Left Ventricular Ejection Fraction Class Research Articles

Need for Late Lower Limb Revascularization and Major Amputation after Coronary Artery Bypass Surgery

The aim of the present study was to estimate the need for late lower limb revascularization and/or major amputation after coronary artery bypass grafting (CABG). Retrospective study. 1307 residents of Oulu who underwent CABG from 1990 to 2006 formed the basis of this community-wide study. During a mean follow-up of 7.1+/-4.5 years, 111 patients (8.5%) underwent 251 vascular procedures for lower limb ischemia and 25 major amputations. In four patients, revascularization was done for complicated wound after vein graft harvesting. Freedom rates from lower limb revascularization and/or major amputation at 5-, 10- and 15-year were 92.9%, 88.4% and 85.1%, whereas freedom rates from lower limb revascularization for critical ischemia and/or major amputation were 98.1%, 95.2% and 94.7%. Age (p=0.013, HR 1.05), extracardiac arteriopathy (p<0.0001, HR 5.39), left ventricular ejection fraction classes (p=0.03), diabetes (p<0.0001, HR 5.78), and estimated glomerular filtration rate<60mg/min/m(2) (p=0.02, HR 2.22) were independent predictors of lower limb revascularization for critical leg ischemia and/or major amputation. Patients with extracardiac arteriopathy, diabetes and decreased glomerular filtration rate at the time of CABG are at risk for late lower limb ischemia. These patients would most benefit of a closer follow-up for prevention of peripheral vascular disease and its related complications.

Abstract 3403: Heart Failure Patients Improve their Exercise Capacity after Cardiac Rehabilitation Irrespective of having a Preserved or Depressed Ejection Fraction

Background: Whether exercise training reduces morbidity and mortality in heart failure (HF) patients is unknown. The objective of this study was to determine if cardiac rehabilitation (CR) outcomes differ in HF patients with and without systolic dysfunction. Methods: We included the 152 patients completing CR from 1996 to 2006 with HF listed as the primary diagnosis or as a co-morbidity. Based on left ventricular ejection fraction (LVEF) at enrollment, we divided patients into 2 groups: those with LVEF ≥ 45% (51/152, 34%) and those with LVEF &lt; 45% (101/152, 66%). At baseline, we compared distance, perceived exertion (Borg Scale), shortness of breath (Dyspnea Scale), and maximum heart rate (MHR) during a 6 minute walk test (MWT);self reported physical activity (total metabolic hours); depressive symptoms (Beck Depression Inventory [BDI]); and quality of life (physical component score [PCS] and mental component score [MCS] of the SF-36) between the 2 groups. Within each group, we compared changes from baseline to CR completion for each parameter. We compared differences between groups with multivariate linear regression to assess the association between LVEF classification and changes in each parameter, controlling for age, race, gender, and baseline value of the parameter. Results: Mean age (61 vs. 62 years), race (43% vs. 43% non-white), and gender (36% vs. 37% women) were similar in the 2 groups. At baseline, both groups had similar 6 MWT values, depressive symptoms, and quality of life, although Borg scores were higher in the LVEF ≥ 45% group. At CR completion, the 2 groups showed improvement in all parameters (all p&lt;0.05) except MHR on 6 MWT, which was unchanged in both groups. After adjusting for age, race, gender, and baseline value of each parameter, there was no difference in the magnitude of the improvement between the 2 groups (table ). Conclusions: Patients with clinical heart failure symptoms, regardless of ejection fraction, benefit from exercise training.

Influence of Ejection Fraction on Cardiovascular Outcomes in a Broad Spectrum of Heart Failure Patients

Left ventricular function is a principal determinant of cardiovascular risk in patients with heart failure. The growing number of patients with preserved systolic function heart failure underscores the importance of understanding the relationship between ejection fraction and risk. We studied 7599 patients with a broad spectrum of symptomatic heart failure enrolled in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) Program. All patients were randomized to candesartan at a target dose of 32 mg once daily or matching placebo and followed up for a median of 38 months. We related left ventricular ejection fraction (LVEF), measured before randomization at the sites, to cardiovascular outcomes and causes of death. Mean LVEF in patients enrolled in CHARM was 38.8+/-14.9% (median LVEF 36%). Patients with lower LVEF tended to have higher baseline New York Heart Association class. The hazard ratio for all-cause mortality increased by 39% for every 10% reduction in ejection fraction below 45% (hazard ratio 1.39, 95% CI 1.32 to 1.46), with adjustment for baseline covariates. All-cause mortality, cardiovascular death, and all components of cardiovascular death declined with increasing ejection fraction until an ejection fraction of 45%, after which the risk of these outcomes remained relatively stable with increasing LVEF. The absolute change in rate per 100 patient-years for each 10% reduction in LVEF was greatest for sudden death and heart failure-related death. The effect of candesartan in reducing cardiovascular outcomes was consistent across LVEF categories. LVEF is a powerful predictor of cardiovascular outcome in heart failure patients across a broad spectrum of ventricular function. Nevertheless, once elevated to a range above 45%, ejection fraction does not further contribute to assessment of cardiovascular risk in heart failure patients.

Accuracy of Emergency Physician Assessment of Left Ventricular Ejection Fraction and Central Venous Pressure Using Echocardiography

Abstract Objectives: Emergency department (ED) bedside echocardiography may offer useful information on cardiac function and volume status. The authors evaluated the accuracy of emergency physician (EP) performance of echocardiography in the assessment of left ventricular ejection fraction (LVEF) and central venous pressure (CVP). Methods: The authors conducted a cross‐sectional observational study at an urban teaching ED, involving a convenience sample of patients presenting to the ED between September 2000 and February 2001. Level III–credentialed EP sonographers who had undergone a three‐hour training session in limited echocardiography, focusing on LVEF and CVP measurement, performed echocardiograms. Vital signs and indication for echocardiography were documented on a study data sheet. LVEF was rated as poor (&lt;30%), moderate (30%–55%), or normal (&gt;55%) and an absolute percentage. Central venous pressure categories included low (&lt;5 cm), moderate (5–10 cm), and high (&gt;10 cm). Formal echocardiograms were obtained within a four‐hour window on all patients and interpreted by a staff cardiologist. Correlation analysis was performed using the κ correlation coefficient for LVEF and CVP categories and a Pearson correlation coefficient for LVEF measurement. Results: A total of 115 patients were assessed for LVEF, and 94 patients had complete information for CVP. Indications for echocardiography included chest pain (45.1%), congestive heart failure (38.1%), dyspnea (5.7%), and endocarditis (10.6%). Results showed a LVEF correlation of r2= 0.712 with 86.1% overall agreement. Subgroup analysis revealed the highest agreement (92.3%) between EP and formal echocardiograms within the normal LVEF category, followed by 70.4% agreement in the poor LVEF category and 47.8% in the moderate LVEF category. Central venous pressure measurements resulted in 70.2% overall raw agreement between EP and formal echocardiograms. Subgroup analysis revealed the highest agreement (83.3%) within the high CVP category followed by 66.6% in the moderate and 20% in the low categories. Conclusions: Experienced EP sonographers with a small amount of focused additional training in limited bedside echocardiography can assess LVEF accurately in the ED.