Persistent Left Ventricular Systolic Dysfunction Research Articles

Longitudinal Cardiac Outcomes of Multisystem Inflammatory Syndrome in Children: A Systematic Review and Meta-Analysis.

There is apaucity of longitudinal data on cardiac outcomes in multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19. We aimed to investigate the longitudinal cardiovascular outcomes in MIS-C. PubMed and EMBASE were searched through May 2022. Observational studies were included, reporting mid-term (≥ 3months) outcomes in children (aged < 21) with MIS-C. Data were extracted by two researchers. Longitudinal outcomes were synthesized by a one-group meta-analysis using a random-effects model. Eleven studies with a follow-up period (3months to 1year) were identified, including 547 MIS-C patients. The mortality was 2.5% (95% CI 1.3-4.9). The majority of left ventricular (LV) systolic dysfunction present in 46.8% (95% CI 32.7-61.3) in the acute phase resolved by 3months, and the prevalence of LV systolic dysfunction was 1.7% (95% CI 0.5-5.7) and 2.1% (95% CI 0.8-5.4) at 3month and 6month follow-up, respectively. Additionally, the persistent LV systolic dysfunction in the small population was mild. However, coronary abnormalities such as coronary artery dilatation or aneurysms, seen in 23.7% (95% CI 17.7-31.1) at baseline, persisted in 4.7% (95% CI 1.5-14.3) at 3months and 5.2% (95% CI 3.0-8.9) at 6months. Mitral regurgitation (MR), which was observed in 56.6% (95% CI 27.7-81.6) at baseline, also persisted in 7.5% at 6months. In conclusion, our study demonstrated largely favorable cardiac outcomes, suggesting resolution of LV systolic dysfunction in the majority of cases. However, coronary abnormalities and MR persisted in a subset of patients at mid-term follow-up.

Value of the Systemic Immune-Inflammatory Index (SII) in Predicting the Prognosis of Patients With Peripartum Cardiomyopathy.

BackgroundPeripartum cardiomyopathy (PPCM) is a potentially life-threatening complication of pregnancy. The identification of early prognostic markers in patients diagnosed with PPCM is very important. The systemic immune-inflammation index (SII) is a new inflammatory biomarker, and the aim of this study was to evaluate the prognostic value of SII in patients with PPCM.MethodsA total of 61 patients with PPCM who were admitted in our hospital from 2015 to 2020 were retrospectively analyzed in this study. The follow-up period of all patients was at least 6 months after diagnosis. Recovery of left ventricular (LV) systolic function was defined as the presence of left ventricular ejection fraction > 45%. The second endpoint was defined as composite adverse cardiac events, including cardiac death or hospitalization due to worsening heart failure. Univariate and multivariate logistic regression analysis were used to determine the independent predictors of non-recovery of LV systolic function. The receiver operating characteristic (ROC) curve analysis was used to establish a cut-off level of SII value to predict persistent LV systolic dysfunction.ResultsThe follow-up duration was 40.5 ± 16.3 months. Among the 61 patients, 43 patients showed left ventricular recovery and 18 patients did not at the last follow-up visit. The baseline SII levels were significantly higher in the non-recovery group (P < 0.05). Multivariate logistic regression showed that the SII and left ventricular end-diastolic dimension (LVEDD) were independent predictors of persistent LV systolic dysfunction (OR: 1.177, 95% CI: 1.038–1.335, P = 0.011 and OR: 1.148, 95% CI: 1.011–1.304, P = 0.033, respectively). A SII value of 876 was the best cut-off value (the area under the curve was 0.791, 95% CI: 0.667–0.915, P < 0.05), and the sensitivity and specificity were 73 and 71%, respectively.ConclusionsThe SII and LVEDD are independent prognostic factors for persistent LV systolic dysfunction in patients with PPCM. The SII may be a useful tool for identifying high-risk PPCM patients.

Counseling Women With Peripartum Cardiomyopathy About Subsequent Pregnancies

Peripartum cardiomyopathy (PPCM) is a potentially catastrophic form of heart failure caused by left ventricular systolic dysfunction that develops during pregnancy or in the early postpartum period. After the initial diagnosis and treatment, many women desire another pregnancy; however, risks of a subsequent pregnancy need to be considered, as PPCM may lead to significant adverse outcomes for both mother and fetus. The goal of this review is to provide information about risk stratification prior to subsequent pregnancy, strategies to mitigate the risk of subsequent pregnancy, and long-term maternal outcomes. The degree of myocardial recovery is currently the most effective predictor of heart failure relapse and adverse outcomes during a subsequent pregnancy. Women with persistent left ventricular systolic dysfunction have worse maternal and fetal outcomes during subsequent pregnancy. Pharmacologic options for the acute management of heart failure during pregnancy are limited to diuretics, beta-blockers, hydralazine, isosorbide dinitrate, and digoxin. After delivery, however, most guideline-directed heart failure medications can be used safely, including in women who are breastfeeding. Because of the risks of subsequent pregnancy, options for contraception should be discussed with women with PPCM. Finally, women with PPCM should be under the care of a multidisciplinary cardio-obstetrics team for preconception counseling and management during a subsequent pregnancy. An essential component of caring for women with PPCM includes detailed counseling about the risks of a subsequent pregnancy.

Prognostic nutritional index as a novel marker for prediction of prognosis in patients with peripartum cardiomyopathy.

The clinical significance of poor nutritional status in patients with peripartum cardiomyopathy (PPCM) is not clearly understood. Prognostic nutritional index (PNI) is a simple nutritional assessment tool, which was first demonstrated to be valuable in patients with colorectal surgeries. We aimed to investigate the predictive value of PNI in patients with PPCM.A total of 92 patients diagnosed with PPCM were enrolled in this study. PNI was calculated using the following formula: 10 × serum albumin value (g/dL) + 0.005 × total lymphocyte count. The primary endpoint was defined as composite adverse cardiac events that included cardiac death or hospitalization due to worsening heart failure (HF). Cardiac death, hospitalization due to worsening HF, and persistent left ventricular (LV) systolic dysfunction were evaluated, respectively, as secondary endpoints.Primary composite endpoint was higher in the lower PNI group. After adjusting for other risk factors, PNI was found to be as an independent predictor of primary composite endpoint (odds ratio 0.805; 95% confidence interval 0.729–0.888; P < .001). In addition, PNI was significantly associated with secondary endpoints; persistent LV systolic dysfunction as well as cardiac death.This study identified nutritional status assessed by the PNI seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.

Incidence of Primary, Dilated Rather Than Tachycardia-Induced Cardiomyopathy among Patients Presenting with New Onset Atrial Arrhythmia and Heart Failure with Reduced Ejection Fraction

Background Tachycardia-induced cardiomyopathy (CMP) is an established cause of left ventricular (LV) systolic dysfunction and heart failure (HF) that is reversible upon treatment of the tachyarrhythmia. The incidence of a primary, dilated CMP among patients (pts) presenting with presumed tachycardia-induced CMP, and the features that distinguish them are not well established. Methods We examined the records of 476 consecutive pts presenting with new atrial fibrillation or flutter (AF) and a rapid ventricular rate (RVR) coupled with acute HF with reduced LV ejection fraction (HFrEF - LVEF≤ 45%). We sought to determine the number of pts with a sustained, presumed primary CMP (persistent LVEF ≤ 45%) rather than one that is reversible. Pts with clinically relevant coronary artery disease, severe valvular disease or other suspected/known cause of CMP were excluded. Clinical variables, ECGs and follow up echocardiography were examined to establish: 1) the number of pts with improvement in LVEF vs. those with persistently depressed LVEF (LVEF ≤ 45%); and 2) variables associated with improvement or persistence of LV systolic dysfunction. Results 92 pts were identified matching our entry criteria having a mean LVEF of 31.2±9.2%. Among these, 37 (40%) exhibited persistent LV systolic dysfunction (LVEF 34.3 ± 8.2%) after a follow-up of 27 ± 35 months. The LVEF normalized in the remaining 55 pts (LVEF 57.1±4.2%) supporting probable tachycardia-induced CMP. We observed no significant differences among clinical, laboratory or ECG variables between those pts whose LVEF normalized vs. those with a persistent CMP. Echocardiographic data from the index hospitalization demonstrated that pts with persistent CMP had an increased left atrial volume index (LAVI) compared to those with normalization in their LVEF (51.6 ± 19.2 ml/m2 vs 37.7 ± 10.4 ml/m2, respectively, p Conclusion The incidence of persistent LV systolic dysfunction was present in 40% of pts presenting with AF with RVR and acute HFrEF supporting that a substantial number have a primary CMP rather than a reversible, tachycardia-induced CMP. These data support early intervention in these pts with guideline directed medical therapy. Greater LAVI on echocardiography may help identify pts with a primary CMP presenting with a new atrial tachyarrhythmia, heart failure and a reduced LVEF.

A novel marker of persistent left ventricular systolic dysfunction in patients with peripartum cardiomyopathy: monocyte count- to- HDL cholesterol ratio

BackgroundPeripartum cardiomyopathy (PPCM) is a rare but potentially life-threatening complication of pregnancy. There is limited data regarding the predictors of persistent left ventricular (LV) systolic dysfunction. Recently, monocyte-to-high density lipoprotein (HDL) cholesterol ratio (MHR) has emerged as a novel indicator of inflammation and oxidative stress. We aimed to assess the predictive value of MHR on LV recovery in patients with PPCM.MethodsA total of 64 patients with PPCM who admitted to our tertiary reference hospital between 2009 and 2017 were retrospectively analyzed in this study. Demographic and clinical data, laboratory parameters and echocardiographic findings were recorded. The duration of follow-up was at least 12 months after diagnosis for all participants. Recovery of LV systolic function was defined as the presence of LV ejection fraction (LV EF) > 45%. Univariate analysis was used to determine the significant predictors of persistent LV systolic dysfunction (non-recovery). A receiver operating characteristic (ROC) curve was used to establish the cut-off values for predictors.ResultsThe mean follow-up duration was 72.1 ± 5.5 months. Of the 64 patients, 35 (55%) had persistent LVSD at their last follow-up while 29 (45%) showed LV EF improvement. The baseline MHR levels were significantly higher in the non-recovery group (P < 0.001). In univariate analysis, increased MHR levels (odds ratio:1.17; 95% confidence interval, 1.01–1.35; P < 0.001) significantly predicted LV non-recovery. Using a cut-off level of 9.73, MHR predicted persistent LV systolic dysfunction with a sensitivity of 89% and specificity of 79%. Besides, lower baseline LVEF increased WBC and CRP levels were identified as predictors of LV non-recovery.ConclusionsOur data firstly indicated that elevated MHR was a significant predictor of persistent LV systolic dysfunction in PPCM. The MHR might contribute to determining high-risk patients with PPCM.

Clinical presentation and early predictors for poor outcomes in pediatric myocarditis: A retrospective study.

BACKGROUNDMyocarditis is an important cause of morbidity and mortality in children, leading to long-term sequelae including chronic congestive heart failure, dilated cardiomyopathy, heart transplantation, and death. The initial diagnosis of myocarditis is usually based on clinical presentation, but this widely ranges from the severe sudden onset of a cardiogenic shock to asymptomatic patients. Early recognition is essential in order to monitor and start supportive treatment prior to the development of severe adverse events. Of note, many cases of fulminant myocarditis are usually misdiagnosed as otherwise minor conditions during the weeks before the unexpected deterioration.AIMTo provide diagnostic clues to make an early recognition of pediatric myocarditis. To investigate early predictors for poor outcomes.METHODSWe conducted a retrospective cross-sectional single-center study from January 2008 to November 2017 at the Pediatric Department of our institution, including children < 18-years-old diagnosed with myocarditis. Poor outcome was defined as the occurrence of any of the following facts: death, heart transplant, persistent left ventricular systolic dysfunction or dilation at hospital discharge (early poor outcome), or after 1 year of follow-up (late poor outcome). We analyzed different clinical features and diagnostic test findings in order to provide diagnostic clues for myocarditis in children. Multivariable stepwise logistic regression analysis was performed using all variables that had been selected by univariate analysis to determine independent factors that predicted a poor early or late outcome in our study population.RESULTSA total of 42 patients [69% male; median age of 8 (1.5-12) years] met study inclusion criteria. Chest pain (40%) was the most common specific cardiac symptom. Respiratory tract symptoms (cough, apnea, rhinorrhea) (38%), shortness of breath (35%), gastrointestinal tract symptoms (vomiting, abdominal pain, diarrhea) (33%), and fever (31%) were the most common non-cardiac initial complaints. Tachycardia (57%) and tachypnea (52%) were the most common signs on the initial physical exam followed by nonspecific signs of respiratory tract infection (44%) and respiratory distress (35%). Specific abnormal signs of heart failure such as heart murmur (26%), systolic hypotension (24%), gallop rhythm (20%), or hepatomegaly (20%) were less prevalent. Up to 43% of patients presented an early poor outcome, and 16% presented a late poor outcome. In multivariate analysis, an initial left ventricular ejection fraction (LVEF) < 30% remained the only significant predictor for early [odds ratio (OR) (95%CI) = 21 (2-456), P = 0.027) and late [OR (95%CI) = 8 (0.56-135), P = 0.047) poor outcome in children with myocarditis. LVEF correlated well with age (r = 0.51, P = 0.005), days from the initiation of symptoms (r = -0.31, P = 0.045), and N-terminal pro-brain natriuretic peptide levels (r = 0.66, P < 0.001), but not with troponin T (r = -0.05, P = 0.730) or C-reactive protein levels (r = -0.13, P = 0.391). N-terminal pro-brain natriuretic peptide presented a high diagnostic accuracy for LVEF < 30% on echocardiography with an area under curve of 0.931 (95%CI: 0.858-0.995, P < 0.001). The best cut-off point was 2000 pg/mL with a sensitivity of 90%, specificity of 81%, positive predictive value of 60%, and negative predictive value of 96%.CONCLUSIONThe diagnosis of myocarditis in children is challenging due to the heterogeneous and unspecific clinical presentation. The presence of LVEF < 30% on echocardiography on admission was the major predictor for poor outcomes. Younger ages, a prolonged course of the disease, and N-terminal pro-brain natriuretic peptide levels could help to identify these high-risk patients.

The prognostic value of positive T wave in lead aVR: A novel marker of adverse cardiac outcomes in peripartum cardiomyopathy.

Peripartum cardiomyopathy (PPCM) is an uncommon complication of pregnancy. Clinical courses of PPCM are markedly heterogeneous. Positive T waves in lead aVR (TaVR) are shown to be associated with adverse cardiac events in several cardiovascular diseases. We aimed to investigate the prevalence and prognostic role of positive TaVR in patients with PPCM. A total of 82 patients (mean age 29.1±6.3years) with the diagnosis of PPCM were enrolled. Presentation electrocardiogram (ECG) was investigated for presence of a positive TaVR. The median follow-up duration was 67.0months. The primary endpoint was defined as composite cardiac events, including cardiac death, arrhythmic events, or persistent left ventricular systolic dysfunction. Patients with positive T wave in lead aVR showed higher rates for persistent left ventricular systolic dysfunction, arrhythmic events, and cardiac death compared to patients without it. In multivariate logistic regression analysis, after adjusting for other confounding factors, the presence of positive TaVR was found to be as an independent and strong predictor of primary composite endpoint (odds ratio 6.21, 95% CI 1.45-26.51; p=0.014). In Kaplan-Meier survival analysis, both primary and secondary endpoints occurred more frequently in the positive TaVR group. Using the cut-off level of 0.25mV, T-wave amplitude in lead aVR predicted primary endpoint with a sensitivity of 100% and specificity of 100%. Positive T wave in lead aVR, as a simple and feasible electrocardiographic marker, seems to be a novel predictor of adverse cardiovascular outcomes in patients with PPCM.

Left Ventricular Dysfunction and Exercise Capacity Trajectory: Implications for Subclinical Heart Failure Staging Criteria

ObjectivesThis study aimed to determine the association of stage B heart failure (SBHF) and its constituent left ventricular (LV) abnormalities with trajectory of exercise capacity over time, and assess whether this association is modified by reversion of these LV abnormalities to normal. BackgroundThe LV abnormalities of SBHF may coincide with a reduction in exercise capacity that precedes the overt exercise intolerance of clinical heart failure (HF). Determining the predictive capacity of established and novel SBHF criteria for exercise capacity decline may improve HF risk stratification. MethodsLV structure/function (echocardiography) and exercise capacity (6-min walk distance [6MWD]) were assessed at baseline and 3-year follow-up in 268 patients from the NIL-CHF (Nurse-led Intervention for Less Chronic Heart Failure) study (all stage A [SAHF] or SBHF). Changes (Δ) in 6MWD were compared between SAHF and SBHF and across each of 4 constituent components of SBHF: LV hypertrophy, regional wall motion abnormality(ies) (RWMA), left ventricular systolic dysfunction (LVSD) (ejection fraction <45%) and elevated early diastolic filling/annular velocity ratio (E/e’ ≥15). ResultsΔ6MWD was similar in those with SAHF (n = 141) and SBHF (n = 127; −5 m [95% confidence interval (CI): −21 to +11 m]; covariate-adjusted). However, within the setting of SBHF there was substantive heterogeneity; that is, reductions in 6MWD were observed with persistent elevated E/e’ (−34 m [95% CI: −62 to −6 m]) and persistent LVSD (−41 m [95% CI: −74 to −8 m]), but not with LV hypertrophy (+17 m [95% CI: −15 to +49 m) or RWMA (+5 m [−27 to +36 m]), nor in patients whose elevated E/e’ or LVSD reverted to normal by 3 years (p > 0.10). ConclusionsElevated E/e’ is associated with a similar degree of exercise capacity decline to LVSD, supporting that both LV functional criteria be considered in distinguishing SBHF from SAHF. That reversion of either manifestation of LV dysfunction was associated with preserved exercise capacity advocates targeting of these factors by HF preventive interventions.

Value of the neutrophil-to-lymphocyte ratio in predicting left ventricular recovery in patients with peripartum cardiomyopathy.

The aim of this study was to assess the value of the neutrophil-to-lymphocyte ratio (NLR) in predicting left ventricular (LV) recovery in patients with peripartum cardiomyopathy (PPCM). Patients with PPCM (n= 40), who were admitted to our tertiary reference hospital between 2007 and 2015 were retrospectively analyzed. All patients were followed-up for at least 12months after the diagnosis. All patients had standard echocardiographic examination at baseline and the last follow-up visit. Recovery of LV function was defined as the presence of LV ejection fraction (EF) >45%. Data on blood parameters were also collected at baseline. Univariate and multivariate analysis were used to assess the significant predictive variables for persistent LV systolic dysfunction. Of the patients 21 (52.5%) did not recover LV function at the last follow-up visit (nonrecovery group), while 19 of the patients (47.5%) exhibited LV recovery (recovery group). The LV EF and fractional shortening (FS) were significantly lower in the nonrecovery group. The baseline LV end-diastolic diameter, LV end-systolic diameter (LVESD) and systolic pulmonary arterial pressure were significantly increased in the nonrecovery group. The NLR, C‑reactive protein and troponin levels were significantly higher in the nonrecovery group. In multivariate logistic regression analysis only NLR and LVESD were identified as independent predictors of persistent LV systolic dysfunction in patients with PPCM (p= 0.020 and p= 0.009 respectively). Elevated NLR and increased LVESD were independent prognostic factors in predicting persistent LV dysfunction in patients with PPCM. The NLR might assist in identifying high risk patients with PPCM.

くも膜下出血術後7 日目にたこつぼ型心筋障害を発症し1 年以上左室収縮障害が遷延した1 例

くも膜下出血の術後7 日目にたこつぼ型心筋障害を発症し，その後1 年以上左室収縮障害が遷延した症例を経験した．症例は67 歳の女性で前交通動脈瘤の破裂によるくも膜下出血を発症し，同日動脈瘤クリッピング術を施行した．術後7 日目に突然胸部不快感を訴え，急性心不全状態となった．心電図検査，経胸壁超音波検査，冠動脈造影の結果たこつぼ型心筋障害と診断した．心筋逸脱酵素が高値を示し過換気負荷試験が陽性のため，冠攣縮が原因の急性心筋梗塞を合併したと考えた．くも膜下出血は順調に回復したが，たこつぼ型心筋障害は左室壁運動・心機能障害は改善なく，1 年後も同様の所見が継続した．たこつぼ型心筋障害にもかかわらず，左室壁運動・心機能障害が1 年以上継続した理由として冠攣縮による急性心筋梗塞が合併したためと考えた．

Reversible Dilated Cardiomyopathy: Into the Thaumaturgy of the Heart - Part 2

Dilated cardiomyopathy (DCM) is a genetic or acquired heart muscle disorder characterized by dilation and impaired contraction of one or both ventricles. In the acquired forms of the disease, if the pathogenic agent is persistent, undiagnosed or untreated, permanent ultrastructural and morphological changes may lead to irreversible dysfunction. Conversely, when DCM is promptly recognized and treated, the heart may show an extraordinary ability to recover from left ventricular (LV) systolic dysfunction. While much research in heart failure has focused on morbidity and mortality associated with persistent LV systolic dysfunction, relatively little attention has been devoted to this remarkable potential for recovery. In this two-part review we will focus on the most common types of reversible DCM. The second part will deal with chemotherapy-induced cardiomyopathy, alcohol- related cardiomyopathy, myocarditis and peripartum cardiomyopathy. Although diverse in etiopathogenesis, genetic background, therapeutic options and outcome, the forms of DCM characterized by reversible LV dysfunction share similar challenges in diagnosis and clinical management. The identification of pathways to recovery may show the way for novel therapeutic targets ultimately benefitting all cardiac patients.

Reversible Dilated Cardiomyopathy: Into the Thaumaturgy of the Heart—Part 1

Dilated cardiomyopathy (DCM) is a genetic or acquired heart muscle disorder characterized by dilation and impaired contraction of one or both ventricles. In the acquired forms of the disease, if the pathogenic agent is persistent, undiagnosed or untreated, permanent ultrastructural and morphological changes may lead to irreversible dysfunction. Conversely, when DCM is promptly recognized and treated, the heart may show an extraordinary ability to recover from left ventricular (LV) systolic dysfunction. While much research in heart failure has focused on morbidity and mortality associated with persistent LV systolic dysfunction, relatively little attention has been devoted to this remarkable potential for recovery. In this two-part review we will focus on the most common types of reversible DCM. The first part will deal with Tako-Tsubo cardiomyopathy, tachycardiainduced cardiomyopathy, metabolic DCM and recovery after Left ventricular assist device implantation. Although diverse in etiopathogenesis, genetic background, therapeutic options and outcome, the forms of DCM characterized by reversible LV dysfunction share similar challenges in diagnosis and clinical management. The identification of pathways to recovery may show the way for novel therapeutic targets ultimately benefitting all cardiac patients.

Concordant and Discordant Cardiac Magnetic Resonance Imaging Delayed Hyperenhancement Patterns in Patients with Ischemic and Non-Ischemic Cardiomyopathy.

Background and ObjectivesThe diagnosis of ischemic (ICM) and non-ischemic cardiomyopathy (NICM) is conventionally determined by the presence or absence of coronary artery disease (CAD) in the setting of a reduced left systolic function. However the presence of CAD may not always indicate that the actual left ventricular (LV) dysfunction mechanism is ischemia, as other non-ischemic etiologies can be responsible. We investigated patterns of myocardial fibrosis using delayed hyperenhancement (DHE) on cardiac magnetic resonance (CMR) in ICM and NICM.Subjects and MethodsPatients with systolic heart failure who underwent a CMR were prospectively analyzed. The heart failure diagnosis was based on the modified Framingham criteria and LVEF <35%. LV dysfunction was classified as ICM or NICM based on coronary anatomy.ResultsA total of 101 subjects were analyzed; 34 were classified as ICM and 67 as NICM. The DHE pattern was concordant with the conventional diagnosis in 27 (79.4%) of the patients with ICM and 62 (92.5%) of the patients with NCIM. A discordant NICM DHE pattern was present in 8.8% of patients with ICM, and an ICM pattern was detected 6.0% of the patients with NICM. Furthermore, 11.8% of the patients with ICM and 1.5% of those with NICM demonstrated a mixed pattern.ConclusionA subset of patients conventionally diagnosed with ICM or NICM based on coronary anatomy demonstrated a discordant or mixed DHE pattern. CMR-DHE imaging can be helpful to determine the etiology of heart failure in patients with persistent LV systolic dysfunction.

Clinical Characteristics and Long-term Predictors of Persistent Left Ventricular Systolic Dysfunction in Peripartum Cardiomyopathy

BackgroundPeripartum cardiomyopathy (PPCM) is a potentially life-threatening dilated cardiomyopathy that occurs in previously well women during pregnancy or postpartum. The predictors of persistent left ventricular (LV) systolic dysfunction (LVSD) in PPCM are poorly understood and were the subject of this study. MethodsPatients with PPCM (n = 71), who were admitted to Beijing Friendship Hospital from 2004 to 2011, were retrospectively analyzed. Data including electrocardiographic and echocardiographic measurements at diagnosis (baseline) and at the last follow-up visit were collected. Data on plasma brain natriuretic peptide (BNP) and C-reactive protein (CRP) levels were also collected at baseline. A receiver operating characteristic curve was used to determine the cutoff values. Univariate and multivariate analyses were used to assess the significant predictive variables for persistent LVSD. ResultsThirty-one patients (44%) did not recover completely at the last follow-up visit (LV nonrecovery group), and 40 patients (56%) had good LV recovery (LV recovery group). Baseline BNP level was positively correlated with LV end-diastolic diameter (r = 0.559; P < 0.001), and inversely correlated with LV ejection fraction (LVEF) (r = −0.548; P < 0.001) and fractional shortening (r = −0.542; P < 0.001). There was no difference in CRP levels between the 2 groups. Receiver operating characteristic curves indicated the cutoff value in terms of predicting persistent LVSD was 34% for LVEF, 64 mm for LV end-diastolic diameter, 16% for fractional shortening, and 1860 pg/mL for BNP. Univariate and multivariate analyses confirmed that LVEF < 34% (95% CI, 1.38-7.30; P = 0.007) and BNP > 1860 pg/mL (95% CI, 1.18-6.99; P = 0.020) were independent prognostic factors in predicting persistent LVSD. ConclusionsLVEF and plasma BNP levels have good predictive value in long-term cardiac dysfunction.

30 Primary Prevention ICD post-STEMI: Impact of Adoption of Nice vs ESC Guidelines

<h3>Background</h3> It has been demonstrated that implantable cardiac defibrillators (ICD) can be effective in the primary prevention of sudden cardiac death in patients with severe left ventricular systolic dysfunction (LVSD). However, studies have been unable to elucidate any benefit from ICD implantation prior to 40 days post-infarct. Therefore, ESC guidelines recommend ICD implantation in patients with a persistent ejection fraction (EF) &lt;/=40% on repeat LV assessment taken at least 40 days post-STEMI. The NICE guidelines are more restrictive, recommending ICD implantation in patients with EF &lt;/=35% and QRS duration &gt;120 ms. The extent to which these guidelines are followed in clinical practice is unclear. <h3>Aims</h3> To evaluate in a primary percutaneous coronary intervention (PPCI) cohort: Whether patients with LVSD are receiving a re-assessment of their EF at least 40 days post-STEMI. The impact of adoption of ESC versus NICE guidelines on ICD implantation rates for primary prevention. <h3>Methods</h3> This was a retrospective observational study carried out at a tertiary referral centre in South West England. Data was collected from consecutive patients referred for PPCI with a diagnosis of STEMI (January to December 2013). LVSD was defined as an EF &lt;/=40% according to echocardiography or cardiac MRI. ECG changes were preferentially sourced from the date closest to the follow-up LV assessment. <h3>Results</h3> 573 patients were included, of which, 74% were male and the median age was 64 years. 214 patients had LVSD on initial assessment and were alive after 40 days. 29% (62/214) of patients were followed up elsewhere (echo data not available) and hence excluded from further analysis. 76% (115/152) had a repeat assessment of their EF; however, only 70% (80/115) of reassessments were carried out at least 40 days after the acute event. Of these, 41% (33/80) had persistent LVSD. Thus, 28% (33/115) patients qualified for an ICD under ESC guidelines. On the contrary, 3% qualified under the NICE guidelines, as 17/80 had an EF &lt;/=35% at repeat echo and only 3 of these had a QRS duration &gt; 120 ms. <h3>Conclusion</h3> In a UK PPCI population, significantly more patients would be eligible for an ICD based on ESC compared to NICE guidelines (28% vs. 3%). This would have significant cost implications. The requirement for repeat echocardiography and ECG least 40 days after the STEMI emphasises the need for appropriate linking of care between the PPCI centre and those hospitals undertaking subsequent follow-up. This remains a challenge to the NHS but we need to find ways to achieve it!

Underutilization of Implantable Cardioverter Defibrillators Post Coronary Artery Bypass Grafting in Patients with Systolic Dysfunction

Evaluation of the need for prophylactic internal cardiac defibrillators among patients with ischemic cardiomyopathies should be deferred until at least 3 months after revascularization procedures to allow adequate time for recovery of ventricular function. Among patients with left ventricular systolic dysfunction (LVSD) who undergo coronary artery bypass grafting (CABG), the proportion of patients who are risk stratified postoperatively with reassessment of left ventricular ejection fraction (LVEF) is unknown. One hundred and six patients with LVSD (LVEF < 40%) who underwent CABG during 2004-2006 and survived 3 months post CABG were evaluated. Follow-up was assessed by chart review and telephone contact. LVEF was not reassessed in 24% (25/106) of the population, none of whom underwent internal cardioverter defibrillator (ICD) implantation. Of those with LVEF reassessed, persistent LVSD was present in 20/81 (25%), 12 of whom were referred for prophylactic ICD placement. One-fourth of patients with LVSD who undergo CABG do not have LVEF reassessed postoperatively which may lead to underutilization of ICDs.

Characteristics of Congestive Heart Failure Accompanied by Atrial Fibrillation With Special Reference to Tachycardia-Induced Cardiomyopathy

Sustained tachycardia causes left ventricular (LV) systolic dysfunction leading to heart failure (HF), which is widely known as "tachycardia-induced cardiomyopathy (TIC)", but its prevalence and prognosis in Japanese remain unclear. Of 213 consecutive patients with HF associated with atrial fibrillation (AF) requiring hospitalization (n=213) between January 1999 and December 2004, and 104 (83 males, 67+/-12.6 years) were identified as not having any structural heart disease. Of them 41 (39%) had a normal LV ejection fraction (LVEF) at the initial admission, and the remaining patients fell into 2 groups: those with rapid (<6 months) normalization of the LVEF after AF management (presumed TIC, 30 patients, 29%) and those with persistent LV systolic dysfunction (dilated cardiomyopathy (DCM), 33 patients, 32%). Although the B-type natriuretic peptide value and LVEF did not differ between the 2 groups, the LV size on admission was significantly smaller in the TIC group (LV end-diastolic dimension (LVDd) 57.6+/-7.2, LV end-systolic dimension (LVDs) 49.4+/-8.0) than in the DCM group (LVDd 63.4 +/-8.8, LVDs 55.3+/-9.6, p<0.05). During a follow-up period of 42.1+/-21.2 months, cardiac death and recurrent HF hospitalization were significantly less frequent in the TIC group than in the DCM group. In AF-associated HF requiring hospitalization, TIC is the presumed cause in approximately one-third of patients without any previously known structural heart disease. That particular group is characterized by a relatively smaller LV and better prognosis under medical treatment.

Section 7: Heart Failure in Patients With Left Ventricular Systolic Dysfunction

Section 7: Heart Failure in Patients With Left Ventricular Systolic Dysfunction