Preserved LVEF Research Articles

Cardio-renal syndromes in patients admitted with ST-elevation myocardial infarctions: Incidence and impact on renal and overall outcome

Abstract Background The importance of cardiorenal syndromes (CRS) in patients with heart failure has been shown in many studies. However, there is little data on the impact of a combination of heart failure and renal disease in patients with acute myocardial infarctions. Aim of the present study was to investigate, how often a combination of heart failure (HF) and kidney disease (KD) could be detected in patients with ST-elevation myocardial infarctions and to estimate its impact on outcome. Methods All patients from a German heart center, admitted with STEMI between 2006 and 2022 were analysed. CRS was defined as a combination of heart failure (HF: left ventricular ejection fraction (LV-EF<40%), HF) and kidney disease (KD: GFR at admission <60 ml/min). Patients were assigned in a 2x2 model: HF-/KD-, HF-/KD+, HF+/KD-, HF+/KD+. Outcome analysis was adjusted by confounders in a multivariate Cox-regression-model. Acute kidney injury (AKI) was calculated by AKIN-criteria (KDIGO) Results Of a total of 8276 STEMI-patients included in the study 5696(69%) had a preserved LV-EF and no KD (HF-/KD-), 1354 (16%) a preserved LV-EF and KD (HF-/KD+), 743 (9%) a reduced LV-EF and no KD (HF+/KD-) and 483 (6%) both a reduced LV-EF and KD (HF+/KD+, CRS-Group). In the CRS-group patients were on average older (74.2±12 yrs. vs. 60.8±13 yrs., p<0.01), more likely to be female (36.9% vs. 23.1% in the control group, p<0.01) and more likely to be diabetics (31.0% vs. 16.8% in the control group, p<0.01). CRS was associated with higher rates of cardiogenic shock (41.5% vs. 8.7% in the control group) and higher rates of subsequent AKI with a 18x higher risk to develop AKIN-3 with or without the need for renal replacement therapy (RRT), (table, upper part). In patients with CRS in 11% of patients a temporal RRT was necessary vs. 0.5% in controls. Furthermore, in CRS-patients in-hospital and 1 year-mortality-rates were markedly higher (table, lower part). When adjusting outcomes for confounders (age, gender, CS, diabetes, anterior STEMI, 3 VD) the detrimental effect of CRS on outcome remained: AKIN-3/RRT: OR 16.5, 95% CI 7.5-30.0, p<0.01, In-hospital-mortality: OR 14.2, 95% CI 7.8-21, p<0.01, 1-year-mortality: HR 10.5, 95% CI 7.5-14.1, p<0.01. Conclusions In this analysis of registry data, cardiorenal disease could be detected in 6% of STEMI-patients, with higher rates in women and in diabetics. Patients with cardiorenal disease showed a more than 18-fold higher risk of suffering severe renal failure during the index event and a 24-fold higher risk of in-hospital death. Patients with either heart failure or renal disease were situated between the CRS and control group with regard to outcome. These results underline the additive effects of cardiac and renal disease.Table:Event rates by HF and KD group

The role of cardiac magnetic resonance in patients with an angiographically diagnosed SCAD

Abstract Background/Introduction Spontaneous coronary artery dissection (SCAD) characterized by its non-atherosclerotic nature, poses challenges in diagnosis and management. While recent efforts shed light on SCAD's clinical aspects, the specific utility of CMR demands deeper investigation for enhanced diagnosis and patient care. Purpose This study aims to analyze the characteristics of patients with an angiographically diagnosed SCAD, evaluate qualitative and quantitative parameters of baseline CMR and investigate predictors of myocardial injury and the association between CMR parameters and clinical outcome (major adverse cardiac events, MACE). Methods The study is a prospective single-center analysis of 59 patients, presented acutely in our hospital, from March 2018 to November 2023, with an angiographically detected SCAD. CMR was performed after a median of 4 days (IQR 1.5-7) from the acute onset of symptoms. SCAD Types were angiographically categorized according to the Yip-Saw classification. Most patients (71%) were screened for fibromuscular dysplasia (FMD) with a brain MR and at least one contrast-enhanced abdominal vessels investigation (CT or MR). CMR imaging was performed on a clinical 1.5 T Scanner. T1-weighted, T2-weighted turbo-spin-echo (TSE) Black-Blood (BB) and Short-Tau-Inversion-Recovery (STIR) sequences in short-axis orientation were acquired. The scan protocol included standard cine and T1/T2-weighted TSE BB and Mapping sequences. Late gadolinium enhanced (LGE) images were acquired ≏10 min after the contrast injection and were visually assessed for the presence and extension of LGE areas. LGE quantification was assessed semiautomatically. Results 40 (68%) were females. 54(92%) complained of chest pain, in 55 (93%) high-sensitive Troponin T was eleveted (>14 ng/l) and 24 (41%) presented with the clinical picture of STEMI on admission. From an angiographic point of view, the majority (69.5%) were classified as SCAD Type 2 (a+b). Among patients who underwent a proper screening, 7 patients (16%) were diagnosed with FMD. Baseline CMR showed signs of active injury in 81% and LGE in 93% of the population; however, it was often moderate in size (median of LGE segments 3, IQR 2-5). Most patients had a preserved LVEF (55±10%). STEMI presentation is an independent predictor of LGE extension (p=0.02, OddsRatio(95% CI)=7(2-24)). ScadType1 (p=0.01, OR=10( 2-39)) and N°LGE transmural segments >3 (p=0.03, OR=5.4(1.2-25)) were found to be significant predictor of MACE. 6 of the 11 MACEs were SCAD recurrence/progression, and 4 out of these 11 had already shown signs of previous myocardial injury in the baseline CMR. Conclusion(s) This study emphasized the significance of CMR, which may provide further insights into extend of myocardial damage and may aid in patients’ risk stratification.

Permanent pacemaker implantation is associated with an increased risk of heart failure hospitalization in transcatheter aortic valve implantation patients with reduced systolic function

Abstract Background The impact of permanent pacemaker implantation (PPI) on outcome of patients following transcatheter aortic valve implantation (TAVI) is not fully understood. Purpose This study aimed to assess the impact of PPI on risk of two-year mortality and hospitalization due to heart failure (HF) in TAVI patients. Methods A total of 1275 consecutive patients who underwent TAVI at our hospital between 2009 and 2021 were enrolled in this study (mean age 81.4±5.6 years, 51.8% male). The primary endpoint was defined as two-year all-cause death after TAVI. The second endpoints included cardiovascular (CV) death and HF related hospitalization after TAVI. Results Among the 1275 patients following TAVI, 297 (23.3%) patients received PPI, with 134 receiving PPI before TAVI and 163 receiving PPI after TAVI. The patients were categorized into two groups: no PPI group (n=978) and PPI group (n=297). Compared to patients without PPI, patients who received PPI were more likely to be male (60.9% vs. 49.1%, P<0.001), higher prevalence of atrial fibrillation (51.2% vs. 43.3%, P=0.016), coronary artery disease (61.6% vs. 53.8%, P=0.017), use aldosterone receptor antagonists (MRAs, 25.3% vs. 15.2%, P<0.001), and lower left ventricular ejection fraction (LVEF, 54.9±13.1% vs. 57.5±11.4%, P<0.001). There were no significant differences in all-cause mortality (16.6% vs. 18.5%), CV mortality (11.3% vs. 13.5%), as well as HF hospitalization rate (18.5% vs, 21.2%) between the two groups (P>0.05). In this cohort, 1012 (79.4%) TAVI patients had a preserved LVEF (≥50%), 122 (9.6%) had a mildly reduced LVEF (41-49%), and 141 (11.1%) had reduced LVEF (≤40%). Their primary and secondary outcomes were similar among LVEF subgroups (all P>0.05). In the subgroup of reduced LVEF, the HF related hospitalization rate after TAVI was significantly higher in TAVI patients with PPI compared to those without PPI (30.6% vs. 13.0%, P=0.003). Multivariable Cox regression models demonstrated a 3-fold increased risk of HF related hospitalization in TAVI patients with PPI in comparison to those without PPI in the subgroup of LVEF≤40% (HR 3.057, 95% CI 1.311-7.130, P=0.010) after adjusting for age, sex, TAVI approach, atrial fibrillation, coronary artery disease, and the use of MRAs. Conclusion All-cause mortality and CV mortality are similar between TAVI patients with and without PPI. However, in the subset of TAVI patients with reduced LVEF (≤40%), PPI is associated with an increased risk of HF hospitalization. Efforts are thus needed to reduce the risk of HF hospitalization in these patients.

Tailored electrocardiographic-based criteria for different pacing locations within the left bundle branch

Abstract Background QRS morphology transition criteria are the current gold-standard for the confirmation of LBB capture during LBBAP, but they are seen in less than 40% of procedures. Thus, physiologic ECG-based criteria are widely used to confirm LBBP. Current CSP guidelines recommend 100% specific cut-off points (V6-RWPT< 75 ms or V6-V1 interpeak interval > 44 ms) to confirm LBB capture but these values were never validated for different pacing locations. Purpose To describe diagnostic performance of paced V6-RWPT, V6-V1 interpeak interval and paced aVL-RWPT for different pacing sites within the LBB and to determine 100% specific values at each pacing location. Methods Consecutive patients with an attempt of LBBAP procedure were screened at our institution. Only patients with unequivocal LBB capture according to QRS transition criteria were selected. The study population was divided into subgroups according to the site of pacing (left bundle trunk pacing (LBTP), left septal fascicular pacing (LSFP), left posterior fascicular pacing (LPFP) and left anterior fascicular pacing (LAFP)). Results 147 patients with unequivocal LBB capture were analyzed (mean age 77.5±10.4 years, 50.3% male, 95.2% preserved LVEF, and 94.6% with bradycardia pacing indication. Non-diseased LBB (narrow QRS complex or isolated RBBB) was present in 70.7% of patients (n=104). Left fascicular pacing was the most common type of LBB capture achieved (82.8%) while LBTP accounted for 17.2% of cases. LFSP was the most frequent fascicular capture (54.1%), followed by LPFP (36%) and LAFP (9.9%). The ROC curves of paced V6-RWPT for the differential diagnosis of LBBP and LVSP showed good diagnostic performance among different pacing locations (figure 1). The highest AUC were found in patients with LSFP and LAFP (94.9% and 93.2%, respectively). The 100% V6-RWPT specific cut-off value was 68 ms (SN) 25%) in LPFP, 75 ms (SN 56.5%) in LBTP, 79.5 ms (SN 75%) in LSFP and 81 ms (SN 90.9%) in LAFP (figure 1). The diagnostic performance of V6-V1 interpeak interval was also good among study subgroups (figure 2). The highest AUC were found in patients with LBTP and LSFP (89% and 89.4%, respectively). The 100% V6-V1 interpeak interval specific cut-off value was 35.5 ms (SN 65.2%) in LBTP, 53.5 ms (SN 32.5%) in LPFP, 46 ms (SN 44.1%) in LSFP and 41 ms (SN 63.6%) in LAFP (figure 2). Diagnostic performance of paced aVL-RWPT was good among study subgroups (AUC of 93% in LAFP, 80.1% in LBTP, 84% in LSFP and 77.5% in LPFP). The 100% specific cut-off values for LBBP confirmation were 74 ms, 74.5 ms and 73.5 ms for LBTP, LSFP and LPFP patients, respectively, but it was 68 ms in patients with LAFP (SN 66.7%). Conclusions Diagnostic performance of the physiologic ECG-based criteria for the discrimination of LBBP, was good among different pacing locations within the LBB. Tailored cut-off values depending on the site of pacing might be useful additional tools for better LBB capture confirmation.Figure 1Figure 2

Echocardiographic follow-up after AV node ablation combined with left bundle branch area pacing for patients with symptomatic atrial fibrillation

Abstract Background AV node ablation combined with permanent pacing is an established therapy for rate control in patients with symptomatic atrial fibrillation (AF) refractory or intolerant to pharmacological rate or rhythm control and not eligible for rhythm control by left atrial catheter ablation. The threshold for performing this so-called "pace-and-ablate" strategy has decreased since the introduction of conduction system pacing, and especially left bundle branch area pacing (LBBAP). Purpose To investigate the change of the left-ventricular (LV) ejection fraction (EF) and left-atrial volume index (LAVI) in patients with symptomatic AF, twelve months after LBBAP and AV-node ablation. Methods Consecutive patients with symptomatic AF intolerant or refractory to pharmacological rate and symptom control and deemed not eligible for left atrial catheter ablation were included. At baseline, the EHRA score was noted and the LVEF and LAVI were measured echocardiographically. Patients were subdivided in a normal baseline LV ejection fraction (LVEF >50%) or diminished baseline LVEF (LVEF <50%) group. After LBBAP, patients underwent AV node ablation in the same procedure or four weeks later. After twelve months, the LVEF and LAVI were reassessed in the entire cohort and the two subgroups. Results Twenty-two patients (68% female, mean age 79±4 years) scheduled for pace-and-ablate therapy were prospectively included. Three (14%) had paroxysmal, sixteen patients (72%) had persistent AF and three patients (14%) long-standing persistent AF. An EHRA class IIb or higher was found in eighteen patients (82%). At baseline, the mean LVEF was 51 ± 7%, the mean LVEDD 47 ± 6 mm and LAVI 54 ± 18 ml/m2. Twelve patients (55%) had a preserved LVEF, whereas ten patients (45%) had an LVEF <50%, fig. 1. After twelve months, the overall ejection fraction increased to 54 ± 5% (p=0.016), fig. 2A. This was mostly attributed to the increase in LVEF to 51 ± 5% in the subgroup with a reduced baseline LVEF (p=0.009 compared to baseline 44 ± 5%), fig. 2A. The LVEF was unaffected in the other group (57 ± 3% vs. 57 ± 4%, p=0.63), fig. 2A. The LAVI was not significantly reduced in the overall cohort or the subgroups (54 ± 18 ml/m2 to 51 ± 19 ml/m2, p=0.16), fig 2B. Conclusion AV node ablation combined with LBBAP results in a significant improvement in LVEF at twelve months follow-up. This is mainly driven by an improvement in LVEF in those patients with a diminished LVEF at baseline. The data suggests that the therapy can reverse a tachycardiomyopathy without inducing a pacing-induced cardiomyopathy. No significant reduction in LAVI was found.Baseline characteristicsChanges in LVEF (A) and LAVI (B)

Beta-blockers in chronic heart failure with preserved left ventricular ejection fraction: is deprescribing possible?

Chronic heart failure (CHF) is a complex clinical syndrome characterized by poor prognosis. According to the Russian epidemiological study EPOHA-CHF, more than half of patients with CHF have preserved left ventricular ejection fraction (LV EF). However, no class of drugs has proven effectiveness in improving the prognosis of this disease. Although current clinical guidelines do not recommend the routine use of beta-blockers in CHF patients with preserved LV EF in the absence of other indications for them, many patients with CHF with preserved LV EF take these drugs unreasonably. The review presents the data from studies on the efficacy and safety of betablockers in CHF with preserved LV EF and it withdrawal. Most studies included patient with LV EF >40%, a few of them analyzed only patients with LVEF ≥50%. Some studies of real clinical practice and meta-analysis of such studies demonstrated a positive effect of beta blockers in patients with LV EF > 40%, however randomized clinical trials and their meta-analyses revealed either a slight beneficial effect of beta-blockers. Studies involving only patients with LV EF ≥50% didn’t show the beneficial effects of beta blockers. There is only one trial accessing the withdrawal of beta blockers in patients with CHF with preserved LV EF and chronotropic insufficiency. The study showed a positive effect of deprescribing on exercise tolerance and quality of life. Due to controversial data, well-designed trials to examine the effect of beta-blockers on symptoms and prognosis in patients with CHF with LVEF ≥50% are required. Deprescribing of beta-blockers also require further assessment.

The PACIFIC ontology for heterogeneous data management in cardiology

With the emergence of health data warehouses and major initiatives to collect and analyze multi-modal and multisource data, data organization becomes central. In the PACIFIC-PRESERVED (PhenomApping, ClassIFication, and Innovation for Cardiac Dysfunction – Heart Failure with PRESERVED LVEF Study, NCT04189029) study, a data driven research project aiming at redefining and profiling the Heart Failure with preserved Ejection Fraction (HFpEF), an ontology was developed by different data experts in cardiology to enable better data management in a complex study context (multisource, multiformat, multimodality, multipartners). The PACIFIC ontology provides a cardiac data management framework for the phenomapping of patients. It was built upon the BMS-LM (Biomedical Study -Lifecycle Management) core ontology and framework, proposed in a previous work to ensure data organization and provenance throughout the study lifecycle (specification, acquisition, analysis, publication). The BMS-LM design pattern was applied to the PACIFIC multisource variables. In addition, data was structured using a subset of MeSH headings for diseases, technical procedures, or biological processes, and using the Uberon ontology anatomical entities. A total of 1372 variables were organized and enriched with annotations and description from existing ontologies and taxonomies such as LOINC to enable later semantic interoperability. Both, data structuring using the BMS-LM framework, and its mapping with published standards, foster interoperability of multimodal cardiac phenomapping datasets.

Treatment Strategies for Chronic Coronary Heart Disease with Left Ventricular Systolic Dysfunction or Preserved Ejection Fraction-A Systematic Review and Meta-Analysis.

We conducted a systematic search to identify all randomized trials directly comparing invasive strategies with optimal medical therapy (OMT) in patients diagnosed with chronic CHD. Data from these trials were pooled using a random-effects meta-analysis. The primary outcome assessed was the all-cause mortality, while secondary endpoints included cardiovascular (CV) death, stroke, myocardial infarction (MI), and unplanned revascularization. This study was designed to assess the benefits of both invasive strategies and OMT in patients with preserved LV function and in those with LV systolic dysfunction. The statistical analysis of the data was conducted using the Review Manager (RevMan) software, version 5.4.1 (The Cochrane Collaboration, 2020). Twelve randomized studies enrolling 13,912 patients were included in the final analysis. Among the patients with chronic CHD and preserved LV systolic function, revascularization did not demonstrate a reduction in all-cause mortality (8.52% vs. 8.45%, p = 0.45), CV death (3.41% vs. 3.62%, p = 0.08), or the incidence of MI (9.88% vs. 10.49%, p = 0.47). However, the need for unplanned myocardial revascularization was significantly lower in the group following the initial invasive approach compared to patients undergoing OMT (14.75% vs. 25.72%, p < 0.001). In contrast, the invasive strategy emerged as the preferred treatment modality for patients with ischemic LV systolic dysfunction. This approach demonstrated lower rates of all-cause mortality (40.61% vs. 46.52%, p = 0.004), CV death (28.75% vs. 35.82%, p = 0.0004), and MI (8.19% vs. 10.8%, p = 0.03). In individuals diagnosed with chronic CHD and preserved LV EF, the initial invasive approach did not demonstrate a clinical advantage over OMT. Conversely, in patients with ischemic LV systolic dysfunction, myocardial revascularization was found to reduce the risks of CV events and enhance the overall outcomes. These findings hold significant clinical relevance for optimizing treatment strategies in patients with chronic CHD, contingent upon myocardial contractility status.

Left ventricular twist in patients with severe aortic stenosis: meaning and evolution after surgery

Abstract Background Structural and functional left ventricular (LV) remodeling is the result of myocardial adaptation to chronic pressure overload in patients with severe aortic stenosis (AS). Changes in LV rotational dynamics are supposed to occur due to increased afterload in order to maintain LV ejection fraction (EF) in this setting. However, data regarding rotational dynamics with AS severity and their evolution after aortic valve replacement (AVR) are scarce. Goal To describe LV twist in patients with severe AS according to LV remodeling and assess its evolution after surgical AVR. Methodology Single center prospective cohort study of patients with classical isolated severe AS referred to surgical AVR. Complete transthoracic echocardiography (TTE) and cardiac magnetic resonance (CMR) were performed before surgery for both valvular and LV remodeling assessment. TTE was performed at the 3rd to 6th post-operative month. LV twist was defined as the peak difference in systolic rotations of LV apex and base as viewed from the apex and calculated at bidimensional strain in short axis views. LV remodeling was categorized by CMR according to Figure 1. Correlation analysis was performed for indexes of AS severity and LV function. Results A total of 80 patients with classical high flow, high gradient, preserved LV EF (46% male; mean age 71 ± 8 years old; mean aortic valve [AV] gradient 61±17.6mmHg, mean AV area 0.73±0.18cm2 , mean LVEF: 58 ± 9%) were included. LV twist before surgery was 24.5 +/- 9.7% and this was modestly correlated with both LV flow (r = 0.315, p= 0.001) and AV gradients (r = 0.315, p = 0.013). Rotational indexes were no different across distinct types of LV remodeling. After AVR there was a significant decrease in LV twist (24.5 +/- 9.7% vs. 16.5 +/- 8.3%, p&amp;lt;0.001), despite significant improvement in global longitudinal strain (-14.7 ± 3.9% vs -16.1 ± 3.1%, p &amp;lt; 0.001) and maintenance of preserved LVEF (58 ± 9% vs 60 +/- 8%, p = 0.07). Conclusion As LV twist has an inverse relation to GLS after AVR, this may represent a compensatory mechanism for LVEF preservation in patients with severe AS. Rotational mechanics seems to be independent from structural LV remodeling in this setting.

Myocardial Work Appraisal in Transthyretin Cardiac Amyloidosis and Nonobstructive Hypertrophic Cardiomyopathy

Global left ventricular (LV) myocardial work (MW) indexes can be recognized at ultrasound imaging from the LV pressure/global longitudinal strain (GLS) loop analysis. A total of 4 indexes, global work index (GWI), global constructive work (GCW), global wasted work (GWW), and global work efficiency (GWE), have been demonstrated to overcome the methodological limitations of GLS and provide useful information on myocardial dysfunction in some clinical settings. Although impaired MW indexes have been demonstrated in patients with transthyretin cardiac amyloidosis (ATTR) or with nonobstructive hypertrophic cardiomyopathy (HCM), there are no comparative studies at present. This study aimed to describe the characteristics of MW in both these clinical settings compared with patients with well-controlled hypertension (HTN). A total of 83 patients, 32 with ATTR (aged 70 ± 11years, 32% mutated, 68% wild-type, 72% men), 29 with HCM (aged 57 ± 17years), and 22 HTN controls (aged 56 ± 5.6years, 59% men) were prospectively enrolled at 2 clinical centers. All participants had New York Heart Association class I or II. Overall, the LV mass index was greater in both study groups than in HTN, whereas the LV ejection fraction (EF) was significantly lower in ATTR compared with other groups. Based on this finding, patients with ATTR were further divided into 2 subgroups: ATTR1 (LVEF ≤0.50), n=14 (44%) and ATTR2 (LVEF >0.50), n=18 (56%). Overall, the GWI and GCW were lower in all ATTR patients (mostly in ATTR1) than in the other groups (p <0.001), whereas only small differences in GWE and none in GWW were found among the groups. Of interest, the pairwise comparison and receiver operating characteristic analysis in preserved LVEF patients showed that GWI was a better discriminator of ATTR2 from HCM patients than GLS, with the cut-off value ≤1,419 mm Hg% (89% sensitivity; 55% specificity; p=0.013). In conclusion, MW analysis was confirmed to be a modern way to investigate myocardial function in patients with hypertrophic phenocopies. GWI and GCW were more impaired in patients with ATTR compared with HCM and HTN controls. Furthermore, this study likely revealed an additional discriminative value of GWI over GLS alone in preserved LVEF settings.

Layer-specific strain in patients with cardiac amyloidosis using tissue tracking MR.

Cardiac infiltration is the major predictor of poor prognosis in patients with systemic amyloidosis, thus it becomes of great importance to evaluate cardiac involvement. We aimed to evaluate left ventricular myocardial deformation alteration in patients with cardiac amyloidosis (CA) using layer-specific tissue tracking MR. Thirty-nine patients with CA were enrolled. Thirty-nine normal controls were also recruited. Layer-specific tissue tracking analysis was done based on cine MR images. Compared with the control group, a significant reduction in LV whole layer strain values (GLS, GCS, and GRS) and layer-specific strain values was found in patients with CA (all P < 0.01). In addition, GRS and GLS, as well as subendocardial and subepicardial GLS, GRS, and GCS, were all diminished in patients with CA and reduced LVEF, when compared to those with preserved or mid-range LVEF (all P < 0.05). GCS showed the largest AUC (0.9952, P = 0.0001) with a sensitivity of 93.1% and specificity of 90% to predict reduced LVEF (<40%). Moreover, GCS was the only independent predictor of LV systolic dysfunction (Odds Ratio: 3.30, 95% CI:1.341-8.12, and P = 0.009). Layer-specific tissue tracking MR could be a useful method to assess left ventricular myocardial deformation in patients with CA.

Abstract #1413268: Prevalence of LV Diastolic Dysfunction in Patients of Type 2 Diabetes Mellitus with a Normal Systolic Function

To determine the incidence of LVDD in T2DM having a normal LV systolic function. The observational study was done to have an idea of the burden of underlying silent myocardial abnormality of heart failure with a preserved ejection fraction in T2DM. The aim of this study was to determine the prevalence of LVDD in a normotensive T2DM population with a preserved LVEF and importance of initiating early therapy with agents like SGLT2is Patients diagnosed with T2DM & disease duration of ≤2 years, on oral agents, underwent TTE and assessment of their LVEF and grading of LV diastolic dysfunction. LVEF was calculated by Simpson's method and LVEF ≥50% was considered as normal. All those having E:e' ≤8, (Grade I LV diastolic dysfunction/impaired relaxation) assessed by TDI were shortlisted. TTE and Doppler imaging, to assess left ventricular systolic and diastolic function was done. Echocardiography was performed by harmonic imaging mode by Acuson-Siemens-X 300 machine's cardiac probe according to the standard protocol. Exclusion criteria was for subjects with hypertension/on antihypertensives, evidence of CAD [excluded by history of angina, chest pain, ECG changes and abnormal TMT results], subjects with evidence of valvular disease, on insulin and HbA1c >9%. A total of 2,150 cases were assessed with the inclusion criteria stated above at the hospital, over a period of 4 years. Of the 2,150 cases included 56% (1204) were males, and 44% (946) were females. 72% (1548), [59% males and 41% females] had Grade I LV diastolic dysfunction. A normal pulse pressure (≤50 mm Hg) was observed in 580 patients (27%). The study concludes that there is a huge prevalence of LV diastolic dysfunction, in T2DM patients, which is an important risk factor increasing cardiac mortality, if not corrected early. As there is a strong evidence of the benefits of SGLT2is in reducing mortality and hospitalisation for heart failure in patients of T2DM with a preserved LVEF all these patients should be treated with them added on to OADs and LSM, unless contraindicated.

Impact of left atrial and diastolic ventricular dysfunction on mortality in patients with aortic stenosis

BackgroundDiastolic dysfunction (DD) is common in severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF≥50%). AimTo determine the impact of American Society of Echocardiography/European Association of Cardiovascular Imaging-recommended DD grading and left atrial strain on mortality in a cohort of patients with severe AS and preserved LVEF. MethodsWe studied patients with severe AS (aortic valve area indexed<0.6 cm2/m2 and/or aortic valve area<1cm2), LVEF≥50% and no or mild AS-related symptoms. The endpoint was all-cause mortality. ResultsA total of 387 patients (median age 76years; 53% women) were studied. During a median follow-up of 57 (interquartile range 37; 83) months, 158 patients died. After adjustment for prognostic factors, patients with grade II or III DD had an increased mortality risk versus patients with grade I DD (adjusted hazard ratio (aHR) 1.62, 95% confidence interval (CI) 1.11–2.38; P=0.013; aHR 4.73, 95% CI 2.49–8.99; P<0.001; respectively). Adding peak atrial longitudinal strain (PALS)≤14% to a multivariable model including DD grade improved predictive performance, with better global model fit, reclassification and discrimination. Patients with grade III DD or grade II DD+PALS≤14% displayed an increased mortality risk versus patients with grade I DD+PALS>14% (aHR 4.17, 95% CI 2.46–7.06; P<0.0001). Those with grade I DD+PALS≤14% or grade II DD+PALS>14% were at intermediate risk (aHR 1.63, 95% CI 1.07–2.49; P=0.024). ConclusionsOur results demonstrate the strong relationship between DD and mortality in patients with severe AS and preserved LVEF. Patients with grade III or grade II DD and impaired PALS are at very high risk. These data demonstrate the importance of a comprehensive assessment of diastolic function in patients with severe AS.

681 RIGHT ARM PAIN WITH RIGHT BUNDLE BRANCH BLOCK: SHOULD WE PERFORM TROPONIN ASSAY?

Abstract We present the case report of a 67 year old man with no previous cardiovascular history, who was admitted to our emergency department (ED) for two days onset of right arm pain which was not responsive to painkillers. On admission, he was asymptomatic for typical angina. His BP was 190/100 mmHg, HR 80 bpm, SpO2 99% and apyretic. The clinical examination was unremarkable. The ECG showed sinus rhythm, complete right-bundle-branch-block (RBBB) and left-axis deviation, negative T-waves in V1-V2 and positive T-waves in V3 &amp;gt; V6 (figure 1A) (no previous ECGs were available). The blood samples showed normal renal function and blood count. Surprisingly, there was a progressive rise in troponin I levels 0.023 &amp;gt; 0.061 &amp;gt; 0.38 ng/ml (ULN 0.010 ng/ml). Echocardiography revealed preserved LVEF without major regional wall motion abnormalities (RWMA), nor any valvulopathy. Despite the atypical presentation and ECG, the troponin rise was strongly suggestive for an acute coronary syndrome (ACS), so the patient was sent to the Cath lab to undergo coronary angiography (CAG). At the time of the CAG he was asymptomatic. The exam revealed thrombotic occlusion of mid-segment left anterior descending artery (LAD). Primary PCI with DES implantation was performed obtaining TIMI 3 flow (figure2). The remaining hospital stay was uneventful, the patient was discharged asymptomatic after 4 days. Pre-discharge echocardiography reported normal LVEF with no RWMA. Discharge ECG showed persistency of the RBBB with negative T-waves from V1 to V4 (figure 1B). On 3 months follow up visit the patient is asymptomatic with preserved LVEF. On ECG there is persistency of RBBB and normalization of the T-waves in the precordial leads (figure 1C). Discussion This case report is an atypical presentation of acute thrombotic occlusion of an epicardial coronary artery, without the typical ST segment elevation (STEMI equivalent) and without the typical angina. RBBB may represent an uncommon ECG presentation of acute myocardial ischemia, with an incidence from 2 to 6% overall, with TIMI 0 flow in the infarct-related artery only in half of the cases. RBBB (especially new or presumably new onset RBBB) is also associated with increased mortality and morbidity, possibly due to delay in diagnosis and primary reperfusion strategies. Troponin dosage was fundamental to understand that we were facing an acute coronary syndrome, however we were not expecting complete occlusion of the LAD. In conclusion, the presence of RBBB on admission may delay primary reperfusion strategies, especially when symptoms are atypical. However, in case of unresponsive pain and presumably new-onset conduction disturbances on ECG it is mandatory to perform troponin assay and therefore drive the correct timing of coronary revascularization.

Magnetic resonance hemodynamic forces predict pathological LVEDP in preserved LV-EF

Increased left ventricular end-diastolic filling pressures (LVEDP) are a hallmark of heart failure with preserved ejection fraction (HFpEF). Thus far, assessment relies on invasive measurement, subjecting the patient to the inherent risks and limitations of the method. Hemodynamic forces (HDF), a marker of the exchange of forces between intracardiac blood and surrounding myocardium, as assessed by cardiovascular magnetic resonance (CMR) is a promising tool to non-invasively evaluate diastolic dysfunction in heart failure with preserved ejection fraction.

External validation of the ACUTE HF score for risk stratification in acute heart failure

BackgroundThe ACUTE HF score is a simple risk score that predicts the prognosis of patients with acute heart failure (HF) using clinical and echocardiographic parameters. As this score was developed for a small European population, we aimed to validate this score in an external population. Methods and resultsThis retrospective observational cohort analysis included patients hospitalized with acute HF during 2015–2019. Of 744 patients, 703 patients with available ACUTE HF scores were analyzed (75 ± 13 years; 61% male; left ventricular ejection fraction [LVEF] 49 ± 17%). Approximately one-third (34.4%) of the patients had reduced LVEF (<40%), and 51.4% exhibited preserved LVEF (≥50%). During a median follow-up of 452 days, primary and secondary outcomes were observed in 110 and 204 patients, respectively. The ACUTE HF score successfully stratified patients for primary (all-cause mortality) and secondary endpoints (a composite of all-cause mortality and heart failure rehospitalization) in Kaplan–Meier analyses (log-rank test, P < 0.001). Multivariable Cox proportional hazards models showed that the score was significantly independently associated with both primary and secondary endpoints after adjusted by covariates (P < 0.001). ConclusionWe validated the risk prediction ability of ACUTE HF score in an Asian population. This score may be applicable in clinical practice.

Association between DLCO index and the severity of heart failure: a cross-sectional study

Background The prognostic role of diffusing capacity of the lung for carbon monoxide (DLCO) in heart failure has not been thoroughly investigated. Therefore, this study aimed to evaluate DLCO variation in different systolic and diastolic heart failure stages. Methods This was a prospective cross-sectional study on 51 patients with systolic (reduced LVEF) or diastolic (preserved LVEF) chronic heart failure (CHF). All patients underwent a standard DLCO test. The associations between the severity of heart failure and reduced carbon monoxide transfer factor (TLCO), carbon monoxide transfer coefficient (KCO), and alveolar volume (VA) were investigated. Data were analysed using SPSS software version 16. p-Values below 0.05 were considered statistically significant. Results The mean age of participants was 59.29 ± 14.91 years, with 72% of the study population being male. Systolic heart failure was observed in 47% of patients, diastolic heart failure in 18%, and a mixed systolic and diastolic pattern in 35%. There were significant differences between TLCO percentage in patients with CHF types and the New York Heart Association (NYHA) functional classes (p = 0.042). Overall, an ejection fraction (EF) of less than 25% correlated with 3%, 53%, and 0.78 declines in TLCO, KCO%, and KCO index, respectively. Conclusion Despite the lack of statistically significant differences between DLCO indices and CHF severity, decreased DLCO parameters correlated with reduced EF. Therefore, DLCO testing might be helpful to predict HF severity.

Left ventricular dyssynchrony as marker of early dysfunction in premature ventricular contraction-induced cardiomyopathy.

BackgroundStrain imaging has been suggested as a tool to detect early left ventricular (LV) dysfunction due to frequent premature ventricular contractions (PVCs) in patients with preserved LV ejection fraction (EF). However, the progression of intraventricular dyssynchrony (IVD), radial, and circumferential strain (RS, CS) in PVC-cardiomyopathy (CM) are unknown. The aim of this study was to elucidate the progression patterns of CS, IVD, and electro-mechanical latency (EML) in PVC-CM.Methods and resultsPacemakers were implanted in 20 canines to reproduce ventricular bigeminy at 200ms (PVCs n = 11) for 12 weeks and compared to a sham group (n = 9). We obtained echocardiograms at baseline, 4-, 8- and 12-weeks. RS and CS were obtained at the LV mid-cavitary level. IVD was defined as the time between the earliest and latest peak RS. EML was defined as the time between the onset of QRS and the earliest peak RS. LVEF (62 ± 5 to 42 ± 7%, p < 0.01), CS (–18 ± 3 to –12 ± 3, p < 0.01), and EML (219 ± 37 to 283 ± 46ms, p = 0.02) changed significantly in the PVC group. Peak CS (–18 ± 3 to –14 ± 4, p = 0.02) and IVD (49 ± 31 to 122 ± 103, p = 0.05) had a significant change at 4-weeks despite preserved LVEF (51 ± 5%). IVD normalized while EML increased at weeks 8 and 12.ConclusionOur findings consolidate the existing theory that changes in strain precede changes in LVEF in PVC-CM. While IVD becomes abnormal early in the development of PVC-CM, it pseudo-normalizes at advanced stages due to further increases in EML suggestive of cardiac contractility remodeling. These findings are consistent with recent published data where abnormal LV mechanics could be part of a substrate that can predispose to worse outcome in PVC-Cardiomyopathy.

P300 ACUTE MYOCARDITIS COMPLICATED BY VENTRICULAR ARRHYTHMIAS

Abstract Background Many kinds of arrhythmias may occur in patients with myocarditis at any stage of the disease. However, as compared to the other clinical presentations, arrhythmic myocarditis has been poorly described in literature. Case Report A 20–year–old girl, without CVRF or comorbidities, presented at the ED because of palpitations and epigastric pain irradiated to left arm. 12–lead ECG evinced elevated HR and aspecific repolarization abnormalities. Blood samples showed high cTn value and normal PCR value. Echocardiography showed a preserved LVEF, without abnormalities. Patient was hospitalized with a diagnosis of suspect acute myocarditis. Following hospital stay has been complicated by recurrent episodes of chest pain with concomitant increase of cTn that finally had presented a sinusoidal trend (peak 12830ng/L). At the same time, continuous ECG monitoring has been showing frequent but short term ventricular extrasystole activity, so B–blocker therapy was optimized. On ECG monitoring, appearance of short runs of asymptomatic mono– and polymorphic NSVT and after a few days appearance of polymorphic NSVT “torsade de pointes” like, symptomatic for presyncope. New changes in kinetics appear on the echocardiogram: hypokinesia of medio–apical segments of lateral, anterior wall septum. Therapy with metoprolol and lidocaine iv was started with subsequent stabilization of the rhythm. CMR presented data suggestive of myocarditis. Patient performed several BEM at different time and centers: diagnostic signs of myocarditis were not be found. Autoimmune and infectious disease screening, abdominal echography and a PET TC total body were been performed to research a potential etiology, without positive result. Patient has been discharged with wearable defibrillator and we waited for the ICD implantation in secondary prevention. Follow–up CMR showed a resolution of inflammation and no signs of fibrosis. Blood samples did not demonstrate a rise of cTn. After discharged, she has not had news onset of ventricular arrhythmias. Conclusion The mechanisms underlying the occurrence of ventricular arrhythmias during myocardial inflammation are less clear. Arrhythmias usually being self–limited with no recurrences that follow the acute phase. Management of acute life–threatening arrhythmias is generally supportive and there is a lack of evidence to support the use of specific antiarrhythmic agents. Wearable life vest has been presented as a possible therapeutic option.

Characteristics of bradyarrhythmia in patients with COVID-19: Systematic scoping review.

COVID‐19 has recently been associated with the development of bradyarrhythmias, although its mechanism is still unclear. We aim to summarize the existing evidence regarding bradyarrhythmia in COVID‐19 and provide future directions for research. Following the PRISMA Extension for Scoping Reviews, we searched MEDLINE and EMBASE for all peer‐reviewed articles using keywords including“Bradycardia,” “atrioventricular block,” and “COVID‐19″ from their inception to October 13, 2021. Forty‐three articles, including 11 observational studies and 59 cases from case reports and series, were included in the systematic review. Although some observational studies reported increased mortality in those with bradyarrhythmia and COVID‐19, the lack of comparative groups and small sample sizes hinder the ability to draw definitive conclusions. Among 59 COVID‐19 patients with bradycardia from case reports and series, bradycardia most often occurred in those with severe or critical COVID‐19, and complete heart block occurred in the majority of cases despite preserved LVEF (55.9%). Pacemaker insertion was required in 76.3% of the patients, most of which were permanent implants (45.8%). This systematic review summarizes the current evidence and characteristics of bradyarrhythmia in patients with COVID‐19. Further studies are critical to assess the reversibility of bradyarrhythmia in COVID‐19 patients and to clarify potential therapeutic targets including the need for permanent pacing.