Left Ventricular Ejection Fraction Values Research Articles

Incremental prognostic value of fully-automatic LVEF by stress CMR using machine learning

Abstract Funding Acknowledgements Type of funding sources: None. Background Although some recent reports showed that fully automated artificial intelligence (AI)-based left ventricular ejection fraction (LVEF) measured at stress has good performance, its prognostic value during a stress CMR exam to predict outcomes is not well established. Aim To determine in patients undergoing stress CMR whether fully automated AI-based LVEF (LVEF-AI) measured at stress can provide incremental prognostic value to predict death. Methods Between 2016 and 2018, we conducted a longitudinal study including all consecutive patients referred for vasodilator stress CMR. LVEF-AI was assessed using AI-algorithm combines multiple deep learning networks for LV segmentation. The primary outcome was all-cause death defined by the French National Registry of Death. Cox regression was used to evaluate the association of stress LVEF-AI with death after adjustment for traditional risk factors. Results In 9,712 patients (66±15 years, 67% men), there was an excellent correlation between stress LVEF-AI measurement and LVEF measured by expert (LVEF-expert) (r=0.94, p<0.001). Using Bland–Altman analysis, we found that the difference between the mean LVEF-expert and the LVEF-AI group was −0.1% (−0.066–0.067), that was not statistically significant (p = 0.46). Stress LVEF-AI was associated with death (median [IQR] follow-up 4.5 [3.7–5.2] years) before and after adjustment for risk factors (adjusted hazard ratio [HR], 0.84 [95% CI, 0.82–0.87] per 5% increment, p<0.001). Stress LVEF-AI had similar significant association with death occurrence compared with LVEF-expert. After adjustment, a lower stress LVEF-AI showed the greatest improvement in model discrimination and reclassification over and above traditional risk factors and stress CMR findings (C-statistic improvement: 0.11; NRI=0.250; IDI=0.049, all p<0.001; LR-test p<0.001), with a superior additional prognostic value than the LVEF-AI measured at rest. Conclusion AI-based fully automated LVEF measured at stress is independently associated with the occurrence of death in patients undergoing stress CMR, with an additional prognostic value above traditional risk factors, inducible ischemia and LGE.

Early effect of contemporary radiotherapy protocol on myocardium in patients with breast cancer assessed with cardiac magnetic resonance

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): University Medical Centre Ljubljana Research Grant. Introduction Early cardiotoxicity of modern radiotherapy (RT) is not known. Purpose To study the early cardiotoxic effect of contemporary RT on myocardium with cardiac magnetic resonance (CMR) in patients with breast cancer (BC). Methods Patients with in-situ ductal carcinoma of the breast, scheduled for RT were included. All patients had undergone surgical tumorectomy. Exclusion criteria were prior systemic chemotherapy, prior RT or known cardiac disease. Patients were treated with 3-dimensional conformal RT or intensity-modulated RT, left-sided BC patients were also scheduled for deep inspiration breath hold protocol, if feasible. Patients underwent CMR imaging prior to RT and within 2 weeks after RT. Left and right ventricular volumes and ejection fraction, global native and postcontrast T1 values and T2 values, prior to and after completion of RT were analyzed. All patients provided written informed consent. Results A total of 40 female patients (mean age 55 ± 7 years) were included, 22 with left-sided BC. The mean radiation dose was 42 Gy. CMR results are presented in Table 1. Left-sided BC patients had statistically significant increase in global T2 values. There were no significant differences in other studied parameters. No patient developed pericardial effusion and no patient had presence of late gadolinium enhancement at both exams. Conclusion Modern RT of left-sided BC is associated with increased T2 values, most likely representing myocardial edema, early after completion of RT.

Intraoperative Augmented Rotation and Circumferential Strain Compensate for Reduction of Left Ventricular Longitudinal Function After On-Pump CABG Surgery

Left ventricular (LV) longitudinal function is reduced after on-pump coronary artery bypass grafting (CABG), while global LV function often is preserved. There are only limited data on the underlying compensatory mechanism. Therefore, the authors aimed to describe intraoperative changes of LV contractile pattern by myocardial strain analysis. A prospective observational study. At a single university hospital. A total of 30 patients scheduled for isolated on-pump CABG with an uneventful intraoperative course and preoperative preserved LV and RV function, sinus rhythm, without more-than-mild heart valve disease, or elevated pulmonary pressure. Transesophageal echocardiography was performed after induction of anesthesia (T1), after termination of cardiopulmonary bypass (T2), and after sternal closure (T3). Echocardiographic evaluation was performed under stable hemodynamics, in sinus rhythm or atrial pacing, and vasopressor support with norepinephrine ≤0.1 µg/kg/min. EchoPAC v204 software (GE Vingmed Ultrasound AS, Norway) was used for analysis of 2-dimensional (2D) and 3-dimensional (3D) LV ejection fraction (EF), LV global longitudinal strain (GLS), LV global circumferential strain (GCS), LV global radial strain (GRS), LV apical rotation (aRot), LV basal rotation (bRot), and LV twist. Strain analysis was feasible in all included patients after termination of cardiopulmonary bypass (T2). Although there were no significant differences in the values of conventional echocardiographic parameters during the intraoperative interval, GLS deteriorated significantly after CABG compared to pre-bypass assessment (T1 v T2, -13.4% ± 2.9 v -11.8% ± 2.9; p=0.007). GCS improved significantly after surgery (T1 v T2, -19.4% (IQR -17.1% to -21.2%) v -22.8% (IQR -21.1% to -24.7%); p < 0.001) as well as aRot (T1 v T2, -9.7° (IQR -7.1° to -14.1°) v -14.5° (IQR -12.1° to -17.1°); p < 0.001), bRot (T1 v T2, 5.1° (IQR 3.8°-6.7°) v 7.2° (IQR 5.6°-8.2°); p=0.02), and twist (T1 v T2, 15.8° (IQR 11.7°-19.4°) v 21.6° (IQR 19.2°-25.1°); p < 0.001), while GRS remained unchanged. There were no significant changes in the values of GLS, GCS, GRS, aRot, bRot, or twist, as well as in the values of 2D and 3D LV EF before and after sternal closure (T2 v T3). Beyond evaluation of longitudinal LV strain, measurements of circumferential and radial strain, as well as LV rotation and twist mechanics, were feasible in the intraoperative course of this study. Reduction of longitudinal function after on-pump CABG was compensated intraoperatively by improvement of GCS and rotation in the authors' group of patients. Perioperative assessment of GCS, GRS, as well as rotation and twist, might provide deeper insight into perioperative changes of cardiac mechanics.

Validation of a Monte Carlo simulated cardiac phantom for planar and SPECT studies

PurposeThis work aimed to validate Monte Carlo (MC) simulated cardiac phantoms for the evaluation of planar- and SPECT-gated-blood-pool (GBP-P and GBP-S) studies. MethodsA comparison of gamma camera system performance criteria measurements (energy resolution, spatial resolution, sensitivity) with MC simulations was conducted. Furthermore, the accuracy of measured and simulated volumes of two stereolithography-printed cardiac phantoms (based on 4D-XCAT phantoms) was assessed. Finally, the simulated GBP-P and GBP-S XCAT studies were validated by comparing calculated left ventricular ejection fraction (LVEF) and ventricle volume values with known parameters. ResultsThe simulated performance criteria compared well with measured values (energy resolution difference: 0.1 ± 0.10%; spatial resolution (full width at half maximum) difference ≤ 0.5 ± 0.8 mm and system sensitivity difference ≤ 6.2 ± 0.62cps/MBq). The measured and simulated cardiac phantoms were in good agreement; the left anterior oblique views compared well. This is supported by line profiles through these phantoms and on average, simulated counts were 5.8% lower than measured counts. The LVEF values calculated from the GBP-P and GBP-S simulated data differ from known values (2.8 ± 0.64% and 0.8 ± 0.52%). The differences between the known XCAT LV volumes and simulated GBP-S calculated volumes were −1.2 ± 1.91 ml and −1.5 ± 0.96 ml for the end-diastolic and end-systolic volumes. ConclusionThe MC-simulated cardiac phantom has been validated successfully. Stereolithography-printing allows researchers to create clinically realistic organ phantoms and is a valuable tool for validating MC simulations and clinical software. By conducting GBP simulation studies with various XCAT models, the user will be able to generate GBP-P and GBP-S databases for future software evaluation.

Trastuzumab-induced cardiotoxicity in breast cancer patients: A meta-analysis and review of the literature (2012-2022).

e24101 Background: Breast cancer (BC) is the most common type of cancer diagnosed, and 10-15% of BC patients develop a HER2-positive disease with a poor prognosis. In a previous meta-analysis of NCCTG N9831 and NSABP B-31 trials, treatment of early-stage HER2-positive BC patients with Trastuzumab and chemotherapeutic drugs improved overall survival by 37%. Trastuzumab-induced cardiotoxicity (TIC) is characterized by cardiac dysfunction, including decreased left ventricular ejection fraction (LVEF) and heart failure. Per package inserts, the incidence of TIC is 4-6 times higher than the control. An important risk factor for TIC is the administration of concomitant anthracycline chemotherapy. Several studies have reported that this treatment combination can significantly reduce LVEF compared to Trastuzumab alone. In this study, we compiled recent randomized controlled trials (RCTs) and clinical trial data to evaluate the incidence of cardiotoxicity in Trastuzumab-treated BC and study management guidelines specifically directed for TIC. This will help reduce the morbidity and mortality in these patients. Methods: Our search included PubMed, EMBASE, Web of Science, and Cochrane Library articles from July 2012 through July 2022. RCTs and clinical trials that used Trastuzumab as a therapy and reported its cardiotoxic effects were included. A random-effects model was utilized with Review Manager, and a P value &lt; 0.05 was considered significant. The entire analysis of treatment and control groups had various guideline-directed chemotherapies, including anthracycline-based regimens. Results: Our initial search yielded 26 results. After a full literature review by two independent reviewers, we selected four studies that included 1481 patients with cardiotoxicity data in the treatment and control groups. The analysis pooled from clinical trials showed that the odds of cardiotoxicity (specifically LVEF reduction) in patients treated with Trastuzumab were about seven times higher than the control group (OR 6.78, 95% CI 2.85-16.09, p-value &lt; 0.0001). The guidelines recommend withholding Trastuzumab for ≥ 16% absolute decrease in LVEF from pre-treatment values or an LVEF value below normal institutional limits and ≥ 10% absolute decrease in LVEF from pretreatment values. The safety of continuation or resumption of Trastuzumab in patients with TIC has not been studied, and there are no standardized management guidelines. Conclusions: We conclude in our study that the odds of TIC are increased by almost seven times compared to chemotherapy alone. In addition to just regular monitoring of these patients with history, physical examination, and determination of LVEF by echocardiogram or MUGA scan per protocol, there is a need to formulate guidelines for continuation or resumption of Trastuzumab in patients with TIC.

Uptitrating Treatment After Heart Failure Hospitalization Across the Spectrum of Left Ventricular Ejection Fraction

BackgroundAcute heart failure (AHF) is associated with a poor prognosis regardless of left ventricular ejection fraction (LVEF). STRONG-HF showed the efficacy and safety of a strategy of rapid uptitration of oral treatment for heart failure (HF) and close follow-up (high-intensity care), compared with usual care, in patients recently hospitalized for AHF and enrolled independently from their LVEF. ObjectivesIn this study, we sought to assess the impact of baseline LVEF on the effects of high-intensity care vs usual care in STRONG-HF. MethodsThe STRONG-HF trial enrolled patients hospitalized for AHF with any LVEF and not treated with full doses of renin-angiotensin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. High-intensity care with uptitration of oral medications was performed independently from LVEF. The primary endpoint was the composite of HF rehospitalization or all-cause death at day 180. ResultsAmong the 1,078 patients randomized, 731 (68%) had LVEF ≤40% and 347 (32%) had LVEF >40%. The treatment benefit of high-intensity care vs usual care on the primary endpoint was consistent across the whole LVEF spectrum (interaction P with LVEF as a continuous variable = 0.372). Mean difference in the EQ-5D visual analog scale change from baseline to day 90 between treatment arms was slightly greater at higher LVEF values, but with no interaction between LVEF as a continuous variable and the treatment strategy (interaction P = 0.358). Serious adverse events were also independent from LVEF. ConclusionsRapid uptitration of oral medications for HF and close follow-up reduce 180-day death and HF rehospitalization after AHF hospitalization independently from LVEF. (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-ProBNP Testing, of Heart Failure Therapies [STRONG-HF]; NCT03412201)

Usefulness of heart failure categories based on left ventricular ejection fraction

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): This study was sponsored by AstraZeneca. Introduction Heart failure, a common disease with a mortality on par with many cancers, is one of the costliest diseases to society in the western world. Current heart failure guidelines are based on categories of left ventricular ejection fraction (LVEF) and have recently introduced a narrow category with mid-range/mildly reduced ejection fraction (HFmrEF; LVEF 41-49%) between the previous categories with reduced (HFrEF; LVEF ≤40%) and preserved (HFpEF; LVEF ≥50%) ejection fraction. The grouping of continuous variables into narrow categories can be questioned if the variability is high. Purpose To determine the shape of the LVEF distribution and quantify the stability of LVEF categories over time in a large real-world heart failure population, in order to establish the usefulness of LVEF categories for treatment decisions. Methods Population-based observational cohort study of all new cases of chronic heart failure in Region Stockholm, Sweden, from 2016-01-01 until 2020-12-31. All available values of LVEF were collected over time and patients were followed until death or end of study. Mixed models were used to quantify within-person variance in LVEF, and Multistate Markov models, with death as an absorbing state, to quantify the stability of LVEF categories. Results During the study period, 8,455 patients were diagnosed with heart failure. LVEF values followed a perfect normal distribution. The standard deviation of the within-person variance in LVEF was 7.4%. Regardless of initial LVEF category, age or sex, the mean time spent in any LVEF category before transition to another category (mean sojourn time) was on average less than 0.6 years (Figure 1). The one-year probabilities of transitioning between states were substantial (Figure 2). Patients with HFmrEF had a probability of 1/4 of remaining in that category one year later; the probability of patients with HFrEF of remaining in that category one year later was 1/4 for women and 1/3 for men; and patients with HFpEF had a probability of remaining in that category of 2/3 for women and 1/2 for men. Conclusion In patients with heart failure, LVEF has considerable variability over time. Hence, LVEF has limited use for categorisation of the heart failure population into narrow categories.

Expression and clinical significance of NRLP1 in patients with ST-segment elevation myocardial infarction combined with malignant ventricular arrhythmia.

To investigate the clinical effects of NRLP1 expression in patients with ST-segment elevation myocardial infarction (STEMI) combined with arrhythmia. We enrolled 231 patients with STEMI in the first hospital of Quanzhou affiliated to Fujian Medical University from January 2019 to December 2020 to the observational group and 230 healthy individuals as the control group. We divided patients with STEMI into a malignant ventricular arrhythmia (MVA) group (n=36) and non-MVA(NMVA) group (n=195) depending on whether the individuals had experienced an episode of MVA within 48 hours after PCI. We recorded general variables such as age, gender, history of smoking, hypertension, of diabetes, hyperlipidemia, left ventricular ejection fraction (LVEF), Gensini score, and mortality. Moreover, we determined NLRP1, IL-1β, TNF-α, high-sensitivity C-reactive protein (hs-CRP), N-terminal pro-brain natriuretic peptide (NT-pro-BNP), cardiac troponin-1 (cTnI), and creatine kinase isoenzyme (CK-MB) in peripheral blood by ELISA. We found significant differences in LVEF, Gensini scores, smoking history, and mortality between the MVA and NMVA groups. The mean NLRP1 expression was highest in the MVA group, which was positively correlated with the levels of IL-1β, TNF-α, hs-CRP, NT-pro-BNP, cTnI and CK-MB. The expression of NLRP1 was associated with the smoking history, the LVEF value, the Gensini score, the MVA incidence and the mortality. Patients with higher NLRP1 expression levels had a higher MACE incidence and worse overall survivals within one year. The NLRP1 pathway is associated with the presence of arrhythmias after PCI treatments, and the NLRP1 expression level may be useful as a predictor of arrhythmia in patients with STEMI.

Correlation Between Coronary and Retinal Microangiopathy in Patients With STEMI.

To investigate the morphological and functional correlation between microvascular retinal changes in optical coherence tomography angiography (OCTA) and the microvascular coronary circulation in patients with ST elevation myocardial infarction (STEMI) coronary heart disease (CHD). A total of 330 eyes from 165 participants (88 cases and 77 controls) were enrolled and imaged. Superficial capillary plexus (SCP) and deep capillary plexus (DCP) vascular density was measured in the central (1 mm) and perifoveal (1-3 mm) areas and in the superficial foveal avascular zone (FAZ) and choriocapillaris (3 mm). These parameters were then correlated to the left ventricular ejection fraction (LVEF), and the number of affected coronary arteries. Decreased vessel densities in the SCP and DCP and choriocapillaris were positively correlated to the LVEF values (P = 0.006, P = 0.026, and P = 0.002, respectively). No statistically significant correlation between the SCP and DCP central area or FAZ area was found. Regarding the number of affected vessels, significant negative correlations were revealed for the SCP and DCP central vessel densities (P < 0.001 and P < 0.001, respectively) and the SCP perifoveal vascular density (P = 0.009). OCTA vascular indices are significantly correlated with morphological and functional parameters in patients with STEMI CHD. SCP vascular density especially seems to be a promising biomarker for the extent of both macrovascular damage (number of affected coronary arteries) and microvascular damage, as mirrored in the decreased LVEF at admission. OCTA vascular indices offer a valuable insight into the microvascular status of coronary circulation.

PO-03-197 THE RISK STRATIFICATION VALUE OF LEFT VENTRICULAR EJECTION FRACTION AND LATE GADOLINIUM ENHANCEMENT ON CARDIAC MAGNETIC RESONANCE FOR PREDICTING VENTRICULAR TACHYARRHYTHMIAS IN NONISCHEMIC CARDIOMYOPATHY: A SYSTEMATIC REVIEW AND NETWORK META-ANALYSIS

The late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) is associated with ventricular tachyarrhythmic substrate in patients with nonischemic cardiomyopathy (NICM), while the left ventricular ejection fraction (LVEF) ≤ 35% is still the sole criterion for implantable cardioverter defibrillator (ICD) implantation. To perform meta-analysis to evaluate the risk stratification value of LVEF and LGE on CMR for ventricular tachyarrhythmic events in NICM patients. PubMed and Embase databases were searched for studies reporting clinical outcomes (all-cause death, cardiovascular death, ventricular tachyarrhythmias[VTAs] and major adverse cardiovascular events[MACEs]) based on LVEF≤35% and LVEF>35% or LGE presence (LGE+) and absence (LGE-), among patients with NICM. Hazard ratios (HRs), both with 95% confidence intervals (CIs), were calculated using random effects models. Network meta-analysis was conducted for the outcome of VTAs, and four groups (“LVEF≤35%&LGE+”,“LVEF>35%&LGE+”, “LVEF≤35%&LGE-” and “LVEF>35%&LGE-”) were compared by using HRs forest plot and rank probability. Data from 7 studies (3002 NICM patients, 1524 with LVEF≤35%) were included in the final analysis. Pooled HRs demonstrated that LVEF≤35% was associated with increased risks of all-cause mortality (HR 2.42, 95% CI: 1.66 to 3.50), VTAs (HR: 1.67, 95% CI: 1.31 to 2.14) and MACEs (HR: 2.36, 95% CI: 1.70 to 3.27). Meanwhile 51 studies were included (15553 NICM patients, 6828 with LGE+) in pooled analyses showing those with LGE+ more likely to encounter all-cause death (HR 2.08, 95% CI: 1.84 to 2.35) , cardiovascular death (HR 2.98, 95% CI: 1.97 to 4.50), VTAs (HR: 4.03, 95% CI: 3.12 to 5.20) and MACEs (HR: 2.79, 95% CI: 2.36 to 3.31). Network analysis composed of 3 studies (2342 NICM patients) with "LVEF>35%&LGE-" serving as the control group, found that a significant reduction in VTAs-free survival for both "LVEF≤35%&LGE+" (HR: 5.2, 95% CI: 3.1 to 8.7) and "LVEF>35%&LGE+" (HR: 5.8, 95% CI: 3.4 to 10.0), while "LVEF≤35%&LGE-" showed no significant value in predicting VTA events (HR: 1.9, 95% CI: 1.0 to 3.5). Both LVEF and LGE are highly sensitive predictor of mortality, VTAs and MACEs in NICM patients. LGE integrated with LVEF significantly improved the risk stratification for VTAs compared with LVEF alone to further discriminate those NICM who will benefit from ICD.

CMR validation of left ventricular volumes and ejection fraction measured by the IQ-SPECT system in patients with small heart size

BackgroundThe IQ-SPECT system is equipped with multifocal collimators and uses ordered-subset conjugate gradient minimization (OSCGM) as its reconstruction algorithm, achieving a shorter acquisition time than conventional SPECT. Left ventricular ejection fraction (LVEF) is overestimated by conventional SPECT in patients with small heart size. In this study, we compared IQ-SPECT with conventional SPECT and cardiovascular magnetic resonance (CMR) for the estimation of LVEF in patients with small hearts (males: EDV ≤ 60 ml, ESV ≤ 25 ml; females: EDV ≤ 45 ml, ESV ≤ 20 ml).MethodsThe study consisted of 49 consecutive patients (20 normal and 29 with small heart size) undergoing gated myocardial perfusion imaging (GMPI) with a 99mTc-labelled agent during stress or rest to assess the risk of coronary artery disease (CAD). The data were reconstructed using filtered back-projection (FBP) for conventional SPECT and OSCGM for IQ-SPECT. ESV, EDV, and LVEF were calculated using quantitative gated SPECT (QGS). To determine the optimal ordered-subset reconstruction parameters, we compared the LVEF from SPECT to the corresponding measurement from CMR.ResultsEDV, ESV, and LVEF values obtained from IQ-SPECT and conventional SPECT showed that the results of these two forms of SPECT were significantly correlated, although the EDV and ESV obtained by IQ-SPECT were higher than those obtained by conventional SPECT. IQ-SPECT yielded lower LVEF measurements than conventional SPECT (normal heart size: 50.6 ± 4.3% vs. 73.4 ± 8.4%, P = 0.002; small heart size: 62.1 ± 7.8% vs. 75.0 ± 11.4%, P < 0.001). There were no significant differences in LVEF measurements made by IQ-SPECT and CMR (normal heart size: 50.6 ± 4.3% vs. 53.2 ± 5.8%, P > 0.05; small heart size: 62.1 ± 7.8% vs. 64.6 ± 8.8%, P > 0.05). Five subsets (S) and 12 iterations (I) did not differ significantly in LVEF between CMR and IQ-SPECT for patients with small hearts (64.6 ± 8.8% vs. 62.1 ± 7.8%, P = 0.120), while 3 S and 10 I were the best parameters for patients with normal heart size (50.6 ± 4.3% vs. 53.1 ± 5.8%, P = 0.117).ConclusionWith CMR as the standard, IQ-SPECT yields more reliable LVEF values than conventional SPECT for populations with small heart size. The best reconstruction parameters from IQ-SPECT were 5 S and 12 I for patients with small hearts.

Comparative efficacy and pharmacological mechanism of Chinese patent medicines against anthracycline-induced cardiotoxicity: An integrated study of network meta-analysis and network pharmacology approach.

This study aimed to evaluate the efficacy of Chinese patent medicines (CPMs) combined with dexrazoxane (DEX) against anthracycline-induced cardiotoxicity (AIC) and further explore their pharmacological mechanism by integrating the network meta-analysis (NMA) and network pharmacology approach. We searched for clinical trials on the efficacy of DEX + CPMs for AIC until March 10, 2023 (Database: PubMed, Embase, Cochrane Library, Chinese National Knowledge Infrastructure, China Science and Technology Journal and China Online Journals). The evaluating outcomes were cardiac troponin I (cTnI) level, creatine kinase MB (CK-MB) level, left ventricular ejection fraction (LVEF) value, and electrocardiogram (ECG) abnormal rate. Subsequently, the results of NMA were further analyzed in combination with network pharmacology. We included 14 randomized controlled trials (RCTs) and 1 retrospective cohort study (n = 1,214), containing six CPMs: Wenxinkeli (WXKL), Cinobufotalin injection (CI), Shenqifuzheng injection (SQFZ), Shenmai injection (SM), Astragalus injection (AI) and AI + CI. The NMA was implemented in Stata (16.0) using the mvmeta package. Compared with using DEX only, DEX + SM displayed the best effective for lowering cTnI level (MD = -0.44, 95%CI [-0.56, -0.33], SUCRA 93.4%) and improving LVEF value (MD = 14.64, 95%CI [9.36, 19.91], SUCRA 98.4%). DEX + SQFZ showed the most effectiveness for lowering CK-MB level (MD = -11.57, 95%CI [-15.79, -7.35], SUCRA 97.3%). And DEX + AI + CI has the highest effectiveness for alleviating ECG abnormalities (MD = -2.51, 95%CI [-4.06, -0.96], SUCRA 96.8%). So that we recommended SM + DEX, SQFZ + DEX, and DEX + AI + CI as the top three effective interventions against AIC. Then, we explored their pharmacological mechanism respectively. The CPMs' active components and AIC-related targets were screened to construct the component-target network. The potential pathways related to CPMs against AIC were determined by KEGG. For SM, we identified 118 co-targeted genes of active components and AIC, which were significantly enriched in pathways of cancer pathways, EGFR tyrosine kinase inhibitor resistance and AGE-RAGE signaling pathway in diabetic complications. For SQFZ, 41 co-targeted genes involving pathways of microRNAs in cancer, Rap1 signaling pathway, MAPK signaling pathway, and lipid and atherosclerosis. As for AI + CI, 224 co-targeted genes were obtained, and KEGG analysis showed that the calcium signaling pathway plays an important role except for the consistent pathways of SM and SQFZ in anti-AIC. DEX + CPMs might be positive efficacious interventions from which patients with AIC will derive benefits. DEX + SM, DEX + SQFZ, and DEX + AI + CI might be the preferred intervention for improving LVEF value, CK-MB level, and ECG abnormalities, respectively. And these CPMs play different advantages in alleviating AIC by targeting multiple biological processes.

Changes of Intestinal Flora in Patients with Atrial Fibrillation and Its Correlation with Cardiovascular Risk Factors.

Based on the 16S rDNA sequence, intestinal flora changes in atrial fibrillation (AF) patients were monitored, the correlation between the changes and - score was analyzed, and the possible related factors affecting the changes of intestinal flora were investigated. According to the inclusion criteria, 53 AF patients were selected as atrial fibrillation group (Group AF), detection of C-reactive protein (CRP), homocysteine (Hcy), total bile acid (TBA), brain natriuretic peptide (BNP), High-sensitivity cardiac troponin (Hs-cTn) and left ventricular ejection fraction (LVEF) were accomplished. A total of 29 healthy subjects who underwent physical examination with matched gender and age were selected as the healthy group (Group H), and the same examinations as in Group AF were handled. Structural composition of intestinal flora was detected and analyzed by 16S rRNA sequencing technology. Flora differences between Group AF and Group H were counted, and the correlation analysis among age, Hs-cTn, CRP, TBA, Hcy, BNP and LVEF were explored. Meanwhile, - score of 53 AF patients was fulfilled, then patients were divided into three subgroups according to different scores, namely: 0 point (AF-0, n = 9), 1 point (AF-1, n = 15), 2 points (AF-2, n = 29). Finally, the correlation of intestinal flora differences and - scores were analyzed. In terms of Alpha diversity, compared with the control group, the abundance and diversity of flora in Group AF were observably reduced. However, at phylum and class level, there was no notable difference in community structure between Group AF and Group H (p 0.05). Further statistics revealed that the composition and abundance of intestinal flora in Group AF were prominently different from those in Group H at phylum, class, order and family levels, which were correlated with CRP and LVEF. Additionally, bioinformatics analysis comparison was performed on three - score subgroups of Group AF with Group H. It was reported that at phylum level, the relative abundance of Firmicutes in Group AF-2 and Chloroflexi in Group H was higher. At class level, the relative abundance of Sphingobacteriia, Flavobacteriia and Alphaproteobacteria was higher in group H. At order level, the relative abundance of Sphingobacteriales, Micrococcales, Flavobacteriales, Sphingobacteriales and Rhizobiales in group H was higher. At family level, the relative abundance of Sphingobacteriaceae, Flavobacteriaceae and Clostridiaceae in group H was higher. At genus level, the relative abundance of Sphingobacterium in group H, Clostridiumsensustricto-1 in Group AF-2, Dialister and Allisonella in Group AF-1, and Prevotella-9 in Group AF-0 were higher. There were changes in the relative abundance of intestinal flora at phylum, class, order and family levels, which was concerned with LVEF and CRP value, whereas Alpha diversity index of the flora decreased. The composition and relative abundance of intestinal flora varied in AF patients with - scores of 0, 1, and 2.

Combination of cardiac color Doppler ultrasound, serum MR-ProANP and NT-ProBNP forecasted hypertensive LVH and LFH

ABSTRACT To analyze the value of the combined test of the cardiac color Doppler ultrasound, the serum middle receptor pro-atrial natriuretic peptide (MR-ProANP) and the N-terminal pro-brain natriuretic peptide (NT-ProBNP) in forecasting the hypertensive left ventricular hypertrophy (LVH) and left heart failure (LHF). All patients were subjected to cardiac color Doppler ultrasound examination to obtain left atrium volume index (LAVI), left ventricular end-diastolic diameter (LVEDD), early-diastolic peak flow velocity (E), early-diastolic mean flow velocity (e’), early-diastolic peak flow velocity/early-diastolic mean flow velocity (E/e’) and left ventricular ejection fraction (LVEF). Biomarkers were performed to obtain serum MR-ProANP and NT-ProBNP concentrations, and statistical analysis was performed. The LVEF was obviously lower than that in the control group (P<0.01). The area under the receiver operating characteristic (ROC) curve (AUC) values of LVEF, E/e’, serum MR-ProANP and NT-ProBNP alone were in the range of 0.7–0.8. The AUC, sensitivity and specificity of LVEF and E/e’ combined with MR-ProANP and NT-ProBNP to diagnose hypertensive LVH and LHF were 0.892, 89.14% and 78.21%, which were higher than those of single diagnosis. In the heart failure group, LVEF was negatively correlated with serum MR-ProANP and NT-ProBNP concentrations (P<0.05), and E/e’ was positively correlated with serum MR-ProANP and NT-ProBNP concentrations (P<0.05). Pump function and ventricular remodeling in patients with hypertensive LVH and LHF are closely related to serum MR-ProANP and NT-ProBNP levels. Combination of the two testing can improve the prediction and diagnostic efficacy of LHF.

Impact of donor ventricular function on heart transplantation outcomes.

Some heart transplant (HTx) centers have expanded their donor eligibility criteria in response to the organ shortage; one area of active interest involves utilizing hearts with ventricular dysfunction. Our study seeks to identify if a relationship exists between donor left ventricular ejection fraction (LVEF) and ischemic time or donor age on HTx outcomes. We performed a retrospective analysis on adult patients who had a HTx between 1996 and 2021 (n=46,936). Donor LVEF (dLVEF) values were categorized into three groups:<50%, 50%-70%, and >70%. Ischemic time and donor age were stratified into four groups: ≤2.0, 2.1-3.0, 3.1-4.0,>4.0h, and ≤30, 31-40, 41-50, >50 years, respectively. The outcome of interest was long-term survival. Multivariable survival analysis found a slight increase in overall mortality risk for patients with donor ejection fractions <50% (HR=1.16, p=.013). However, subsequent subgroup investigation discovered that this elevated hazard was only applicable when ischemic time was prolonged to>3.0h (3.1-4.0h: HR=1.23, p=.024;>4.0h: HR=1.52, p<.001). There was no significant difference in survival between dLVEF groups when ischemic time was limited to ≤3.0h or when stratified by donor age. HTx patients with a low donor ejection fraction have comparable survival to recipients with a normal dLVEF when ischemic time is limited to ≤3.0h. Reduced dLVEF does not appear to be sensitive to advanced donor age. The clinical implications of our study may encourage the recruitment of more donor hearts for transplantation.

SGLT2 Inhibitors: Statins or ACE-Inhibitors of the 21st Century?

Current guidelines propose therapeutic algorithms based on left ventricular ejection fraction values and clinical presentations; however, these guidelines do not specify which of the four pillar drugs to start first [...].

Diagnostic value of echocardiography combined with serum C-reactive protein level in chronic heart failure

BackgroundChronic heart failure (CHF) is regarded as common clinical heart disease. This study aims to investigate the clinical diagnostic value of echocardiography (Echo) and serum C-reactive protein (CRP) levels in patients with CHF.MethodsA total of 75 patients with CHF (42 males, 33 females, age 62.72 ± 1.06 years) were enrolled as study subjects, with 70 non-CHF subjects (38 males, 32 females, age 62.44 ± 1.28 years) as controls. The left ventricular ejection fraction (LVEF), fraction shortening rate of the left ventricle (FS), and early to late diastolic filling (E/A) were determined by Echo, followed by an examination of the expression of serum CRP by ELISA. In addition, the Pearson method was used to analyze the correlation between echocardiographic quantitative parameters (EQPs) (LVEF, FS, and E/A) and serum CRP levels. Receiver operating characteristic (ROC) curve was adopted to evaluate the diagnostic efficacy of EQPs and serum CRP levels for CHF. The independent risk factors for CHF patients were measured by logistics regression analysis.ResultsThe serum CRP level of CHF patients was elevated, the values of LVEF and FS decreased, and the E/A values increased. ROC curve revealed that the EQPs (LVEF, FS, and E/A) combined with serum CRP had high diagnostic values for CHF patients. Logistic regression analysis showed that the EQPs (LVEF, FS, and E/A) and serum CRP levels were independent risk factors for CHF patients.ConclusionEcho combined with serum CRP level has high clinical diagnostic values for CHF patients.

Analysis of Left Ventricular Indexes and Mortality Among Asian Adults With Hemodynamically Significant Chronic Aortic Regurgitation

Chronic hemodynamically significant aortic regurgitation (AR) is associated with excess risk of death, yet data for Asian patients are lacking, and whether Asian patients can abide by Western guidelines as to when aortic valve surgery should be performed is unknown. To assess AR presentation and cutoffs of left ventricular ejection fraction (LVEF), LV end-systolic dimension index (LVESDi), and LV end-systolic volume index (LVESVi) that are associated with risk of death in Asian patients with AR. This retrospective cohort study included consecutive patients with chronic, moderately severe to severe AR from 3 tertiary referral centers (2 in Japan and 1 in Taiwan) from June 11, 2008, through November 19, 2020, with follow-up through November 11, 2021. Aortic regurgitation severity, graded by a comprehensive integrated approach. The primary outcome was the association between volume-derived LVEF, LVESDi, and LVESVi and all-cause death (ACD). The secondary outcome was the association of these LV indexes with cardiovascular death (CVD). Clinical and echocardiographic data were analyzed retrospectively. A de novo disk-summation method was used to derive LV volumes and volume-derived LVEF. Of 1259 patients (mean [SD] age, 64 [17] years; 934 [74%] male), 515 (41%) were Japanese and 744 (59%) were Taiwanese. The median follow-up was 4.1 years (IQR, 1.56-7.24 years). The mean (SD) body surface area was 1.67 (0.21) m2; LVEF, 55% (11%); LVESDi, 24.7 (5.7) mm/m2; LVESVi, 50.1 (28.0) mL/m2; and indexed mid-ascending aorta size, 24.7 (5.5) mm/m2. Aortic valve surgery occurred in 483 patients (38%); 240 patients (19%) died during follow-up. Overall mean (SD) 8-year survival was 74% (2%). Separate multivariate models adjusted for covariates demonstrated independent associations of LVEF, LVESDi, and LVESVi with ACD (LVEF: hazard ratio [HR] per 10%, 0.80; 95% CI, 0.70-0.92; P = .002; LVESDi: HR, 1.04; 95% CI, 1.01-1.06; P = .002; LVESVi: HR per 10 mL/m2, 1.11; 95% CI, 1.05-1.17; P < .001) and CVD (LVEF: HR per 10%, 0.69; 95% CI, 0.56-0.85; P < .001; LVESDi: HR, 1.05; 95% CI, 1.01-1.09; P = .01; LVESVi per 10 mL/m2: HR, 1.15; 95% CI, 1.06-1.24; P < .001). In the total cohort, spline curves showed that mortality started to increase for an LVEF of 53% or less, LVESDi of 22 mm/m2 or greater, and LVESVi of 46 mL/m2 or greater for both ACD and CVD. Early surgery was beneficial in 3 strata of LVESDi (<20, 20 to <25, and ≥25 mm/m2) and 2 strata of LVESVi (<46 and ≥46 mL/m2). This multicenter cohort study of Asian patients with hemodynamically significant AR found cutoff values of LVEF, LVESDi, and LVESVi that were associated with increased risk of death. These findings suggest that Western guidelines seem applicable in Asian patients and, most importantly, that indexed LV parameters with a lower cutoff could be used in discriminating patients with excess mortality risk.

Focused cardiac ultrasound with mitral annular plane systolic excursion (MAPSE) detection of left ventricular dysfunction

ObjectivesDetecting reduced left ventricular ejection fraction (LVEF) by an emergency physician (EP) is an important skill. The subjective ultrasound assessment of LVEF by EPs correlates with comprehensive echocardiogram (CE) results. Mitral annular plane systolic excursion (MAPSE) is an ultrasound measure of vertical movement of the mitral annulus, which correlates to LVEF in the cardiology literature, but has not been studied when measured by an EP. Our objective is to determine whether EP measured MAPSE can accurately predict LVEF <50% on CE. MethodsThis is a prospective observational single center study using a convenience sample to evaluate the use of a focused cardiac ultrasound (FOCUS) for patients with possible decompensated heart failure. The FOCUS included standard cardiac views to estimate LVEF, MAPSE, and E-point septal separation (EPSS). Abnormal MAPSE was defined as <8 mm and abnormal EPSS as >10 mm. The primary outcome assessed was the ability of an abnormal MAPSE to predict an LVEF <50% on CE. MAPSE also was compared to EP estimated LVEF and EPSS. Inter-rater reliability was determined by two investigators performing independent blinded review. ResultsWe enrolled 61 subjects, 24 (39%) had an LVEF <50% on a CE. MAPSE <8 mm had a 42% sensitivity (95% CI 22–63), 89% specificity (95% CI 75–97), and accuracy of 71% for detecting LVEF <50%. MAPSE demonstrated lower sensitivity than EPSS (79% sensitivity [95% CI 58–93], and 76% specificity [95% CI 59–88]) and higher specificity than estimated LVEF (100% sensitivity [95% CI 86–100], 59% specificity [95% CI 42–75]). PPV and NPV for MAPSE was 71% (95% CI 47–88) and 70% (95% CI 62–77) respectively. The ROC for MAPSE <8 mm is 0.79 (95% CI 0.68–0.9). MAPSE measurement interrater reliability was 96%. ConclusionsIn this exploratory study evaluating MAPSE measurements by EPs, we found the measurement was easy to perform with excellent agreement across users with minimal training. A MAPSE value <8 mm had moderate predictive value for LVEF <50% on CE and was more specific for reduced LVEF than qualitative assessment. MAPSE had high specificity for LVEF <50%. Further studies are needed to validate these results on a larger scale.

Relationship between Oxidative Stress and Left Ventricle Markers in Patients with Chronic Heart Failure

Oxidative stress is proposed in the literature as an important player in the development of CHF and correlates with left ventricle (LV) dysfunction and hypertrophy in the failing heart. In this study, we aimed to verify if the serum oxidative stress markers differ in chronic heart failure (CHF) patients' groups depending on the LV geometry and function. Patients were stratified into two groups according to left ventricular ejection fraction (LVEF) values: HFrEF (<40% (n = 27)) and HFpEF (≥40% (n = 33)). Additionally, patients were stratified into four groups according to LV geometry: NG-normal left ventricle geometry (n = 7), CR-concentric remodeling (n = 14), cLVH-concentric LV hypertrophy (n = 16), and eLVF-eccentric LV hypertrophy (n = 23). We measured protein (protein carbonyl (PC), nitrotyrosine (NT-Tyr), dityrosine), lipid (malondialdehyde (MDA), oxidizes (HDL) oxidation and antioxidant (catalase activity, total plasma antioxidant capacity (TAC) markers in serum. Transthoracic echocardiogram analysis and lipidogram were also performed. We found that oxidative (NT-Tyr, dityrosine, PC, MDA, oxHDL) and antioxidative (TAC, catalase) stress marker levels did not differ between the groups according to LVEF or LV geometry. NT-Tyr correlated with PC (rs = 0.482, p = 0.000098), and oxHDL (rs = 0.278, p = 0.0314). MDA correlated with total (rs = 0.337, p = 0.008), LDL (rs = 0.295, p = 0.022) and non-HDL (rs = 0.301, p = 0.019) cholesterol. NT-Tyr negatively correlated with HDL cholesterol (rs = -0.285, p = 0.027). LV parameters did not correlate with oxidative/antioxidative stress markers. Significant negative correlations were found between the end-diastolic volume of the LV and the end-systolic volume of the LV and HDL-cholesterol (rs = -0.935, p < 0.0001; rs = -0.906, p < 0.0001, respectively). Significant positive correlations between both the thickness of the interventricular septum and the thickness of the LV wall and the levels of triacylglycerol in serum (rs = 0.346, p = 0.007; rs = 0.329, p = 0.010, respectively) were found. In conclusions, we did not find a difference in serum concentrations of both oxidant (NT-Tyr, PC, MDA) and antioxidant (TAC and catalase) concentrations in CHF patients' groups according to LV function and geometry was found. The geometry of the LV could be related to lipid metabolism in CHF patients, and no correlation between oxidative/antioxidant and LV markers in CHF patients was found.