Left Ventricular Wall Motion Score Research Articles

Influence of gender on the diagnostic and prognostic significance of the dobutamine stress echocardiography for ischemia

Background/Aim. Cardiovascular diseases are the most common cause of mortality and morbidity worldwide, with the highest incidence in low-middle-income countries. Dobutamine stress echocardiography (DSE) plays a significant role in diagnosing coronary artery disease. The aim of the study was to examine the influence of gender on the accuracy of DSE and on the prognostic significance of the left ventricular wall motion score index (WMSI) as a parameter of DSE for adverse cardiovascular events (ACEs). Methods. The prospective, observational study conducted at the Clinic for Cardiovascular Diseases of the University Clinical Center of the Republic of Srpska, Bosnia and Herzegovina, included 143 patients who, due to suspicion of coronary disease, underwent a DSE from January 1, 2021, until February 1, 2022. ACEs that we observed one year after DSE were: unstable angina, acute myocardial infarction, percutaneous coronary intervention, in-stent restenosis, aortocoronary bypass, heart failure, and death. Results. A positive DSE was more common in men (45%) compared to women (25%), which was statistically significant (p < 0.05). The sensitivity of the test in men was 96.0%, and the specificity was 93.9%. In women, the sensitivity was 86.7%, and specificity was also 86.7%. ACEs were more frequent in men (43%) than in women (19%), which was statistically significant (p < 0.01). In men, WMSI had a sensitivity of 96.0% and a specificity of 82.4%. In women, WMSI had a sensitivity of 93.3% and a specificity of 90.6% in predicting ACEs. Conclusion. Our results confirmed the influence of gender on the accuracy of DSE in diagnosing coronary artery disease. WMSI as a parameter of DSE was identified as a significant prognostic factor for ACEs in both sexes, with the sensitivity being higher in men and specificity in women.

Impact of thrombus aspiration on left ventricular remodeling and function in patients with ST-segment elevation myocardial infarction: A meta-analysis of randomized controlled trials

BackgroundRoutine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI). MethodsPubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA. ResultsA total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference [MD] -0.11, 95% confidence interval [CI] -0.19 to −0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to −3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = −2.13, p = 0.03; z = −3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04). ConclusionTA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling.

A novel echo-score for the prediction of cardiovascular outcomes in patients with STEMI

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Echocardiography is a tool extensively studied for predicting adverse outcomes in heart failure and after MI. However, most studies are focused on predicting long-term events, and tools to predict in-hospital outcomes are needed. Objectives to identify echocardiographic parameters associated with the occurrence of in-hospital major adverse cardiovascular events and to develop an echocardiographic score to predict outcomes in patients with STEMI. Methods Single-center, observational, descriptive, longitudinal study, including consecutive STEMI patients undergoing reperfusion therapy within 12 hours since symptom onset. An echocardiogram was performed early (&amp;lt;48h) during hospitalization. An echocardiographic score (Echo Score) including LVEF (0 = LVEF &amp;lt;45%, 1 = LVEF between 44% and 35%, 2 &amp;lt;35% ), left ventricular wall motion score index (LVWMSi) (1 = LVWMSi&amp;gt;1.5, 0 = LVWMSi≤1.5) E/e’ ratio (1 = E/e’&amp;gt; 15, 0 = E/e’≤ 15)and RV fractional shortening (RVFS) (1 = RVFS &amp;lt;30%, 0 = RVFS ≥ 30%) was derived. The study's primary objective was to evaluate the primary endpoint (a composite of cardiovascular death, congestive heart failure, cardiogenic shock, and recurrent MI) and its relation with echo score during 30 days follow-up. Results A total of 270 consecutive patients participate in this study. The mean echo score was 2 (1-3). Patients with a mean echo score &amp;gt; 2 exhibited an increased risk for the primary endpoint during 30-day follow-up (HR 2.18. 95%CI 0.99-4.86, p= 0.06). Individual components of the primary endpoint exhibited an increased risk of mainly heart failure 5.9 vs. 14.1% (p=0.03). AUC-ROC was analyzed for echo score, and GRACE / TIMI scores on admission; no significant differences were found between these scores (Echo score: 0.65, GRACE 0.66 &amp; TIMI 0.68, p = 0.06). Conclusion in patients with STEMI receiving reperfusion, an echocardiographic score including LVEF, LVWMSi, E/e´ratio, and RVFS performed similarly to GRACE and TIMI scores in the prediction of major cardiovascular events in the short term.

Advantages of long-term combination pharmacotherapy with a beta-blocker and eplerenone in patients with ST-segment elevation acute coronary syndrome

Aim.To conduct a comparative analysis of the effect of long-term pharmacotherapy (12 months) using a β-blocker (nebivolol) and its combination with eplerenone in patients after ST-segment elevation acute coronary syndrome (STE-ACS) with heart failure with mildly reduced ejection fraction (EF) (HFmrEF) on the structural and functional cardiac parameters.Material and methods. We examined 130 patients with STE-ACS and HFmrEF after successful myocardial revascularization by percutaneous coronary intervention. The mean age of patients was 53,6 [46;57] years. Ten patients withdrew from the study due to personal reasons. Subsequently, patients were randomly divided into 2 treatment groups as follows: 60 patients received nebivolol; 60 patients received nebivolol and eplerenone. Patients were examined at two stages: 1st day of the disease before PCI and 12 months later. All patients underwent a clinical examination, echocardiography, followed by assessment of left ventricular (LV) EF, LV end-diastolic volume index (EDVI), LV endsystolic volume index (ESVI), LV myocardial index (LVMI), LV wall motion score index (WMSI), the ratio of peak early diastolic flow over peak late diastolic flow (E/A), the ratio of early diastolic transmitral flow velocity to the mitral annular velocity (E/e´).Results.Twelve-month pharmacotherapy with nebivolol in patients after STE-ACS showed an increase in LVEF by 7,2% (p&lt;0,05), a decrease in WMSI by 13,0% (p&lt;0,05), an increase in the E/A ratio by 11,1% (р&lt;0,05), decrease in the E/e’ ratio by 7,2% (р&lt;0,05). LV EDVI increased by 4,6% (p&gt;0,05). Twelve-month combined pharmacotherapy with nebivolol and eplerenone showed an increase in LVEF by 16,0% (p&lt;0,01), a decrease in LV ESVI by 17,9% (p&lt;0,05), and a decrease in WMSI by 26,7% (p&lt;0,01), LVMI — by 23,8% (р&lt;0,01). At the same time, LV EDVI decreased by 0,7% (p&gt;0,05). The E/A ratio increased significantly by 22,2% (&lt;0,01), E/e’ decreased by 29,6% (р&lt;0,01). Comparative analysis also found that combination therapy had a more pronounced positive effect on LVEF (p&lt;0,05), ESVI (p&lt;0,05), WMSI (p&lt;0,05), LVMI (p&lt;0,01), as well as diastolic function in the form of a significant increase in E/A (p&lt;0,05) and E/e’ (p&lt;0,01), which recovered to normal values.Conclusion.The advantages of long-term combination pharmacotherapy of nebivolol and eplerenone in HFmrEF patients after STE-ACS on both structural and functional cardiac parameters were established.

Rationale and design of the open-label, prospective, randomized study of the efficacy of intravenous versus oral iron deficiency therapy in improving left ventricular systolic function in patients with myocardial infarction (OPERA-MI)

Aim. Iron has a protective effect on cardiomyocytes during hypoxia, while iron deficiency (ID) directly affects its function, disrupting mitochondrial respiration, reducing their contractility and relaxation. Some studies have shown that ID is a predictor of adverse outcomes in patients with acute coronary syndrome (ACS). However, the impact of ID and its treatment, quality of life and prognosis of patients with ID and myocardial infarction (MI) has not been fully established. The study aim is to determine the effectiveness of intravenous ferric carboxymaltose (FCM) compared with oral iron (ferrous sulfate) in relation to left ventricular (LV) systolic function, assessed by echocardiography.Material and methods. This open-label, prospective, randomized study includes 360 patients with or without ID who were hospitalized with acute myocardial infarction (MI). Patients with ID will be randomized (1:1) to intravenous FCM and oral ferrous sulfate therapy. Treatment in groups will be started at the time of hospitalization. Patients without ID will form the control group. The follow-up period for patients will be 1 year. The primary endpoint was a reduction in LV wall motion score index (WMSI) in the FCM group compared to the ferrous sulfate group. The key secondary endpoint is a composite endpoint of cardiovascular death, non-fatal MI and stroke, and hospitalization for decompensated heart failure.Conclusion. The OPERA-MI study will determine the effect of ID treatment with intravenous FCM compared with oral ferrous sulfate on WMSI, which reflects LV systolic function.

Functional ischemic mitral regurgitation in acute myocardial infarction: Importance of changes in left ventricular shape and regional function

Functional ischemic mitral regurgitation (IMR) is common in patients with ischemic left ventricular dysfunction after myocardial infarction, and significantly worsens prognosis. The aim of this study is to determine the relative importance of the global and regional left ventricular (LV) remodelling in the occurrence of IMR. Eighty-one patients (mean age = 61 ± 11 years) admitted with acute myocardial infarction (AMI) were screened. Patients with atrial fibrillation and organic valvular diseases were excluded from the study. Echocardiography (two-dimensional and Doppler echocardiograms) was performed in the first week after admission. The 81 patients were divided in 2 groups: with IMR (group1 = 39 patients) and without IMR (group2 = 42 patients). LV volumes were calculated by apical biplane Simpson's rule. The LV wall-motion score (WMS) index was obtained in a 17-segment model according to established methods. To identify the influence of regional wall-motion impairment for each individual LV segment, the mean WMS was calculated for each segment and compared between the 2 groups. The echocardiographic parameters that were associated with IMR were: LV dilatation and sphericity ( P < 0.0001), reduced ejection fraction ( P < 0.0001), inferior ( P < 0.001) inferolateral ( P = 0.01) and anterolateral ( P = 0.02) asynergy. The results of this study indicate the importance of abnormalities of both LV geometry and regional wall motion in the pathogenesis of IMR after myocardial infarction. Clinically, these findings imply that myocardial salvage by early coronary revascularisation may improve outcome by preserving LV function and decreasing the incidence of IMR.

Baseline Myocardial Work on Echocardiography Reflects the Severity of Coronary Disease in Patients Presenting with Acute Coronary Syndrome

The aim of the study is to establish a relationship between baseline myocardial work (MW) assessed by echocardiography and the extent of coronary artery disease (CAD) using SYNTAX score in patients presenting with acute coronary syndrome (ACS) who underwent coronary angiography (CA). SYNTAX score from CA has proven to be a clinically useful anatomical scoring system to assess the burden and complexity of coronary artery disease (CAD). MW is a novel non-invasive measure of cardiac function using echocardiography. Other parameters of cardiac function, such as left ventricular ejection fraction (LVEF) and wall motion score index (WMSI), were also assessed. In this retrospective study, consecutive patients with ACS underwent echocardiography at the presentation to a large, tertiary hospital emergency department from March 2019 to April 2020 were included and analysed. There were 94 patients recruited to the study; age ± 12 years, 62% male. Median Syntax score was 12 (IQR 7–19). All echocardiographic parameters correlated with SYNTAX score. While GLS and MW showed a strong relationship with SYNTAX score (GLS r=0.33, p<0.01; GWW r=0.29, p<0.01; GWE r=0.31, p<0.01), WMSI, a standard assessment in assessing the extent of coronary disease, was a less significant predictor for the complexity of CAD (r=0.22, p=0.03). Baseline assessment of myocardial work correlates better with the extent of coronary disease than standard measures. This assessment may have a role in assisting with the type and timing of coronary intervention in patients presenting with acute coronary syndrome.

609 Prognostic role of renal function in patients with previous myocardial infarction. A study with cardiac magnetic resonance

Abstract Aims There is not strong evidence in literature about the impact of renal function on the prognosis of patients with ischaemic cardiomyopathy. Thus, the aim of the study was to investigate mild renal impairment [estimated glomerular filtration rate (eGFR): 60–89 ml/min] as an independent prognostic factor in patients with history of myocardial infarction (MI). Methods and results We studied 339 consecutive patients (65 ± 13 years old, female 13%) from 2001 and 2012 with previous MI. Patients with eGFR &amp;lt;60 ml/min were excluded. We performed cardiac magnetic resonance (CMR) in all patients to quantify left ventricular ejection fraction (LVEF), volumes, and wall motion score index (WMSI), and to measure the infarction extent by late gadolinium enhancement (LGE). Renal function was estimated by creatinine value with Cockcroft–Gault formula and patients were divided according to normal (≥90 ml/min) and reduced (60–89 ml/min) eGFR. Patients with normal eGFR were 106 (31%, 56.9 ± 10.5 years old), 233 (69%, 66.1 ± 9.9 years old) had renal impairment. During follow-up (median 3.5 years), cardiac events (cardiac death or appropriate intra-cardiac defibrillator shock) occurred in 28/233 (12%) of patients with eGFR &amp;lt;90 ml/min and in 4/106 (4%) of patients with eGFR ≥90 ml/min (P &amp;lt; 0.05). Furthermore, survival curve showed a significantly worst prognosis in patients with renal impairment (P &amp;lt; 0.03). In the group of patients with ejection fraction (EF) &amp;lt; 35% (121 patients), cardiac events were observed only in patients with eGFR &amp;lt;90 ml/min (23/99, 23%, P &amp;lt; 0.05). At multivariate stepwise analysis, age &amp;gt;65 years old, eGFR &amp;lt;90 ml/min and WMSI &amp;gt;1.7 turned out to be independent predictor of cardiac events (P &amp;lt; 0.05). Conclusions In patients with previous MI, a mild renal impairment (eGFR between 60 and 89 ml/min) was an independent predictor of prognosis, especially if combined with left ventricular disfunction.

Growth Differentiation Factor 15 is Related with Left Ventricular Recovery in Patients with ST-Elevation Myocardial Infarction after Successful Reperfusion by Primary Percutaneous Intervention.

The determinants of left ventricular (LV) recovery after successful revascularization in ST-elevation myocardial infarction (STEMI) patients are not clear. In addition, the relationship between growth differentiation factor15 (GDF-15) and left ventricular ejection fraction (LVEF) improvement is also unknown. This study hypothesizes that a low GDF-15 level would be associated with LVEF recovery. One hundred and sixty-one STEMI patients were included in this study. Echocardiographic examinations were performed before and 12-18 weeks after discharge. The patients were divided into three groups according to the changes in LVEF as 62 patients with ≥ 10% change, 47 patients with 1-9% change, and 52 patients ≤ 0% change. LV recovery was defined as ≥ 10% LVEF improvement and the predictors of LV recovery were investigated. Moreover, two groups were created according to GDF-15 values, and the follow-up/baseline echocardiographic parameters were compared between these groups. LV recovery was detected in 38.5% of the patients. Low baseline LVEF [odds ratio (OR): 0.85, 95% confidence interval (CI) 0.82-0.94, p = 0.001], low GDF-15 (OR: 0.79, 95% CI 0.68-0.93, p = 0.004), previous angina (OR: 2.34, 95% CI 1.10-4.96, p = 0.027), and symptom-to-balloon time (OR: 0.97, 95% CI 0.95-1.00, p = 0.043) were independent predictors of LV recovery. The ratios of follow-up/baseline LV end-diastolic volume index, LV end-systolic volume index and wall motion score index were lower in the low GDF-15 group (0.96 vs. 1.04, p < 0.001; 0.96 vs. 1.10, p < 0.001; 0.89 vs. 0.96, p < 0.001). Moreover, being in the low GDF-15 group was associated with LV recovery (OR: 2.93, 95% CI 1.43-6.02, p = 0.001). Lower GDF-15 level was associated with better LV improvement and less adverse remodeling in STEMI patients.

Effects of deferred versus immediate stenting on left ventricular function in patients with ST elevation myocardial infarction.

Background:Previous studies have shown conflicting results on the benefits of deferred stenting (DS) in infarct size and the incidence of microvascular obstruction in patients with ST elevation myocardial infarction (STEMI). However, effect of DS on left ventricular (LV) function was not known. We aimed to evaluate whether DS improve LV function and relevant clinical outcomes after STEMI, using follow-up data from the INNOVATION study (NCT02324348).Methods:In total, 114 patients were randomly assigned to DS group or immediate stenting (IS) group at a 1:1 ratio. LV functional remodeling indices and MACE (major adverse cardiac events: a composite of death, non-fatal MI, unplanned target vessel revascularization, or hospitalization due to heart failure) were compared between DS and IS groups.Results:Serial echocardiographic analyses were completed in 89 subjects (78%). There were no significant changes in LV volume in either group. While LV ejection fraction and wall motion score index (WMSI) improved in both groups during follow-up, the increments were not statistically different between the 2 groups (4.3 ± 8.2 vs 3.2 ± 7.1, P = .504 for ΔLV ejection fraction; –0.16 ± 0.25 vs –0.16 ± 0.25, P = .99 for ΔWMSI). However, E/e′’ was decreased and e′ was increased only in the DS group (–3.31 ± 5.60 vs –0.46 ± 3.10, P = .005 for ΔE/e′; 0.77 ± 1.71 vs –0.22 ± 1.64, P = .009 for Δe′). The incidence of major adverse cardiac events was numerically lower in the DS group than in the IS group without a statistical significance at 1-year follow-up.Conclusions:Routine DS improved LV diastolic function but not systolic function compared with IS in patients with STEMI.

2D speckle tracking echocardiography as predictor of major adverse cardiac events (MACE) in patients with non ST elevation myocardial infarction and unstable angina

Abstract Funding Acknowledgements Type of funding sources: None. BACKGROUND 2D speckle strain echocardiography has been recognized in different studies to provide additional important prognostic information in patients with chronic stable coronary artery disease or acute coronary syndrome (ACS)—more often on (ST elevation myocardial infarction (STEMI) patients. PURPOSE This study aimed to determine the clinical utility of 2D speckle tracking echocardiography in predicting major adverse cardiac events (MACE) in patients with non ST elevation – acute coronary syndrome (NSTE-ACS). METHODOLOGY This is a prospective cohort study which included 91 patients diagnosed to have NSTE-ACS. Baseline characteristics were collected and echocardiographic evaluations of patients were done within 48 hours of admission. In hospital and 6 months MACE were evaluated in relation to their baseline echocardiographic parameters, 2D speckle strain and strain rate analyses. RESULTS Among the conventional echocardiographic parameters, only left ventricular end systolic diameter (LVESD) and wall motion score showed significant difference between those with and without outcomes after 6 months. There were no significant difference among the 2D speckle tracking strain and strain rate parameters between those patients with and without major cardiac events during their in hospital admission. However after 6 months follow-up, there were significantly lower mean left ventricular global longitudinal strain (GLS) (-14.22% ± 4.45 versus -16.44% ± 4.19, p-value 0.0261) and strain rate (-0.69 1/sec ± 0.36 versus -0.94 1/sec ± 0.25, p-value 0.009) were observed among patients with MACE compared to those without. Also, incidence of reduced GLS strain and strain rate, were significantly higher in those with MACE after 6 months. The left ventricular global circumferential strain and strain rate, and right ventricular global longitudinal strain did not have significant difference between those with and without but these had a generally lower value among those who had in-hospital and 6 months MACE. In this study, LV GLS sensitivity and specificity were 64.64% and 61.70% respectively, at cut-off value of &amp;lt;-15.0% for detecting MACE within 6 month follow-up. LV GLS cut-off point &amp;lt;-12.0%, which detects severe LV dysfunction in previous studies, have sensitivity of 40% but high specificity of 82.98% for predicting MACE after 6 months. CONCLUSION Both LV GLS strain and strain rate can be used to predict major adverse cardiovascular events after NSTE-ACS. Abstract Figure. ROC curve LV strain and strain rate

Original Article--Value of Pathological Q Waves and Angiographic Collateral Grade in Patients Undergoing Coronary Chronic Total Occlusion Recanalization: Cardiac Magnetic Resonance Study.

Background/aimSuccessful coronary chronic total occlusion (CTO) revascularization was found by many studies to be associated with improved left ventricular (LV) systolic function and survival if evidence of viability is present. Little is known about the association of CTO revascularization in patients with electrocardiographic Q waves and improvement in angina burden as a measurement of health-related quality of life (HRQOL) afterwards.MethodsIn this study, 100 patients with single vessel CTO were included. Myocardial viability was tested by late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) and 50 patients showed evidence of viability. Seattle Angina Questionnaire (SAQ) scores were used as a measure of HRQOL.ResultsPathological Q waves were present in 48 patients (including 19 patients with viable CTO territory) out of 100 patients. Patients with Q waves tended to have worse Seattle Angina Questionnaire (SAQ) scores compared to those with no Q waves (31.2 ± 11.7 vs 45.3 ± 13.9 respectively, p = 0.002), worse LV systolic function and wall motion score index (WMSI) on CMR. They also had significantly less prevalence of viability (p < 0.001). Patients with Q waves and positive viability had lower SAQ scores (37.2 ± 10.1 vs 52.7 ± 13.2 respectively, p = 0.02), higher LVEF and lower WMSI. They also had well developed collateral grade (2.1 ± 1.03 vs 0.7 ± 0.82 respectively, p < 0.001). After successful percutaneous coronary intervention (PCI), in the viable LV group, presence of Q waves was not associated with better LV functional recovery, while those with higher collateral grades were more likely to have better LV functional recovery post CTO-PCI. Patients with Q waves and viable CTO territory showed significantly better SAQ scores compared to pre-PCI (87.3 ± 12.2 vs 37.2 ± 10.1 respectively, p < 0.001). For angina frequency, post–PCI score was 80.2 ± 7.9 compared to 39.2 ± 7.1 before PCI, p < 0.001). Multivariate regression analysis showed that pathological Q waves, Rentrop's collateral grade and the Canadian Cardiovascular Society (CCS) angina class before PCI were the most significant independent predictors of improved HRQOL as reflected by SAQ (OR for Q waves 7.83, 95% CI 1.62–18.91,p 0.003), (OR for Rentrop's collateral grade 8.31,95% CI 2.21–26.33, p < 0.001), (OR for CCS class 8.39, 95% CI 1.21–20.8, p 0.01).ConclusionWell-developed collateral circulation could independently predict LV functional recovery after CTO-PCI. Patients with Q waves and viable CTO territory tend to have higher CCS class before revascularization and get significant improvement of HRQOL after PCI. Other predictors of improved HRQOL are Rentrop's collateral grade and worse CCS class before PCI.

Global longitudinal strain at rest predicts significant coronary artery stenosis in patients with peripheral arterial disease

Abstract Funding Acknowledgements Type of funding sources: None. Background Critical peripheral artery disease (PAD) is expression of systemic chronic atherosclerosis, it being often associated with cardiovascular events. The assessment of global longitudinal strain (GLS) at rest by speckle tracking echocardiography could be useful to unmask significant coronary artery disease (CAD) in asymptomatic PAD patients. Purpose To determine whether resting GLS is able to predict significant coronary artery stenosis in PAD patients selected for peripheral or carotid angiography. Methods One-hundred three clinically relevant PAD patients (M/F = 76/27, age = 66.8 ± 10,2 years, 72 with significant lower limb artery stenosis and 31 with carotid artery stenosis ≥50%), asymptomatic for CAD, underwent standard echo-Doppler exam at rest, comprehensive of GLS analysis, prior peripheral and coronary angiography. Information on cardiovascular (CV) risk factors and comorbidities were collected. Patients with know CAD and previous myocardial infarction, left ventricular (LV) ejection fraction &amp;lt; 50% and inadequate echocardiographic imaging were excluded. According to the results of coronary angiography, patients were divided in two groups: with significant coronary artery stenosis (&amp;gt;50% of obstruction. n = 73) and without significant coronary artery lesions (n = 30). Results No intergroup difference in the prevalence of CV risk factors and comorbidities was found. Age, body mass index and blood pressure were comparable between the two groups. LV ejection fraction (59.9 ± 4.2% in patients with significant coronary stenosis vs. 60.2 ± 4.7% in those without coronary stenosis, p = 0.75) and wall motion score index (1.02 ± 0.09 vs 1.03 ± 0.09 respectively, p = 0.67) did not differ significantly. Conversely, GLS was lower in patients with significant coronary artery stenosis than in those without (21.6 ± 2.7% vs. 22.8 ± 2%, p &amp;lt; 0.02) (Figure 1). This difference remained significant comparing the carotid subgroup with coronary stenosis vs. those without (p &amp;lt; 0.05) whereas it did not achieve the statistical significance in patients with lower limb artery lesions (p = 0.42). Conclusion In PAD patients, GLS at rest shoes the capability in identifying patients at higher probability of significant coronary artery stenosis. This involves in particular patients with carotid artery stenosis. GLS might be helpful to select patients who need to extend the peripheral angiographic evaluation to the coronary tree.

Every minute counts: in-hospital changes of left ventricular regional and global function in patients with ST-segment elevation myocardial infarction.

The aim of our study was to assess the effects of an early percutaneous coronary intervention on changes of in-hospital left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) in patients with ST-segment elevation myocardial infarction. The study population consisted of 324 consecutive patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention, divided into two groups, according to the first medical contact (FMC)-to-reperfusion time, respectively, 90 min or less (n = 173) and more than 90 min (n = 151). Moreover, we performed a sub-analysis in the group of patients who showed at discharge an improvement in the LVEF of at least 10%. In both groups at baseline, patients suffered from a moderately reduced LVEF (40.88 ± 8.38% in ≤90 min group vs. 40.70 ± 8.98% in >90 min group; P = 0.858). A WMSI of more than 1 was recorded uniformly: 1.71 ± 0.37 in patients with FMC-to-reperfusion 90 min or less and 1.72 ± 0.38 in patients more than 90 min (P = 0.810). At the time of discharge, a significant improvement in LVEF (43.82 ± 8.38%, P = 0.001) and WMSI (1.60 ± 0.41, P = 0.009) exclusively emerged in the 90 min or less group. Furthermore, we identified 105 patients who experienced an improvement in the LVEF of at least 10% compared with baseline values. In these patients FMC-to-reperfusion and total ischemic time resulted as significantly shorter, when compared with patients with LVEF improvement of less than 10%. Our study confirms and reinforces the concept that reducing the duration of the time between FMC and reperfusion, as well as the total ischemic time influences a positive recovery of left ventricular global and regional function during in-hospital stay.

Reversible exercise-induced left ventricular dysfunction in symptomatic patients with previous Takotsubo syndrome: insights from stress echocardiography.

Takotsubo syndrome (TTS) is usually associated with rapid and spontaneous recovery of left ventricular (LV) function. However, a proportion of patients may have persistent symptoms. This study aimed to determine the haemodynamic and LV contractile responses to exercise in these patients. Thirty symptomatic TTS patients referred for exercise echocardiography, a median of 15 months following the index TTS episode, were matched with 30 controls with normal exercise echocardiography. Beta-blockers were withheld prior to the test. LV volumes, ejection fraction (EF) and wall motion score index (WMSI), were measured at rest and stress. The TTS cohort were Caucasian women with mean age of 64.6 ± 7.4 years and similar coronary risk factor profile and EF to controls. Resting systolic blood pressure (SBP), LV end-diastolic volume, wall stress, and right ventricular fractional area change were higher in TTS patients compared with controls. Stress echo data showed similar exercise time, peak heart rate, and peak SBP in TTS patients vs. controls, but TTS patients had higher LV volumes, lower exercise LVEF (70 ± 10% vs. 78 ± 7%; P = 0.001), ΔLVEF (4 ± 8% vs. 12 ± 5%; P < 0.001), and WMSI (1.4 ± 0.4 vs. 1 ± 0; P < 0.001) compared with controls. Twenty TTS patients had clear exercise-induced wall motion abnormalities, mainly involving the apex or more globally, with a mean ΔLVEF of 1% compared with 12% in controls. Among the other 10 TTS patients, the ΔLVEF was 10%. Symptomatic patients with previous TTS have a blunted contractile response to exercise. The therapeutic and prognostic implications of these findings need further investigation.

Effects of sacubitril/valsartan on ventricular remodeling in patents with left ventricular systolic dysfunction following acute anterior wall myocardial infarction.

The aim of this study was to investigate the effect of sacubitril/valsartan (Sal/Val) on left ventricular (LV) remodeling in patients with LV systolic dysfunction following acute anterior wall myocardial infarction (AAMI). AAMI patients with LV systolic dysfunction were enrolled in this study. All patients underwent percutaneous coronary intervention. After hemodynamic stabilization, patients were randomly assigned either to group T (Sal/Val treatment) or group C (enalapril treatment). Changes in echocardiographic parameters and plasma biochemical markers were used to evaluate the effects of Sal/Val on LV remodeling and cardiac function. The incidence of major cardiac adverse events (MACEs) and adverse reactions during follow-ups was also recorded. In total, 137 eligible patients were prospectively included. Compared to group C, LV ejection fraction significantly improved (P < 0.05), while the LV end-systolic volume index and wall motion score index showed a tendency to decrease in group T. There was no difference in the LV end-diastolic volume index between groups. During follow-ups, the plasma N-terminal pro-B-type natriuretic peptide and soluble suppression of tumorigenesis-2 levels in both groups decreased (all P < 0.05), and the change was more prominent in group T. Additionally, drug-related adverse effects were similar between the two groups (P > 0.05); however, the incidence of MACEs was lower in group T than in group C (39.71% vs. 53.62%, P = 0.103), although the difference was insignificant. Sac/Val attenuated LV remodeling and dysfunction and was safe and effective in LV systolic dysfunction patients post AAMI.

Efficacy and safety of intracoronary prourokinase during percutaneous coronary intervention in treating ST-segment elevation myocardial infarction patients: a randomized, controlled study

BackgroundProurokinase is a single-chain plasminogen activator presenting with fewer hemorrhagic complications and reduced reocclusion rate compared with the conventional fibrinolytic agents in patients with coronary artery disease. However, prourokinase intracoronary injection during PCI for treating patients with ST-segment elevation myocardial infarction (STEMI) is rarely investigated. Therefore, this study aimed to evaluate the efficacy and safety of intracoronary prourokinase during the percutaneous coronary intervention (PCI) in treating STEMI patients.MethodsFifty STEMI patients who underwent primary PCI were consecutively enrolled and randomly assigned to intracoronary prourokinase group (N = 25) or control group (N = 25). During the primary PCI procedure, patients in the intracoronary prourokinase group received 10 ml prourokinase injection, while patients in control group received 10 ml saline injection as control. The primary endpoints were coronary physiological indexes, the secondary endpoints were angiographic assessments, myocardial infarct size/reperfusion assessment, cardiac function evaluations, major adverse coronary events (MACEs) and hemorrhagic complications. All patients were followed up for 3 months.ResultsPost PCI, the index of microcirculatory resistance (IMR) was decreased in intracoronary prourokinase group than that in control group (34.56 ± 7.48 vs. 49.00 ± 8.98, P < 0.001), while no difference of coronary flow reserve (CFR) (2.01 ± 0.32 vs. 1.88 ± 0.23, P = 0.267) or fractional flow reserve (FFR) (0.89 ± 0.05 vs. 0.87 ± 0.04, P = 0.121) was found between the two groups. The thrombolysis in myocardial infarction myocardial perfusion grade (TMPG) (P = 0.024), peak values of creatine kinase (CK) (P = 0.028), CK isoenzyme-MB (CK-MB) (P = 0.016), cardiac troponin I (cTnI) (P = 0.032) and complete ST-segment resolution (STR) (P = 0.005) were better in intracoronary prourokinase group compared with control group. At 3-months post PCI, left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) were higher, while left ventricular end-diastolic diameter (LVEDd) was lower in intracoronary prourokinase group compared with control group (all P < 0.05). There was no difference in hemorrhagic complication or total MACE between the two groups.ConclusionIntracoronary prourokinase during PCI is more efficient and equally tolerant compared with PCI alone in treating STEMI patients.Trial registrationChinese Clinical Trial Registry ChiCTR1800016207. Prospectively registered.

Determinants of Diastolic Dysfunction Following Myocardial Infarction: Evidence for Causation Beyond Infarct Size

The determinants of severe diastolic dysfunction (DD) following myocardial infarction (MI) are not well defined. This study sought to define the determinants of severe DD (restrictive mitral inflow pattern on Doppler echocardiography [RFP]) in patients with a first-ever MI, with particular emphasis on the impact of infarct size. Retrospective single-centre study including consecutive patients admitted to a tertiary referral centre with a first-ever non-ST-elevation-MI (NSTEMI) or ST-elevation-MI (STEMI) (n=477). Peak troponin-I (Peak-TnI) was used as the principal measure of infarct size, whilst left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) were regarded as surrogate measures. Echocardiography was performed within 24 hours of admission for all patients. RFP was defined as E/A ratio >2.0 or E/A ratio >1.5 and E-wave deceleration time <140 ms. A total of 69 patients (14.5%) had RFP. Peak-TnI levels were higher in the RFP group (32.6±32.7 versus 16.9±25.2 μg/L, p<0.001). In sequential multivariable models incorporating significant clinical, angiographic and left ventricular (LV) size-related variables, Peak-TnI (OR 1.98, p=0.001), WMSI (OR 2.34, p=0.048) and LVEF (OR 0.97, p=0.044) were independent predictors of RFP. Presence of diabetes was also an independent predictor in all the models constructed. When patients were stratified according to an LVEF of 50%, 39% of RFP patients had a preserved LVEF (RFP/preserved EF group), and these patients had lower Peak-TnI levels compared to the RFP/reduced EF group (14.4±18.7 vs 44.5±35.5 μg/L). Whilst infarct size is a major determinant of severe diastolic dysfunction after MI, a significant subset of patients develop severe diastolic dysfunction despite a small infarct size and preserved LVEF, highlighting that other factors such as pre-existing diastolic dysfunction due to risk factors such as diabetes have an important role in causation.

Impact of drug-eluting stents on left ventricular wall motion after successful reperfusion of first anterior ST elevation myocardial infarction.

BACKGROUND Timely myocardial reperfusion by primary percutaneous coronary intervention (pPCI) prevents the development of left ventricular (LV) dysfunction after myocardial infarction (MI). We aimed to investigate whether bare-metal stents (BMS) and drug eluting stents (DES) differently affect the recovery of LV function in patients with ST-elevation MI (STEMI). METHODS Overall 103anterior STEMI patients were retrospectively analyzed. All patients had single vessel disease with culprit lesion at the left anterior descending coronary artery. Patients were categorized in DES group (N.=67) and BMS group (N.=36). Changes in LV contractility were assessed by trans-thoracic echocardiogram as Left Ventricular Wall Motion Score Index (LVWMSI). Follow-up visits were performed between 6 and 12 months after hospital discharge. RESULTS Compared to baseline, LV ejection fraction (EF) remained unchanged between the two groups at the follow-up; LVWMSI significantly improved in patients treated with DES (1.95±0.25 vs. 1.78±0.38, P<0.05), whereas did not change in those treated with BMS (2.09±0.21 vs. 1.98±0.33, P: not significant). At follow-up the LVWMSI was significantly higher in patients with DES than with BMS (P=0.048). LV end-systolic and end-diastolic volumes (LVESV, LVEDV) significantly increased in patients receiving a BMS, whereas it did not change in those receiving a DES (P<0.05). Multivariate analysis adjusted for age, gender, type of stent (DES or BMS), and type of revascularization (primary PCI or rescue PCI or thrombolysis + PCI) showed that DES implantation was an independent predictor of LVWMSI improvement (OR: 3.8 [1.143-12.969] P=0.03). CONCLUSIONS DES implantation is associated with a favorable impact on LV remodeling and regional contractility.

Impact of drug-eluting stents on left ventricular wall motion after successful reperfusion of first anterior ST elevation myocardial infarction.

Timely myocardial reperfusion by primary percutaneous coronary intervention (pPCI) prevents the development of left ventricular (LV) dysfunction after myocardial infarction (MI). We aimed to investigate whether bare-metal stents (BMS) and drug eluting stents (DES) differently affect the recovery of LV function in patients with ST-elevation MI (STEMI). Overall 103anterior STEMI patients were retrospectively analyzed. All patients had single vessel disease with culprit lesion at the left anterior descending coronary artery. Patients were categorized in DES group (N.=67) and BMS group (N.=36). Changes in LV contractility were assessed by trans-thoracic echocardiogram as Left Ventricular Wall Motion Score Index (LVWMSI). Follow-up visits were performed between 6 and 12 months after hospital discharge. Compared to baseline, LV ejection fraction (EF) remained unchanged between the two groups at the follow-up; LVWMSI significantly improved in patients treated with DES (1.95±0.25 vs. 1.78±0.38, P<0.05), whereas did not change in those treated with BMS (2.09±0.21 vs. 1.98±0.33, P: not significant). At follow-up the LVWMSI was significantly higher in patients with DES than with BMS (P=0.048). LV end-systolic and end-diastolic volumes (LVESV, LVEDV) significantly increased in patients receiving a BMS, whereas it did not change in those receiving a DES (P<0.05). Multivariate analysis adjusted for age, gender, type of stent (DES or BMS), and type of revascularization (primary PCI or rescue PCI or thrombolysis + PCI) showed that DES implantation was an independent predictor of LVWMSI improvement (OR: 3.8 [1.143-12.969] P=0.03). DES implantation is associated with a favorable impact on LV remodeling and regional contractility.