Asymptomatic left ventricular systolic dysfunction in essential hypertension: prevalence, determinants, and prognostic value

Prevalence, determinants, and prognostic value of asymptomatic left ventricular systolic dysfunction (LVSD) in uncomplicated subjects with essential hypertension are still incompletely known. We studied 2384 initially untreated subjects with hypertension, no previous cardiovascular disease, and no symptoms or physical signs of congestive heart failure (CHF). These subjects were studied at entry and followed for up to 17 years (mean 6.0). Asymptomatic LVSD (ALVSD), defined by an echocardiographic ejection fraction <50%, was found in 3.6% of subjects. Cigarette smoking (P=0.013), increased left ventricular (LV) mass (P=0.001), and higher 24-hour heart rate (P=0.014) were independent correlates of ALVSD. During follow-up, a first cardiovascular event occurred in 227 subjects, and 24 of these events were hospitalizations for symptomatic CHF. Incidence of CHF per 100 persons per year was 0.12 in patients without and 1.48 in patients with ALVSD (log-rank test P=0.0001). In a Cox model, after adjustment for age (P=0.0001), LV mass (P=0.0001), and cigarette smoking (P=0.039), LVSD conferred a markedly increased risk for CHF (odds ratio, 9.99; 95% confidence interval, 3.67 to 27.2). Incidence of coronary (0.84 versus 0.62x100 person years) and cerebrovascular (0.80 versus 0.62x100 person years) events did not differ (all P=NS) between subjects with and without ALVSD. ALVSD is a potent and early marker of evolution toward severe CHF requiring hospitalization in subjects with essential hypertension.     

Epidemiology of left ventricular systolic dysfunction in the general population of Germany: results of an echocardiographic study of a large population-based sample]

The prevalence of left ventricular systolic dysfunction (LVSD) in the general population is poorly defined. Specifically, the number of asymptomatic individuals with LVSD and, thus, the most appropriate strategy to identify and treat such subjects is still unknown. Therefore, the aim of this study was to document LV dysfunction in a middle-aged (25 to 75 years, mean 51.8+/-13.8) population - based sample in Germany (MONICA Augsburg, n=1678; echocardiography technically adequate n=1418) by M-mode and 2D-echocardiography and to analyze the importance of predisposing contributors. The overall prevalence of an ejection fraction (EF) less than 48% (mean minus 2 SD=LVSD) was 2.3% (n=33), with a slightly higher rate in men than in women (2.8% vs 1.9%, n.s.). LVSD rate increased with age: from 1.5% in individuals younger than 40 years to 4.0% among those older than 60 years of age (p<0.05). Of 33 participants with reduced left ventricular systolic function, 20 presented with at least one cardiovascular disease. The most frequent diagnoses were arterial hypertension, obesity and coronary heart disease. Only 13 subjects (0.9%) of the study population were asymptomatic without a history of cardiovascular disease. Furthermore, only 6 subjects (0.4%, 4 male) in this population presented with a moderate impairment of LV function (EF of 30 to 40%) and only 1 subject (0.07%, male) had severe LVSD (EF less than 30%). Almost all subjects with an EF less than 40% (6 of 7 individuals) had a known history of cardiovascular disease. In conclusion, LVSD is a relatively common finding in the general population. However, severe LVSD is rare in subjects without any concomitant cardiovascular disease. Thus, echocardiographic screening cannot be recommended in the unselected, middle-aged population to identify such patients.     

Prevalence, predictors, time course, and long-term clinical implications of left ventricular functional recovery after mechanical reperfusion for acute myocardial infarction

This study prospectively evaluated the prevalence, predictors, time course, and prognostic impact of left ventricular (LV) functional recovery after successful primary percutaneous coronary intervention in 228 consecutive patients with acute myocardial infarctions (AMIs) and LV dysfunction. Serial echocardiographic exams were performed within 24 hours (time 1) and at 1 month (time 2) and 6 months (time 3) after AMI. Overall, 133 patients (58%) showed significant LV functional recovery (> or =10% ejection fraction increase compared with time 1 or ejection fraction > or =50%) at time 3. Early (from time 1 to time 2) and late (from time 2 to time 3) functional recovery patterns were detected in 102 patients (45%) and 31 patients (14%), respectively. Independent predictors of LV functional recovery were enzymatic infarct size (p = 0.0001), time from symptom onset to reperfusion (p = 0.022), extent and severity of baseline LV wall motion abnormalities (p = 0.007), and female gender (p = 0.031). Six-month LV remodeling rates were 36% and 64% in patients with and without LV functional recovery (p = 0.0001). The five-year cardiac death rate was significantly lower in patients with LV functional recovery than in those without (8% vs 18%, respectively, p = 0.024). The time course of LV functional recovery during 6 months did not significantly affect long-term survival. In conclusion, after successful mechanical reperfusion of AMIs, nearly half of patients showed poor LV functional recovery. The presence of significant LV functional recovery 6 months after reperfused AMI, but not the specific time course of recovery, is clearly associated with a better long-term clinical outcome. Simple baseline variables can predict the improvement of cardiac function after reperfused AMI.     

Value of three-dimensional speckle-tracking longitudinal strain for predicting improvement of left ventricular function after acute myocardial infarction

Identification of patients with reversible left ventricular (LV) dysfunction has important prognostic implications after acute myocardial infarction (AMI). This study aimed to determine the value of LV segmental and global longitudinal strains assessed with 3-dimensional (3D) speckle-tracking analysis in predicting improvement of LV function after AMI. One hundred fifty-three patients (80% men, 59 ± 11 years old) with AMI and treated with primary percutaneous coronary intervention underwent 3D echocardiography. LV segmental and global 3D longitudinal strains were assessed with speckle-tracking analysis using a novel dedicated software. At 6-month follow-up, improvement in segmental LV function was defined as a decrease of ≥1 grade in segmental wall motion score. Improvement in global LV function was defined as an absolute improvement ≥5% in LV ejection fraction. Segments with functional improvement at follow-up showed a significantly higher baseline 3D longitudinal strain compared to segments without improvement (-16.4 ± 4.0% vs -7.6 ± 3.5%, p <0.001). A cut-off value of -11.1% for segmental 3D longitudinal strain had 92% sensitivity and 91% specificity in predicting functional improvement. In addition, 67 patients (44%) showed an improvement in global LV function at 6-month follow-up. These patients showed significantly higher baseline global 3D longitudinal strain compared to patients without improvement (-16.7 ± 2.1% vs -13.3 ± 2.6%, p <0.001). Global 3D longitudinal strain provided incremental value over clinical and conventional echocardiographic variables in predicting global LV function improvement (c-statistic improved from 0.64 to 0.71 to 0.84). In conclusion, longitudinal strain assessed by 3D speckle-tracking analysis is an important predictor for segmental and global LV function improvement after AMI.     

Prognostic significance of persistent right ventricular dysfunction as assessed by radionuclide angiocardiography in patients with inferior wall acute myocardial infarction

We evaluated cardiac hemodynamics and long-term prognosis in patients with right ventricular (RV) acute myocardial infarction (AMI) using Fourier phase and amplitude analysis of radionuclide angiocardiographic scanning. In 143 patients with RV AMI, delayed phase and low amplitude in radionuclide RV images persisted in 54 patients (persistent RV dysfunction group) 3 months after AMI, but disappeared in the remaining 89 patients (improved RV function group). No significant differences were present in RV dimensions, left ventricular (LV) wall motion, LV ejection fraction, or RV ejection fraction between these groups during the acute phase. At 3 months, RV dimension and LV and RV wall motion indexes were significantly higher (p = 0.0292, p = 0.0124, p<0.0001, respectively), and LV and RV ejection fractions were lower (p = 0. 0174 and p = 0.0008, respectively) in the persistent RV dysfunction group. Percutaneous transluminal coronary angioplasty in the acute phase was performed in a smaller group of patients (15% vs. 34%, p = 0.0223), and the degree of residual stenosis in the proximal right coronary artery was significantly greater in the persistent RV dysfunction group than in the improved RV function group (82+/-22% vs. 53+/-30%, p<0.0001). The 8-year survival rate was significantly lower in the persistent RV dysfunction group (p<0.0001). Persistent abnormality of phase and amplitude in radionuclide RV images was a significant independent predictor of long-term survival (odds ratio 10.42; 95% confidence interval 3.65 to 29.71; p<0.0001). Radionuclide angiocardiographic Fourier phase and amplitude scanning can detect persistent RV dysfunction in patients with RV AMI and can predict patient outcome.     

Efficient utilization of echocardiography for the assessment of left ventricular systolic function

BACKGROUND: We hypothesized that patients could be selected for echocardiographic evaluation of left ventricular (LV) systolic function on the basis of historic, clinical, radiographic, and electrocardiographic criteria. METHODS AND RESULTS: We prospectively evaluated 300 consecutive inpatients referred for the echocardiographic assessment of LV function, of whom 124 (41%) had LV systolic dysfunction (LVSD) (LV ejection fraction <0.45). Among the historic variables, male sex was the only predictor of LVSD, whereas of the abnormal physical and radiographic findings, cardiomegaly on chest radiography was the only predictor. Among the electrocardiographic findings, the presence of left bundle branch block was positively correlated with the presence of LVSD, whereas a normal electrocardiogram was negatively correlated with this finding. Only 2 patients with LVSD had a normal electrocardiogram. The addition of significant predictors on physical examination and chest radiography doubled the predictive value of the historic variables for determining LVSD. The addition of electrocardiographic findings further doubled the predictive value of the model. Almost 45% of the predictive power of the final multivariate model (chi-square of 48 of the total chi-square of 108) was based on the absence of normal electrocardiogram in patients with LVSD. When chest radiographic findings were excluded from the model, the overall predictive power of the model did not change, with the normal electrocardiogram gaining greater prominence: Full 56% of the predictive power of the model (chi-square of 60 of the total chi-square of 108) resided in the ability of a normal electrocardiogram to discriminate between patients with and those without LVSD. CONCLUSIONS: Historic, chest radiographic, and electrocardiographic variables can be used to predict low likelihood of LVSD on echocardiography. In particular, when the electrocardiogram is normal, it is extremely unlikely to have LVSD. It can be argued that such patients should not be referred for echocardiography.     

实时三维超声心动图与磁共振对比评价左心室射血分数≥45%患者的左心室容量

目的:评价实时三维超声心动图(RT3D)测量左心室射血分数(LVEF)≥45% 成年人左心室容量的准确性和重复性.方法:选取因各种不同原因进行心脏磁共振(MRI)检查显示 LVEF ≥45%的患者37例,同时进行RT3D检查.RT3D检查采用Philips iE-33型超声心动图仪,左心室容量及左心室功能的分析通过TomTec工作站用人工描记法完成,并与MRI所得结果相比较.结果:MRI测量的左心室舒张末期容量(EDV)为:60～208.76(110.48±33.50)ml,左心室收缩末期容量(ESV)为:19～102.4(45.80±17.84 )ml,LVEF为:45.40～71.10(59.13±7.24)%.RT3D测量的EDV为:42.8～ 211.9(100.64±34.48)ml,ESV为:14.30 ～94.54(44.08 ±17.62)ml,LVEF为:35.1～73.4(56.70±7.02)%.与MRI相比,RT3D低估EDV(P＜0.01,r=0.842,y=0.867x+4.88,SEE=18.86ml),二者平均相差(-9.84±38.26) ml.RT3D同时低估ESV,二者相比差异无统计学意义(P＞0.05,r=0.846,y=0.835x+5.82,SEE=9.53 ml),二者平均相差(-1.71±19.68)ml.RT3D所测的LVEF稍小于MRI所测得的LVEF,二者相比差异有统计学意义(P＜0.05,r=0.616,y=0.597x+21.38,SEE=5.61%),平均相差(-2.42±12.5 )%.在不同观察者间及观察者自身不同时间内测量的RT3D,结果显示良好的重复性.结论:与MRI相比,RT3D测量成人患者的左心室容量及LVEF有较好的准确性和重复性.     

Eplerenone improves prognosis in postmyocardial infarction diabetic patients with heart failure: results from EPHESUS

Background:  The Epleronone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) trial demonstrated that selective aldosterone blockade with eplerenone significantly reduced total mortality by 15%, combined cardiovascular (CV) mortality/CV hospitalization by 13%, CV mortality by 17% and sudden cardiac death by 21%, vs. placebo when added to standard care in patients with left ventricular systolic dysfunction (LVSD) and signs of congestive heart failure (CHF) following acute myocardial infarction (AMI). We retrospectively evaluated the effect of eplerenone vs. placebo in a subset of 1483 diabetic patients with LVSD and signs of CHF following AMI.
Methods:  Diabetic status was determined from medical histories at screening. Analyses were based on time to first occurrence of an event. Results were based on a Cox's proportional hazards regression model stratified by region with treatment, subgroup and treatment-by-subgroup interaction as factors. The 95% confidence intervals for the risk ratios were based on the Wald's test.
Results:  Treatment with eplerenone in diabetic patients with CHF following AMI reduced the risk of the primary endpoint, a composite of CV mortality or CV hospitalization, by 17% (p = 0.031). The absolute risk reduction of the primary endpoint was greater in the diabetic cohort (5.1%) than in the non-diabetic cohort (3%). Hyperkalaemia occurred more often with eplerenone than with placebo (5.6 vs. 3%, p = 0.015). Among the diabetic cohorts, the prespecified endpoint of 'any CV disorder' occurred in 28% of the eplerenone group and 35% of the placebo group (p = 0.007).
Conclusion:  Eplerenone treatment may reduce adverse CV events in diabetic patients with LVSD and signs of CHF following AMI.     

Value of the Paced QRS Duration

BackgroundThe value for paced QRS duration (pQRSd) to detect left ventricular (LV) dysfunction in right ventricular apex (RVA)–paced patients has not been evaluated.Methods and ResultsA total of 272 RVA-paced patients, including 99 with LV systolic dysfunction (LVSD) and 173 without LVSD, were enrolled in this study. The pQRSd, echocardiographic variables, and plasma N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were measured. Relationships between pQRSd and echocardiographic variables, NT-proBNP levels, and New York Heart Association (NYHA) functional classification were analyzed. pQRSd was correlated with LV end-diastolic and end-systolic dimensions (β = 1.59 and 1.54, respectively; all P < .001), NT-proBNP levels (β = 12.98, P < .001) and LV ejection fraction (β = –109.25, P < .001). There was a stepwise increase in pQRSd with increasing NYHA Class (all P < .001). The pQRSd cutoff value of 200 ms, derived from the receiver operator characteristic curve, had sensitivity of 71.72% and specificity of 86.71% to detect LVSD. pQRSd ≥ 240 ms gave a positive predictive value of 100%, whereas <180 ms excluded >97.3% of patients with LVSD.ConclusionsIn RVA-paced patients, pQRSd is correlated with left ventricular structures and function and pQRSd of 200 ms is a satisfactory cutoff value in terms of sensitivity and specificity for detecting LVSD.     

Relation of left ventricular dilation during acute myocardial infarction to systolic performance, diastolic dysfunction, infarct size and location

The quantification of left ventricular (LV) volumes and assessment of their relation to systolic and diastolic dysfunction, infarct size and anatomic location were performed in 54 patients with a first acute myocardial infarction (AMI). Blood pool radionuclide angiography was used to assess LV end-diastolic, end-systolic, and stroke volume indexes, ejection fraction and peak diastolic filling rate. Infarct size was estimated from plasma MB creatine kinase activity. Substantial LV dilation occurred within the initial 24 hours of AMI. The peak diastolic filling rate was low, even in those patients with a normal ejection fraction. In comparison with inferior AMI (n = 25), patients with anterior AMI (n = 29) had a larger end-diastolic volume index (105 +/- 8 vs 81 +/- 4 ml/m2, p less than 0.01) and end-systolic volume index (64 +/- 7 vs 37 +/- 4 ml/m2, p less than 0.001), but similar stroke volume index (41 +/- 3 vs 43 +/- 2 ml/m2, difference not significant). No significant relation was noted between infarct size estimated by MB creatine kinase and any volumetric index. On repeat study (day 10 after AMI), end-diastolic and end-systolic volume indexes increased further (p less than 0.05 vs day 1) but ejection fraction and peak diastolic filling rate were unchanged. It was concluded that: (1) LV dilation occurs within hours of AMI in both inferior and anterior AMI, but is more marked in the latter; (2) significant LV diastolic dysfunction is the rule, even in patients with preserved LV systolic function; and (3) LV dilation is an early compensatory mechanism that maintains normal stroke volume, even in patients with severely reduced LV function.     

The prevalence of treatable left ventricular systolic dysfunction in patients who present with noncardiac vascular episodes: a case-control study.

OBJECTIVES: We sought to determine the prevalence of treatable left ventricular (LV) systolic dysfunction (LVSD) in patients who present with their first noncardiac vascular episode. BACKGROUND: Screening for LV dysfunction in patients who present with their first stroke (cerebrovascular accident), their first transient ischemic attack (TIA) or their first manifestation of peripheral vascular disease (PVD) may represent a golden opportunity to identify treatable LV dysfunction, and so their known high incidence of sudden cardiac death may be reduced. METHODS: Participating in this study were 522 (75%) of 700 consecutive patients (302 patients with stroke, TIA or PVD and 220 age- and gender-matched control subjects). Each underwent a full clinical assessment, 12-lead electrocardiography and two-dimensional echocardiography. Left ventricular dysfunction was defined as LV ejection fraction < or = 40%. RESULTS: Seventy-two (28%) patients with vascular disease and 11 (5.5%) control subjects were found to have LVSD. Twenty-six (28%) stroke patients, 22 (26%) patients with TIA and 24 (31%) patients with PVD had LVSD. Left ventricular systolic dysfunction was symptomatic in 44% of patients and in 35% of control subjects. CONCLUSIONS: Left ventricular systolic dysfunction is five times more common among patients with stroke, TIA and PVD than among age- and gender-matched control subjects. Asymptomatic LVSD is more common than symptomatic LVSD in these patients. These findings suggest that routine screening of all patients with noncardiac vascular episodes for LVSD should now be considered. Future studies should investigate whether identifying and treating LVSD in these patients would reduce their known high rate of cardiac death.     

Clinical significance of brain natriuretic peptide in patients with postmyocardial infarction

BACKGROUND: Risk stratification after acute myocardial infarction (AMI) includes the evaluation of left ventricular (LV) function. Natriuretic peptides, and particularly brain natriuretic peptide (BNP), emerged as a potential marker of ventricular function and prognosis after AMI. HYPOTHESIS: Brain natriuretic peptide levels are related to ventricular function, either systolic or isolated diastolic, and can give prognostic information in patients surviving AMI. METHODS: In all, 101 patients were enrolled. An echocardiographic (M-mode, two-dimensional, and pulsed Doppler) evaluation was performed and blood samples for BNP measurement were obtained. Clinical events were recorded during 12 months of follow-up. RESULTS: A negative correlation between BNP and LV ejection fraction was observed (r = -0.38; p < 0.001). The BNP levels were higher among patients with LV systolic dysfunction than in patients with isolated diastolic dysfunction (339.1 +/- 249.9 vs. 168.0 +/- 110.5 pg/ml, p = 0.001). The latter had higher levels of BNP than those with normal LV function (68.3 +/- 72.6 pg/ml, p < 0.001). The BNP accuracy to detect LV systolic dysfunction was good (area under the ROC curve [AUC] = 0.83) and increased when isolated diastolic dysfunction was also considered (AUC = 0.87). Brain natriuretic peptide had a very good accuracy in the prediction of death (AUC = 0.95) and the development of heart failure (AUC = 0.90). CONCLUSION: These results extend previous evidence relating BNP to systolic function after AMI. Furthermore, a relationship between BNP levels and diastolic function was found. Brain natriuretic peptide had a very good performance in detecting the occurrence of an adverse event. We conclude that BNP can detect high-risk patients and help select patients for more aggressive approaches.     

Usefulness of left ventricular end-systolic dimension by echocardiography to predict reverse remodeling in patients with newly diagnosed severe left ventricular systolic dysfunction

In many patients with left ventricular (LV) systolic dysfunction, the LV ejection fraction (LVEF)-a surrogate for reverse remodeling-fails to improve despite optimal medical therapy. The early identification of such patients would allow instituting aggressive treatment, including early therapy with implantable cardioverter defibrillators. We sought to establish the predictors of reverse remodeling in patients with LV systolic dysfunction receiving optimal medical therapy. Patients (n = 568) with newly documented LVEF of ≤0.35, who had ≥1 follow-up echocardiogram after ≥3 months, were evaluated. Reverse remodeling was defined as improvement in LVEF to >0.35. The clinical, laboratory, and echocardiographic data were compared between patients with (n = 263) and without (n = 305) reverse remodeling. The mean follow-up was 27 ± 16 months. Patients who demonstrated reverse remodeling had a significantly greater mean follow-up LVEF (0.51 ± 0.09 vs 0.25 ± 0.08; p <0.001). On multivariate analysis, the baseline LV end-systolic diameter index was the strongest predictor of reverse remodeling (odds ratio 5.79; 95% confidence interval 1.82 to 18.46; p <0.001). Other independent predictors of reverse remodeling were female gender (odds ratio 1.88; 95% confidence interval 1.19 to 2.98; p = 0.007), and nonischemic cardiomyopathy (odds ratio 1.65; 95% confidence interval 1.05 to 2.58; p = 0.03). Baseline LVEF was not an independent predictor of reverse remodeling. In conclusion, among patients with newly diagnosed LV systolic dysfunction, the LV end-systolic diameter index, but not the LVEF, at diagnosis, was a strong predictor of reverse remodeling. Patients with a low likelihood of reverse remodeling might benefit from more aggressive heart failure therapy, including the possible early use of implantable cardioverter defibrillators.     

Echocardiographic markers for mitral valve surgery to preserve left ventricular performance in mitral regurgitation

BACKGROUND: The timing of mitral valve (MV) surgery to preserve left ventricular (LV) contractility in patients with mitral regurgitation (MR) has been defined by complex cardiac catheterization techniques. Whether noninvasive methods can identify patients with MR, a normal LV ejection fraction, and early LV contractile impairment is unknown. We hypothesized that echocardiographic measures would separate patients with MR and a normal LV ejection fraction into those with and without contractile dysfunction and, thus, prospectively predict the response of LV size and performance to MV surgery. METHODS AND RESULTS: We studied 27 patients with micromanometer LV pressures and radionuclide angiography to obtain a determination of LV volumes and ejection fraction and calculate chamber elastance, a measure of LV contractility, before MV surgery. Echocardiographic studies were performed before MV surgery and repeated at 3 and 12 months after surgery. Age, New York Heart Association class, LV plus maximum pressure per unit change in time, LV systolic and end-diastolic pressures, and echocardiographic posterior wall thickness and radius to wall thickness ratio did not identify preoperative LV contractile dysfunction. However, other echocardiographic measures were related to LV contractility, including LV end-diastolic dimension (r = -0.50, P <.005), LV end-systolic dimension (r = -0.60, P <.0001), and LV fractional shortening (r = 0.50, P =.005). From analysis of receiver operator characteristic curves, an LV end-systolic dimension of >/=40 mm was identified as most predictive for separating patients with MR before surgery into those with and without LV contractile dysfunction (sensitivity of 82% and specificity of 100%). The patients with MR and impaired preoperative LV contractility showed a dramatic deterioration in LV fractional shortening at 3 months after MV surgery (P =.01), which recovered to within the normal range for fractional shortening at 12 months (P =.02) from a progressive reduction in LV end-systolic dimension. This response in LV size and performance temporally differed from that in the patients with MR and normal contractility (2-way analysis of variance P <.0001). However, at 12 months after MV surgery, LV end-diastolic dimension, end-systolic dimension, and fractional shortening were normal in both groups of patients with MR. CONCLUSION: We conclude that echocardiographic measures, particularly an end-systolic dimension of >/=40 mm, may be useful for identifying patients with MR before surgery with early, occult LV contractile dysfunction in whom MV surgery may be recommended to preserve LV systolic performance.     

Comparison of the frequency of abnormal cardiac findings by echocardiography in patients with and without peripheral arterial disease

Peripheral arterial disease (PAD) diagnosed by ankle-brachial index (ABI) evaluation is associated with a high cardiovascular mortality rate. Transthoracic echocardiography (TTE) allows identification of left ventricular (LV) dysfunction and other cardiac findings associated with an increased cardiovascular mortality rate, for which treatments to alter prognosis are available. We sought to determine the prevalence of important TTE abnormalities in outpatients with symptomatic PAD by performing screening TEE. Outpatients without previous echocardiography who had been referred for ABI evaluation for suspected PAD underwent prospective screening TTE. The primary end points were LV dysfunction (LV ejection fraction 0.9, n = 84), and PAD was found to be an independent predictor of LV dysfunction (odds ratio 2.8, 95% confidence interval 1.2 to 6.4) and composite clinically important echocardiographic findings (3.2 95% confidence interval 1.5 to 7.1, p <0.01). In conclusion, outpatients with symptomatic PAD have a high prevalence of clinically important TTE abnormalities, including LV dysfunction, and PAD is an independent predictor of an abnormal echocardiogram.     

Left ventricular dysfunction after acute myocardial infarction--the impact of cardiovascular risk factors.

INTRODUCTION: Left ventricular (LV) systolic function is an important prognostic factor in coronary heart disease. Left ventricular ejection fraction (LVEF) should be assessed in all patients after acute myocardial infarction (AMI). Although reperfusion therapy has been found effective in the reduction of complications of AMI, LVEF impairment is a common consequence of an acute coronary event. The aim of this study was to estimate the incidence of LVEF depression after ST-elevation myocardial infarction (STEMI) and to evaluate the effect of previous cardiovascular risk factors on the risk of LV dysfunction. METHODS: One hundred and forty-seven consecutive patients with a first STEMI were included in this study. Most patients were male (70.7%) and mean age was 60.7 years. LVEF was assessed by echocardiography (using the single-plane area-length method and automatic border detection). LV systolic function was considered depressed when ejection fraction was less than 45 %. The chi-square test was used in the statistical analysis to compare proportions and a logistic regression model was fitted to assess the independent effect of each variable. RESULTS: Incidence of LV dysfunction was 55.8% in STEMI patients. No association was found between gender or age and LVEF impairment. The proportion of patients with diabetes was higher in the impaired LVEF group than in normal LVEF patients (44.7% vs. 31.7%, p = 0.12); the prevalence of smoking was also higher in patients with LV dysfunction (46.9% vs. 33.8%, p = 0.11). On the other hand, dyslipidemia was less common in patients with depressed LV function (35.4% vs. 56.9%, p = 0.01). Hypertension was not associated with impaired LVEF. After adjustment for ST-elevation location and number of vessels with critical stenosis, diabetes and smoking were associated with a significantly higher risk of LVEF impairment (diabetes: OR = 3.73, 95% CI 1.25-11.16; smoking: OR = 3.9, 95% CI 1.37-11.07) and dyslipidemia with a significantly lower risk of LV dysfunction (OR: 0.37, 95% CI 0.15-0.88). Conclusions: In STEMI patients, previous cardiovascular risk factors have a significant impact on the likelihood of LV dysfunction and hence could influence long-term prognosis.     

Elevated cardiac troponin T predicts adverse outcomes in hypertensive patients

Ongoing myocardial damage detected as elevated serum cardiac troponin T (cTnT) indicates increased risk for future cardiac events in patients with chronic heart failure. Whether elevated cTnT is associated with adverse outcomes in patients with hypertension (HT) without left ventricular (LV) systolic dysfunction is unknown.We measured cTnT levels in 176 patients with essential HT without LV systolic dysfunction (LV ejection fraction ≤ 55%), renal failure, and prior cardiovascular or cerebrovascular diseases and 39 normal controls. Levels of cTnT were elevated (≥ 0.02 ng/mL) in 15 (9%) of the 176 patients and in 0 (0%) of the 39 normal controls (P = 0.04). The rate of diabetes mellitus (DM), the cardiothoracic ratio, plasma B-type natriuretic peptide (BNP) value, and LV mass index were significantly higher in patients with than without elevated cTnT (DM, 8/15 versus 29/161, P = 0.004; cardiothoracic ratio, 54.5 ± 4.5 versus 51.6 ± 5.2%, P = 0.04; BNP, 103.3 ± 142.3 versus 36.9 ± 50.7 pg/mL, P = 0.04; LV mass index, 227 ± 87 versus 152 ± 57 g/m(2), P = 0.0001). Kaplan-Meier analysis demonstrated that significantly fewer (P < 0.000001) patients with, than without elevated cTnT remained free of events (hospitalization due to cardiovascular or cerebrovascular disease, n = 34). Stepwise Cox multivariate analysis revealed that elevated cTnT (hazard ratio, 6.58; P = 0.000001) and smoking (hazard ratio, 2.24; P = 0.04) were independent predictors of events.The present findings indicate that cTnT is a novel and useful predictor of future cardiovascular or cerebrovascular events in hypertensive patients.     

Cardiac correlates of exercise induced pulmonary hypertension in patients with chronic heart failure due to left ventricular systolic dysfunction

BACKGROUND: Patients with chronic heart failure (CHF) due to left ventricular systolic dysfunction (LVSD) may develop pulmonary hypertension at rest and during exercise. The cardiac correlates of pulmonary hypertension have been ascertained in the resting state, but seldom during exercise in these patients. AIMS: We sought to determine the cardiac correlates of exercise induced pulmonary hypertension in patients with LVSD by monitoring the estimated pulmonary artery systolic pressure (PASP) by continuous Doppler echocardiography during semirecumbent bicycle exercise. METHODS: Eighty-five patients (mean age 57 +/- 13 years, 75% male) with CHF due to LVSD (LV ejection fraction [EF] <45%, mean LVEF 26 +/- 8%) were studied. RESULTS: Mitral effective regurgitant orifice area and E-wave were independent predictors of resting PASP. Resting PASP and exercise induced changes in PASP were unrelated (r =-0.08, P = 0.45). Decrease in LV end-systolic volume, increase in left atrial (LA) area, resting LV asynchrony, and decreased tricuspid annular plane systolic excursion (TAPSE) were independent predictors of exercise PASP. CONCLUSIONS: Resting LV asynchrony, impaired LV contractile reserve, and increase in LA dilatation correlate with the severity of exercise induced pulmonary hypertension in patients with CHF due to LVSD, while right ventricular systolic dysfunction is inversely related to the severity of exercise induced pulmonary hypertension.     

Early detection of left ventricular systolic dysfunction using two-dimensional speckle tracking strain evaluation in healthy subjects after acute alcohol intoxication

Objectives: We evaluated the ability of two-dimensional speckle tracking strain echocardiography to detect left ventricular (LV) systolic dysfunction as compared with LV ejection fraction (EF) in healthy subjects following acute alcohol intoxication. Methods and Results: In total, 25 healthy subjects were investigated using echocardiography 4-6 hours after the onset of alcohol intoxication at a regional festive gathering, and then compared to 23 healthy control subjects without alcohol consumption. Heart rate, blood pressure, blood alcohol level, LV volumes, EF, shortening fraction, E/A ratio, as well as global longitudinal strain (LS) were recorded. Mean blood alcohol level was 1.3 ± 0.3 g.L(-1) . Mean systolic blood pressure and heart rate were slightly increased in the alcohol group compared to controls (147.5 ± 21.8 mmHg vs 127.0 ± 9.9 mmHg, P = 0.003, and 79.7 ± 10.7 bpm vs 70.6 ± 7.6 bpm, P < 0.001, respectively). While there was no significant difference in terms of LVEF (62.9 ± 4.4% vs 64.8 ± 5.9%, P = 0.18) or shortening fraction (34.7 ± 5.9% vs 36.0 ± 4.3%, P = 0.54), global LS was significantly impaired (-17.8 ± 2.0% vs -21.2 ± 1.8%, P < 0.001). In addition, subjects who consumed alcohol had increased LV end-diastolic (108.3 ± 20.1 mL vs 95.5 ± 14.6 mL, P = 0.037) and end-systolic volumes (41.6 ± 11.4 mL vs 33.7 ± 6.9 mL, P = 0.024), along with depressed aortic time-velocity integral (19.9 ± 3.2 mL vs 21.9 ± 2.5 mL, P = 0.034). According to multivariate linear regression analyses, blood alcohol level was the only factor significantly associated with global LS (β=-3.6 ± 1.0, P = 0.005). Conclusion: Alcohol intoxication around festive days induces acute LV contraction abnormalities, which may be detected using global LS by speckle tracking at an earlier stage and more accurately than LVEF decreases.     

Left ventricular hypertrophy in aortic valve stenosis: preventive or promotive of systolic dysfunction and heart failure?

AIMS: In aortic stenosis (AS), left ventricular (LV) hypertrophy is considered a compensatory response helping maintain systolic function. Recent research in experimental AS suggests, however, that LV hypertrophy is not necessary to sustain LV contractions but may in fact be maladaptive. The present work aimed to clarify the role of LV hypertrophy in AS-related heart failure (HF) in man. METHODS AND RESULTS: We studied 137 adult patients with isolated AS undergoing pre-operative echocardiography and cardiac catheterization. HF was diagnosed by the European criteria and LV hypertrophy by sex-specific limits of echocardiographic LV mass. The higher the LV mass was, the poorer was the LV ejection fraction (beta=-0.26, P< 0.001, linear regression) and the greater the likelihood of HF independent of the severity of AS (P< 0.001, logistic regression). In the subgroup of critical AS (valve area <0.4 cm(2)/m(2), n=85), patients with absent LV hypertrophy (n=19) had better preserved ejection fraction (mean+/-SE, 64+/-3 vs. 57+/-2%, P=0.045) and less HF (16 vs. 48%, P=0.025) than patients with LV hypertrophy (n=66). CONCLUSION: In isolated AS, increased LV mass predicts the presence of systolic dysfunction and HF independent of the severity of valvular obstruction. LV hypertrophy may be maladaptive rather than beneficial in AS in man.