalities, in whom LVEF values derived from different apical views can significantly vary. For this reason the group of patients with history of myocardial infarction (40pts, 42%) was analysed separately and we found that the difference between LVivo and 3D LVEF was also not statistically significant (mean difference 6,1± 3,3%; P= 0,14). The correlation coefficient equalled r = 0,78; (P &amp;lt; 0,0001). Conclusion The LVivo software despite its limitations is capable of the accurate LVEF measurement when the acquired views are of at least good imaging quality. Such expanded capabilities of HUDs can potentially lead to the overall improvements of the diagnostic accuracy of the ultrasonographic examinations, particularly when in hands of the non-expert echocardiographers.

Kinetics and prognostic value of soluble VCAM-1 in ST-segment elevation myocardial infarction patients.

BackgroundSoluble vascular cell adhesion molecule‐1 (sVCAM‐1) is a biomarker of endothelial activation and inflammation. There is still controversy as to whether it can predict clinical outcome after ST‐elevation myocardial infarction (STEMI). Our aim was to assess the sVCAM‐1 kinetics and to evaluate its prognostic predictive value.MethodWe prospectively enrolled 251 consecutive STEMI patients who underwent coronary revascularization in our university hospital. Blood samples were collected at admission, 4, 24, 48 h and 1 month after admission. sVCAM‐1 serum level was assessed using ELISA assay. All patients had cardiac magnetic resonance imaging at 1‐month for infarct size (IS) and left ventricular ejection fraction (LVEF) assessment. Clinical outcomes were recorded over 12 months after STEMI.ResultssVCAM‐1 levels significantly increased from admission up to 1 month and were significantly correlated with IS, LVEF, and LV end‐systolic and diastolic volume. (H48 area under curve (AUC) ≥ H48 median) were associated with an increased risk of adverse clinical events during the 12‐month follow‐up period with a hazard ratio (HR) = 2.6 (95% confidence interval [CI] of ratio = 1.2–5.6, p = .02). The ability of H48 AUC for sVCAM‐1 to discriminate between patients with or without the composite endpoint was evaluated using receiver operating characteristics with an AUC at 0.67 (0.57–0.78, p = .004). This ability was significantly superior to H48 AUC creatine kinase (p = .03).ConclusionsIn STEMI patients, high sVCAM‐1 levels are associated with a poor clinical outcome. sVCAM‐1 is an early postmyocardial infarction biomarker and might be an interesting target for the development of future therapeutic strategies.

Patterns of Left-Ventricular Function Assessment in Patients With Acute Coronary Syndromes

BackgroundIn patients with acute coronary syndromes (ACS), guidelines recommend the assessment of left-ventricular ejection fraction (LVEF). Many patients with ACS undergo multiple assessments of LVEF, the clinical value of which is unknown. MethodsPatients with ACS undergoing cardiac catheterization between 2012 and 2016 were evaluated and assessments of LV function identified. To evaluate changes in LVEF over time, available echocardiograms were reviewed in a subsample of patients with LVEF data available (n = 3221). Patients with ACS were classified into 3 groups: group 1 (LVEF > 50%), group 2 (LVEF 35% to 50%), and group 3 (LVEF < 35%). ResultsOur cohort consisted of 8327 patients with ACS (76% men), presenting with a mean age of 62.4 ± 12.4 years. At index presentation, 66% of patients had an LVEF > 50%, 27% had an LVEF between 35% and 50%, and 7% had severely reduced LVEF of < 35%. More than half of the cohort (n = 4600) had follow-up assessment of LV function, performed over an average of 2.71 ± 1.31 years. In the subsample of 3221 patients, only 1.1% of those in group 1, and 5.1% of those in group 2, deteriorated to an LVEF < 35%. ConclusionsPatients with ACS often undergo multiple assessments of LV function. Those with initially preserved EF rarely demonstrate a decline in EF to < 35%. A reduction in low-value cardiac tests may be an important first step in improving the quality of care for patients with ACS.

Relationship of LVEF and Myocardial Scar to Long-Term Mortality Risk and Mode of Death in Patients With Nonischemic Cardiomyopathy.

Nonischemic cardiomyopathy is a leading cause of reduced left ventricular ejection fraction (LVEF) and is associated with high mortality risk from progressive heart failure and arrhythmias. Myocardial scar on cardiovascular magnetic resonance imaging is increasingly recognized as a risk marker for adverse outcomes; however, left ventricular dysfunction remains the basis for determining a patient's eligibility for primary prophylaxis with implantable cardioverter-defibrillator. We investigated the relationship of LVEF and scar with long-term mortality and mode of death in a large cohort of patients with nonischemic cardiomyopathy. This study is a prospective, longitudinal outcomes registry of 1020 consecutive patients with nonischemic cardiomyopathy who underwent clinical cardiovascular magnetic resonance imaging for the assessment of LVEF and scar at 3 centers. During a median follow-up of 5.2 (interquartile range, 3.8, 6.6) years, 277 (27%) patients died. On survival analysis, LVEF ≤35% and scar were strongly associated with all-cause (log-rank test P=0.002 and P<0.001, respectively) and cardiac death (P=0.001 and P<0.001, respectively). Whereas scar was strongly related to sudden cardiac death (SCD; P=0.001), there was no significant association between LVEF ≤35% and SCD risk (P=0.57). On multivariable analysis including established clinical factors, LVEF and scar are independent risk markers of all-cause and cardiac death. The addition of LVEF provided incremental prognostic value but insignificant discrimination improvement by C-statistic for all-cause and cardiac death, but no incremental prognostic value for SCD. Conversely, scar extent demonstrated significant incremental prognostic value and discrimination improvement for all 3 end points. On net reclassification analysis, the addition of LVEF resulted in no significant improvement for all-cause death (11.0%; 95% CI, -6.2% to 25.9%), cardiac death (9.8%; 95% CI, -5.7% to 29.3%), or SCD (7.5%; 95% CI, -41.2% to 42.9%). Conversely, the addition of scar extent resulted in significant reclassification improvement of 25.5% (95% CI, 11.7% to 41.0%) for all-cause death, 27.0% (95% CI, 11.6% to 45.2%) for cardiac death, and 40.6% (95% CI, 10.5% to 71.8%) for SCD. Myocardial scar and LVEF are both risk markers for all-cause and cardiac death in patients with nonischemic cardiomyopathy. However, whereas myocardial scar has strong and incremental prognostic value for SCD risk stratification, LVEF has no incremental prognostic value over clinical measures. Scar assessment should be incorporated into patient selection criteria for primary prevention implantable cardioverter-defibrillator placement.

Progression of Myocardial Fibrosis in Nonischemic DCM and Association With Mortality and Heart Failure Outcomes

ObjectivesThe purpose of this study was to assess whether the presence and extent of fibrosis changes over time in patients with nonischemic, dilated cardiomyopathy (DCM) receiving optimal medical therapy and the implications of any such changes on left ventricular ejection fraction (LVEF) and clinical outcomes. BackgroundMyocardial fibrosis on cardiovascular magnetic resonance (CMR) imaging has emerged as important risk marker in patients with DCM. MethodsIn total, 85 patients (age 56 ± 15 years, 45% women) with DCM underwent serial CMR (median interval 1.5 years) for assessment of LVEF and fibrosis. The primary outcome was all-cause mortality; the secondary outcome was a composite of heart failure hospitalization, aborted sudden cardiac death, left ventricular (LV) assist device implantation, or heart transplant. ResultsOn CMR-1, fibrosis (median 0.0 [interquartile range: 0% to 2.6%]) of LV mass was noted in 34 (40%) patients. On CMR-2, regression of fibrosis was not seen in any patient. Fibrosis findings were stable in 70 (82%) patients. Fibrosis progression (increase >1.8% of LV mass or new fibrosis) was seen in 15 patients (18%); 46% of these patients had no fibrosis on CMR-1. Although fibrosis progression was on aggregate associated with adverse LV remodeling and decreasing LVEF (40 ± 7% to 34 ± 10%; p < 0.01), in 60% of these cases the change in LVEF was minimal (<5%). Fibrosis progression was associated with increased hazards for all-cause mortality (hazard ratio: 3.4 [95% confidence interval: 1.5 to 7.9]; p < 0.01) and heart failure–related complications (hazard ratio: 3.5 [95% confidence interval: 1.5 to 8.1]; p < 0.01) after adjustment for clinical covariates including LVEF. ConclusionsOnce myocardial replacement fibrosis in DCM is present on CMR, it does not regress in size or resolve over time. Progressive fibrosis is often associated with minimal change in LVEF and identifies a high-risk cohort.

Healthcare quality and mortality among patients hospitalized for heart failure by hospital level in Beijing, China.

AimsThis study sought to compare healthcare quality and 30 day, 90 day, and 1 year mortality rates among patients admitted to secondary and tertiary hospitals for heart failure (HF) in Beijing.Methods and resultsThis study retrospectively enrolled patients hospitalized with a primary discharge diagnosis of HF during January 2014 to December 2015, from five tertiary and four secondary hospitals, in Beijing, China. Mortality data were extracted from Beijing Death Surveillance Database. HF healthcare quality indices were used to evaluate in‐hospital care. Associations between hospital level and mortality rates were assessed using generalized linear mixed models, adjusting for patients' baseline characteristics and intra‐hospital correlation. Data from 1413 patients (median [interquartile range] age = 74 [65–80] years, 52.7% female) from secondary hospitals and 1250 patients (median [interquartile range] age = 72 [61–79] years, 43.3% female) from tertiary hospitals were collected. Rates of left ventricular ejection fraction assessment (73.2% vs. 90.1%) and combined use of β‐blockers and angiotensin‐converting enzyme inhibitors/angiotensin II receptor blockers (30.1% vs. 49.3%) were lower in secondary hospitals than those in tertiary hospitals, respectively. Patients admitted to secondary hospitals had a higher 90 day mortality [10.8% vs. 5.0%; adjusted odds ratio (OR): 2.06; 95% confidence interval (CI): 1.10–3.84, P = 0.024 and a higher 1 year mortality rate [21.0% vs. 12.1%; adjusted OR: 1.64; 95% CI: 1.02–2.62, P = 0.039], but 30 day mortality rates were not significantly different (5.5% vs. 3.0%; adjusted OR: 1.49; 95% CI: 0.63–3.52, P = 0.368).ConclusionsWorse quality of care for patients with HF in secondary hospitals was associated with higher 90 day and 1 year mortality rates. Improving care quality in secondary hospitals is crucial to improve prognosis of patients they served.

Prevalence and prognostic value of cirrhotic cardiomyopathy as defined according to the proposed new classification.

Aim of the studyPrevalence and prognostic relevance of cirrhotic cardiomyopathy (CCM), as defined according to the new core criteria proposed in 2019, are still unknown. We investigated this relevant issue in a large cohort of cirrhotic patients.Material and methodsWe retrospectively interrogated a data set of 162 collected cirrhotic patients followed up for at least 6 years, who underwent standard Doppler echocardiography and were compared with 46 healthy subjects. Left ventricular (LV) geometry, systo-diastolic function, global longitudinal strain and the main hemodynamic parameters were assessed according to current guidelines. Systolic dysfunction was diagnosed if LV ejection fraction (LVEF) ≤ 50% and/or global longitudinal strain (GLS) < 18% or > 22%.ResultsAdequate echocardiographic images permitting speckle tracking analysis were available in 83 patients. No patient presented LVEF ≤ 50%, GLS < 18% or > 22% was evident in 25%, advanced diastolic dysfunction was evident in 10%. Overall the prevalence of CCM was 29%. Patients with and without CCM presented similar clinical, biochemical, hemodynamic and echocardiographic features at baseline and similar incidence of death or type 1 hepatorenal syndrome at follow-up.ConclusionsAccording to the new criteria CCM is detected in 29%, mainly due to altered GLS at rest, but without prognostic relevance and therefore useless for the clinical management of cirrhotic patients. We propose to modify the criteria by removing the LVEF assessment and adding also a stress test assessing the cardiac contractile reserve to distinguish patients with a blunted cardiac response, which could present a worst prognosis.

Cardiac Safety of Osimertinib: A Review of Data.

PURPOSEOsimertinib is a third-generation, CNS-active, irreversible, oral epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) that potently and selectively inhibits both EGFR-TKI-sensitizing and T790M resistance mutations. We assess the cardiac failure risk in patients receiving osimertinib by evaluating the available data.METHODSPost hoc analyses of cardiac data from (1) studies in patients with advanced non–small-cell lung cancer, FLAURA (osimertinib, n = 279; comparator EGFR-TKI, n = 277) and AURA3 (osimertinib, n = 279; chemotherapy, n = 140), and (2) a pooled data set of patients treated with osimertinib 80 mg from across the clinical trial program (n = 1,142), including cardiac failure-related adverse events and left ventricular ejection fraction (LVEF) reductions. An LVEF pharmacokinetic or pharmacodynamic analysis of the pooled data set was performed. The sponsor's global safety database was analyzed for cardiac failure-related adverse events, and a literature search was conducted.RESULTSDecreases in LVEF from a baseline of ≥ 10 percentage points to an absolute value of < 50% following osimertinib treatment were observed in 8 (3.1%) and 14 (5.5%) patients in FLAURA and AURA3, respectively, and in 35 (3.9%) patients in the pooled population. Most events were asymptomatic and resolved without treatment of the event or osimertinib discontinuation. The pharmacokinetic or pharmacodynamic analysis did not indicate a relationship between exposure to osimertinib and decreases in LVEF from baseline. The database and literature search showed no specific trend or pattern that was suggestive of a safety issue in patients receiving osimertinib.CONCLUSIONThese data do not suggest a causal relationship between osimertinib and cardiac failure. However, because of LVEF decreases that were observed in patients with cardiac risk factors before osimertinib treatment, cardiac monitoring, including an assessment of LVEF at baseline and during osimertinib treatment, is advised.