Poor Cardiac Prognosis Research Articles

Prediction of Cardiac Events in Patients With Reduced Left Ventricular Ejection Fraction With Dobutamine Cardiovascular Magnetic Resonance Assessment of Wall Motion Score Index

The purpose of this study was to assess the utility of dobutamine cardiovascular magnetic resonance (DCMR) results for predicting cardiac events in individuals with reduced left ventricular ejection fraction (LVEF). It is unknown whether DCMR results identify a poor cardiac prognosis when the resting LVEF is moderately to severely reduced. Two hundred consecutive patients ages 30 to 88 (average 64) years with an LVEF <or=55% that were poorly suited for stress echocardiography underwent DCMR in which left ventricular wall motion score index (WMSI), defined as the average wall motion of the number of segments scored, was assessed at rest, during low-dose, and after peak intravenous infusion of dobutamine/atropine. All participants were followed for an average of 5 years after DCMR to ascertain the post-testing occurrence of cardiac death, myocardial infarction (MI), and unstable angina or congestive heart failure warranting hospital stay. After accounting for risk factors associated with coronary arteriosclerosis and MI, a stress-induced increase in WMSI during DCMR was associated with future cardiac events (p < 0.001). A DCMR stress-induced change in WMSI added significantly to predicting future cardiac events (p = 0.003), after accounting for resting LVEF, but this predictive value was confined primarily to those with an LVEF >40%. In individuals with mild to moderate reductions in LVEF (40% to 55%), dobutamine-induced increases in WMSI forecast MI and cardiac death to a greater extent than an assessment of resting LVEF. In those with an LVEF <40%, a dobutamine-induced increase in WMSI does not predict MI and cardiac death beyond the assessment of resting LVEF.

Effects of antidepressant treatment following myocardial infarction

Depression following myocardial infarction is associated with poor cardiac prognosis. It is unclear whether antidepressant treatment improves long-term depression status and cardiac prognosis. To evaluate the effects of antidepressant treatment compared with usual care in an effectiveness study. In a multicentre randomised controlled trial, 2177 myocardial infarction patients were evaluated for ICD-10 depression and randomised to intervention (n=209) or care as usual (n=122). Both arms were evaluated at 18 months post-myocardial infarction for long-term depression status and new cardiac events. No differences were observed between intervention and control groups in mean scores on the Beck Depression Inventory (11.0, s.d.=7.5 v.10.2, s.d.=5.1, P=0.45) or presence of ICD-10 depression (30.5 v. 32.1%, P=0.68). The cardiac event rate was 14% among the intervention group and 13% among controls (OR=1.07, 95% CI 0.57-2.00). Antidepressant treatment did not alter long-term depression post-myocardial infarction status or improve cardiac prognosis.

276 Arterial stiffness and diastolic dysfunction in patients with systemic sclerosis

s S33 Eur J Echocardiography Abstracts Supplement, December 2006 276 Arterial stiffness and diastolic dysfunction in patients with systemic sclerosis J. Bozo 1 ; R. Faludi 1 ; G. Kumanovics 1 ; L. Czirjak 1 ; A. Cziraki 1 ; T. Simor 1 ; L. Papp 1 1Univ. Pecs, Heart Institute, Faculty of Med., Pecs, Hungary Objectives: Vascular abnormalities are hallmarks of almost all systemic sclerosis patients. Impaired relaxation of the left ventricle is also characteristic for scleroderma heart disease. The aim of our study was to determine whether parameters of arterial stiffness correlate with echocardiographic indices of left ventricular relaxation impairment. Material: 21 patients with limited and diffuse scleroderma (18 women, mean age: 55±9 years) were studied. Methods: Parameters of local and systemic arterial stiffness (pulse wave velocity: PWV; augmentation index: Aix) were determined by automatic brachial pulse wave analysis (Arteriograph®). The same parameters and elastic modulus (Ep), stiffness index (s), arterial compliance (AC) were measured on left brachial and common carotid arteries by echo-tracking (Aloka ProSound 5500). Indices of diastolic function were also determined with the same ultrasound system: in addition to the conventional Doppler parameters of the transmitral flow early (E) and late (A) diastolic velocities, deceleration time (DT), isovolumic relaxation time (IVRT) myocardial early (Ea) and late (Aa) diastolic velocities were measured at the lateral border of the mitral annulus using tissue Doppler imaging. E/A and E/Ea ratios were calculated. Simple associations between the variables were estimated by Pearson’s method. Results: Carotid Ep showed significant correlations with both A (r=0.537, p<0.05) and E/A (r=-0.500, p<0.05) values, and correlated with IVRT also significantly (r=0.489, p<0.05). Carotid s correlated with A (r=0.479, p<0.05), E/A (r=-0.548, p<0.05) and IVRT (r=0.564, p<0.01). Carotid AC correlated with A (r=-0.512, p<0.05), E/A (r=0.551, p<0.05) and IVRT values (r=-0.436, p<0.05). Carotid PWV and Aix showed similarly significant correlations with A, E/A, IVRT and with A and E/A values, respectively. Ep, s and PWV determined by pulse-wave analysis and brachial artery echo-tracking did not correlate with the echocardiographic parameters of the left ventricular diastolic function. Brachial AC showed a significant correlation with A (r=-0.478, p<0.05) and DT (r=0.469, p<0.05). Significant correlation was found between Aix measured by pulse-wave analysis and Aa (r=0.560, p<0.05). Conclusion: Distensibility of elastic arteries correlates well with the echocardiographic indices of the left ventricular diastolic function, but stiffness of muscular type arteries is less useful to predict the degree of diastolic impairment. Selected parameters of arterial stiffness are good predictors of diastolic dysfunction in scleroderma patients ±. 277 Tissue Doppler analysis of regional myocardial dysfunction in patients with systemic sclerosis M. Hirata 1 ; A. Takagi 2 ; K. Shimamoto 3 ; S. Ihara 1 ; H. Watanabe 1 ; K. Mizuochi 1 ; M. Endou 1 ; M. Kawana 3 1Institute of Geriatrics, TWMU, Cardiology Dept., Tokyo, Japan; 2Tokyo Women’s Medical University Hospital, Cardiology Dept., Tokyo, Japan; 3TWMU Aoyama Hospital, Cardiology Dept., Tokyo, Japan Purpose: Systemic sclerosis (SSc) is a multi-system disorder characterized by connective tissue fibrosis resulting in poor cardiac prognosis. Tissue Doppler imaging (TDI) might be useful in early detection of regional myocardial dysfunction. The aim of this study is to estimate the early myocardial dysfunction in SSc patients by using TDI. Methods: Twenty patients with SSc without obvious wall motion abnormalities were compared to 25 age-matched control subjects. E/A ratio and deceleration time (DCT) of trnasmitral inflow were recorded. Peak systolic strain (A) and diastolic strain at the first 30% of diastolic duration (B) were measured on strain curve at midventricular septum. Strain diastolic index was calculated as (A-B)/A×100(%). Results: There was no difference between the two groups in E/A, DCT and peak systolic strain. In contrast, strain diastolic index in SSc was significantly lower than those of control (p<0.01) (Table 1). Conclusion: TDI derived strain diastolic index appeared to be useful in early detection of diastolic dysfunction in patients with SSc.

The relationship between vital exhaustion, depression and comorbid illnesses in patients following first myocardial infarction

Objective Vital exhaustion and depression are both independent risk factors for cardiovascular disease, yet the relationship between these highly similar dimensions remains unclear. We have examined the association between depression and vital exhaustion and investigated the extent to which any association is the result of comorbid illnesses. Methods Three hundred and five consecutive patients were examined on average 3.6 days following hospital admission with first myocardial infarction (MI). The Maastricht Questionnaire (MQ; vital exhaustion) was administered together with the Hospital Anxiety and Depression Scale (HADS), and details of comorbid physical illness were recorded. The factor structure of the MQ was explored using factor analysis. Results Depression and vital exhaustion were highly correlated ( r=.61, P<.01). This correlation did not diminish on controlling for age, sex, and comorbidity ( r=.59, P<.01). Factor analysis of MQ score gave a four-factor solution: fatigue (18.2% of variance), depression (17.9%), lack of concentration (9.5%), and sleep difficulties (8.1%). The fatigue dimension of the MQ remained highly associated with HADS depression score ( r=.50, P<.01), controlling for age, sex, and comorbidity. Conclusions Depression and fatigue are highly correlated and their association is not attributable to comorbid physical illnesses or the tendency of the MQ to measure depression. Future studies should investigate fatigue instead of vital exhaustion as a potential risk factor for poor cardiac prognosis independent of the influence of depression.

VI. Drug Therapy

VI. Drug Therapy

Influence of cardiac autonomic neuropathy on heart rate dependence of ventricular repolarization in diabetic patients.

Prolongation of the QT interval and increased QT dispersion are associated with a poor cardiac prognosis. The goal of this study was to assess the long-term influence of the autonomic nervous system on the heart rate dependence of ventricular repolarization in patients with diabetic autonomic neuropathy (DAN). We studied 27 subjects (mean age 51.8 years) divided into three age- and sex-matched groups: nine control subjects, nine diabetic subjects with DAN (mostly at a mild stage; DAN+), and nine diabetic subjects without DAN (DAN-). DAN was assessed on heart rate variations during standard maneuvers (Valsalva, deep-breathing, and lying-to-standing maneuvers). No subject had coronary artery disease or left ventricular dysfunction or hypertrophy, and no subject was taking any drugs known to prolong the QT interval. All subjects underwent electrocardiogram and 24-h Holter recordings for heart rate variations (time and frequency domain) and QT analysis (selective beat averaging QT/RR relation, nocturnal QT lengthening). Rate-corrected QT intervals (Bazett formula) did not differ significantly between the three groups. The diurnal and nocturnal levels of low frequency/high frequency, an index of sympathovagal balance, were significantly reduced in DAN+ subjects. Using the selective beat-averaging technique, a day-night modulation of the QT/RR relation was evidenced in control and DAN- subjects. This long-term modulation was significantly different in DAN+ subjects, with a reversed day-night pattern and an increased nocturnal QT rate dependence. In diabetic patients with mild parasympathetic denervation, QT heart rate dependence was found to be impaired, as determined by noninvasive assessment using Holter data. Analysis of ventricular repolarization could represent a sensitive index of the progression of neuropathy. The potential prognostic impact of a reversed day-night pattern with steep nocturnal QT/RR relation still remains to be defined.

Mortality and cholesterol metabolism in familial hypercholesterolemia. Long-term follow-up of 96 patients.

The aim of this prospective study was to explore the association of different prognostic factors including parameters of cholesterol metabolism with coronary morbidity and mortality in a study group of 96 patients who were heterozygous for familial hypercholesterolemia. During a 15-year follow-up period, 27% of the patients (44% of the men and 10% of the women, p less than 0.01) died from coronary disease, and an additional 4% died of noncoronary causes. Of the baseline characteristics, male gender, previous myocardial infarction, and smoking were the classical risk factors significantly associated with poor cardiac prognosis. In addition, a low bile acid synthesis predicted enhanced coronary mortality both in univariate and multivariate analysis, and in men bile acid synthesis was significantly correlated with cardiac mortality. Further analysis indicated that also in subjects without baseline myocardial infarction, low bile acid, cholesterol synthesis, or both predicted increased risk of coronary events. In multivariate analysis, male gender, previous myocardial infarction, and low bile acid synthesis at baseline explained 5%, 15%, and 5% (25%), respectively, of the variability of survival. Age, serum total cholesterol, and triglyceride values were unrelated to survival.