Left Ventricular Wall Motion Abnormalities Research Articles

Prevalence of Neurogenic Stress Cardiomyopathy in Acute Ischemic Stroke and Relationship with Leukocytosis

Describe the prevalence and features of neurogenic stress cardiomyopathy in acute ischemic stroke. Describe leukocytosis as an inflammatory marker in neurogenic stress cardiomyopathy. Retrospective review of 688 adult ischemic stroke patients at a tertiary care center (1/2018 - 12/2021). Neurogenic stress cardiomyopathy was identified by one of: low left ventricular ejection fraction, ventricular wall motion abnormalities, elevated Troponin-I, or elevated brain natriuretic peptide. Leukocytosis defined as white blood cell count ≥12.0 × 10^9/L. Clinical and demographic data were collected. Neurogenic stress cardiomyopathy was observed in 147 (21%) patients. In this group, mean age was 68, 44% were female, mean National Institutes of Health Stroke Scale was 10 and mean hospital stay was 8 days. Low left ventricular ejection fraction (median 40%) was observed in 64% of these patients, elevated Troponin-I (median 0.252 ng/mL) in 40%, and ventricular wall motion abnormalities in 55%. Stroke mechanisms were cryptogenic (43%), cardioembolic (24%), small vessel disease (13%), large artery atherosclerosis (12%), and other (8%). Mean white blood cell count was 8.63 × 10^9/L. Leukocytosis occurred in 12% of patients with cardiomyopathy and 8% without, with no significant difference (p=0.9). We propose defining neurogenic stress cardiomyopathy by one of four cardiac biomarkers. The prevalence aligns with prior reports, most frequently identified by low left ventricular ejection fraction or ventricular wall motion abnormalities. Unlike Takotsubo Cardiomyopathy, abnormal wall motion patterns were predominantly diffuse. No significant difference in leukocytosis was found between groups. Further research is needed to identify neurogenic stress cardiomyopathy risk factors.

A novel murine model of stress-induced cardiomyopathy achieved by chemogenetic stimulation of the locus coeruleus-norepinephrine system

Abstract Background Takotsubo syndrome (TTS) is a stress-induced acute cardiomyopathy characterized by transient left ventricular (LV) dysfunction without obstructive coronary artery disease. TTS is often underdiagnosed and undertreated and typically occurs in middle-aged women who recover from initial symptoms within a few weeks. Despite the apparent recovery, TTS patients have a worse cardiovascular prognosis compared to healthy individuals. To date, the pathophysiology underlying TTS remains unclear. So far, preclinical models barely reflect the complete clinical picture of TTS observed in humans. Moreover, these models display several limitations, e.g., high mortality or disregarding the involvement of the central nervous system. Consequently, much of the current obscurity concerning the pathophysiology of TTS is due to the lack of appropriate preclinical models. Purpose The present study aimed to assess whether chemogenetic activation of the locus coeruleus-(LC)-norepinephrine-(NE) system in vivo can induce LV dysfunction similar to that observed in patients with TTS. For this purpose, we used the designer excitatory receptor activated exclusively by designer drug (DREADD) system. Methods 11-13 weeks-old female Cre-dependent DREADD mice were genetically modified to express a codon-improved Cre recombinase under the dopamine-beta-hydroxylase-(DBH) promoter. For this purpose, a designed excitatory receptor exclusively activated by designer drugs or a control vector was stereotactically delivered to the LC using adenoviral transfection. Restricted expression of DBH-positive noradrenergic neurons to the LC was validated using pupillometry. LC-NE was activated by administering low-dose clozapine 0.03 mg/kg/day intraperitoneally. Serial anatomical and functional assessments of the cardiac phenotype in these mice were performed at baseline, the end of stress induction, and after ten days and three months of the recovery phase using echocardiography and cardiac magnetic resonance imaging. Results Targeted stimulation of the LC-NE system resulted in apical LV wall motion abnormality in 70–83% of mice. A complete recovery of LV wall motion abnormality was observed after the recovery phase. Conclusions Chemogenetic stimulation of the LC-NE system in mice mimics LV wall abnormalities similar to those observed in patients with TTS and may, therefore, be a novel preclinical model to investigate the pathophysiology of TTS.

Initial experience with a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting

Abstract Background Echocardiography is the test-of-choice for the initial evaluation of many cardiac diseases and requires expertise that is often limited in rural area. Robotic arm-assisted remote echocardigram has been attampted for teleconsultation but was limited to heart failure patients(ref), primarily due to the network delay in telecommunication and the subsequent incoordination in robotic arm control. Purpose We aim to assess the feasibility and diagnostic accuracy of a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting. Methods 51 pts were enrolled from the outpatient cardiology clinic of our institute. All pts underwent standard comprehensive echocardiography on a 5G cellular network and robotic arm-based remote echocardiographic system (the robotic part was deployed at our hospital and the control part was located at another campus 20 kilometers away) (Figure 1)and a conventional echocardiographic platform (at our hospital) successively. The order in which patients were examined on the remote and conventional instruments was randomly determined. There was no interval between the two examinations, and examinations of the same patient were performed by experienced but different cardiologists, who were blinded to each other’s diagnosis. The doctor who used the remote system was also randomly allocated and had not been previously specifically trained. The exams were real-time and diagnoses were made right after the exams. Results Of the 51 pts, the image quality was sufficient for diagnosis in 50 patients (48% female, 40±18 years). 1 pt was excluded because some key views could not be obtained using the remote system (98% of exams successful). 17 pts had positive findings, including 10 with a primary diagnosis of valvulopathy (1 Barlow's syndrome, 1 bicuspid aortic valve and 8 less-than-moderate regurgitation), 2 cardiac surgery follow-ups (1 case of aortic valve replacement and septal myectomy, and 1 case of mitral valve replacement and tricuspid annuloplasty), and 2 hypertrophic cardiomyopathy (including 1 case of obstruction at papillary muscle level), 2 with abnormal left ventricular wall motion(including 1 case of apical mural thrombus) (Figure 2), and 1 with congenital heart disease (secumdum atrial septal defect). The main diagnosis was consistent in 98% of cases (papillary muscle level obstruction was missed in one case), using conventional echocardiographic findings as the standard. Time for image acquision using remote echocardiography was significantly longer than conventional one (24 minutes 36 seconds ± 4 minutes 52 seconds vs. 16 minutes 15 seconds ± 1 minute 54 seconds, p<0.0001, paired t-test). Conclusions Comprehensive echocardiographic exam with a 5G cellular network and robotic arm-based remote system is feasible with relatively good diagnostic accuracy.Figure 1Figure 2

Thromboembolic Complications in Takotsubo Cardiomyopathy.

Apical ballooning syndrome, commonly known as Takotsubo syndrome, is a distinct cardiomyopathy often resembling acute myocardial infarction in presentation. Takotsubo syndrome patients exhibit varied patterns of left ventricular wall motion abnormalities, most frequently apical dyskinesis with basal hyperkinesis, that are characteristically transient. Although emotional or physical stressors precipitate Takotsubo syndrome in most cases, a significant proportion presents without identifiable triggers, with a pronounced female predominance. Despite recovery of left ventricular function, Takotsubo syndrome may lead to serious complications akin to acute coronary syndromes. The pathophysiology remains incompletely understood, with catecholamine surge implicated in the genesis of myocardial injury, although direct causation remains debated. Diagnosis involves integrating clinical history, imaging modalities like echocardiography, and cardiac MRI. Psychiatric disorders, particularly anxiety and depression, are frequently associated with Takotsubo syndrome, suggesting a role of chronic stress in disease susceptibility. Management includes supportive care, with anticoagulation considered in cases of apical thrombus, alongside close monitoring for complications and recovery of left ventricular function. This article reviews the current understanding, challenges in diagnosis, and management strategies for Takotsubo syndrome.

Type I Kounis syndrome in a young woman without chest pain: a case report

BackgroundKounis syndrome is defined as the concurrence of acute coronary syndromes in the setting of allergic or anaphylactic reactions. It primarily affects men aged 40–70 years and is often associated with chest pain. This syndrome is often unrecognized and undiagnosed in clinical practice due to a low level of awareness. Herein, we present a case of type I Kounis syndrome in a young woman without chest pain.Case presentationA 28-year-old Japanese woman with a history of atopic dermatitis received a glycyrrhizin, glutathione, and neurotropin preparation (a preparation of inflamed skin extract from rabbits inoculated with vaccinia virus) at a dermatology clinic to treat pruritus caused by atopic dermatitis. Immediately after the administration, the patient developed abdominal pain and generalized body wheals. The patient was diagnosed with anaphylaxis and was transported to our hospital. She had no chest pain on arrival at our hospital; however, a 12-lead electrocardiogram showed ST elevation in leads I, aVL, V2, and V3, and an echocardiogram showed decreased wall motion in the anterior and lateral walls of the left ventricle. Sublingual nitroglycerin administration improved ST-segment elevation and left ventricular wall motion abnormalities. The patient underwent emergency coronary angiography, which revealed no significant stenosis, and was diagnosed with type I Kounis syndrome.ConclusionKounis syndrome without chest pain is rare in young women. Since it can be fatal in cases with severe allergic symptoms such as anaphylaxis, the possibility of concurrent acute coronary syndrome should be considered when treating systemic allergic reactions, regardless of age, sex, or the presence or absence of chest symptoms.

Donor heart dysfunction and graft survival in liver and kidney transplants-A register-based study from Sweden.

Stress cardiomyopathy in donors can potentially affect graft function and longevity. This study aims to investigate the association between echocardiographic left ventricular ejection fraction (LVEF)<50%, and/or the presence of left ventricular regional wall motion abnormalities (RWMA) in organ donors, and short- and long-term liver and kidney graft survival. Our secondary aim was to link graft survival with donor and recipient characteristics. All donors considered for liver and kidney donation with echocardiographic records at Sahlgrenska University Hospital between 2006 and 2016 were matched with their recipients through the Scandiatransplant register. The studied outcomes were graft survival, re-transplantation, and recipient death. Kaplan-Meier curves were used to plot time to event. Multivariate Cox-regression was used to test independence. There were 370 liver donors and 312 kidney donors (matched with 458 recipients) with echocardiographic records at Sahlgrenska University Hospital between June 2006 and November 2016. Of patients with LV dysfunction by echocardiography, there were 102 liver- and 72 kidney donors. Univariate survival analyses showed no statistical difference in the short- and long-term graft survival from donors with LV dysfunction compared to donors without. Donor age>65 years, recipient re-transplantation and recipient liver tumor were predictors of worse outcome in liver transplants (p<.05). Donor age>65, donor hypertension, recipient re-transplantation, and a recipient diagnosis of diabetes or nephritis/glomerulonephritis had a negative association with graft survival in kidney transplants (p<.05). We found no significant association between donor LV dysfunction and short- and long-term graft survival in liver and kidney transplants, suggesting that livers and kidneys from such donors can be safely transplanted.

Stress Echocardiography by the ABCDE Protocol ln the Assessment of Prognosis of Stable Coronary Heart Disease.

To assess the role of clinical indicators and parameters of stress echocardiography performed according to an extended protocol as predictors for the occurrence of a composite cardiovascular endpoint (CCVEP) in IHD. The study included 186 patients (60.2% men, mean age 60.6±9.9 years) with an established (n=73; 39.2%) and suspected (60.8%) diagnosis of IHD. Stress EchoCG with adenosine triphosphate (38.2%), transesophageal pacing (15.1%), dobutamine (2.6%), and bicycle ergometry on a recumbent ergometer (44.1%) was performed. The stress EchoCG protocol included assessment of regional wall motion abnormalities (WMA), B-lines, LV contractile reserve (CTR), coronary reserve (CR), and heart rate reserve. The median follow-up period was 13 [9; 20] months. The composite CCVEP included death from cardiovascular diseases and their complications, acute coronary syndrome, and revascularization and was defined at the first of these events. Statistical analysis was performed with the Statistica 16.0 and SPSS Statistics 23.0 software packages. Differences were considered statistically significant at p&lt;0.05. Invasive or noninvasive coronary angiography was performed in 90.3% of patients; obstructive coronary disease (stenosis ≥50%) was detected in 67.9% of cases. During the follow-up period, 58 (31.2%) patients had cardiovascular complications. The risk of developing CCVEP was associated with the pretest probability (PTP) of ischemic heart disease (odds ratio, OR, 1.05; 95% confidence interval, CI, 1.02-1.08), dyslipidemia (DLP) (OR 0.40; 95% CI 0.20-0.82), carotid atherosclerosis (OR 0.39; 95% CI 0.18-0.86), LV ejection fraction (OR 0.96; 95% CI 0.93-0.99), appearance at peak stress of new significant (2 LV segments or more) regional WMAs (OR 0.32; 95% CI 0.18-6.55), decreased LV CTR (OR 0.46; 95% CI 0.27-0.79) and CR (OR 0.33; 95% CI 0.18-0.61); p&lt;0.05 for all. In a multivariate analysis with Cox regression, the model with clinical indicators included PTP of IHD (OR 1.04; 95% CI 1.01-1.07; p=0.01) and DLP (OR 0.14; 95% CI 0.02-1.01; p=0.05) as predictors. The model with stress EchoCG parameters included the appearance of new significant WMAs (OR 0.33, 95% CI 0.16-0.65; p=0.001) and reduced &lt;2.0 CR (OR 0.44; 95% CI 0.24-0.82; p=0.01). A comparative analysis of Kaplan-Meier curves confirmed statistically significant differences in the dynamics of the CCVEP occurrence depending on the absence or presence of hemodynamically significant WMAs and/or reduced CR during stress EchoCG (p&lt;0.01). Reduced LV CR and WMA during stress EchoCG in patients with suspected or confirmed IHD are significant independent predictors for the CCVEP occurrence. Among clinical indicators, PTP of IHD and DLP are of the greatest importance for prognosis.

Pulmonary Embolism in Patients Admitted With Takotsubo Cardiomyopathy: Prevalence and Associated In-Hospital Adverse Events.

Introduction Takotsubo cardiomyopathy (TCM) is a poorly understood condition typically characterized by abnormal left ventricular wall motion without causative coronary artery disease and typically presents in post-menopausal women after the experience of a physical or emotional stressor. The pathophysiology of TCM is complex and multifactorial, resulting in complications with varied severity; one of the most concerning complications is thromboembolism, specifically, pulmonary embolism (PE), which is understudied in its relation to TCM.The purpose of this study was to characterize and evaluate the real-world prevalence and outcomes of PE in TCM. Methods Data were derived from the National Inpatient Sample database from January 2016 to December 2019. The primary outcomes assessed were baseline and hospital admission characteristics and comorbidities for patients with TCM with and without PE. Outcomes for TCM patients with PEand predictors of mortality in TCM were also analyzed. Results PE developed in 788 of 40,120 patients with TCM (1.96%). After multivariate adjustment, PE was found to be independently associated with intracardiac thrombus (adjusted odds ratio (aOR) 2.067; 95% confidence interval (CI): 1.198-3.566; p = 0.009) and right heart catheterization (RHC) (aOR: 1.971; 95% CI: 1.160-3.350; p = 0.012). Mortality in patients with TCM was associated with, among other factors, age in years at admission (aOR: 1.104; 95% CI: 1.010-1.017; p = 0.001), African American race (aOR: 1.191; 95% CI: 1.020-1.391; p = 0.027), Asian or Pacific Islander race (aOR: 1.637; 95% CI: 1.283-2.090; p = 0.001), coagulopathy (aOR: 3.393; 95% CI: 2.889-2.986; p = 0.001), liver disease (aOR: 1.446; 95% CI: 1.147-1.824; p = 0.002), atrial fibrillation (aOR: 1.460; 95% CI: 1.320-1.615; p = 0.001), and pulmonary embolism (aOR: 2.217; 95% CI: 1.781-2.760; p = 0.001). Conclusion In a large cohort of patients admitted with TCM,we found the prevalence of PE to be 1.96%. PE, along with comorbidities such as coagulopathy and atrial fibrillation, was found to be a significant predictorof mortality in this patient cohort.

Takotsubo cardiomyopathy after solid organ transplantation: a scoping review.

Takotsubo syndrome (TTS) is a stress-induced cardiomyopathy that causes temporary left ventricular wall motion abnormalities and abrupt reversible heart failure. The incidence of perioperative TTS is proportional to the severity of surgical trauma, the duration of the procedure, and the degree of apparent sympathetic activity. A growing number of articles have discussed TTS after a solid organ transplant (SOT), which is one of the circumstances in which physical and emotional stress are at their highest levels. The majority of published cases involved patients who had received an orthotopic liver transplant (OLT). TTS occurred in 0.3-1.7% of liver transplant recipients, but a limited number of cases of TTS in patients who had received kidney, heart, or lung transplants have also been documented. In this study, we analyzed the TTS instances that developed after SOT, highlighting the symptoms and causes as well as the various treatment approaches that were applied. Most TTS cases following OLT and kidney transplant cases occurred in the first week of the surgery. However, the majority of cases occurred years after heart transplantation. Dizziness, dyspnoea, and chest discomfort are the most typical symptoms. Patients may also experience syncope and generalized weakness. In spite of this, the symptoms differ depending on the transplanted organ. Dyspnoea is a common symptom after lung transplants, whereas chest discomfort and dizziness are a common symptom after liver and kidney transplants. Yet, chest pain is not a typical symptom after a heart transplant.

Resting strain analysis to identify myocardial ischemia in patients with advanced chronic kidney disease.

Chronic kidney disease (CKD) is associated with higher incidence of cardiovascular death. Screening for coronary artery disease in asymptomatic or mildly symptomatic patients is challenging. The aim of this study was to investigate the incremental value of resting deformation analysis in predicting positive results for myocardial ischemia during stress transthoracic echocardiography in patients with end-stage CKD. Sixty-one patients (mean age: 62.3 ± 11.8, 65.7% men) with end-stage CKD were included in the study. Patients underwent a resting transthoracic echocardiogram and a dobutamine stress contrast echo (DSE) protocol. Positive results of DSE were defined as stress-induced left ventricular (LV) wall motion abnormalities. The study cohort had normal or mildly impaired systolic function: mean LV ejection fraction (EF) was 49.2% (±10.4) and mean LV global longitudinal strain (GLS) was 14.4% (±4.5). Half of our population had impaired left atrial (LA) strain: mean LA reservoir, conduit, and contractile reserve were 24.1% (±12.6), 10.6% (±5.9), and 13.6% (±9.2), respectively. DSE was positive for ischemia in 55.7%. A significant negative association with DSE results was found for LV EF, LV GLS and the conduit phase of LA strain. Both LV and LA dimensions showed positive correlation with presence of ischemia in DSE. Multivariate logistic regression analysis showed that LV GLS was independently associated with DSE (p = 0.007), after controlling for covariates, with high diagnostic accuracy. Resting LV deformation could predict positive results during DSE, thus may be useful to better identify renal patients who might benefit from coronary artery screening.

Exploratory Review of the Takotsubo Syndrome and the Possible Role of the Psychosocial Stress Response and Inflammaging.

Takotsubo syndrome (TTS) is a cardiomyopathy that clinically presents as a transient and reversible left ventricular wall motion abnormality (LVWMA). Recovery can occur spontaneously within hours or weeks. Studies have shown that it mainly affects older people. In particular, there is a higher prevalence in postmenopausal women. Physical and emotional stress factors are widely discussed and generally recognized triggers. In addition, the hypothalamic-pituitary-adrenal (HPA) axis and the associated glucocorticoid-dependent negative feedback play an important role in the resulting immune response. This review aims to highlight the unstudied aspects of the trigger factors of TTS. The focus is on emotional stress/chronic unpredictable mild stress (CUMS), which is influenced by estrogen concentration and noradrenaline, for example, and can lead to changes in the behavioral, hormonal, and autonomic systems. Age- and gender-specific aspects, as well as psychological effects, must also be considered. We hypothesize that this leads to a stronger corticosteroid response and altered feedback of the HPA axis. This may trigger proinflammatory markers and thus immunosuppression, inflammaging, and sympathetic overactivation, which contributes significantly to the development of TTS. The aim is to highlight the importance of CUMS and psychological triggers as risk factors and to make an exploratory proposal based on the new knowledge. Based on the imbalance between the sympathetic and parasympathetic nervous systems, transcutaneous vagus nerve stimulation (tVNS) is presented as a possible new therapeutic approach.

Enhancing predictive accuracy of the cardiac risk score in open abdominal aortic surgery: the role of left ventricular wall motion abnormalities.

Open abdominal aortic surgery carries many potential complications, with cardiac adverse events being the most significant concern. The Vascular Study Group Cardiac Risk Index (VSG-CRI) is a commonly used tool for predicting severe cardiac complications and guiding clinical decision-making. However, despite the potential prognostic significance of left ventricular wall motion abnormalities (LVWMAs) and reduced LV ejection fraction (LVEF) for adverse outcomes, the VSG-CRI model has not accounted for them. Hence, the main objective of this study was to analyze the added value of LV wall motion on the discriminatory power of the modified VSG-CRI in predicting major postoperative cardiac complications. A prospective study was conducted involving 271 patients who underwent elective abdominal aortic surgery between 2019 and 2021. VSG-CRI scores were calculated, and preoperative transthoracic echocardiography was conducted for all patients. Subsequently, a modified version of the VSG-CRI, accounting for reduced LVEF and LVWMAs, was developed and incorporated into the dataset. The postoperative incidence of the composite endpoint of major adverse cardiac events (MACEs), including myocardial infarction, clinically relevant arrhythmias treated with medicaments or by cardioversion, or congestive heart failure, was assessed at discharge from the index hospitalization, with adjudicators blinded to events. The predictive accuracy of both the original and modified VSG-CRI was assessed using C-Statistics. In total, 61 patients (22.5%) experienced MACEs. Among these patients, a significantly higher proportion had preoperative LVWMAs compared to those without (62.3% vs. 32.9%, p < 0.001). Multivariable regression analysis revealed the VSG-CRI [odds ratio (OR) 1.46, 95% confidence interval (CI) 1.21-1.77; p < 0.001] and LVWMA (OR 2.76; 95% CI 1.46-5.23; p = 0.002) as independent predictors of MACEs. Additionally, the modified VSG-CRI model demonstrated superior predictability compared to the baseline VSG-CRI model, suggesting an improved predictive performance for anticipating MACEs following abdominal aortic surgery [area under the curve (AUC) 0.74; 95% CI 0.68-0.81 vs. AUC 0.70; 95% CI 0.63-0.77; respectively]. The findings of this study suggest that incorporating preoperative echocardiography can enhance the predictive accuracy of the VSG-CRI for predicting MACEs after open abdominal aortic surgery. Before its implementation in clinical settings, external validation is necessary to confirm the generalizability of this newly developed predictive model across different populations.

Resting strain analysis to identify myocardial ischemia in patients with advanced chronic kidney disease

Abstract Background Chronic kidney disease (CKD) is associated with a higher incidence of cardiovascular death, particularly as the disease progresses and patients are on long term dialysis treatment. Screening for coronary artery disease in asymptomatic or mildly symptomatic patients is challenging and controversial. Objective The aim of this study was to investigate the incremental value of resting deformation analysis with speckle tracking echocardiography in predicting positive results on stress transthoracic echocardiography in patients with end-stage renal disease on dialysis (stage 5 CKD). Methods Our cohort consisted of 61 consecutive patients (mean age 62.3±11.8, 65.7% men) with stage 5 CKD. Patients with a confirmed diagnosis of pre-existing cardiac diseases, such as obstructive coronary artery disease, heart failure, severe arrhythmias or severe valvular disease were excluded. Patients underwent a resting transthoracic echocardiogram and a dobutamine stress contrast echo (DSCE) protocol. Positive results of DSCE were defined as stress-induced LV wall motion abnormalities (new or worsening preexisting abnormalities). Results The study cohort had normal or mildly impaired systolic function with mean LV ejection fraction (EF) of 49.17% (±10.41) and a mean LV GLS of 14.35% (±4.49) (Figure 1). In addition, half of our population had impaired LA strain: mean LA reservoir, LA conduit, and LA contractile reserve were 24.11% (±12.61), 10.56% (±5.88), and 13.60% (±9.15), respectively. DSCE was positive for ischemia in 55.7%. Age, gender, and history of diabetes were significantly correlated with positive result in DSCE (p=0.027, p=0.022 and p=0.039, respectively). Additionally, a significant negative association with DSCE results was found for the echocardiographic parameters LV EF, LV GLS, the conduit phase of LA strain, LV end diastolic volume as well as LA dimensions (p=0.002, p=0.002, p=0.004, p= 0.002 and p=0.048, respectively). Logistic regression analysis showed that LV global longitudinal strain was independently associated with DSCE outcome (p=0.007), after controlling for covariates. The area under the curve (AUC) to predict positive results for LV GLS was 0.92 with with a sensitivity of 96%, a specificity of 56% and an overall diagnostic accuracy of 84% (Fig 2). Conclusion The present findings demonstrate that resting LV deformation is associated with the presence of coronary ischemia and may be useful to better identify patients with advanced CKD who might benefit from coronary artery screening.LV GLSAUC

Abstract 15120: Effect of Prolonged Left Ventricular Global Longitudinal Strain Reduction After Exercise on the Development of Cardiovascular Events

Introduction: Recently, it has also been reported that patients with ischemic heart disease have prolonged left ventricular (LV) GLS reduction after exercise. Hypothesis: To investigate the influence of prolonged LV GLS reduction after exercise on the development of cardiovascular events. Methods: One hundred thirty-three consecutive patients with at least one of the following coronary risk factors: hypertension, hyperlipidemia, or diabetes mellitus underwent echocardiography (ARTIDA; Canon medical, Japan) before and 30 minutes after Master double exercise and LV GLS was measured offline (Vitria; Canon medical, Japan). Patients with obvious LV wall motion abnormalities, significant valvular heart disease, or atrial fibrillation were excluded. The incidence of cardiovascular events was determined from the patients' medical records. Patients were divided into three groups based on the occurrence of cardiovascular events up to 6 months after the examination: non-events group, minor cardiovascular event group (chest pain, palpitations, other additional tests), and major cardiovascular event group (coronary revascularization, cardiac hospitalization). The LV GLSs before and 30 minutes after exercise were compared in each patient group. Results: Mean age was 63±11.5years (female: 25%). Patients had hypertension (53%), hyperlipidemia (47%), and diabetes (65%). Of the 133 eligible patients, non-event group (n=68), minor cardiovascular event group (n=50), and major cardiovascular event group (n=15). LV GLS before exercise was not significantly different between the groups, however LV GLS at 30 minutes after exercise were significantly lower in the cardiovascular event groups and were proportional to the severity of the event. (Figure) Conclusions: The prolonged reduction in LV GLS after exercise could be a useful predictive index for the development of cardiovascular events.

Takotsubo Cardiomyopathy in the setting of Urosepsis

Takotsubo cardiomyopathy is a rare cardiac condition associated with transient left ventricular apical wall motion abnormalities in association with stress but without any signifcant coronary artery disease. We present a case of takotsubo cardiomyopathy presenting as acute pulmonary edema in the background of urosepsis.

Role of speckle-tracking echocardiography in diagnosis and further prognosis of coronary heart disease

Echocardiography is one of the first-line methods of detection and evaluation of coronary artery disease, which helps clinicians in the diagnostic and prognostic evaluation of this disease. However, visual assessment of abnormal left ventricular myocardial wall motion is not always appropriate in detecting less severe or transient myocardial ischemia and in making an accurate differential diagnosis. Speckle-tracking echocardiography is a widely available non-invasive tool that can easily and quickly provide clarifying information and significantly extend the standard echocardiographic study, as the method allows you to identify subtle myocardial damage and local areas of ischemia that correspond to the pattern of coronary disease, and obtain an objective report in the form of simple visual scheme, very easy to use for differential diagnosis and treatment. Therefore, this method, which is increasingly used in various manifestations of coronary insufficiency and is convenient to use both at rest and with stress echocardiography, has proved efficient results in terms of predicting coronary heart disease, quantitative interpretation of emerging or persistent ischemia, assessment of the clinical course and outcome, and left ventricular remodeling. In this review, we have attempted to reflect the currently available findings that demonstrate the significance of speckle-tracking echocardiography for the evaluation and follow-up of coronary heart disease, including some congenital anomalies of the coronary arteries, and to touch on the main achievements and discoveries in the use of two-dimensional and three-dimensional deformation parameters and their potential application for a wider introduction into clinical practice.

Inter- and intra-observer variability in the echocardiographic evaluation of wall motion abnormality in patients with ST-elevation myocardial infarction or takotsubo syndrome - A novel approach.

Using existing transthoracic echocardiographic indices to quantify left ventricular wall motion abnormalities (WMAs) can be difficult due to the variations in the location of the abnormalities within the left ventricle, the quality of examinations, and the inter-/intra-observer variability of available indices. This study aimed to evaluate a new approach for measuring the extent of WMA by calculating the percentage of abnormal wall motion and comparing it to the wall motion score index (WMSI). The study also sought to assess inter- and intra-observer variability. The study included 140 echocardiograms from 54 patients presenting with ST-elevation myocardial infarction or Takotsubo syndrome. All patients underwent an echocardiographic examination according to a standard protocol and the images were used to measure the extent of akinesia (proportion akinesia, PrA), akinesia and hypokinesia (proportion akinesia/hypokinesia, PrAH), and WMSI. The inter-observer variability between the two operators was analyzed. The intra-observer analysis was performed by one observer using the same images at least 1 month after the first measurement. The agreement was analyzed using the Pearson correlation coefficient and Bland-Altman plots. Inter- and intra-observer variability for PrA and PrAH were low and comparable to those for WMSI. PrA and PrAH are reliable and reproducible echocardiographic methods for the evaluation of left ventricular wall motion.

#5621 BENEFICIAL EFFECTS OF CHRONIC INTRADIALYTIC EXERCISE TRAINING ON HEMODIALYSIS-INDUCED-MYOCARDIAL STUNNING

Abstract Background and Aims Hemodialysis (HD) induces left ventricular (LV) segmental regional wall motion abnormalities (RWMAs) due to hypoperfusion, leading to acute LV transient dysfunction, well known as myocardial stunning. Repeated episodes of HD-related myocardial stunning contribute directly to the development of heart failure and increased mortality in patients receiving HD (Burton et al., 2009). Exercise training exert pleiotropic favorable effects on the cardiovascular system. No study has however investigated its impact on the kinetics of regional myocardial function during HD. This study aims to evaluate the effect of intradialytic exercise (IDE) on RWMAs compared with standard care. Method This was a prospective, open-label, two-center trial (clinicaltrials.gov NCT04697459) with two parallel groups: 31 patients (ENT) undergoing a 4-month IDE program (30min of cycling + 30min of resistance training starting 30 min after HD onset) and 21 patients continuing usual care (CTRL). Untrained adults, aged 20-79 years, undertaking maintenance HD for &amp;gt;3 months were eligible to participate. Exclusion criteria were poor echogenicity, contraindication to exercise, orthopedic complications, severe heart (ischemic, valvular, ...), vascular or respiratory diseases, ejection fraction &amp;lt;45% and body mass index &amp;gt;35. Longitudinal strain (LS) using speckle-tracking echocardiography were measured during a standard HD session, just before HD onset (HDT0) and at peak stress of HD (30 min before HD-ending, HDPeak). The same procedure was used before and after 4-months of IDE or usual care. LS from a 18 LV segment model were used to assess the presence of HD-induced RWMAs, defined as a ≥20% reduction in LS at peak stress compared to baseline. A generalized linear mixed model (Poisson model) was used to analyze the effect of IDE on RWMAs. Results After 4 months of IDE, we observed a significant reduction of RWMAs at HDPeak (mean before: 6.03±3.19 vs after: 4.55±2.26; point estimate: -1.48, 95% confident interval CI: -0.39/-2.57, p = 0.03), whereas its occurrence remained unchanged in CTRL (mean before: 6.14±3.51 vs after: 6.09±3.16; point estimate: -0.05; 95% CI: 1.45/-1.54, p = 0.96). There was also evidence that IDE program significantly attenuated the decline of global LS observed during HD (before: 2.11±2.39% vs after: 1.10±1.95%; point estimate: -1.01%; 95% CI: -1.86/-0.13, p = 0.02) compared to the similar impairment in CTRL (before: 1.60±2.30% vs after: 1.79±2.08%; point estimate: +0.18%; 95% CI: +1.20/-0.85 p = 0.72). Conclusion There is clear evidence that chronic IDE is cardioprotective. Identifying the underlying mechanisms responsible for exercise-induced cardioprotection was beyond the scope of our study, but we can reasonably assume that structural and/or functional changes in the coronary arteries, especially in microcirculatory territories (i.e. increased collateral circulation due to angiogenesis/arteriogenesis, improved endothelial function, reduced blood viscosity) and/or intrinsic changes in the cardiac myocyte (reduced fibrosis, enhanced calcium handling/sensitivity, altered mitochondrial turnover and phenotype), related among others to reduced oxidative stress and/or inflammation, might play a role (Powers et al 2014). Whether our results translate to longer-term reduction in clinical outcomes and cardiovascular mortality in end-stage renal disease patients require further studies.

Stress Cardiomyopathy and Spontaneous Coronary Artery Dissection: Linked or Overlooked?

This case series aimed to explore the association between spontaneous coronary artery dissection (SCAD) and stress cardiomyopathy (SCM), which are conditions that share similar features and can present as acute coronary syndrome. Both can be precipitated by emotional and/or physical stressors. Diagnosis is with coronary angiogram for SCAD, and echocardiogram for SCM. It is less common for people to have features of both. The overlap syndrome becomes evident if the territory of the involved coronary artery is incongruent with the left ventricular (LV) regional wall motion abnormality (RWMA). This single-centre case series identified cases with possible overlap of stress cardiomyopathy and SCAD. Patients were searched for individually, using an electronic health database (Health Connect South) through discharge summaries over a 2-year period. Cases with a likely diagnosis of both stress cardiomyopathy and SCAD were identified. The echocardiographic abnormalities included LV apical hypo/akinesis in all cases. In most cases, SCAD was confined to the mid and/or distal left anterior descending (LAD) artery. Two cases involved SCAD in multiple coronary arteries. This case series was able to clearly see the coexistence of an overlap syndrome in some cases. However, the association between the two conditions is under-recognised. It is proposed that an invasive coronary angiogram or computerised tomography coronary angiogram be actively reviewed to diagnose SCAD in patients with SCM, and early and repeat imaging in patients with SCAD is essential to identify SCM.

Association between echocardiographic features and inflammatory biomarkers with clinical outcomes in COVID-19 patients in Saudi Arabia.

Respiratory infections are one of the most common comorbidities identified in hospitalized patients. The coronavirus disease 2019 (COVID-19) pandemic greatly impacted healthcare systems, including acute cardiac services. This study aimed to describe the echocardiographic findings of patients with COVID-19 infections and their correlations with inflammatory biomarkers, disease severity, and clinical outcomes. This observational study was conducted between June 2021 and July 2022. The analysis included all patients diagnosed with COVID-19 who had transthoracic echocardiographic (TTE) scans within 72 h of admission. The enrolled patients had a mean age of 55.6 ± 14.7 years, and 66.1% were male. Of the 490 enrolled patients, 203 (41.4%) were admitted to the intensive care unit (ICU). Pre-ICU TTE findings showed significantly higher incidence right ventricular dysfunction (28 [13.8%] vs. 23 [8.0%]; P = 0.04) and left ventricular (LV) regional wall motion abnormalities (55 [27.1%] vs. 29 [10.1%]; p < 0.001) in ICU patients compared to non-ICU patients. In-hospital mortality was 11 (2.2%), all deaths of ICU patients. The most sensitive predictors of ICU admission (p < 0.05): cardiac troponin I level (area under the curve [AUC] = 0.733), followed by hs-CRP (AUC = 0.620), creatine kinase-MB (AUC = 0.617), D-dimer (AUC = 0.599), and lactate dehydrogenase (AUC = 0.567). Binary logistic regression showed that reduced LV ejection fraction (LVEF), elevated pulmonary artery systolic pressure, and dilated right ventricle were echocardiographic predictors of poor outcomes (p < 0.05). Echocardiography is a valuable tool in assessing admitted patients with COVID-19. Lower LVEF, pulmonary hypertension, higher D-dimer, C-reactive protein, and B-type natriuretic peptide levels were predictors of poor outcomes.