Impaired Left Ventricular Ejection Fraction Research Articles

Off-pump coronary artery bypass surgery outcomes in patients with ischaemic left ventricular systolic dysfunction with or without detected viable myocardium.

The prognostic value of myocardial viability before coronary bypass grafting remains controversial. The present study evaluated the effects of off-pump coronary artery bypass (OPCAB) grafting on patients with coronary artery disease (CAD) with or without viable myocardium (VM) preoperatively detected via nuclear imaging. A total of 115 consecutive patients with 3-vessel disease and impaired left ventricular ejection fraction (LVEF ≤ 45%) who underwent OPCAB grafting were recruited in this prospective study. The patients were divided into 2 groups based on myocardial viability, the non-viable myocardium (NVM, 55 patients) and VM (60 patients) groups. Positron emission tomography and radionuclide imaging examination were applied to evaluate the myocardium viability. A Kaplan-Meier analysis was conducted to evaluate the 1-year survival rate. The preoperative data were similar between groups. An improvement in the LVEF was observed in both groups 12 months after OPCAB grafting (P < 0.05). A binary logistic regression revealed that NVM was an independent predictor of a 5% improvement in LVEF at 6 months (P = 0.012). The rate of main adverse cardiovascular and cerebrovascular events (MACCEs) rate at 1 year was similar between the 2 groups (P = 0.06). At 1 year, the death rates were 14.5% in the NVM group and 5% in the VM group (P = 0.17). A Cox regression analysis revealed that NVM and age were independent predictors of mortality [the hazard ratio for death associated with NVM and age were 1.62, 95% confidence interval (CI) = 1.16-2.89, P = 0.036 and 1.05, 95% CI = 0.98-1.12, P =0.025, respectively]. The MACCEs and mortality rates of the NVM group were higher than those of the VM group. However, OPCAB surgery improved LVEF, regardless of myocardium status. Therefore, the assessment of myocardial viability might not be the sole deciding factor in decision-making process regarding OPCAB surgery.

Long-term left ventricular remodelling after revascularisation for ST-segment elevation myocardial infarction as assessed by cardiac magnetic resonance imaging

ObjectiveLeft ventricular remodelling following a ST-segment elevated myocardial infarction (STEMI) is an adaptive response to maintain the cardiac output despite myocardial tissue loss. Limited studies have evaluated long term ventricular...

Meta-analysis of Risk of Ventricular Arrhythmias After Improvement in Left Ventricular Ejection Fraction During Follow-Up in Patients With Primary Prevention Implantable Cardioverter Defibrillators.

Implantable cardioverter defibrillators (ICDs) reduce the risk of sudden cardiac death in patients with impaired left ventricular ejection fraction (LVEF). However, there are limited data on the long-term benefit of ICD therapy in patients whose LVEF subsequently improves. We conducted a meta-analysis to evaluate the effect of LVEF improvement on ICD therapy during follow-up. Incidence rate ratios (IRRs) with 95% confidence intervals (CIs) were calculated using random-effects modeling. Sixteen studies with 3,959 patients were included in our analysis. Study arms were defined by LVEF improvement at follow-up (improved LVEF [>35%]: 1,622; low LVEF [≤35%] 2,337). Mean age (64.8 vs 64.9years, p= 0.97) was similar, whereas men were overrepresented in the persistent low LVEF group (79% vs 72%, p <0.001). Appropriate ICD therapy rate was 9.7% (improved LVEF) versus 21.8% (low LVEF) over a median follow-up period of 2.9years. In the meta-analysis, improved LVEF group had significantly lower (3.3% vs 7.2% per year IRR 0.52; CI 0.38 to 0.70; p <0.001) appropriate ICD therapies which was uniformly seen across all subgroups (ICD-only studies: IRR 0.59; p= 0.004) (cardiac resynchronization therapy-defibrillator-only studies: IRR 0.31; p= 0.002) (super-responder studies [mean LVEF > 45%]: IRR 0.53; p= 0.002). Inappropriate ICD therapy rates were, however, similar in both groups (3.01% vs 2.56% per year IRR 0.76; CI 0.43 to 1.36; p= 0.35). All-cause mortality rates in our meta-analysis favored (3.63% vs 8.23% per year IRR 0.49; CI 0.35 to 0.69; p <0.001) the improved LVEF group. In conclusion, our meta-analysis demonstrates that an improvement in LVEF is associated with a significantly reduced risk of ventricular arrhythmia and mortality. However, inappropriate ICD therapy rates remain similar.

Prediction of sudden and non-sudden cardiac death in post-infarction patients with reduced left ventricular ejection fraction by periodic repolarization dynamics: MADIT-II substudy.

AimsTo test the value of Periodic Repolarization Dynamics (PRD), a recently validated electrocardiographic marker of sympathetic activity, as a novel approach to predict sudden cardiac death (SCD) and non-sudden cardiac death (N-SCD) and to improve identification of patients that profit from ICD-implantation.Methods and resultsWe included 856 post-infarction patients with left-ventricular ejection fraction (LVEF) ≤30% of the MADIT-II trial in sinus rhythm. Of these, 507 and 348 patients were randomized to ICD or conventional treatment. PRD was assessed from multipolar 10-min baseline ECGs. Primary and secondary endpoints were total mortality, SCD and N-SCD. Multivariable analyses included treatment group, QRS-duration, New York Heart Association classification, blood-urea nitrogen, diabetes mellitus, beta-blocker therapy and LVEF. During follow-up of 20.4 months, 119 patients died (53 SCD and 36 N-SCD). On multivariable analyses, increased PRD was a significant predictor of mortality (standardized coefficient 1.37[1.19–1.59]; P < 0.001) and SCD (1.40 [1.13–1.75]; P = 0.003) but also predicted N-SCD (1.41[1.10–1.81]; P = 0.006). While increased PRD predicted SCD in conventionally treated patients (1.61[1.23–2.11]; P < 0.001), it was predictive of N-SCD (1.63[1.28–2.09]; P < 0.001) and adequate ICD-therapies (1.20[1.03–1.39]; P = 0.017) in ICD-treated patients. ICD-treatment substantially reduced mortality in the lowest three PRD-quartiles by 53% (P = 0.001). However, there was no effect in the highest PRD-quartile (mortality increase by 29%; P = 0.412; P < 0.001 for difference) as the reduction of SCD was compensated by an increase of N-SCD.ConclusionIn post-infarction patients with impaired LVEF, PRD is a significant predictor of SCD and N-SCD. Assessment of PRD is a promising tool to identify post-MI patients with reduced LVEF who might benefit from intensified treatment.

Comparing characteristics and clinical and echocardiographic outcomes in low-flow vs normal-flow severe aortic stenosis with preserved ejection fraction in an Asian population.

In severe aortic stenosis (AS), deterioration of left ventricular ejection fraction (LVEF) to <50% is an AHA/ACC class I indication for valve replacement, regardless of symptoms. Controversy surrounds prognosis of low-flow AS compared to normal-flow, and no study has examined LVEF deterioration. We compared factors associated with LVEF deterioration (to <50%) and clinical outcomes. Consecutive subjects with low-flow (stroke volume index <35mL/m2 , n=56) and normal-flow (n=72) severe AS (aortic valve area <1cm2 ) with preserved LVEF (>50%) and with paired echocardiography were studied. Univariate and multivariate analyses identified factors associated with LVEF deterioration. Clinical outcomes were determined on follow-up for more than 5years. Significant LVEF deterioration (to <50%) was seen in 18% of low-flow (initial LVEF 63±8% to 32±9%) and 18% of normal-flow AS (61±7% to 31±12%). Independent factors in low-flow AS were hypertension (OR: 30.7, 95% CI: 2.0-467.6, P=.014) and higher end-systolic wall stress (OR: 1.086, 95% CI: 1.022-1.153, P=.008), compared to normal-flow, which were hypertension (OR: 15.9, 95% CI: 3.1-81.9, P=.001), higher septal E/E' ratio (OR: 1.16, 95% CI: 1.01-1.35, P=.043), lower septal S' velocity (OR: 0.204, 95% CI: 0.061-0.682, P=.010), and higher end-systolic wall stress (OR: 1.051, 95% CI: 1.001-1.104, P=.047). Overall, a third of the cohort experienced MACE, regardless of flow (log-rank 0.048, P=.827). However, aortic valve replacement (AVR) rates were lower in low-flow AS (20% vs 43%, P=.005). Low-flow AS despite normal LVEF appears similar to normal-flow in terms of LVEF deterioration and clinical outcomes in our Asian population. AVR rate was lower even though low-flow may not reflect less severe disease.

SGLT-2 Inhibition with Dapagliflozin Reduces the Activation of the Nlrp3/ASC Inflammasome and Attenuates the Development of Diabetic Cardiomyopathy in Mice with Type 2 Diabetes. Further Augmentation of the Effects with Saxagliptin, a DPP4 Inhibitor.

We assessed whether (1) dapagliflozin (Dapa, an SGLT2-inhibitor) attenuates the deterioration of heart functionNlrp3 and inflammasome activation in diabetic mice. (2) The effects can be augmented with saxagliptin (Saxa), a DDP4-inhibitor. (3) Dapa effect is possibly SGLT2-independent on cardiofibroblasts in vitro. Type 2 diabetic (BTBR ob/ob) and wild-type (WT) mice received vehicle, Dapa, or Dapa+Saxa for 8weeks. Glucose tolerance test and echocardiogram were performed. Cardiofibroblasts from WT and BTBR hearts were incubated with Dapa and exposed to LPS. Left ventricular ejection fraction (LVEF) was 81±1% in the WT and 53±1% in the T2D-cont mice. Dapa and Dapa+Saxa improved LVEF to 68±1 and 74.6±1% in the BTBR mice (p<0.001). The mRNA levels of NALP3, ASC, IL-1β, IL-6, caspase-1, and TNFα were significantly higher in the BTBR compared to the WT hearts; and Dapa and Dapa+Saxa significantly attenuated these levels. Likewise, protein levels of NLRP3, TNFα, and caspase-1 were higher in the BTBR compared to the WT hearts and Dapa, and to a greater extent Dapa+Saxa, attenuated the increase in the BTBR mice. Collagen-1 and collagen-3 mRNA levels significantly increased in the BTBR mice and these increases were attenuated by Dapa and Dapa+Saxa. P-AMPK/total-AMPK ratio was significantly lower in the BTBR mice than in the WT mice. Dapa and Dapa+Saxa equally increased the ratio in the BTBR mice. This in vitro study showed that NALP3, ASC, IL-1β, and caspase-1 mRNA levels were higher in the BTBR cardiofibroblasts and attenuated with Dapa. The effect was AMPK-dependent and SGLT1-independent. Dapa attenuated the activation of the inflammasome, fibrosis, and deterioration of LVEF in BTBR mice. The anti-inflammatory, anti-fibrotic effects are likely SGLT2- and glucose-lowering-independent, as they were replicated in the in vitro model. The effects on remodeling were augmented when Saxa was added to Dapa. Yet, adding Saxa to Dapa did not result in a greater effect on myocardial fibrosis and collagen levels.

La insuficiencia cardiaca con fracción de eyección en rango intermedio ¿es similar a la de fracción de eyección preservada? En contra

The new European guidelines (2016) for heart failure (HF) include the concept of HF with intermediate left ventricular ejection fraction (LVEF), i.e. an LVEF between 40 and 49%. Although few studies have been carried out, there are claims that HF with intermediate LVEF is not the same as HF with preserved LVEF. Perhaps the most consistent claim is the high percentage of associated ischemic heart disease, which could reflect LVEF recovery after adequate anti-ischemic treatment of HF with depressed LVEF, or even the progressive deterioration of LVEF following an ischemic event.

Toward evidence-based diagnosis of myocarditis in children and adolescents: Rationale, design, and first baseline data of MYKKE, a multicenter registry and study platform

After an initial 6-month pilot phase, MYKKE was opened in June 2014 as a prospective multicenter registry for patients from pediatric heart centers, university hospitals, and community hospitals with pediatric cardiology wards in Germany. Inclusion criteria consisted of age<18 years and hospitalization for suspected myocarditis as leading diagnosis at the discretion of the treating physician. By December 31, 2015, fifteen centers across Germany were actively participating and had enrolled 149 patients. Baseline data reveal 2 age peaks (<2 years, >12 years), show higher proportions of males, and document a high prevalence of severe disease courses in pediatric patients with suspected myocarditis. Severe clinical courses and early adverse events were more prevalent in younger patients and were related to severely impaired leftventricular ejection fraction at initial presentation. MYKKE represents a multicenter registry and research platform for children and adolescents with suspected myocarditis that achieve steady recruitment and generate a wide range of real-world data on clinical course, diagnostic workup, and treatment of this group of patients. The baseline data reveal the presence of 2 age peaks and provide important insights into the severity of disease in children with suspected myocarditis. In the future, MYKKE might facilitate interventional substudies by providing an established collaborating network using common diagnostic approaches.

Cardiac involvement in granulomatosis with polyangiitis: a magnetic resonance imaging study of 31 consecutive patients.

Specific cardiac involvement in granulomatosis with polyangiitis (GPA) is probably underestimated since many of these conditions are subclinical. The objective of this study was to assess the prevalence and patterns of cardiac abnormalities detected by cardiac MRI (CMRI) in patients with GPA. Thirty-one consecutive patients with newly diagnosed or relapsing GPA underwent CMRI to assess morphological, functional, perfusion at rest and delayed enhancement abnormalities. At least one abnormality was observed on CMRI for 19 of 31 patients (61%). Four patients (13%) had an impaired left ventricle ejection fraction (LVEF). LV regional wall motion abnormalities were found in 11 patients (35%). Late gadolinium enhancement (LGE) was detected in 10 of 31 patients (32%). LGE was mostly nodular ( n = 9). Myocardial early contrast enhancement was detected in 5 of the 31 patients (16%), which was systematically associated with LGE in the same territory. CMRI detected pericarditis in eight patients (26%). GPA with <18 months duration was associated with a higher LVEF ( P = 0.03), fewer CMRI abnormalities ( P = 0.04) and less LV hypokinesia ( P = 0.04) than GPA with a longer duration. Patients with recent-onset GPA had a higher LVEF ( P = 0.01) and less LV hypokinesia ( P = 0.006) than patients experiencing a relapse ( P = 0.02). CMR is an accurate technique for detecting heart involvement in GPA. This unique non-invasive technique may provide information with important clinical implications for the accurate early assessment of cardiac lesions in GPA patients and for detecting cumulative, irreversible damage. It may also have prognostic implications.

Clinical Phenotyping of Heart Failure with Biomarkers: Current and Future Perspectives.

Heart failure (HF) is a complex clinical syndrome with diverse risk factors and etiologies, differing underlying pathophysiology, and large phenotypic heterogeneity. Advances in imaging techniques coupled with clinical trials that targeted only in those with impaired left ventricular ejection fraction (LVEF) have largely shaped the current management strategy for HF that focuses predominantly in patients with systolic HF. In contrast, there are no effective treatments for HF with preserved ejection fraction (HFpEF). Instead of this "one-size-fits-all" approach to treatment, better precision to define HF phenotypic classifications may lead to more efficient and effective HF disease management. Integrating variables-including clinical variables, HF biomarkers, imaging, genotypes, metabolomics, and proteomics-can identify different pathophysiologies, lead to more precise phenotypic classification, and warrant investigation in future clinical trials.

Surgery for Acute Type A Aortic Dissection: Auckland City Hospital Contemporary Experience

Background: Type A aortic dissection remains a fatal acute condition, and emergency surgery is the recommended treatment despite significant risk. We reviewed the characteristics and outcomes of type A aortic dissection surgery at our centre. Methods: Patients undergoing acute surgery for type A aortic dissection at Auckland City Hospital during 2005-2016 were included, and clinical data were retrospectively collected in this cohort study for analyses. Results: Amongst the 147 patients studied, mean age was 58+/-14 years, 41% (60) were female and 38% (56) were Polynesian. Baseline characteristics included critical preoperative state15% (22), previous cardiac surgery 3% (5), hypertension 68% (100), impaired left ventricular ejection fraction 11% (16) and mean creatinine 106+/-47umol/L. Surgery was performed in the aorta in all, aortic valve 20% (30), coronary bypass grafting 10% (15) and mitral valve 1% (2), with cardiopulmonary and cross-clamp times of 197+/-73 and 121+/-52 minutes respectively. Operative mortality rate was 16% (23), and postoperative complications (as defined by the Society of Thoracic Surgeon's database) occurred in for stroke 21% (31), acute kidney injury 46% (68), ventilation > 24 hours 17% (25), and return to theatre 25% (37). Survival at 1 and 5 years were 83% and 80% over mean follow-up of 3.5+/-3.5 years. Conclusion: Surgery for acute type A aortic dissection continues to be associated with significant mortality and morbidity, although after surviving the initial surgical admission, late deaths are rare.

Type A Aortic Dissection Surgery: 12-Year Contemporary Cohort Study

Background: Type A aortic dissection remains a fatal acute condition, and emergency surgery is the recommended treatment despite significant risk. We reviewed the characteristics and outcomes of type A aortic dissection surgery at out centre. Methods: Patients undergoing acute surgery for type A aortic dissection at Auckland City Hospital during 2005-2016 were included, and clinical data were retrospectively collected in this cohort study for analyses. Results: Amongst the 147 patients studied, mean age was 58+/-14 years, 41% (60) were female and 38% (56) were Polynesian. Baseline characteristics included critical preoperative state15% (22), previous cardiac surgery 3% (5), hypertension 68% (100), impaired left ventricular ejection fraction 11% (16) and mean creatinine 106+/-47umol/L. Surgery was performed in the aorta in all, aortic valve 20% (30), coronary bypass grafting 10% (15) and mitral valve 1% (2), with cardiopulmonary and cross-clamp times of 197+/-73 and 121+/-52 minutes respectively. Operative mortality rate was 16% (23), and postoperative complications (as defined by the Society of Thoracic Surgeon's database) occurred as stroke 21% (31), acute kidney injury 46% (68), ventilation > 24 hours 17% (25), and return to theatre 25% (37). Survival at 1 and 5 years were 83% and 80% over mean follow-up of 3.5+/-3.5 years. Conclusion: Surgery for acute type A aortic dissection continues to be associated with significant mortality and morbidity, although after surviving the initial surgical admission, late deaths are rare.

Echocardiographic abnormalities and their impact on health status in patients with COPD referred for pulmonary rehabilitation.

Both patients with cardiac diseases as well as those with COPD report an impaired health status. The frequencies of objectively assessed co-morbid cardiac diseases and their impact on health status in patients with COPD are unknown. We aimed to investigate echocardiographic abnormalities and their impact on health status in a large cohort of patients with COPD referred for pulmonary rehabilitation (PR). In this cross-sectional, observational analyses, demographic and clinical characteristics were assessed during an inpatient pre-PR assessment. All patients underwent Doppler echocardiographic evaluation. Health status was assessed using the COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ) and St George's Respiratory Questionnaire (SGRQ). A total of 514 patients (55.3% males, age: 64.1 (9.1) years, forced expiratory volume in 1 s (FEV1 ): 48.6 (20.0) % predicted) were included for analyses. Two hundred and seventy-six patients (53.7%) were diagnosed with one or more echocardiographic abnormalities. Most prevalent were left ventricular (LV) hypertrophy (LVH, 31.0%), increased right ventricular systolic pressure (RVSP, 20.4%) and impaired LV ejection fraction (LVEF, 16.5%). Of the 276 patients, 176 (63.8%) with echocardiographic abnormalities did not have these recorded in their medical history. Patients with echocardiographic abnormalities reported a worse health status as assessed with the SGRQ total score (62.5 (17.1) vs 59.3 (17.6) points, P = 0.044). CCQ and CAT did not differ between groups. More than half of the patients referred to PR had echocardiographic abnormalities of which two-third did not have them recorded in their medical history. We detected a limited impact of echocardiographic abnormalities on health status.

Long-Term Prognostic Value of Cardiac Magnetic Resonance in Left Ventricle Noncompaction: A Prospective Multicenter Study

BackgroundCardiac magnetic resonance (CMR) is useful for the diagnosis of left ventricular noncompaction (LVNC). However, there are limited data regarding its prognostic value. ObjectivesThe goal of this study was to evaluate the prognostic relevance of CMR findings in patients with LVNC. MethodsA total of 113 patients with an echocardiographic diagnosis of LVNC underwent CMR at 5 referral centers. CMR diagnostic criterion of LVNC (noncompacted/compacted ratio >2.3 in end-diastole) was confirmed in all patients. We performed left ventricular (LV) and right ventricular quantitative analysis and late gadolinium enhancement (LGE) assessments and analyzed the following LVNC diagnostic criteria: left ventricular noncompacted myocardial mass (LV-ncMM) >20% and >25%, total LV-ncMM index >15 g/m2, noncompacted/compacted ratio ≥3:1 ≥1 of segments 1 to 3 and 7 to 16 or ≥2:1 in at least 1 of segments 4 to 6 of the American Heart Association model. Outcome was a composite of thromboembolic events, heart failure hospitalizations, ventricular arrhythmias, and cardiac death. ResultsAt a mean follow-up of 48 ± 24 months, cardiac events (CEs) occurred in 36 patients (16 heart failure hospitalizations, 10 ventricular arrhythmias, 5 cardiac deaths, and 5 thromboembolic events). LV dilation, impaired LV ejection fraction, and LV-ncMM >20% was significantly more frequent in patients with CEs. LV fibrosis was detected by using LGE in 11 cases. CMR predictors of CEs were LV dilation and LGE. LGE was associated with improved prediction of CEs, compared with clinical data and CMR functional parameters in all 3 models. No CEs occurred in patients without dilated cardiomyopathy and/or LGE. ConclusionsIn patients with LVNC evaluated by using CMR, the degree of LV trabeculation seems to have no prognostic impact over and above LV dilation, LV systolic dysfunction, and presence of LGE.

TCT-633 Treatment of mitral regurgitation in patients with severely impaired left ventricular ejection fraction with the MitraClip system – MVARC outcome

Several studies and registers such as EVEREST, ACCESS-EU and PILOT EUROPEAN SENTINEL showed safety and effectiveness of the MitraClip system. However, only limited data exists for patients with MR and severely reduced left ventricular (LV) ejection fraction (LVEF). We report our single-centre

What is the impact of impaired left ventricular ejection fraction in COPD after adjusting for confounders?

BackgroundIt remains unknown whether and to what extent impaired left ventricular ejection fraction (LVEF) affects physical and psychological status in COPD. We aimed to compare health outcome measures between COPD patients with and without impaired LVEF after adjusting for age, sex, BMI and FEV1. MethodsImpaired LVEF was defined as values <50%. 85 COPD patients with impaired LVEF and 85 COPD patients with normal LVEF were matched for sex, age, BMI and FEV1. Exercise capacity, quadriceps muscle function, functional mobility, inflammatory status, health status, care dependency, and mood disorders were cross-sectionally assessed. ResultsPatients with impaired LVEF had shorter 6-minute walk distance (mean −59 (95% confidence interval: −94, −25)m), lower symptom-limited peak oxygen uptake (−131 (−268, 7)ml/min), weaker quadriceps muscles (−12 (−20, −3)Nm) and had more symptoms of anxiety (+2 (1, 3) points) and depression (+1 (0, 2) points) than those with normal LVEF (all P<0.05). Health status was not statistically different between groups (P>0.05). ConclusionsImpaired LVEF has a clear impact on physical and psychological status in patients with COPD, even after adjusting for confounders. This reinforces the importance of assessing and treating cardiac problems in COPD.

Risk stratification for the primary prevention of arrhythmic sudden cardiac death in postinfarction patients

AbstractSudden cardiac death (SCD) threatens ischemic cardiomyopathy patients. Antiarrhythmic protection may be provided to these patients with implanted cardiac defibrillators (ICD), after an efficient risk stratification approach. The proposed risk stratifier of an impaired left ventricular ejection fraction has limited sensitivity. Current risk stratification strategies focus on markers that, by identifying the arrhythmic substrate and the severity of the arrhythmia mechanisms present, are also considered to quantify the risk of SCD. Such markers reflect: (1) myocardial substrate lesions and postinfarction fibrosis (LVEF, QRS, LBBB, SAECG, fragmented QRS, CMR, PVBs, NSVT), (2) abnormal repolarization (QT, QTd, T‐wave alternans, QT/RR, QTVI, TWV), (3) impaired autonomic nervous system function (HR, heart rate variability (HRV), HRT, deceleration capacity (DC), BRS, HR recovery after exercise), and (4) inducibility on programmed ventricular stimulation during electrophysiological testing. Ventricular tachyarrhythmias have a strong dynamic component because transient and unpredictable factors can trigger a fatal arrhythmic episode. For this reason, SCD risk stratification is not simple and no ideal marker or a completely successful predictive model is existing. The evolution of technology made possible all the noninvasive markers to be incorporated in the Holter software. Noninvasive risk stratification has been simplified. Innovative Holter technology enforced the doctors, providing them with the tools for primarily screening their patients through the ICD protection process.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/4469459/Activity.aspx

ICD risk stratification studies – EU-CERT-ICD and the European perspective

Background and rationaleIn patients with ischemic or non-ischemic cardiomyopathy and impaired left ventricular ejection fraction, treatment with implantable cardioverter-defibrillator (ICD) has been shown to improve survival and guidelines recommend their use for primary prevention of sudden cardiac death. Experts disagree regarding the validity of decade-old trial results as the basis for this recommendation, therefore, reconsideration of prophylactic ICD treatment is needed. EU-CERT-ICD, DANISH-ICD and DO-ITIn order to update the evidence on prophylactic ICD treatment, several prospective studies are underway in Europe. The prospective EU-CERT-ICD cohort study (NCT 02064192) is enrolling 2500 patients and compares patients undergoing first ICD implantation with controls with an earlier clinical decision to go without ICD implantation strictly unrelated to the study. The DANISH ICD study (NCT 00542945) has randomized 1000 patients with dilated cardiomyopathy and an LVEF ≤35% (1:1 ICD implantation vs. control). The prospective DO-IT multicenter registry will include 1500 ICD patients in multiple Dutch high-volume implanting centers. Due to the widespread use of ICD therapy, new randomized trials seem not straightforward to envisage in many countries. ConclusionThe above described ICD studies will provide additional evidence regarding the effectiveness of primary prophylactic ICDs in Europe and may have an impact on ICD treatment guidelines. They could also help to design randomized trials in low risk patients.

Incremental predictive value of mean platelet volume/platelet count ratio in in-hospital stroke after acute myocardial infarction

Stroke is a serious complication after acute myocardial infarction (AMI) and is associated with an increased risk of death. Though the pathophysiological mechanisms are not exactly known, increased inflammation and platelet reactivity could play an important role in the occurrence of stroke during AMI. We aimed to investigate the relationship between both mean platelet volume (MPV), a parameter of platelet function, and C-reactive protein (CRP) and the occurrence of in-hospital ischemic stroke (IHS) after AMI. Data were obtained from a French regional survey for AMI that included 5976 patients admitted to an intensive care unit (ICU) between 2001 and 2010. Patients were divided into two groups according to the occurrence of IHS. MPV, platelet count (PC), and CRP were routinely measured at admission to the ICU; 99 (1.6%) IHSs were recorded during hospitalization after admission for AMI. In multivariate analysis, IHS was independently associated with a history of stroke (OR: 1.99%, CI: 1.1–3.49, p = 0.01), impaired left ventricular ejection fraction <40% (OR: 1.88, 95% CI: 1.20–2.94, p = 0.006), impaired renal function (OR: 1.94, 95% CI: 1.27–2.95, p = 0.002), CRP > 10 mg/l (OR: 2.19, 95% CI: 1.44–3.33, p < 0.001), and MPV/PC ratio (OR: 1.04, 95% CI: 1.01–1.08, p = 0.023). Compared with the first to fourth quintiles, the last quintile of the MPV/PC ratio was associated with higher rates of IHS on survival curve analysis (p = 0.014). At hospital admission, a high MPV/PC ratio and a high level of CRP might help to identify patients at increased risk of IHS. Moreover, these results provide new insights into the potential role played by increased inflammation and platelet reactivity in the occurrence of stroke after AMI.

Right ventricular systolic function as a marker of prognosis after ST-elevation inferior myocardial infarction 5-year follow-up

BackgroundThere is scarce data about clinical value of right ventricular (RV) systolic function assessed in pre-discharge transthoracic echocardiography for predicting long-term prognosis in patients with inferior ST-elevation myocardial infarction (MI). MethodsThe aim of this study was to assess correlations of RV function parameters in patients after inferior ST-elevation MI with preserved or mildly impaired left ventricular ejection fraction with prognosis during 5-year follow-up. Primary endpoint was death from any cause or unscheduled hospitalization for cardiac causes (unstable angina/MI, percutaneous coronary intervention/coronary artery bypass grafting due to progression of coronary artery disease, heart failure exacerbation or pacemaker implantation), secondary endpoints were all listed above components analyzed separately. RV systolic function was measured with pulsed tissue Doppler as systolic myocardial velocity at the basal segment of RV free wall in the acute phase and pre-discharge echocardiography. ResultsFollow-up was conducted in 86 consecutive patients (mean age 61±10years, 74% males). Multivariate regression analysis revealed that only RV systolic function in pre-discharge echocardiography correlated independently with the primary endpoint (OR 0.56, 95% CI 0.34–0.92, p=0.02). A positive predictive value of 44% and a negative predictive value of 83% (sensitivity 80%, specificity 49%, AUC 0.7) for predicting the primary endpoint was established for RV systolic myocardial velocity<13cm/s in pre-discharge echocardiography. ConclusionsIn patients after inferior wall ST-elevation MI with preserved or slightly impaired LV systolic function, pre-discharge RV systolic dysfunction correlated independently with worse long-term prognosis.