Regional Wall Motion Abnormalities Research Articles

Abstract 11015: Pacemaker Lead Insertion Sites Contribute to Regional and Global Ventricular Dysfunction

Introduction: Ventricular pacing can cause dysfunction but how the lead is anchored to the myocardium has not been studied. We evaluated patterns of regional and global ventricular function in patients with a ventricular pacemaker or defibrillator using cine cardiac CT (CCT). Methods: This was a single center retrospective study of patients with a ventricular pacemaker or defibrillator who underwent a cine CCT from September 2020 to June 2021. Regional wall motion abnormalities (RWMAs) were assessed in relation to lead insertion site (sew-on vs screw-in) and pacing activity (active vs. inactive). Results: A total of 122 ventricular lead insertion sites were analyzed in 43 patients (53% male, median age 20 years, range 3-57 years). Thirteen patients (30%) had palliated single ventricle physiology, twenty-nine patients had congenital heart disease with biventricular circulation (67%), and one patient had a structurally normal heart (2%). RWMAs were present in 51/122 (42%) lead insertion sites among 23/43 (53%) patients. The prevalence of a lead insertion site associated RWMA was higher with active pacing (54% vs 19%; p < 0.001) and highest for active epicardial sew-on sites ( Figure 1 ). RWMAs were not associated with position of the insertion site relative to the chest wall (p = 0.85) or the distance between the two heads of a bipolar lead (p = 0.23). Patients with lead insertion site associated RWMAs had a lower systemic ventricular ejection fraction (mean of 37.5% vs 52.5%, p < 0.001) compared to those without a RWMA. Conclusions: Pacemaker lead insertion site RWMAs are common and associated with systemic ventricular dysfunction. The mechanism and clinical significance of this regional and global dysfunction warrant further study.

Abstract 12059: Speckle-Tracking Echocardiography Derived Global Circumferential Strain Predicts Adverse Outcomes in Cardiac Sarcoidosis With Preserved Ejection Fraction

Introduction: Risk stratification in cardiac sarcoidosis (CS) remains challenging, especially in those with preserved left ventricular ejection fraction (LVEF). Myocardial strain parameters are more sensitive than LVEF for detecting early sub-clinical myocardial dysfunction, but their prognostic value in CS is not known. Methods: We investigated consecutive newly diagnosed CS patients between 2015 and 2018. All patients underwent 2D echocardiography including global longitudinal strain (GLS) and global circumferential strain (GCS) measurement, cardiac magnetic resonance (CMR) for late gadolinium enhancement (LGE) and FDG-PET imaging to derive the maximum standard uptake value (SUVmax). The LGE score was quantified as the number of myocardial segments with LGE. Major adverse cardiac events (MACE) were all-cause death, sustained ventricular arrhythmia (VA), device implantation and new onset heart failure (HF) admission. Results: A total of 120 patients were included with age of 55±12 years; 87% were Caucasian, 43% had hypertension and 13% had diabetes. Mean LVEF was 55±12.3%, GLS was -13.4±4.2%, GCS was -16.0±5.6% and regional wall motion abnormalities (RWMA) occurred in 36% of cases. During median follow-up of 4.3 years, 43 patients experienced MACE consisting of 15 deaths, 19 VAs, 7 devices and 2 HF admissions. In multivariate analysis syncope, ethnicity, echo-derived left atrial volume and RWMA were independent predictors of MACE along with CMR-derived right ventricular EF and LGE score. Although GLS and GCS were lower in those with MACE, neither had independent prognostic value. SUVmax was also not predictive of events. In a subgroup analysis of the 86 patients with LVEF ≥50%, 20 patients experienced MACE. Multivariate analysis showed non-Caucasian ethnicity (HR 3.18 [95% CI 1.02-9.88]; P = 0.04), RWMA (HR 3.76 [95% CI 1.29-10.98]; P = 0.02), LGE-score (HR 1.26 95% CI 1.05-1.51]; P = 0.01 and GCS (HR 1.18 [95% CI 1.04-1.36]; P = 0.01) were independent predictors of MACE. A GCS value above the optimal cut-off of -16.4% was associated with a worse outcome (log-rank P = 0.005). Conclusion Ethnicity, RWMA and LGE-score are robust markers of outcome in newly diagnosed CS. Reduced GCS provides additional prognostic information in those with preserved LVEF.

Abstract 10445: Detection of Viability and Clinical Implications Using Pet/Mri in Patients With Acute Myocardial Infarction

Background: The purpose of this study is to evaluate the role of viability on PET-MRI to predict improvement of echocardiographic findings such as regional wall motion index and left ventricular ejection fraction after successful percutaneous coronary intervention (PCI) for patients with acute myocardial infarction (AMI). Method: A total of 154 patients with AMI who was performed cardiac PET/MRI within 7 days after PCI were enrolled were enrolled. We performed TTE twice before and after in We performed TTE twice before and after PCI in 103 patients. We categorized these patients according to presence of viability on PET-MRI: group A (N=53, patients with viability on PET-MRI) and group B (N=50, patients without viability on PET-MRI) and compared. The primary end point is improvement of regional wall motion abnormality (RWMA) on TTE. Results: Clinical and angiographic findings were similar between the two groups during follow-up of 11months. Among 53 patients in group A, 30 patients (56.6%) showed the result of slight improvement of RWMA on TTE and among them 13 patients (24.5%) showed result of disappeared RWMA on TTE. In contrast, among 50 patients in group B, 22 patients (44%) showed the result of slight improvement and among them, only 4 patients (8%) showed result of disappeared RWMA on TTE. The proportion of patients who showed slight improvement of RWMA between two groups are not statistically significant (p=0.201). But, the proportion of patients who showed disappeared RWMA between two groups are statistically significant (p=0.024). Conclusions: PET/MRI is useful tool to detect viability in patients with AMI. It seems to be predictable to improve cardiac function for the patients with viability on PET-MRI.

Abstract 12919: Stress Induced Cardiomyopathy After the Covid-19 Vaccine

Introduction: The SARS-CoV-2 virus has potential to cause acute and long-term cardiac effects. The vaccines were developed to prevent severe illness, but there are concerns about vaccine related side effects. Specific to the heart there have been case reports of mRNA vaccine related cardiomyopathies, particularly myocarditis. We present a case of a patient with presumptive stress induced cardiomyopathy in the setting of recent Covid-19 mRNA vaccination. Case Presentation: A 93-year-old female with a past medical history of hypertension presented with worsening shortness of breath and bilateral lower extremity edema. She received her second dose of the Covid-19 mRNA vaccine five days prior to presentation. She had no history of heart disease, was a nonsmoker, and denied alcohol or drug use. In the ED she was noted to be fluid-overloaded, and her CT chest showed minimal coronary calcification and bilateral pleural effusions. She was admitted for heart failure exacerbation and started on IV furosemide. Her transthoracic echocardiogram showed an ejection fraction of 40-45%. The pattern of left ventricular dysfunction was consistent with stress induced cardiomyopathy with apical akinesis and basal sparing of the left ventricular wall segments. Cardiology was consulted and recommended management with diuretics and beta blocker. She had a diuresis of 5 liters during her hospitalization. At clinic follow-up, dyspnea had improved, and her peripheral edema had resolved. Repeat echocardiogram showed recovery of left ventricular ejection fraction to 61% by Simpsons biplane technique with no regional wall motion abnormalities. Further cardiac assessment to evaluate for obstructive coronary artery disease and myocarditis was discussed and offered to the patient but was declined due to her positive response to conservative management. Discussion: The precise etiology of stress induced cardiomyopathy is unknown, but it is thought to be secondary to the sudden release of stress hormones. There are isolated reports of stress induced cardiomyopathy associated with Covid-19 vaccination, but the potential mechanism is unclear. An improved understanding of the potential effects of mRNA vaccines may help guide decisions regarding future booster vaccinations.

Abstract 12668: Coronary CTA Finding of Libman Sacks Endocarditis Presenting as Chest Pain

Case Presentation: A 65-year-old female with a history of hypertension, hyperlipidemia, microscopic colitis, fibromyalgia, left hand dupuytren's contractures, Grave’s disease and seronegative rheumatoid arthritis presented to the outpatient office for evaluation of right sided stabbing and heavy chest pain. ECG showed sinus bradycardia without any ST segment changes. She had an Echo and exercise stress Echo prior to her office visit. Her echo showed normal left ventricular size and systolic function with no regional wall motion abnormality and thickened aortic valve with mild aortic stenosis (peak transvalvular gradient 9.9 mmHg and mean 5.9 mmHg). Her stress echo was negative for ischemia although submaximal (exercised for 6.05 minutes, achieving only 75% MPHR, and double product of 18720). It was then decided to pursue a coronary CTA given the suboptimal nature of her stress testing and intermediate pretest probability of coronary artery disease. This revealed mild-to-moderate non-obstructive CAD and thickening of her left coronary cusp. The thickening was concerning for Libman-Sacks endocarditis vs native aortic valve thrombosis (see figure). Her Antinuclear antibody (ANA) titers was 1280. She was started on therapeutic anticoagulation with a plan for repeat imaging in six months. Discussion: Coronary cusp thickening represents a variety of differentials and has comparable structural and clinical qualities. Atypical chest pain in our patient led to the incidental finding of left coronary cusp thickening. In the presence of elevated ANA and her autoimmune disorder, Libman-Sacks endocarditis vs native aortic valve thrombosis was suspected hence the initiation of anticoagulation. Both have a propensity for fatal outcomes including, but not limited to myocardial infarction, embolic events, cardiogenic shock, or death. Follow-up imaging with a resolution of thrombus would confirm the diagnosis of native aortic valve thrombus.

Abstract 11062: Temporal Change of Severity of Atrial Functional Mitral Regurgitation

Introduction: Left atrial (LA) remodeling due to long burden of atrial fibrillation can cause atrial functional mitral regurgitation (A-FMR). However, longitudinal echocardiographic follow-up of patients with A-FMR has rarely been reported. Methods: We retrospectively identified 23 outpatients diagnosed with significant (≥ moderate) A-FMR on transthoracic echocardiography (TTE), with at least two studies performed more than one year apart. A-FMR was defined as 1) left ventricular ejection fraction ≥ 50% without regional wall motion abnormalities; 2) absence of primary valvular pathology; and 3) presence of atrial fibrillation. We excluded patients with significant aortic valve disease or mitral stenosis, treated valvular or congenital disease, any form of cardiomyopathy or carditis, or previous heart transplant. Follow-up was censored at the time of any interventions for valvular disease. The mitral regurgitation (MR) severity was graded based on the current guidelines, and classified as none (0); mild (1+); moderate (2+); moderate-to-severe (3+); or severe (4+). The change (Δ) of the echocardiographic variables between baseline and latest follow-up was assessed. Results: The median observation period was 3.4 [interquartile range: 2.6-6.6] years. At baseline, the mean LA diameter was 51 ± 7 mm and MR vena contracta width was 4.4 ± 1.1 mm. As shown in Figure 1a, 1b , there was a moderate positive correlation between observation period and Δ LA diameter (r = 0.504, P = 0.014). However, there was no significant correlation between observation period and Δ MR vena contracta width (r = -0.041, P = 0.85). During the observation period, guideline-based MR severity progressed in 4 (17%), unchanged in 12 (52%), and decreased in 7 (30%). The MR severity was not significantly different between baseline and follow-up (P = 0.60) ( Figure 1c ). Conclusion: In patients with A-FMR, LA size increased over time, whereas the severity of A-FMR did not progress significantly over time.

A Case of Type 2 MI with Normal Coronary Arteries: Case Report & Literature Review

Clinicians have long recognized that acute myocardial infarction (MI) can occur in the absence of atherothrombosis . The Universal Definition of MI Global Taskforce introduced a classification system in 2007 (and reaffirmed in 2012) that defined type 2 MI (following standard diagnostic criteria) as MI occurring due to an imbalance in myocardial oxygen supply and/or demand not caused by atherosclerotic plaque disruption. Nevertheless, ambiguity remains regarding how to diagnose type 2 MI and how to distinguish it from both type 1 MI and myocardial injury. Here we report a case of a 23 year old young woman attended to emergency department, with typical chest pain and shortness of breath for 6 hours, Diarrhoea for 2 days, and single time loss of consciousness for 5 minutes, 6 hours before attending to hospital. Cardiac enzymes were rising titres in subsequent samples, Serum Creatinine was also high. Echocardiography performed 36 hour later, showed no regional wall motion abnormality, coronary angiogram showed normal coronary arteries. So, a diagnosis of Myocardial Infarction (Type 2 MI) with Non Obstructive Coronary Artery (MINOCA) was made, and MINOCA was attributed to hypovolemic shock (resulting from Dirrrahoea), manifested as MI, Syncope and AKI.
 University Heart Journal 2022; 18(2): 128-131

Abstract 13870: Ventricular Fibrillation Arrest in a 27-Year-Old Woman Due to Takotsubo Cardiomyopathy

Introduction: Sudden cardiac death in young patients may be due to coronary artery disease, primary electrical disease, cardiomyopathy, or congenital anomalies. We explore potential causes for sudden cardiac arrest in a young patient. Case Description: A 27-year-old woman was found unconscious. Initial rhythm showed ventricular fibrillation. Cardiopulmonary resuscitation was done for 5 minutes before return of spontaneous circulation. ECG showed ST elevations in aVL, V4, and V5. She was admitted for therapeutic temperature management. Troponin peaked at 1.86 ng/mL on the evening of arrival. Transthoracic echocardiography (TTE) demonstrated hypokinesis of the mid to distal septum, anterior wall, and apex (Figure 1). Repeat TTE 3 days later showed resolution of the wall motion abnormalities. She reported marijuana use and a domestic dispute with her significant other the night prior. Coronary CT angiography showed calcium score of 0 with normal coronary anatomy, no significant coronary artery stenosis, and incidental finding of bilateral pulmonary artery filling defects. Lower limb venous duplex was unremarkable. Therapeutic dose of enoxaparin was started. Cardiac MRI showed no myocardial infarction, scar, or infiltrative disease. An electrophysiology study revealed adequate QT shortening during epinephrine infusion and no inducible ventricular arrhythmias. Genetic testing was unremarkable. She was discharged with a wearable defibrillator before ultimately receiving a subcutaneous implantable cardioverter-defibrillator. Discussion: The presentation of transient regional wall motion abnormalities, with ST-segment elevations and negative ischemic workup, is highly suggestive of Takotsubo cardiomyopathy, mid-ventricular variant. Marijuana use is a risk factor, and the domestic dispute is a potential emotional trigger. This case highlights Takotsubo cardiomyopathy as a possible cause of sudden cardiac arrest in young patients.

Abstract 13369: Takotsubo Cardiomyopathy Following Electroconvulsive Therapy

Case Presentation: A 71-year-old woman presented to our institution for treatment-refractory depression requiring electroconvulsive therapy (ECT). She underwent a transthoracic echocardiogram (TTE) during a pre-ECT evaluation, which demonstrated no regional wall motion abnormalities and a left ventricular ejection fraction (LVEF) of 60 - 65%. The patient subsequently underwent ECT. During the procedure, sinus tachycardia with associated ST-segment changes were noted on telemetry. Esmolol was administered with subsequent improvement in her tachycardia, however ST-segment changes persisted. A twelve-lead electrocardiogram was obtained and was notable for new T-wave inversions in leads V1-V4 and Q-waves in leads III and aVF. However, STEMI criteria was not met. A TTE obtained shortly after her ECT demonstrated ballooning of the LV apex and an LVEF of 35%, consistent with takotsubo cardiomyopathy. Laboratory evaluation was notable for a high sensitivity troponin peak of 130 ng/L and a brain natriuretic peptide level of 746 pg/mL. Cardiac catheterization was not performed as the patient had a negative stress test prior to admission. The patient’s symptoms improved over the next two days, and she was discharged with close outpatient follow-up. Discussion: Takotsubo cardiomyopathy occurs following physical or psychological stress. Greater than half of patients with takotsubo cardiomyopathy have neurologic or psychiatric disorders. Takotsubo cardiomyopathy is an increasingly recognized serious complication of ECT and can be seen in post-menopausal women with depression. The introduction of beta blocker therapy has been used to prevent recurrent episodes of post-ECT takotsubo cardiomyopathy. Despite this, there are reports of post-ECT takotsubo cardiomyopathy in patients on chronic beta blocker therapy. Thus, the risks and benefits of proceeding with additional ECT treatments must be weighed after an initial episode of takotsubo cardiomyopathy.

PSAT006 Two Cases of Pheochromocytoma Associated Takotsubo Syndrome- Importance of Early Recognition and Treatment

Abstract Introduction Pheochromocytoma is a rare catecholamine producing adrenal medullary tumor that classically presents with hypertension. Takutsubo cardiomyopathy (TC) is a rare but increasingly recognized presentation of pheochromocytoma. We present two cases of TC likely caused by pheochromocytoma. Case 1 A 60 y/o male who presented with acute onset nausea, vomiting and abdominal pain. Systolic BP was 150-160 mm Hg, and diastolic BP was 100 mmHg. Troponin was elevated (4.15 ng/ml; nl = 0-0.04). An echocardiogram showed a reduced left ventricular ejection fraction (LVEF) of 15-20% (nl = 50-75%), a mildly dilated left ventricle, and apical ballooning suggestive of TC. Coronary arteries were normal on cardiac catheterization. CT scan identified a 5.3×5.6×5.7 cm adrenal mass of 50 HU pre-contrast. Further evaluation revealed markedly elevated plasma metanephrine concentration of 858 pg/ml (nl<57) and normetanpehrine concentration of 1729 pg/ml (<148). His presentation was strongly suggestive of pheochromocytoma associated TC. He was prepared for surgery with doxazosin 2 mg twice daily followed by metoprolol succinate and metyrosine up to 500 mg/d. Final pathology revealed a 5.3 cm left pheochromocytoma with negative surgical margins. Germline genetic testing was negative for pheochromocytoma/paraganglioma pathogenic gene mutations, and an MIBG scan did not reveal metastatic disease. Echocardiogram one month after adrenalectomy showed a marked improvement in LVEF to 55-60% with no regional wall motion abnormalities, and plasma metanephrine concentrations normalized. Case 2 A 61 y/o female smoker with type 2 diabetes mellitus, hypertension, Graves disease and obesity presented with sudden onset of nausea followed by chest discomfort, bilateral shoulder discomfort and shortness of breath. Troponin was 0.6 ng/ml (nl = 0-0.04), EKG showed ST elevations in leads I, 2, V5 V6 with hyperacute T waves. Coronary arteries were normal on catheterization. She required intubation, and systolic BP ranged from 110 to 200 mm Hg. On echocardiogram the LVEF was 35% to 40% (nl = 50-75), and there was diffuse hypokinesis of the mid to apical LV myocardium with hypercontractility of the LV base, suggestive of TC. The plasma metanephrine concentration was 3.31 nmol/l (nl= 0-0.49), and normetanephrine concentration was 5.02 nmol/l (nl= 0-0.89). CT imaging revealed a 2.9 cm left adrenal mass. She underwent successful left adrenalectomy after preparation with alpha, beta blockade and metyrosine. Germline genetic testing was negative for pheochromocytoma/paraganglioma pathogenic gene mutations . Echocardiogram nine months post-adrenalectomy showed normal EF of 50-55% and resolution of apical hypokinesis. Discussion We present two pheochromocytoma patients presenting with TC that reversed following appropriate pheochromocytoma management. Few case series report the association of pheochromocytoma and TC. These patients usually present acutely without prodromal stressors commonly found with classic TC. Conclusion In the setting of TC, pheochromocytoma should be considered. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Differential diagnosis of angina pectoris in the practice of the regional vascular center: a clinical observation

The leading cause of myocardial ischemia in case of coronary atherosclerosis and coronary vasospasm combination in one patient is difficult to establish. However, it is important to know for optimal treatment strategy: choosing between beta-blockers and calcium channel blockers as a preferred treatment, need for percutaneous coronary intervention. We present a case of a 56-yearold patient who was admitted with acute coronary syndrome without ST-segment elevation, low Killip class, and low GRACE score. Stress echocardiography revealed inducible transmural myocardial ischemia (regional wall motion abnormalities and ST segment elevation on the ECG) accompanied by polymorphic ventricular tachycardia. The coronary angiography showed single-vessel moderate stenosis in the left anterior descending artery. There were no changes in comparison with previous angiography. The patient was considered to have vasospastic angina. A probable mechanism is coronary artery spasm at the site of the atherosclerotic plaque. The article is discussed the difficulties in diagnosing vasospastic angina, especially in the presence of borderline stenosis in the coronary artery. We reviewed similar cases and discussed the difficulties of a vasospastic angina diagnosis especially in the presence of moderate coronary artery stenosis, the role of the provocative tests, and the pharmacological management. Demonstrating, discussing and analyzing cases of patients with a combined mechanism of myocardial ischemia is substantiated for further improving their diagnosis and treatment.

Strain Analysis Using Speckle Tracking Echocardiography for Detection of Coronary Artery Disease in Stable Angina Patients with No Regional Wall Motion Abnormality at Rest

Background: Speckle-tracking imaging is a novel method for assessing left ventricular (LV) function and ischemic changes. The aim of this study was to predict the presence of coronary artery disease by longitudinal 2D strain analysis using speckle tracking echocardiography in patients with stable or unstable angina with no regional wall motion abnormality at rest. Objectives: Objective of this study is to predict the presence of significant CAD in a patient with no regional wall motion abnormality by longitudinal 2D strain analysis using speckle tracking echocardiography. Methods: This cross-sectional study included a total 66 patients (mean age, 51.92±8.9 years) with suspected CAD without RWMA on resting echocardiography who underwent coronary angiography. Longitudinal 2D strain analysis by STE was performed in all patients before coronary angiography. Global and segmental peak systolic longitudinal strain (PSLS) were recorded & computed by offline dedicated software semi-automatically on bull’s-eye report. The patients were divided into two groups according to the coronary angiographic findings; group- I: significant CAD on coronary angiogram (n=35), group-II: normal coronaries on CAG (n=31).All the baseline characteristics and outcome were then compared between the two groups. Results: PSLSs of all left ventricular segments were obtained successfully in 66 patients. PSLS (both global and segmental) was significantly decreased in patients with significant CAD on CAG group. Receiver operating characteristic (ROC) curve analysis demonstrated that global PSLSs could effectively detect patients with CAD (area under ROC curve = 0.877, 95% CI=0.749–0.960). According to ROC curve analysis, -18.77% appeared to be a good cutoff value for predicting those with significant CAD (specificity 77.4% and sensitivity 82.9%). Conclusion: Global and segmental PSLS using speckle tracking echocardiography at rest was significantly lower in patients with CAD without RWMA, and might be useful for identifying patients with a significant CAD with good degree of sensitivity and specificity.

Heart rate reserve complements regional wall motion abnormality for predicting outcome in hypertensives during stress echocardiography

Abstract Background Stress echocardiography (SE) was recently upgraded to include imaging-independent heart rate reserve (HRR) which assesses cardiac sympathetic balance and is simply based on one-lead electrocardiogram present in the echo monitor. The value of HRR for risk stratification of hypertensive patients remains undetermined. Aim To assess the prognostic value of SE with HRR in hypertensive patients in a prospective, large scale, multicenter, international, effectiveness study. Methods From July 2016 to December 2020, we enrolled 2747 hypertensives (age 66±10 years, 1599 males, 58.2%; ejection fraction 61±8%) referred from 12 certified laboratories. All patients underwent clinically indicated SE. The employed stress modality was exercise (n=754) or pharmacological stress (n=1993). Exercise modality was either semi-supine bike (n=674) or treadmill (n=80). Pharmacological stress was either vasodilator (n=1695, 1661 with dipyridamole and 34 with adenosine) or dobutamine (n=298). SE response included the evaluation of regional wall motion abnormality (RWMA) and non-imaging HRR (peak/rest heart rate), with stress-specific cutoff values abnormal response <1.80 for exercise or dobutamine, <1.22 for dipyridamole or adenosine. All-cause death was the only end-point. Results Rate of abnormal results was 17% for RWMA and 40% for HRR. During a median follow-up of 624 days (interquartile range: 380–1037 days), 60 deaths occurred. Global X2 was 25.0 considering clinical and resting echocardiographic variables, with no change after stress-induced RWMA and a significant increase after HRR (Figure 1). Annual mortality rate was 0.7% person/year for patients (n=1496) with normal HRR and absence of stress-induced RMWA, 0.4% for patients (n=151) with RWMA and normal HRR, up to 2.1% person/year for patients (n=1101) with abnormal HRR with (n=321) or without (n=780) RWMA. At multivariable analysis, only age (HR: 1.070, 95% CI: 1.039–1.101, p<0.001) and abnormal HRR 2.651 (HR: 2.651, 95% CI: 1.550–4.543, p<0.001) showed independent value in predicting survival. Conclusion SE with either exercise or pharmacological stress allows an effective prediction of survival in hypertensive patients with chronic coronary syndromes, but only when the conventional criterion of RWMA is complemented with imaging-independent HRR. Funding Acknowledgement Type of funding sources: None.

Prognostic value of coronary flow and heart rate reserve in emergency department chest pain

Abstract Aims To estimate the prognostic value of stress echo (SE) with the assessment of coronary flow velocity reserve (CFVR) and heart rate reserve (HRR) in patients admitted for chest pain with non-diagnostic EKG, negative troponin, and without inducible regional wall motion abnormalities (RWMA). Methods 658 patients (age 67±12 years) admitted to our Emergency Department with chest pain, non-diagnostic EKG, and negative serial troponin underwent dipyridamole (0.84 mg/kg in 6') SE with simultaneous assessment of RWMA, CFVR in the left anterior descending artery, and HRR as peak/rest heart rate. The outcome measure was all-cause mortality. Results Of the 658 patients initially enrolled, 20 (3%) showed RWMA during SE and were referred to ischemia-driven revascularization. In the remaining 638, CFVR was abnormal (<2.0) in 148 patients (23%). HRR was abnormal (<1.22 in patients in sinus rhythm, or <1.17 in patients with permanent atrial fibrillation) in 196 patients (31%). The main clinical and echocardiographic characteristics according to CFVR and HRR response are shown in Table 1. During a follow-up of 7.3±4.3 years, 151 (24%) patients died. Survival at 8 years was 93% in patients with normal CFVR and HRR, 76% in patients with abnormal CFVR only, 73% in patients with abnormal HRR only, and 38% in those with abnormal CFVR and HRR (p<0.0001) (Figure 1). At multivariable analysis, abnormal CFVR (HR 1.49, 95% CI 1.05–2.10, p=0.02) and abnormal HRR (HR 2.01, 95% CI 1.43–2.84, p<0.0001) were independent predictors of survival. Conclusions In admitted patients with non-ischemic EKG, negative serial troponin, and whitout RWMA during dipyridamole SE, a reduced CFVR and blunted HRR independently identify a subset with worse survival in the long-term. Funding Acknowledgement Type of funding sources: None.

Prognostic role of acute myocardial infarction diagnostic criteria in patients presenting with non-ST segment elevation myocardial infarction

Abstract Background The Fourth Universal Definition of Myocardial Infarction (UDMI) defines acute myocardial infarction (AMI) as an acute myocardial injury associated with clinical evidence of acute myocardial ischemia. However, the prognostic role of each single diagnostic criteria has never been explored. Purpose To evaluate the prognostic role of the different diagnostic criteria of AMI according to the Fourth UDMI in patients with non-ST-segment elevation myocardial infarction. Methods We enrolled all consecutive patients with NSTEMI undergoing coronary angiography at our Centre. The admission diagnosis was performed according to the current guidelines criteria, namely the detection of an increase and/or decrease of high-sensitivity cardiac troponin I, with at least one value above the 99th percentile of the upper reference limit and at least one of the following: symptoms of ischemia, ECG changes (new ST depression or negative T-waves), echocardiographic evidence of new regional wall motion abnormality. Patients with very high-risk NSTEMI were excluded. Patients were then divided into different subgroups according to the combination of diagnostic criteria presented at admission. A composite endpoint of all-cause mortality, re-hospitalization for myocardial reinfarction or heart failure was collected. The predictive value of AMI diagnostic criteria alone and their combination were evaluated using Kaplan-Meier survival curves and subsequent Cox-regression analysis to find independent predictors of major adverse events. Results Our study population consisted of 2791 patients. The mean age was 68.3±13.4 and 31.5% were female. The mean follow-up time was 23.3±14.5 months. Depending on the AMI diagnostic criteria and their combination, patients were divided into three subgroups: 196 patients fulfilling only clinical criteria (group A), 187 with clinical and ECG-graphic criteria (group B) and 829 patients with clinical, ECG-graphic and echo-graphic criteria (group C). Baseline characteristics of the three groups were similar. At two-year follow-up, patients with clinical criteria alone exhibited the best outcome, whereas those with all three criteria fulfilled showed the worse prognosis (14.8% for group A vs 23.6% for group B vs 28.0% for group C; p-value <0.001). In multivariable Cox-regression model, the presence of clinical criteria alone was the independent predictor of better prognosis compared to the other diagnostic criteria combination (HR=0.48; CI 95% 0.31–0.74; p<0.001). Conclusions In non-very high-risk NSTEMI, not all diagnostic criteria have the same prognostic value. In fact, prognosis is significantly more favorable in patients exhibiting only the clinical criteria at admission. We hypothesize that the absence of ECG-graphic and echocardiographic alterations may indirectly indicate smaller infarct sizes that contribute to patients' outcomes. These findings could enhance the current risk stratification in patients admitted with NSTEMI. Funding Acknowledgement Type of funding sources: None.

Machine-learning algorithms for prediction of survival by stress echocardiography in chronic coronary syndromes

Abstract Background Stress echocardiography (SE) is based on regional wall motion abnormalities and coronary flow velocity reserve (CFVR). They recognise different and complementary pathophysiological targets, and show independent and incremental value in predicting survival [1]. The approach based on machine-learning (ML) has the recognised potential to identify unsuspected patterns, and this can be especially relevant in the field of risk stratification by cardiac functional stress testing due to multiple parameters used in comprehensive stress testing and the variable weight of covariates [2]. Aim To assess SE outcome data analysis with ML approach. Methods We included 6,881 prospectively recruited and retrospectively analyzed patients (median age 67 years, IQR 59–74) with suspected (n=4,279) or known (n=2,602) coronary artery disease submitted to clinically-driven dipyridamole SE in 5 Italian institutions (Figure 1). The primary outcome measure was all-cause death. A Random Forest Survival model has been implemented to model the survival function according to the patient's characteristics. The Random Forest predicted response dependency on covariates has been investigated by reporting the variable dependence and the partial dependency plot (Figure 2). A web application was developed to predict the survival function according to the patients' characteristics. The external validation cohort was made of additional 1,002 patients recruited by a single, independent center in the same time period. Results During a median duration of follow-up of 3.4 years (IQR 1.6–7.5), 814 (12%) patients died. The mortality risk was higher for patients aged more than 60 years, resting ejection fraction <60%, resting WMSI, positive delta WMSI scores, and CFVR <3.0. The C-index performance (perfect prediction=1) was 0.79 in the internal validation cohort and 0.81 in the external, independent validation data set. Survival functions for individual patient were easily obtained with an open-access web-app. Conclusion An ML approach can be fruitfully applied to outcome data obtained with SE. Survival showed a constantly increasing relationship between survival and CFVR <3.0 and stress-rest wall motion score index >0. Since processing is largely automated, this approach can be easily scaled to larger and more comprehensive data sets to further refine stratification, guide therapy and be ultimately adopted as an open-source on-line decision tool. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was partially funded by CNR-MIUR (National Research Council, Italian Ministry of University and Research) Ageing subproject.

The predictive value of regional 2D longitudinal strain in determining the localization of coronary artery stenosis in NSTE-ACS patients

Abstract Background and purpose Previous studies have shown that the role of global longitudinal 2DS in diagnosing and detecting coronary artery disease is modest. However, data on the sensitivity of the regional 2DS assessment is lacking (1–6). The aim of this study was to determine whether in echocardiographic evaluation of myocardial ischemia, regional 2D strain (2DS) assessment is more sensitive and specific in detecting ischemia due to critical stenosis of one or more coronary arteries in comparison with current standard of visual assessment of regional wall motion abnormalities (RWMA). Material and methods This retrospective study included 123 patients admitted through the Emergency Department across 36 months with the diagnosis of NSTE-ACS without previously known CAD or LBBB who underwent coronary angiography within the first 24 hours and had an echocardiogram with RWMA analysis done prior to procedure. 2DS analysis of regional longitudinal peak systolic strain (LPSS) according to the 18-segment model was performed by four clinicians, blinded to patient's clinical data. Results A significant correlation was found between individual parameters of LPSS and significant stenosis of all three major coronary vessels (>70% narrowing on coronary angiography, Table 1). Lower regional LPSS correlated well anatomically with the supplying arteries; for example, patients with LAD stenosis had significantly lower regional LPSS in all apical segments, lateral, anteroseptal and anterior mid segments and anterior basal segment. Similar patterns were seen in the LCx and RCA regions. Three graphs show the sensitivity and specificity of the most sensitive segments for each artery. The diagnostic accuracy of endocardial and epicardial regional LPSS was similar to the average regional LPSS. Conclusion We have shown that regional 2DS could be a good predictor of the presence and localization of coronary stenosis for each of the three main coronary arteries but further studies are needed to confirm this assumption. Funding Acknowledgement Type of funding sources: None.

Prognostic role of early cardiac magnetic resonance in myocardial infarction with non-obstructive coronary arteries

Abstract Background Myocardial infarction with non-obstructive coronary arteries (MINOCA) represents a significant proportion of acute myocardial infarction (AMI) population. MINOCA is a working diagnosis and an accurate investigation of the underlying causes should always be performed. In this setting, cardiac magnetic resonance (CMR) imaging plays a pivotal diagnostic role. However, a prognostic stratification based on the CMR findings in ischemic MINOCA is still unavailable. Purpose To evaluate the potential prognostic impact of specific CMR findings - especially ischemic late gadolinium enhancement (LGE) patterns - in order to look for measurable parameters that may guide the management of this still troubled clinical entity. Methods We assessed 461 MINOCA from January 2016 to June 2021. We excluded acute myocarditis, Tako-tsubo syndromes, cardiomyopathies, or non-pathological CMR. According to CMR findings, MINOCA were classified in two phenotypes: LGE-positive (an ischemic subendocardial or transmural LGE pattern) or LGE-negative (cases without LGE but exhibiting regional myocardial injury defined by myocardial edema in a coronary territory with a typically ischemic “wave-front” and/or regional wall motion abnormality consistent with coronary distribution). All-cause mortality, re-infarction, stroke, heart failure (HF) and the composite endpoint (MACE) were evaluated. Extended LGE was considered as the presence of >2 segments with transmural LGE. The mean follow-up was 36.1±15.2 months and CMR was performed at a mean of 6±2.9 days from the acute presentation. Results The final cohort included 175 MINOCA with a likely-ischemic etiology: 121 (69.1%) constituted the LGE-positive group. The mean age of the study population was 62.3±12.9 years and more than 61% were females. During follow-up, HF (15.7% vs 1.9%, p=0.008) and MACE (20.7% vs 7.4%, p=0.029) occurred more frequently in MINOCA “LGE-positive” compared to the “LGE-negative” ones. Extended LGE was significantly more prevalent in patients with versus without subsequent HF. On multivariable Cox regression, extended LGE was an independent predictor of HF occurrence (HR 18.49, 95% CI 4.65–73.61, p<0.001) and MACE (HR 14.64, 95% CI 3.91–54.86, p<0.001). Conclusions Our data suggest that in MINOCA patients the detection of LGE is correlated with the incidence of major cardiovascular events and heart failure during long-term follow-up. In fact, LGE extension was identified as the strongest predictor of cardiac adverse events. The early execution of CMR is useful in the prognostic stratification of MINOCA and this could guide the subsequent clinical and therapeutic management. Funding Acknowledgement Type of funding sources: None.

Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is associated with cardiac injury and stroke severity in patients after acute ischemic stroke

Abstract Background Patients after acute stroke frequently show signs of myocardial injury. The pathophysiology and impact on patient's outcome are not fully understood. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) is cytokine known to be associated with cardiovascular events. Purpose We aimed to assess TRAIL level dynamic changes in patients after acute ischemic stroke and its relations to cardiac injury, stroke severity and impact on short-term outcome. Methods Between August 2020 and August 2021, 104 consecutive patients after acute ischemic stroke (AIS) were enrolled in our study. Blood samples were obtained from patients at the time of admission, 24- and 48-hours later to determine levels of Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), N-terminal prohormone of brain natriuretic peptide (NT-proBNP), and high-sensitive Troponin I (hs-cTnI). Twelve lead ECG at admission, 24-, 48-hours later and at the release of the patients were obtained. Patients underwent echocardiographic examination within first 5 days of hospitalization, if eligible. National Institutes of Health Stroke Scale (NIHSS) at admission and modified Rankin Scale (mRS) at 90 days following the patient's discharge from the hospital were performed. Chi-square, Fishers exact test and regression analysis were performed to detect differences between variables using SPSS statistics. Results were considered statistically significant at a significance level of p<0.05. Results We found significant negative association between TRAIL and NT-proBNP at admission (p=0.039), after 24 (p=0.043) and 48 hours (p=0.023) of hospitalization. There was significant negative association between TRAIL and hs-cTnI at admission (p=0.04). Moreover, we found significant negative association between TRAIL and stroke severity evaluated by NIHSS at admission (p=0.044) and negative association with severe disability or death evaluated by mRS at 90 days both after 24 (p=0.0022) and 48 hours (p=0.044) of hospitalization. In ECG analysis, lower TRAIL levels were associated with the occurrence of premature ventricular extrasystoles (p=0.043), and there was a near statistically significant association with prolonged QTc interval (p=0.07). Two patients presented with new left ventricular regional wall motion abnormality. Conclusions Lower TRAIL levels are associated with laboratory markers of cardiac injury, stroke severity and unfavorable functional outcome in patients after acute ischemic stroke. Funding Acknowledgement Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Charles University Research Program Cooperatio – Cardiovascular sciences

Prognostic value of left ventricular contractile reserve and heart rate reserve in dilated cardiomyopathy

Abstract Background Stress echocardiography (SE) allows to assess simultaneously left ventricular contractile reserve (LVCR) and heart rate reserve (HRR) in dilated cardiomyopathy (DCM). Aim To assess the prognostic value of LVCR and HRR in DCM patients Methods We prospectively enrolled 395 DCM patients with ejection fraction ≤40% (age 62±27 years, 270 males, 68%; ejection fraction 35±9%) referred from 9 certified laboratories, 264 with nonischemic DCM (67%) and 131 (33%) with ischemic DCM. All patients underwent clinically indicated SE. The employed stress modality was exercise (n=63), or pharmacological stress (n=332, with vasodilator, n=232; or dobutamine, n=100). LVCR was present with a rest-stress decrease ≥0.20 in wall motion score index. HRR was normal with a peak-rest value ≥1.80 with exercise or dobutamine and ≥1.22 with dipyridamole or adenosine stress. Results New regional wall motion abnormality was present in 46 (12%), LVCR in 131 (33%) and abnormal HRR in 275 (70%) DCM patients. During a median follow-up of 950 days (interquartile range: 360–1187 days) 71 deaths occurred. Annual mortality was 10.5%/year in DCM patients with abnormal HRR (HRR−) and absence of LVCR (LVCR−), 5.4%/year in patients with either abnormal HRR or absent LVCR, and 2.5%/year in patients with normal HRR and presence of LVCR (Figure 1). At multivariable analysis, only abnormal HRR (HR: 2.952, 95% CI: 1.547–5.630, p=0.001) but not absence of LVCR (HR: 1.545, 95% CI: 0.929–2.568, p=0.094), was independent predictors of survival. Conclusion Abnormal HRR predicts adverse prognosis in DCM patients, in addition to the presence of LV CR. Funding Acknowledgement Type of funding sources: None.