Preserved Left Ventricular Systolic Function Research Articles

The value of using fractional flow reserve measurements in helping to diagnose acute left ventricular failure in the presence of normal left ventricular systolic function

1. Case history A 57-year-old female smoker with a longstanding history of hypertension and diabetes presented to hospital with sudden onset of severe breathlessness in the absence of chest pain. Examination revealed sinus tachycardia, hypertension (blood pressure 200/120) and pulmonary oedema. Routine blood investigations and 12-h troponin measurements were normal, and a diagnosis of acute decompensated heart failure secondary to hypertensive crisis was made. She was treated with diuretics and betablockers and made a good recovery. Transthoracic echocardiography demonstrated left ventricular hypertrophy with preserved left ventricular systolic function and Grade 2 diastolic dysfunction. Renal ultrasound confirmed structurally normal kidneys with no evidence of renal artery stenosis. The patient was able to exercise to Stage 3 of a standard Bruce protocol exercise test without symptoms or electrocardiographic changes and subsequent coronary angiography demonstrated a 50% tubular stenosis of the proximal left anterior descending (LAD) artery and 60% stenoses of the mid LAD and origin of the second diagonal (D2) (Fig. 1). Consequently, moderate non-flowlimiting coronary disease was diagnosed, and the patient was discharged with appropriate medical therapy. Unfortunately, the patient re-presented on three subsequent occasions with further episodes of acute pulmonary oedema. The haemodynamic significance of the LAD disease was therefore reassessed, with additional measurements of fractional flow reserve (FFR). This revealed an FFR of 0.71 distal to the mid LAD bifurcation. The D2 and LAD/ D2 bifurcation was therefore stented resulting in a post-stent FFR of 0.85 with a pressure “jump” of 0.08 over the proximal vessel on pull-back (Fig. 2). This led to an additional stent being deployed at the site of the proximal LAD stenosis with complete restoration of flow and perfusion in the distal LAD and a post-stent FFR of 0.9 in the distal LAD. Following discharge the patient has remained well and over 18 months, there have been no further episodes of acute pulmonary oedema.

Risk of Sudden Death in End-Stage Hypertrophic Cardiomyopathy

Background It remains unclear whether end-stage hypertrophic cardiomyopathy (HCM) is associated with as high a rate of sudden death as occurs among HCM patients with preserved left ventricular (LV) systolic function. The purpose of this study was to evaluate the incidence of sudden death among patients with end-stage HCM and to identify high-risk end-stage patients. Methods and Results A total of 490 consecutive patients with HCM, who were diagnosed and followed-up at our hospital, were analyzed retrospectively. End-stage HCM was defined by an LV ejection fraction <50% on echocardiography during follow-up. Among the 490 HCM patients, 43 patients (8.8%) were diagnosed as having end-stage HCM during a mean follow-up period of 12 ± 7 years after the initial diagnosis. During a mean follow-up period of 5 ± 3 years after progression to end-stage HCM, sudden death occurred in 21 of 43 patients (47%). Cox proportional hazards analysis identified syncope as an independent predictor of sudden death (hazard ratio = 6.15; 95% confidence interval, 2.40-15.75; P < .001). Conclusions This study demonstrated that patients with end-stage HCM have a high incidence of sudden death. Therefore, it is suggested that an aggressive therapeutic strategy to counter sudden death should be considered for patients with end-stage HCM.

Left ventricular apical thrombus formed in a case with preserved left ventricular systolic function

Left ventricular apical thrombus formed in a case with preserved left ventricular systolic function

Modern treatment of patients at risk: still a HOPE for ACE inhibitors?

Indications for angiotensin-converting enzyme (ACE) inhibitors include heart failure, postmyocardial infarction, diabetes mellitus and proteinuric chronic renal disease. ACE inhibitors provided life-saving benefits in patients with heart failure or left ventricular systolic dysfunction. On the other hand, there are conflicting data regarding the ability of ACE inhibitors to reduce the incidence of cardiovascular events in patients with vascular disease and preserved left ventricular systolic function. Results of the main randomized clinical trials that evaluated the benefit of ACE inhibitors in patients with vascular disease are discussed in this editorial. In particular, the different prognostic impact of ACE inhibitors in high-risk patients with and without heart failure or preserved left ventricular systolic function is examined in detail. The possible impact of lipids and statins on the effect of ACE inhibitors is also discussed. In our opinion, the available data indicate that ACE inhibitors should continue to be used in all patients with documented coronary artery disease or different phenotypes of high vascular risk, even in a context of modern and aggressive preventive strategies.

Aortic Root Dilatation as a Marker of Subclinical Left Ventricular Diastolic Dysfunction in Patients with Cardiovascular Risk Factors

Consensus is lacking about the clinical importance of aortic root dilatation in assessment of the risk of cardiovascular disease. In this study, correlations between aortic root diameter and echocardiographic features of left ventricular (LV) diastolic function were investigated in 333 patients with at least one cardiovascular risk factor (hypertension, diabetes or dyslipidaemia) and preserved LV systolic function. Aortic root diameter was measured by M-mode echocardiography, and LV diastolic function was evaluated by measuring the peak velocity of early (E) and late (A) diastolic transmitral blood flow and peak early diastolic mitral annular velocity (E') by Doppler echocardiography. Linear regression analysis showed that, in men, age was not related to aortic root diameter but hypertension and LV hypertrophy were, whereas the converse was true in women. The parameters E, E/A ratio and E', were related to aortic root diameter in both sexes. Stepwise multiple regression analysis confirmed that E in women and E' in men were independently associated with aortic root diameter. It is concluded that aortic root dilatation might be a useful marker of subclinical LV diastolic dysfunction. Patients with preserved systolic function showing aortic root dilatation should, therefore, be given preventative therapy against LV diastolic heart failure.

E/e' Ratio Is a Strong Prognostic Predictor of Mortality in Patients With Non-Valvular Atrial Fibrillation With Preserved Left Ventricular Systolic Function

The purpose of this study was to investigate the prognostic values of the E/e' ratio and other echocardiographic and clinical parameters in patients with non-valvular atrial fibrillation (AF) with preserved left ventricular (LV) systolic function. A total of 488 patients (322 men, age: 66 ± 11 years) with non-valvular AF with preserved LV systolic function (LV ejection fraction >50%) were included. The E and e' velocities were measured in 5 consecutive heart beats and averaged. Mean follow-up duration after enrollment was 17.7 ± 5.3 months. All-cause deaths occurred in 45 patients (cardiovascular deaths: n=29). There were significant differences in age (65.6 ± 11.3 vs. 71.5 ± 9.1, P < 0.001) and hemoglobin concentration (13.6 ± 2.9 vs. 11.5 ± 3.4g/dl, P<0.0001) between the deceased group and the survivors. E/e' ratio in the deceased group was significantly higher than that in the survivors (17.67 ± 3.39 vs. 10.8 ± 3.30, P < 0.001). Survival analysis showed that a high E/e' ratio (> 15.0) represents a poorer prognosis (P < 0.001 by Log-Rank test) than an E/e' ratio of 15 and below. Multivariate analysis identified 2 significant variables that were predictive of all-cause deaths: hemoglobin (hazard ratio (HR)=0.806, 95% confidence interval (CI) = 0.733-0.886, P < 0.0001), and E/e' > 15 (HR=3.064, 95%CI = 1.38-6.804, P = 0.006). E/e' ratio is a useful independent prognostic parameter for predicting mortality in patients with AF with preserved LV systolic function.

138 Brain natriuretic peptide predicts left ventricular contractile reserve in asymptomatic degenerative mitral regurgitation

Current guidelines recommend mitral surgery in asymptomatic patients with severe degenerative mitral regurgitation (DMR) even when left ventricular (LV) systolic function is preserved. LV longitudinal deformation, quantified with 2D speckle tracking analysis (2DSt), can detect LV contractile reserve (CR). Moreover, plasma brain natriuretic peptide (BNP) may be used for risk stratification in patients with DMR. We sought to assess whether BNP may be used to identify LVCR in asymptomatic DMR. Resting and exercise transthoracic echocardiography was performed in 82 consecutive asymptomatic patients with moderate to severe DMR and with preserved LV systolic function. The presence of LVCR was defined as an exercise-induced changes in global longitudinal strain (GLS) >2%. Simultaneously to resting echocardiography, plasma BNP level was measured. GLS increased during exercise (from 20.9 ± 3.1 to 23.4 ± 3.4%, p < 0.001) and CR was found in 45 patients (56%). Patients with CR were significantly younger (p = 0.025) and had lower LV filling pressure (p = 0.04) than to those without CR. BNP was significantly higher in patients without CR (42.7 ± 2 vs.14.8 ± 2pg/ml, p < 0.0001) and there was a good correlation between BNP and exercise-induced changes in GLS (r = −0.77, p < 0.001). On multivariable analysis, BNP was independently associated with exercise-induced changes in GLS (p < 0.001). ROC curves showed that BNP>26 pg/ml predicted the absence of CR with good accuracy (sensitivity: 92%; specificity: 93%). Moreover, multivariable regression revealed that, after adjustment for age, sex, E/Ea ratio and resting GLS, only BNP was independently associated with CR (OR = 1.4, 95%CI: 1.2–2, p < 0.001). In asymptomatic DMR and normal LV systolic function, CR may be absent in a large proportion of patients (45%). BNP is highly accurate to identify patients with subclinical LV dysfunction and no CR. Consequently, BNP could routinely be used to improve risk stratification.

Interpretation of Annular Tissue Doppler Imaging

Refer to the page 137-142 Diastolic dysfunction has become a more predominant form of heart failure (HF) than systolic dysfunction in the community. However, diastolic dysfunction is not always related to HF. Diastolic HF is defined as HF with preserved left ventricular (LV) systolic function, usually a LV ejection fraction (EF) of more than 50%, in the absence of valvular heart disease. The clinical importance of diastolic dysfunction has increased because its prevalence has increased with worsening morbidity and mortality, especially in the elderly and women. The standard criteria for LV diastolic dysfunction is characterized by impairment of LV relaxation during the isovolumic relaxation time (Tau) in cardiac catheterization. However, routine invasive cardiac catheterization is not always feasible, and therefore, we need simple noninvasive modalities to replace catheterization.1),2) The initial approach to assess diastolic function was the pulsed-wave Doppler of mitral inflow, based on the early filling (E) and atrial contraction (A) ratio and E-deceleration time. However, there were some limitations, first being its dependency on loading conditions and difficulty in differentiation between the normal and pseudonormal pattern. To overcome these limitations, mitral annular tissue Doppler imaging (TDI), with primary measurements of systolic (s'), early diastolic (e') and late diastolic velocity (a') has been widely used. TDI-derived velocities also have some limitations. The e' velocity can change with increase in age and it may not be useful in conditions of heavy mitral annular calcification, septal or lateral wall infarction, constrictive pericarditis, and severe mitral regurgitation. Despite these limitations, TDI is a sensitive and load-independent measure of LV relaxation, and has been a part of the most widely used and important echocardiographic parameter. A recent study by Baek et al.3) identified that when interpreting diastolic function in elderly subjects, different cut-off values should be considered according to TDI modality, annulus site, and gender. Study results have shown that spectral TDI has a somewhat higher e' than that of color-coded TDI, and the e' value in both these methods of tissue Doppler is lower in women as compared with men.

Decreased Cardiac Functional Reserve in Heart Failure With Preserved Systolic Function

Background Heart failure in patients with preserved left ventricular systolic function (HFpEF) is a prevalent disease characterized by exercise intolerance with poorly understood pathophysiology. We hypothesized that recruitable contractility is impaired in HFpEF, accounting for the appearance of symptoms with exertion. Methods and Results Echocardiographic analysis of myocardial performance was performed at baseline and after a modified dobutamine protocol (max dose 16 μg/kg/min) in participants with known HFpEF and age- and gender-matched controls. The primary outcome variable was change in contractile reserve, measured as a change in ejection fraction (EF). Recruitable contractility was decreased in HFpEF participants compared with control subjects (HFpEF 0.4 ± 1.9% vs control 19.0 ± 1.4%; P < .001). During dobutamine infusion, velocities increased in control participants but remained unchanged in the HFpEF group, yielding a significant difference between groups ( P < .05) for both longitudinal displacement and velocity. Conclusions Patients with HFpEF have an impaired contractile response to adrenergic stimulation. The blunted response to adrenergic stimulation in the HFpEF group suggests that these patients may be unable to respond to periods of increased cardiac demand. This inability to increase contractility appropriately suggests abnormalities of systolic function in this disease and may contribute to exertional intolerance in HFpEF.

Bioelectrical impedance vector analysis (BIVA) in stable and non-stable heart failure patients: A pilot study

Heart failure (HF) patients have a high morbidity and mortality and often require numerous visits and hospital readmissions related to fluid retention [ [1] Gonseth J. Guallar-Castillon P. Banegas J.R. Rodriguez-Artalejo F. The effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports. Eur Heart J. 2004; 18: 1570-1595 Crossref Scopus (366) Google Scholar ]. Biompedance is a method of body composition analysis studied in HF in different ways such as impedance cardiography [ [2] Thompson B. Drazner M.H. Dries D.L. Yancy C.W. Systolic time ratio by impedance cardiography to distinguish preserved vs impaired left ventricular systolic function in heart failure. Congest Heart Fail. 2008; 14: 261-265 Crossref PubMed Scopus (16) Google Scholar ] or as a home monitoring method in telemedicine systems [ [3] Radai M.M. Arad M. Zlochiver S. Krief H. Engelman T. Abboud S. A novel telemedicine system for monitoring congestive heart failure patients. Congest Heart Fail. 2008; 14: 239-244 Crossref PubMed Scopus (8) Google Scholar ], but little data exist about the analysis of the components of the impedance vector (BIVA-Bioimpedance Vector Analysis-) in HF. The result of a measurement using bioelectrical impedance is a vector (Z vector) in which the opposition of an alternating current flow through intra- and extra-cellular ionic solutions is resistance (R), and the capacitance of biological tissues, is reactance (Xc). The arc tangent of the vector is the phase angle (PA) [ [4] Grimnes S. Martinsen Ø.G. Bioimpedance and bioelectricity basics. in: Academic Press, London2000: 114-115 Google Scholar ]. BIVA is a validated method where the components of the impedance vector are normalized by the height (H) of the subjects (R/H and Xc/H) [ [5] Piccoli A. Pastori G. BIVA software. Department of Medical and Surgical Sciences, University of Padova, Italy2002 Google Scholar ]. They are represented on confidence and tolerance ellipses in an RXc-graph [ [6] Piccoli A. Rossi B. Pillon L. Bucciante G. A new method for monitoring body fluid variation by bioimpedance analysis: the RXc graph. Kidney Int. 1994; 46: 534-539 Crossref PubMed Scopus (502) Google Scholar ] separated by gender [ 7 Piccoli A. Nigrelli S. Caberlotto A. Bivariate normal values of the bioelectrical impedance vector in adult and elderly populations. Am J Clin Nutr. 1995; 61: 269-270 PubMed Google Scholar , 8 Piccoli A. Pillon L. Dumler F. Impedance vector distribution by sex, race, body mass index, and age in the United States: standard reference intervals as bivariate Z scores. Nutrition. 2002; 18: 156-170 Google Scholar ]. Many populations have already been characterized by BIVA [ 7 Piccoli A. Nigrelli S. Caberlotto A. Bivariate normal values of the bioelectrical impedance vector in adult and elderly populations. Am J Clin Nutr. 1995; 61: 269-270 PubMed Google Scholar , 8 Piccoli A. Pillon L. Dumler F. Impedance vector distribution by sex, race, body mass index, and age in the United States: standard reference intervals as bivariate Z scores. Nutrition. 2002; 18: 156-170 Google Scholar , 9 Piccoli A. Fanos V. Peruzzi L. et al. Reference values of the bioelectical impedance vector in neonates in the first week after birth. Nutrition. 2002; 18: 17-21 Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar , 10 De Palo T. Messina G. Edefonti A. et al. Normal values of the bioelectrical impedance vector in childhood and puberty. Nutrition. 2000; 16: 417-424 Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar , 11 Piccoli A. Brunani A. Savia G. Discriminating between body fat and fluid changes in the obese adult using bioimpedance vector analysis. Int J Obes. 1998; 22: 97-104 Crossref PubMed Scopus (128) Google Scholar , 12 Nescolarde L. Piccoli A. Doñate T. Rosell J. Bioelectrical impedance vector analysis in haemodialysis patients: relation between oedema and mortality. Physiol Meas. 2004; 25: 1271-1280 Crossref PubMed Scopus (63) Google Scholar , 13 Nescolarde L. Doñate T. Piccoli A. Rosell J. Comparison of segmental with whole-body impedance measurements in peritoneal dialysis patients Med. Eng Phys. 2008; 30: 817-824 Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar , 14 Toso S. Piccoli A. Gusella M. Menon D. Bononi A. Crepaldi G. Altered tissue electric properties in lung cancer patients as detected by bioelectric impedance vector analysis. Nutrition. 2000; 16: 120-124 Abstract Full Text Full Text PDF PubMed Scopus (160) Google Scholar ], but little data exist in HF. The aim of this pilot study was to assess the usefulness of BIVA in assessing the hydration state in stable and non-stable HF patients.

Left Ventricular Hypertrophy Determines the Severity of Diastolic Dysfunction in Patients with Nonvalvular Atrial Fibrillation and Preserved Left Ventricular Systolic Function

Regression of left ventricular (LV) hypertrophy (LVH) is known to be related to a lower incidence of stroke in hypertensive patients with nonvalvular atrial fibrillation (NV-AF). However, its mechanism remains controversial. Recently, diastolic dysfunction (DD) was reported to be correlated with ischemic stroke in NV-AF. We hypothesized that hypertension (HTN) and resultant LVH might be associated with the severity of DD in NV-AF. Two hundred and ninety-four patients (204 males, age 66 ± 12 y) with NV-AF with preserved LV systolic function were included. Clinical and echocardiographic data were compared between patients with enlarged left atrial (LA) volume (n == 237) and patients with normal LA. Age (60 ± 12 vs. 67 ± 11 years), sex (male; 81 vs. 62%%), duration of NV-AF (4.1 ± 7.8 vs. 45.7 ± 49.0 months), brain natriuretic peptide (108.3 ± 129.3 vs. 236.1 ± 197.0 pg//mL), right ventricular systolic pressure (24.5 ± 5.5 vs. 33.1 ± 11.1 mmHg), mitral inflow velocity (E [77.4 ± 22.2 vs. 88.3 ± 22.0 cm//s]), LV mass index (LVMI [87.6 ± 22.2 vs. 105.1 ± 23.2 g//m2]), peak systolic mitral annular velocity (S' [7.2 ± 2.0 vs. 5.8 ± 1.8 cm//s]), and mitral inflow velocity to diastolic mitral annular velocity (E//E' [9.8 ± 3.4 vs. 12.1 ± 4.4]) were significantly different between the two groups, respectively (P < 0.05). In multivariate analysis, LVMI was independently correlated with increased LA volume (OR: 1.037 [95%% CI: 1.011–1.063], P < 0.05), whereas HTN was not. LA enlargement, which reflects the severity and chronicity of DD, is independently associated with LVH in patients with NV-AF. Therefore, regression of LVH with anti-hypertensive treatment may lead to improvement of diastolic function and favorable clinical outcomes in hypertensive patients with NV-AF.

Interventricular Septal Hematoma and Ventricular Septal Defect After Retrograde Intervention for a Chronic Total Occlusion of a Left Anterior Descending Coronary Artery

A 73-year-old man with unstable angina was found to have a severely calcified chronic total occlusion (CTO) of the mid left anterior descending coronary artery (LAD). Diagnostic coronary angiography confirmed the CTO to be complex, with a “flush” occlusion occurring in a segment associated with proximal septal and diagonal branches. Retrograde filling of the distal LAD occurred via 2 large septal perforators from the right coronary artery (RCA). Cardiac magnetic resonance imaging demonstrated preserved left ventricular systolic function with viability. After discussion, the patient opted for percutaneous coronary intervention. Intervention was performed by 2 high-volume CTO operators with extensive experience of retrograde CTO percutaneous coronary intervention. An initial antegrade approach failed to negotiate the calcific CTO lesion (Figure 1A). A subsequent attempt was made to treat the CTO via …

Mismatch between arterial stiffness increase and left ventricular diastolic dysfunction

Previous studies which included patients with preserved left ventricular (LV) systolic function demonstrated that arterial stiffness progressively increased as LV diastolic function decreased. However, it was unknown whether this correlation was still present in a heterogeneous study population involving patients with a wide range of LV systolic function. Seventy-five patients with depressed LV systolic function were consecutively included and 192 patients with preserved LV systolic function were randomly selected from subjects arranged for echocardiography examination. Brachial-ankle pulse wave velocity (baPWV) was measured using an ABI-form device. Of the 267 subjects (mean age 58±14years) included in the study, 105 had normal diastolic function, 74 had impaired relaxation, and 60 had pseudonormal and 28 restrictive diastolic dysfunction. BaPWV was only lower in patients with normal diastolic function than in those with abnormal diastolic function (p≤0.001). It did not gradually rise as diastolic dysfunction grade increased. Multivariate analysis showed that increased age and systolic blood pressure and decreased LV ejection fraction, transmitral A velocity, and left atrial volume index (p≤0.039) were correlated with increased baPWV. Our study showed that there were no positive correlation between echocardiographic LV diastolic parameters and baPWV. BaPWV did not progressively rise with increasing LV diastolic dysfunction grade. Therefore, patients with advanced LV diastolic dysfunction may not have increased arterial stiffness.

G-CSF and Erythropoietin Combination Therapy for Infarct Repair: Two Plus Two Equals Two?

G-CSF and Erythropoietin Combination Therapy for Infarct Repair: Two Plus Two Equals Two?

Left Ventricular Mass Index Is an Independent Determinant of Diastolic Dysfunction in Patients on Chronic Hemodialysis: A Tissue Doppler Imaging Study

Background: Diastolic heart failure is the most common clinical form of heart failure. Tissue Doppler imaging (TDI) is often used to quantitate left ventricular (LV) diastolic function. The purpose of this study was to identify the determinant(s) of diastolic dysfunction in patients with end-stage renal disease on hemodialysis (HD), using the TDI method. Methods: The study subjects were 53 patients with end-stage renal disease and preserved LV systolic function on maintenance HD. LV function was assessed by conventional echocardiography. The ratio of early trans-mitral flow velocity to early mitral annular velocity (E/e′) was measured by TDI. Patients were stratified into two groups based on E/e′ value (≤15 and >15 groups). Arterial stiffness was evaluated by pulse wave velocity and cardio-ankle vascular index. Results: Patients of the E/e′ >15 group were older (p = 0.025). There were no significant differences in blood pressure, ejection fraction, E/A, deceleration time, and pulse wave velocity between the E/e′ >15 and E/e′ ≤15 groups. However, there were significant differences in LV mass index (LVMI; p < 0.001) and cardio-ankle vascular index (p = 0.048) between the two groups. Multiple regression analysis identified that LVMI was an independent determinant of E/e′ (p = 0.003). Conclusions:Our findings suggest that LVMI is an independent determinant of LV diastolic dysfunction in patients on HD.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Prevalence and Risk Factors of Pulmonary Hypertension in Patients With Elevated Pulmonary Venous Pressure and Preserved Ejection Fraction

Pulmonary hypertension (PH) is a well-recognized complication of left-sided heart failure with preserved left ventricular systolic function that portends a worse prognosis. The identification of risk factors may provide insight into possible mechanisms for the development of PH in this population. Targeting these risk factors could possibly attenuate the development of PH. The limited data available regarding the prevalence of PH and its risk factors in patients with heart failure with preserved left ventricular systolic function are based on echocardiography. To further study this, an institutional database was searched for all patients who underwent right-sided and left-sided cardiac catheterization with ventriculography from October 1996 to September 2007 who met the following criteria: left ventricular end-diastolic pressure (LVEDP) >15 mm Hg, a left ventricular ejection fraction > or =50%, and no significant left-sided cardiac valvular disease. The demographic, clinical, and hemodynamic data of these patients were then analyzed. Of 455 patients who met these criteria, 239 (52.5%) had PH, defined as mean pulmonary artery pressure >25 mm Hg. Using multivariate logistic regression, PH was strongly and independently associated with LVEDP > or =25 mm Hg (odds ratio 4.3), morbid obesity (odds ratio 3.4), and atrial arrhythmias (odds ratio 3.1). Other significant associations were age > or =80 years, chronic obstructive pulmonary disease, and dyspnea on exertion. In conclusion, PH is a frequent finding in patients with elevated LVEDPs and preserved left ventricular systolic function. Factors associated with its development are LVEDP > or =25 mm Hg, morbid obesity, atrial arrhythmias, age > or =80 years, chronic obstructive pulmonary disease, and dyspnea on exertion.

B-type natriuretic peptide in outpatients after myocardial infarction: Optimized cut-off value for incident heart failure prediction

Higher levels of natriuretic peptides were identified in outpatients after myocardial infarction (MI) compared to the healthy population, even in the absence of heart failure (HF). Therefore, we assessed the optimal cut-off value of B-type natriuretic peptide (BNP) in relation to new-onset HF prediction in 79 post-MI patients with preserved left ventricular systolic function (ejection fraction >40%). Plasma BNP was measured by enzyme immunoassay, 6 months after MI and patients were followed-up for the next one year. Cox proportional regression model analysis revealed the independent prognostic value of BNP for HF prediction ( p = 0.005). As assessed by ROC analysis the optimal cut-off value of BNP was 175 pg/mL (sensitivity 82%; specificity 77%, AUC 0.77), associated with significantly different rates of incident HF by Kaplan–Meier analysis ( p = 0.001). In this population of outpatients with preserved left ventricular systolic function after MI, BNP strongly correlated with new-onset HF development at the optimal cut-off value of 175 pg/mL.

Persistent Increase of Cardiac Troponin I in Plasma without Evidence of Cardiac Injury

A 69-year-old man with diabetes mellitus type II, hypertension, dyslipidemia, and prior ischemic strokes presented to the emergency department with complaints of balance difficulties and inability to stand unassisted of 2 weeks’ duration. The patient’s home medication regimen included atenolol, lisinopril, amlodipine, metformin, and glipizide. He is a retired chef and a former smoker (20 pack-years). He has 2 brothers, both of whom had myocardial infarctions in their 50s. The patient’s physical examination was remarkable for frequent premature contractions, left lower extremity weakness, and impaired coordination. His electrocardiogram revealed sinus rhythm with frequent premature ventricular contractions and diffuse nonspecific T-wave abnormalities. Results of a comprehensive metabolic chemistry panel were within the reference intervals except for increases in glucose (158 mg/dL; reference interval, 74–99 mg/dL) and creatinine (1.5 mg/dL; reference interval, 0.7–1.3 mg/dL). The hemoglobin A1c value was 7.4% (reference interval, <6.0%). Cardiac troponin I (cTnI)1 concentrations were increased at 0.27, 0.22, and 0.25 μg/L (Abbott Architect assay; 99th percentile, <0.03 μg/L) over a span of approximately 8 h. The patient was admitted to the cardiology service on the basis of these abnormal results. A transthoracic echocardiogram revealed a preserved left ventricular systolic function with evidence of impaired diastolic filling. A cardiac catheterization evaluation revealed an ulcerated plaque in the left anterior descending artery with >70% stenosis, which was treated with a bare-metal stent. The presenting symptom of balance difficulty failed to resolve after the coronary intervention, and the patient remained unable to stand unassisted. A neurologic evaluation included magnetic resonance imaging, which found no evidence of an acute stroke. He was discharged with a diagnosis of orthostatic hypotension. Three months later, the patient presented to the emergency department with several days of balance difficulty. The initial cTnI value was increased at 0.10 μg/L, prompting admission to the cardiology …

Role of pericardium in the maintenance of left ventricular twist

BackgroundThe role of pericardium in left ventricular (LV) twist has not been directly investigated. We sought to determine the role of pericardium in maintenance of LV twist function in an...