Subnormal Left Ventricular Ejection Fraction Research Articles

Caregiver burden of patients with heart failure with a left-ventricular ejection fraction (LVEF) less than or equal to 60%: a cross-sectional survey in the EU

Abstract Background and purpose The majority of patients with heart failure (HF) have difficulties in independently carrying out activities of daily living and hence, require support from caregivers (CGs). This study assessed the quality of life (QoL) of CGs of HF patients with sub-normal LVEF (≤60%). Methods A cross-sectional survey of HF patients and their CGs was conducted in France, Germany, Italy, Spain and the UK. Cardiologists and primary care physicians completed patient record forms (PRF) between June and November 2019. Caregivers of the same patients were invited to complete a caregiver self-completion survey, which included the Family Caregiver QoL Scale (FAMQOL) and EQ-5D. Patient demographics were derived from PRFs. Results 361 CGs (73.1% female, mean age: 58.8 yrs) and HF patients (39.9% female, mean age: 71.2 yrs) were included. 58.2% of the CGs were spouses, 23.4% a child of the patient. On average, CGs devoted 20 hrs/week in the care of HF patients; this CG time increased from 12 to 26 hrs/week with NYHA class I to III/IV of the HF patient. Further, anxiety/stress was experienced overall by 29/31% of CGs which increased from 27/17% for NYHA I to 40/41% for NYHA III/IV of the HF patient (Table 1). Conclusions Caregivers of patients with HF and LVEF ≤60% spend a significant amount of time to provide daily support to HF patients. Patients with progressive disease were older, more polymorbid and had a higher disease duration. These factors likely contributed towards increased caregiver burden of HF patients with increased NYHA class. Funding Acknowledgement Type of funding source: Private company. Main funding source(s): Novartis Pharma AG

The use of B‐type natriuretic peptide in the management of elderly patients with acute dyspnoea ( J Intern Med 2005;258:77–85)

Dear Sir, The findings of the above study [1] would have been more readily applicable to routine clinical practice if the radiographic stigmata of acute left ventricular failure (LVF) had also been documented, using parameters which have not only been found to be positively correlated with B-type atrial natriuretic factor, but have also proved to be highly predictive of LVF itself [2]. Coupled with a categorization of the patients into those with subnormal left ventricular ejection fraction (LVEF) and those with intact LVEF, the inclusion of radiographic stigmata as well as the radiographic response to antifailure therapy would have considerably enhanced our understanding of left ventricular diastolic failure in addition to validating the therapeutic trial as an alternative diagnostic tool in the evaluation of the acutely breathless patient with normal LVEF. No conflict of interest was declared.

Prognostic Impact of Systolic Hypertension on Asymptomatic Patients With Chronic Severe Aortic Regurgitation and Initially Normal Left Ventricular Performance at Rest

The influence of systolic hypertension (SH) on the natural history of chronic aortic regurgitation (AR) and the clinical effect of antihypertensive medication on patients who have hypertension and AR are incompletely defined. Therefore, we reviewed the clinical course of 80 unoperated patients who were entered prospectively into an assessment of natural history of AR and its predictors and were asymptomatic with normal left ventricular ejection fraction (LVEF) at rest at study entry; 30 of 80 patients had SH (systolic blood pressure >140 mm Hg); 20 of 80 patients (16 had SH) used antihypertensive drugs for the long term (not mandated by protocol). During an average 7.2-year event-free follow-up, 24 patients developed symptoms alone (n = 14), subnormal LVEF with or without symptoms (n = 8), or died suddenly (n = 2). SH tripled the average annual risk of cardiac events (8.47% vs 2.85%, p = 0.004). The effect of systolic blood pressure was independent of age, gender, diastolic blood pressure, LV diastolic dimension, fractional shortening, and LVEF at rest (p = 0.004 to <0.008). However, positive prognostic interactions existed between systolic blood pressure and pulse pressure (p <0.001), LVEF during exercise (p <0.001), change in LVEF from rest to exercise (p <0.001), and the contractility index (p <0.02). Among patients who had SH, antihypertensive therapy predicted increased event risk (average annual risk 15.46% vs 3.98%, p <0.02) and remained predictive when analysis was adjusted for potentially confounding subgroup variations at study entry (p <0.03, all models). In conclusion, SH portends poor clinical outcome in chronic severe AR. As a group, antihypertensive drugs do not mitigate outcome, although the effect of individual drugs is uncertain and at least some may be deleterious. The theoretically based practice of giving antihypertensive drugs to patients who have AR requires reexamination.

Usefulness of Subnormal Midwall Fractional Shortening in Predicting Left Ventricular Exercise Dysfunction in Asymptomatic Patients With Systemic Hypertension

We have recently shown that a subgroup of asymptomatic hypertensive patients exhibit subnormal left ventricular (LV) midwall fiber shortening at rest and that this finding predicts morbidity and mortality independently of age, blood pressure (BP), or the presence of LV hypertrophy. However, it is unknown whether abnormal midwall fractional shortening predicts either subnormal LV functional reserve or extracardiac damage in asymptomatic hypertensive patients. Accordingly, we compared radionuclide cineangiographic LV ejection fraction at rest and maximum exercise as well as clinical findings between 89 patients with normal and 16 patients with subnormal midwall fractional shortening by echocardiogram. Patients with low midwall fractional shortening were similar in gender, age, and systolic BP to those with normal shortening but had higher mean diastolic BP and body mass indexes (both p <0.05). The 2 groups also had similar resting ejection fraction (56 ± 9% vs 55 ± 15%, with normal or subnormal shortening, respectively, p = NS). Patients with subnormal midwall fractional shortening had higher LV mass and tended to have higher urinary protein excretion and serum creatinine levels. Subnormal LV ejection fraction with exercise (<54%) was observed in 13 of 89 patients (15%) with normal midwall fractional shortening but in 7 of 16 patients (44%) with subnormal shortening (p <0.05). Multiple linear regression analysis revealed that midwall fractional shortening independently predicted exercise performance (p <0.001). Thus, subnormal midwall fractional shortening predicts depressed LV functional reserve in asymptomatic hypertensive patients and may contribute to identification of patients with extracardiac target-organ damage.Radionuclide cineangiographic left ventricular (LV) ejection fraction at rest and maximum exercise were compared between 89 patients with normal and 16 patients with subnormal midwall fractional shortening by echocardiogram. Patients with subnormal midwall fractional shortening had higher LV mass and were more likely to have subnormal (<54%) LV exercise ejection fraction (7 of 16 or 44% vs 13 of 89 or 15%, p <0.05); multiple linear regression analysis revealed that low midwall fractional shortening independently predicted subnormal exercise performance (p <0.001).

Relation of obesity, high sodium intake, and eccentric left ventricular hypertrophy to left ventricular exercise dysfunction in essential hypertension

purpose: To elucidate determinants of abnormal left ventricular functional responses to exercise in hypertensive patients. patients and methods: One hundred twenty-seven patients with uncomplicated essential hypertension were studied by rest and exercise radionuclide angiography and by echocardiography at rest. results: The 24 patients with subnormal left ventricular ejection fraction at peak exercise (less than 54%) were similar in age and rest and exercise blood pressures to the 103 with normal exercise ejection fraction, but were more obese (p <0.005) and had greater left ventricular mass ( p <0.03) and internal dimensions ( p <0.001). The parallel increase in left ventricular chamber size and mass (eccentric hypertrophy) in the group of patients with exercise dysfunction was associated with higher resting end-systolic wall stress ( p <0.001) and abnormal increases of end-systolic left ventricular volume from rest to peak exercise ( p <0.001). Multivariate analysis revealed that exercise left ventricular dysfunction was independently associated with higher left ventricular mass ( p <0.005), end-systolic wall stress ( p <0.001), dietary sodium intake ( p <0.01), and body mass index ( p <0.03). conclusion: Among patients with uncomplicated essential hypertension, abnormal functional responses to exercise are strongly associated with eccentric ventricular hypertrophy, obesity, and high sodium intake.

Left ventricular function and beta-blockers: does intrinsic sympathomimetic activity have any influence during chronic therapy?

A study comparing the chronic effects of propranolol (n = 21) and pindolol (n = 19) on male patients with stable angina pectoris was performed. Left ventricular function was assessed by serial radionuclide ventriculography. Radionuclide ventriculography was performed at rest and during cold pressor test. Both drugs improved symptoms of angina pectoris by at least one division of the New York Heart Association classification. Cold pressor testing caused increases in heart rate and blood pressure in both groups throughout the study. At rest, pretreatment ejection fraction was similar in both groups. During propranolol treatment this rose sequentially from 49% to 55% at 26 weeks. No change in the resting ejection fraction occurred in those taking pindolol. The difference in response between the groups reached significance at 26 weeks. In those with subnormal left ventricular ejection fraction (less than 50%), resting ejection fraction improved significantly throughout treatment with propranolol rising from a basal value of 39% to 51% at 26 weeks. In comparison, pindolol caused no significant change. There is no apparent advantage to intrinsic sympathomimetic activity in terms of preservation or improvement of left ventricular performance in patients with stable angina pectoris prescribed beta-blockers for extended periods of time.

Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function.

Recent studies suggest that preoperative left ventricular function may no longer be an important determinant of survival or functional results after operation for aortic regurgitation because of improved operative techniques. To assess the effect of left ventricular function on prognosis in the current surgical era, we performed echocardiographic and radionuclide angiographic studies in 80 consecutive patients undergoing valve replacement from 1976 to 1983. No patient had associated coronary artery disease. For all patients, 5 year survival was 83 +/- 5%, significantly better than the 62 +/- 9% 5 year survival in our patients operated on from 1972 to 1976. Preoperative resting left ventricular ejection fraction (p less than .001), fractional shortening (p less than .001), and end-systolic dimension (p less than .01) were the most significant predictors of survival (univariate life-table analysis). Five year survival was 63 +/- 12% in patients with subnormal ejection fraction (n = 50) compared with 96 +/- 3% in those with normal ejection fraction (n = 30). Patients with subnormal left ventricular ejection fraction and poor exercise tolerance or prolonged duration of left ventricular dysfunction (greater than 18 months) comprised the high-risk subgroup (5 year survival 52 +/- 11%). Patients in this subgroup also had persistent left ventricular dysfunction after operation, with greater left ventricular end-diastolic dimensions and reduced ejection fraction (both p less than .001) compared with patients with normal preoperative left ventricular ejection fraction or a brief duration of left ventricular dysfunction (less than 14 months). Cold hyperkalemic cardioplegia was used for myocardial preservation in 46 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

MYOCARDIAL INVOLVEMENT IN CHILDREN WITH ENTEROVIRAL ILLNESS

Although enteroviral (EV) infections have been associated with myocarditis, the potential for these agents to cause subclinical myocardial dysfunction (MD) has not been studied. From 7/1/83, until 10/31/83, we prospectively studied all hospitalized pts under 2 years of age whose illnesses were compatible with EV infection (22 pts) to determine if those pts had clinical, electrocardiographic,or echocardiographic evidence of MD. CSF, rectal swab, and NP swab specimens were cultured for virus, and CSF, blood and urine specimens were sent for bacterial culture. Electrocardiograms (EKG) and echocardiograms (EC) were obtained within 48 hours of admission. Five pts were culture positive for EV (2 with Echo 11, 1 with Echo 14, 1 with Coxsackie A9, and 1 untyped EV). Four of the 5 pts had EKG and EC as described above,and 2 of those 4 pts had EC evidence of MD:1 pt had subnormal left ventricular ejection fraction, and 1 pt had a pericardial effusion. Two additional pts had systemic bacterial infections, 1 of whom had EC changes. None of the 22 pts had clinical or EKG evidence of MD. Of the 15 pts with presumed EV infections whose viral and bacterial cultures were negative, 11 were studied with EKG and EC; 1 pt had decreased left venticular ejection fraction. These data demonstrate that subclinical MD is a frequent complication of EV illness, and that neither physical examination nor EKG is adequate for its detection.

Effects of digoxin on left ventricular function in coronary artery disease patients

To assess whether digitalis modifies or prevents the deterioration of the left ventricular ejection fraction and wall motion during acute ischemia, we performed gated blood pool radionuclide ventriculograms in 15 patients with angiographically documented coronary artery disease. All patients were studied in the resting state and during maximal supine bicycle exercise, both before and 1 hour after 1 mg intravenous digoxin. There was no significant difference, pre-digoxin vs post-digoxin, in exercise tolerance (415 ± 84 vs 418 ± 107 seconds), number of segments with abnormal resting wall motion (12 vs 11) or exercise wall motion (21 vs 19). Ten patients developed angina during the same exercise load, irrespective of digoxin administration. Twelve patients had subnormal left ventricular ejection fraction during exercise pre-digoxin, vs 13 patients post-digoxin ( P = ns). In the resting state, the left ventricular ejection fraction was higher after digoxin (53 ± 14% pre vs 58 ± 14% post, P < 0.05). During exercise, however, the left ventricular ejection fraction was not significantly improved after digoxin (50 ± 16% pre vs 53 ± 17% post, P = ns). These data indicate that although acute administration of digoxin improves the resting left ventricular function, it does not improve exercise tolerance to angina. Furthermore, intravenous digoxin does not appear to prevent the deterioration of left ventricular wall motion and ejection fraction during exercise induced ischemia.