老年射血分数保留的心力衰竭合并贫血患者心脏结构及功能分析

目的 分析老年射血分数保留的心力衰竭(HFpEF)合并贫血患者的心脏结构及功能特点。方法 选取2008年2月至2019年12月于中国人民解放军总医院第一医学中心住院的≥60岁的老年HFpEF患者2 281例,根据是否合并贫血,分为贫血组(n=949)和对照组(n=1 332)。分析2组患者的临床特征、心脏超声结构及功能差异。采用EmpowerStats统计软件(3.0版)和R软件进行数据分析。根据数据类型,组间比较分别采用独立样本t检验、Kruskal-Wallis H检验或χ²检验。采用多元线性回归模型分析血红蛋白(HGB)的影响因素,以及HGB与心脏超声指标的相关性。结果 老年HFpEF住院患者中41.6%(949/2 281)合并贫血。贫血组男性[54.69%(519/949)和47.75%(636/1 332)]、年龄[(74.79±7.99)和(73.40±7.72)年]、收缩压[(140.06±23.80)和(136.77±23.05)mmHg(1 mmHg=0.133 kPa)]、院内全因死亡率[3.58%(34/949)和1.50%(20/1 33...     

The correlation of left atrial volume index to the level of N-terminal pro-BNP in heart failure with a preserved ejection fraction

Background: Patients with heart failure with a preserved ejection fraction (HFPEF) have high N‐terminal pro‐B‐type natriuretic peptide (NT‐pro‐BNP) level and a high ratio of early transmitral inflow to diastolic velocity of the mitral annulus (E/E′) derived from tissue Doppler imaging (TDI). Because left atrial volume indexed to body surface area (LAVI) is believed to reflect chronic diastolic dysfunction, we assessed the ability of LAVI and E/E′ ratio to predict NT‐pro‐BNP level in patients with HFPEF. Methods: One hundred forty‐eight patients with HFPEF (ejection fraction ≥ 50%, NT‐pro‐BNP ≥ 100 pg/ml) underwent conventional echocardiography including LAVI and E/E′ ratio, which were compared with NT‐pro‐BNP level. Results: In the overall patient population, modest correlations were found between NT‐pro‐BNP level and peak systolic TDI (S′) (P = 0.009), LAVI (P = 0.009), and E/E′ ratio (P = 0.017). However, in patients with E/E′ ratio ≥13, LAVI was the most important predictor of NT‐pro‐BNP level (P < 0.001), whereas in those with E/E′ ratio <13 it was S′ (P < 0.001) in multivariate analysis. Conclusion: In patients with HFPEF evidenced by high NT‐pro‐BNP level, LAVI correlates with NT‐pro‐BNP level in the setting of elevated E/E′ ratio. However, in the setting of low E/E′ ratio, LAVI does not seem to be associated with NT‐pro‐BNP level.     

Increased left atrial volume index is an independent predictor of raised serum natriuretic peptide in patients with suspected heart failure but normal left ventricular ejection fraction: Implication for diagnosis of diastolic heart failure

BACKGROUND: Left atrial volume index (LAVI) is increasingly recognised as a relatively load-independent marker of left ventricular (LV) filling pressures. We assessed the capacity of LAVI to predict LV diastolic dysfunction in comparison with N-terminal pro B-type natriuretic peptide (NTproBNP) in patients with suspected heart failure and a normal ejection fraction (EF). METHODS: 137 patients with suspected heart failure (HF), referred from the community for echocardiography, prospectively underwent Doppler echocardiography, LAVI and NTproBNP estimation. Raised LAVI and reduced LV systolic function were defined as >26 ml/m2 and LV EF <50% respectively. RESULTS: Of 137 patients, 21 were excluded (2 with significant mitral valve disease and 19 with atrial fibrillation). Of the remaining 116 subjects, 92 showed normal LV systolic function. The univariate predictors of serum log NTproBNP were age (p < 0.001), LA dimension (p = 0.001), LAVI (p < 0.001), A wave (p = 0.001), E:A (p = 0.07) and septal wall thickness (p = 0.004). However on multivariate analysis, LAVI was found to be the most consistent and significant predictor of NTproBNP. The area under the curve of the receiver operating characteristic (ROC) curve for NTproBNP in detecting patients with LVEF > or = 50% and LAVI >26 ml/m2 was 0.81 (p < 0.0001) and for patients with LAVI > 26 ml/m2 with and without LVEF > or = 50% was 0.82 (p < 0.0001). CONCLUSION: This data confirms that LAVI on resting echocardiography, specifically in patients with suspected HF and normal LV systolic function is a powerful independent predictor of LV diastolic dysfunction as predicted by serum NTproBNP. In a population with a high suspicion of diastolic heart failure, LAVI may significantly contribute to diagnostic precision.     

Increased temporal dispersion of myocardial repolarization in myotonic dystrophy type 1: beyond the cardiac conduction system

Objectives

To assess ventricular dysfunction and ventricular interaction after repair of Tetralogy of Fallot (ToF) employing echocardiography speckle-tracking and cardiac magnetic resonance imaging (CMR).

Background

Severe pulmonary regurgitation and right ventricular (RV) dysfunction are common after repair of ToF and may also affect the shape and function of the left ventricle (LV). Recent studies suggest that LV dysfunction may be of particular prognostic value.

Methods and results

Twenty-one consecutive adults with repaired ToF (15 male, mean age 38 ± 11 years, 7 with severe PR) underwent a comprehensive echocardiographic exam including speckle-tracking analysis, CMR and cardiopulmonary exercise testing. Twenty-one subjects without relevant heart disease served as controls. Echocardiographically measured RV diameters correlated with RV volumes obtained from CMR (r = 0.63; p = 0.006). In addition, a close correlation was found between RV and LV function on CMR (r = 0.74, p = 0.002), speckle-tracking LV and RV peak longitudinal 2D strain (r = 0.66, p = 0.003) and mitral and tricuspid annular plain systolic excursion (r = 0.71, p = 0.0003). While LV ejection fraction was normal in the majority of patients and not different from controls, LV longitudinal strain was significantly reduced in ToF patients (− 16.5 ± 3.3 vs. -20.5 ± 2.7%, p = 0.0001).

Conclusion

Left and right ventricular function both by CMR and speckle-tracking is interrelated in adults with repaired ToF. Despite normal LV ejection fraction, 2D longitudinal strain is significantly reduced in ToF patients, suggesting subclinical LV myocardial damage. Considering the potential prognostic value of LV dysfunction in ToF, this measurement may gain importance and should be included in future outcome studies.     

沙库巴曲缬沙坦在射血分数保留心力衰竭患者中的临床研究进展

目前我国心力衰竭(简称心衰)患病率高达1.3％,约1370万例,心衰5年生存率不足50％,与恶性肿瘤相当,给我国心血管疾病防治工作带来沉重负担.沙库巴曲缬沙坦是全球首个血管紧张素受体脑啡肽酶抑制剂(ARNI)类药物,2017年在我国上市,2018年即被写入中国心衰指南,推荐用于射血分数降低心衰(HFrEF)患者.然而射...     

Left anterior descending coronary artery flow impaired by right ventricular apical pacing: The role of systolic dyssynchrony

Introduction

Right ventricular (RV) pacing may affect myocardial perfusion and coronary blood flow; however, it remains unknown whether this is related to systolic dyssynchrony induced by RV pacing. This prospective study was aimed to assess the relationship between dyssynchrony and the changes of coronary blood flow.

Methods

Seventy patients with sinus node dysfunction were prospectively enrolled. Coronary flow was evaluated by measuring diastolic velocity time integral (VTI) and duration at the distal-portion of left anterior descending coronary artery (LAD) with transthoracic echocardiography at baseline and follow-up. Systolic dyssynchrony was assessed with tissue Doppler imaging by time standard deviation to peak systolic velocity of 12 left ventricular segments (Ts-SD, cutoff value ≥ 33 ms).

Results

Adequate data for analysis was available from 65 patients. At follow-up (mean follow up time: 127 ± 45 days), LAD velocity-time integral (LAD-VTI: 12.1 ± 4.2 vs. 10.7 ± 4.6 cm, p < 0.001) was decreased and there was deterioration of left ventricular systolic function (left ventricular ejection fraction: 65 ± 7% vs. 62 ± 7%). However, these changes were only detected in those with RV pacing induced systolic dyssynchrony. Significant reduction of LAD-VTI (defined as ≥ 5%) occurred in 34 (52%) patients which was more prevalent in those with pacing-induced systolic dyssynchrony than those without (85.3% versus 16.1%, χ² = 31.1, p < 0.001). Though similar at baseline, LAD-VTI was significantly lower in the dyssynchrony group at follow up (p < 0.001). Cox-regression analysis showed that pacing-inducing systolic dyssynchrony [hazard ratio (HR): 3.62, p = 0.009] and higher accumulative pacing percentage (HR: 1.02, p = 0.002) were independently associated with reduction of LAD-VTI. ROC curve demonstrated that accumulative pacing percentage ≥ 35% was 97% sensitive and 84% specific in revealing significant reduction (area under the curve: 0.961, p < 0.001).

Conclusions

RV pacing induced dyssynchrony is associated with reduced coronary flow and this may account for, in part, the deleterious effect of RV pacing on ventricular function over time.     

Evolving changes in Doppler mitral flow velocity pattern in rats with hypertensive hypertrophy

OBJECTIVES

The aim of our study was to explore evolving changes in a mitral flow velocity pattern (MFVP) and its hemodynamic and pathological correlates in hypertensive rats in an isolated diastolic heart failure model.

BACKGROUND

Development of left ventricular (LV) hypertrophy and concomitant diastolic dysfunction cause heart failure in hypertensive hearts even with normal systolic function; however, associated evolving change in MFVP is still unclear.

METHODS

Mitral flow velocity pattern was recorded every 2 weeks from 7 to 19 weeks in six hypertensive rats. Hemodynamic and pathological correlates of Doppler mitral flow indexes were examined as an additional part of the study using the hypertensive rats at the age of 13 weeks (compensatory stage, N = 7) and at 19 weeks (heart failure stage, N = 8).

RESULTS

Initial development of pressure overload LV hypertrophy resulted in a decrease in early diastolic filling wave (E), a reciprocal increase in the filling wave due to atrial contraction (A) and prolongation of deceleration time of E wave (relaxation abnormality pattern). These changes were associated with an increase in tau, an index of LV relaxation, but without a change in LV end-diastolic pressure. Transition to congestive heart failure caused an increase in E, a decrease in A and shortening of deceleration time. These changes were not associated with further increase in tau but with elevation of LV end-diastolic pressure, reflecting marked LV hypertrophy and myocardial fibrosis.

CONCLUSIONS

Development of pressure overload LV hypertrophy is associated with evolving changes in MFVP from normal to relaxation abnormality pattern and, in turn, to pseudonormalized to restrictive pattern. Analysis of MFVP may be useful to follow not only functional but also constitutional changes of the myocardium in hypertensive hearts.