Prospective risk stratification of sudden cardiac death in Marfan's syndrome

Background

Marfan syndrome (MFS) is a variable, autosomal-dominant disorder of the connective tissue. In MFS serious ventricular arrhythmias and sudden cardiac death (SCD) can occur. The aim of this prospective study was to reveal underlying risk factors and to prospectively investigate the association between MFS and SCD in a long-term follow-up.

Methods

77 patients with MFS were included. At baseline serum N-terminal pro-brain natriuretic peptide (NT-proBNP), transthoracic echocardiogram, 12-lead resting ECG, signal-averaged ECG (SAECG) and a 24-h Holter ECG with time- and frequency domain analyses were performed. The primary composite endpoint was defined as SCD, ventricular tachycardia (VT), ventricular fibrillation (VF) or arrhythmogenic syncope.

Results

The median follow-up (FU) time was 868 days. Among all risk stratification parameters, NT-proBNP remained the exclusive predictor (hazard ratio [HR]: 2.34, 95% confidence interval [CI]: 1.1 to 4.62, p = 0.01) for the composite endpoint. With an optimal cut‐off point at 214.3 pg/ml NT-proBNP predicted the composite primary endpoint accurately (AUC 0.936, p = 0.00046, sensitivity 100%, specificity 79.0%). During FU, seven patients of Group 2 (NT-proBNP ≥ 214.3 pg/ml) reached the composite endpoint and 2 of these patients died due to SCD. In five patients, sustained VT was documented. All patients with a NT-proBNP < 214.3 pg/ml (Group 1) experienced no events. Group 2 patients had a significantly higher risk of experiencing the composite endpoint (logrank-test, p < 0.001).

Conclusions

In contrast to non-invasive electrocardiographic parameter, NT-proBNP independently predicts adverse arrhythmogenic events in patients with MFS.     

Cardiovascular magnetic resonance-derived intramyocardial hemorrhage after STEMI: Influence on long-term prognosis,adverse left ventricular remodeling and relationship with microvascular obstruction

Background

T2 weighted cardiovascular magnetic resonance (CMR) can detect intramyocardial hemorrhage (IMH) after ST-elevation myocardial infarction (STEMI). The long-term prognostic value of IMH beyond a comprehensive CMR assessment with late enhancement (LE) imaging including microvascular obstruction (MVO) is unclear. The value of CMR-derived IMH for predicting major adverse cardiac events (MACE) and adverse cardiac remodeling after STEMI and its relationship with MVO was analyzed.

Methods

CMR including LE and T2 sequences was performed in 304 patients 1 week after STEMI. Adverse remodeling was defined as dilated left ventricular end-systolic volume indexes (dLVESV) at 6 months CMR.

Results

During a median follow-up of 140 weeks, 47 MACE (10 cardiac deaths, 16 myocardial infarctions, 21 heart failure episodes) occurred. Predictors of MACE were ejection fraction (HR .95 95% CI [.93–.97], p = .001, per %) and IMH (HR 1.17 95% CI [1.03–1.33], p = .01, per segment). The extent of MVO and IMH significantly correlated (r = .951, p < .0001). dLVESV was present in 40% of patients. CMR predictors of dLVESV were: LVESV (OR 1.11 95% CI [1.07–1.15], p < .0001, per ml/m²), infarct size (OR 1.05 95% CI [1.01–1.09], p = .02, per %) and IMH (OR 1.54 95% CI [1.15–2.07], p = .004, per segment). Addition of T2 information did not improve the LE and cine CMR-model for predicting MACE (.744 95% CI [.659–.829] vs. .734 95% CI [.650–.818], p = .6) or dLVESV (.914 95% CI [.875–.952] vs. .913 95% CI [.875–.952], p = .9).

Conclusions

IMH after STEMI predicts MACE and adverse remodeling. Nevertheless, with a strong interrelation with MVO, the addition of T2 imaging does not improve the predictive value of LE-CMR.     

The S-wave angle identifies arrhythmogenic right ventricular cardiomyopathy in patients with electrocardiographically concealed disease phenotype

Background

Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) carries risk of sudden death. We hypothesize that the S-wave angle differentiates ARVD/C with otherwise normal electrocardiograms from controls.

Indications,safety and image quality of cardiovascular magnetic resonance: Experience in > 5,000 North American patients

Background

CMR offers accurate assessment of structure and function with high resolution. Although the use of CMR has been well established in Europe, information is lacking for the extent of this emerging modality in North America.

Objectives

This study aimed to summarize indications, safety, image quality, extent of contrast use and extent of stress tests performed in a high-volume CMR centre.

Methods

Consecutive patients scanned from July 2005 to November 2010 were included, with duplicates and research subjects removed. Original clinical referrals were categorized into 10 main indications.

Results

Retrospective analysis was performed on 6463 patients (mean ± SD age = 50 ± 17). The most common clinical indications were non-ischemic cardiomyopathies (28%), including myocarditis (18%), coronary artery disease (17%), ARVD and/or other RV disease (12%), and congenital heart disease (11%). Gadolinium-based contrast was given to 89.5% of patients as part of their CMR protocol. Of 10.9% (703/6463) of patients that underwent stress CMR, adenosine was administered most commonly. Of 703 patients, 1 (0.14%) suffered ventricular tachycardia during adenosine stress, and transient, asymptomatic AV block was occasionally observed. Moderate to severe complications after contrast agent administration occurred in 9 (0.16%) of 5782 contrast-enhanced studies, characterized by nausea and vomiting in 6 (0.12%) and by symptoms of acute systemic allergic reaction in 2 (0.04%). Image quality was good (82.0%), moderate but diagnostic (16.6%) and poor in 1.4% of cases.

Conclusion

In the high-volume CMR centre, main clinical indications were for myocarditis/cardiomyopathies, coronary artery disease and RV-related queries. CMR showed an excellent safety profile and high image quality in 99% of cases.     

Electrocardiographic ST-segment monitoring during controlled occlusion of coronary arteries

Background

Ischemia monitoring cannot always be performed by 12-lead ECG. Hence, the individual performance of the ECG leads is crucial. No experimental data on the ECG's specificity for transient ischemia exist.

Methods

In 45 patients a 19-lead ECG was registered during a 1-minute balloon occlusion of a coronary artery (left anterior descending artery [LAD], right coronary artery [RCA] or left circumflex artery [LCX]). ST-segment shifts and sensitivity/specificity of the leads were measured.

Results

During LAD occlusion, V3 showed maximal ST-segment elevation (0.26 mV [IQR 0.16–0.33 mV], p = 0.001) and sensitivity/specificity (88% and 80%). During RCA occlusion, III showed maximal ST-elevation (0.2 mV [IQR 0.09–0.26 mV], p = 0.004), aVF had the best sensitivity/specificity (85% and 68%). During LCX occlusion, V6 showed maximal ST-segment elevation (0.04 mV [IQR 0.02–0.14 mV], p = 0.005), and sensitivity/specificity was (31%/92%) but could be improved (63%/72%) using an optimized cut-off for ischemia.

Conclusion

V3, aVF and V6 show the best performance to detect transient ischemia.     

Prognostic value of cardiovascular magnetic resonance in patients with suspected arrhythmogenic right ventricular cardiomyopathy

Background

Early recognition and accurate risk stratification are important in the management of arrhythmogenic right ventricular cardiomyopathy (ARVC). Identification of predictors of outcome by cardiovascular magnetic resonance (CMR) in patients undergoing evaluation for ARVC is limited. We investigated the predictive value of morphological abnormalities detected by CMR for major clinical events in patients with suspected ARVC.

Methods

We performed a longitudinal study on 369 consecutive patients with at least one criterion for ARVC. Abnormal CMR was defined by the presence of one of the following: increased right ventricular (RV) volumes, reduced RV ejection fraction, RV regional wall motion abnormalities, myocardial fatty infiltration, and myocardial fibrosis. The end-point was a composite of cardiac death, sustained ventricular tachycardia, ventricular fibrillation, and appropriate ICD discharge.

Results

Twenty patients met the composite end-point over a mean follow-up of 4.3 ± 1.5 years. An abnormal CMR was an independent predictor of outcomes (p < 0.001). The presence of multiple abnormalities heralded a particular high risk of events (HR 23.0, 95% CI 5.7–93.2, p < 0.001 for 2 abnormalities; HR 35.8, 95% CI 9.7–132.6, p < 0.001 for 3 or more abnormalities). The positive predictive value of an abnormal CMR study was 21.0% for an adverse event, whilst the negative predictive value of a normal CMR study was 98.8% over the follow-up period.

Conclusions

CMR provides important prognostic information in patients under evaluation for ARVC. A normal study portends a good prognosis. Conversely, the presence of multiple abnormalities identifies a high risk group of patients who may benefit from ICD implantation.     

Recognizing and treating myocarditis in recent-onset systemic sclerosis heart disease: Potential utility of immunosuppressive therapy in cardiac damage progression

Objectives

Scleroderma heart disease is a major risk of death in systemic sclerosis (SSc). Mechanisms underlying myocardial damage are still unclear. We performed an extensive study of SSc patients with recent-onset symptoms for heart disease and examined the efficacy of immunosuppressive therapy.

Methods

A cohort of 181 SSc patients was enrolled. Of these, 7 patients newly developed clinical symptoms of heart disease (heart failure, chest pain, and palpitation); all of them showed mild but persistent increase in cardiac enzymes. These patients underwent Holter ECG, 2D-echocardiography, perfusional scintigraphy, delayed-enhancement-cardiac magnetic resonance (DE-CMR), coronary angiography, and endomyocardial biopsy. Patients were treated for at least 12 months and followed-up for 5 years.

Results

Ventricular ectopic beats (VEBs) were found in 4 patients, wall motion abnormalities in 3, pericardial effusion in 6, and DE in CMR in 6 with T2-hyperintensity in 2. In all patients, histology showed upregulation of endothelium adhesion molecules and infiltration of activated T lymphocytes, with (acute/active myocarditis in 6) or without (chronic/borderline myocarditis in 1) myocyte necrosis. Parvovirus B19 genome was detected in 3. None showed occlusion of coronary arteries or microvessels. Compared with SSc controls, these patients more often had early disease, skeletal myositis, c-ANCA/anti-PR3 positivity, VEBs, pericardial effusion, and systolic and/or diastolic dysfunction. Immunosuppressive therapy improved symptoms and led to cardiac enzyme negativization; however, 2 patients died of sudden death during follow-up.

Conclusions

Myocarditis is a common finding in SSc patients with recent-onset cardiac involvement. Its early detection allowed to timely start an immunosuppressive treatment, preventing cardiac damage progression in most cases.     

Comparison of 24-hour Holter Monitoring with 14-day Novel Adhesive Patch Electrocardiographic Monitoring

Background

Cardiac arrhythmias are remarkably common and routinely go undiagnosed because they are often transient and asymptomatic. Effective diagnosis and treatment can substantially reduce the morbidity and mortality associated with cardiac arrhythmias. The Zio Patch (iRhythm Technologies, Inc, San Francisco, Calif) is a novel, single-lead electrocardiographic (ECG), lightweight, Food and Drug Administration–cleared, continuously recording ambulatory adhesive patch monitor suitable for detecting cardiac arrhythmias in patients referred for ambulatory ECG monitoring.

Methods

A total of 146 patients referred for evaluation of cardiac arrhythmia underwent simultaneous ambulatory ECG recording with a conventional 24-hour Holter monitor and a 14-day adhesive patch monitor. The primary outcome of the study was to compare the detection arrhythmia events over total wear time for both devices. Arrhythmia events were defined as detection of any 1 of 6 arrhythmias, including supraventricular tachycardia, atrial fibrillation/flutter, pause greater than 3 seconds, atrioventricular block, ventricular tachycardia, or polymorphic ventricular tachycardia/ventricular fibrillation. McNemar's tests were used to compare the matched pairs of data from the Holter and the adhesive patch monitor.

Results

Over the total wear time of both devices, the adhesive patch monitor detected 96 arrhythmia events compared with 61 arrhythmia events by the Holter monitor (P < .001).

Conclusions

Over the total wear time of both devices, the adhesive patch monitor detected more events than the Holter monitor. Prolonged duration monitoring for detection of arrhythmia events using single-lead, less-obtrusive, adhesive-patch monitoring platforms could replace conventional Holter monitoring in patients referred for ambulatory ECG monitoring.     

A mismatch index based on the difference between measured left ventricular ejection fraction and that estimated by infarct size at three months following reperfused acute myocardial infarction

Background and Aim

The reduction of left ventricular ejection fraction (LVEF) following ST-segment elevation myocardial infarction (STEMI) is a result of infarcted myocardium and may involve dysfunctional but viable myocardium. An index that may quantitatively determine whether LVEF is reduced beyond the expected value when considering only infarct size (IS) has previously been presented based on cardiac magnetic resonance (CMR). The purpose of this study was to introduce the index based on the electrocardiogram (ECG) and compare indices based on ECG and CMR.

Method and Results

In 55 patients ECG and CMR were obtained 3 months after STEMI treated with primary percutaneous coronary intervention. Significant, however moderate inverse relationships were found between measured LVEF and IS. Based on IS and LVEF an IS estimated LVEF was derived and an MI–LVEF mismatch index was calculated as the difference between measured LVEF and IS estimated LVEF. In 41 (74.5%) of the patients there was agreement between the ECG and CMR indices in regards to categorizing indices as > 10 or ≤ 10 and generally no significant difference was detected, mean difference of 1.26 percentage points (p = 0.53).

Conclusion

The study found an overall good agreement between MI–LVEF mismatch indices based on ECG and CMR. The MI–LVEF mismatch index may serve as a tool to identify patients with potentially reversible dysfunctional but viable myocardium, but future studies including both ECG and CMR are needed.     

Electrocardiographic abnormalities in the first year after heart transplantation

Study Aim

Describe ECG abnormalities in the first year following transplant surgery.

Methods

Analysis of 12-lead ECGs from heart transplant subjects enrolled in an ongoing multicenter clinical trial.

Results

585 ECGs from 98 subjects showed few with abnormal cardiac rhythm (99% of ECGs were sinus rhythm/tachycardia). A majority of subjects (69%) had either right intraventricular conduction delay (56%) or right bundle branch block (13%). A second prevalent ECG abnormality was atrial enlargement (64% of subjects) that was more commonly left atrial (55%) than right (30%).

Conclusions

Right intraventricular conduction delay or right bundle branch block is prevalent in heart transplant recipients in the first year following transplant surgery. Whether this abnormality is related to acute allograph rejection or endomyocardial biopsy procedures is the subject of the ongoing clinical trial. Atrial enlargement ECG criteria (especially, left atrial) are also common and are likely due to transplant surgery with subsequent atrial remodeling.     

The frequency and severity of cardiac involvement in myotonic dystrophy type 2 (DM2): Long-term outcomes

Background

Frequency and severity of cardiac involvement in DM2 are still controversial. The aims of our study were to determine the frequency and progression of cardiac and muscle involvement in a relatively large cohort of patients with DM2 throughout Italy and Germany and to provide long-term outcomes in this disorder.

Methods

104 DM2 and 117 DM1 patients underwent baseline and follow-up assessments of, ECG, 24 h Holter monitoring, 2D echocardiography and electrophysiological study (EPS) when appropriate, and manual muscle strength testing (mean follow-up: 7.4 ± 4.1 for DM2 and 5.7 ± 4 years for DM1).

Results

Overall, 10% of DM2 patients vs 31% of DM1 patients had PR ≥ 200 ms and 17% of DM2 patients vs 48% of DM1 patients had QRSD ≥ 100 ms. Six patients with DM2 vs 28 patients with DM1 required PM/ICD implantations. DM2 patients were stronger than DM1 patients at baseline, but muscle strength worsened significantly over time (p < 0.0001), just as in DM1, although at a slower annual rate.

Conclusion

Our data demonstrate that the frequency and severity of cardiac involvement and of muscle weakness are reduced in DM2 compared to DM1 and that progression is slower and less severe. Nonetheless, careful cardiac evaluation is recommended in this patient population to identify patients at risk for potential major cardiac arrhythmias.     

Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project: prehospital digitally-assisted reperfusion strategies

Background

Guidelines for reperfusion in ST-elevation myocardial infarction (STEMI) were recently adopted by the Canadian Cardiovascular Society. We have developed a blended model of prehospital thrombolytic (PHL) therapy or primary percutaneous coronary intervention (PPCI) activation, in order to achieve guideline times.

Methods

In our urban centre of 658,700 people, emergency medical services (EMS) were trained to perform and screen electrocardiograms (ECGs) for suspected STEMI. Suspected ECGs were transmitted to a physician's hand-held device. If the physician confirmed the diagnosis they coordinated initiation of either PHL or PPCI. In cases where physicians found the prehospital ECG negative for STEMI (PHENST), patients were transported to the closest emergency room.

Results

From July 21, 2008 to July 21, 2010, the Cardiac Outcomes Through Digital Evaluation (CODE) STEMI project received 380 transmitted calls. There were 226 confirmed STEMI by the on-call physician, 158 (70%) received PPCI, 48 (21%) received PHL, and 20 (9%) had angiography but no revascularization. The PPCI, median time from first medical contact to reperfusion was 76 minutes (interquartile range [IQR], 64-93). For PHL, median time from first medical contact to needle was 32 minutes (IQR, 29-39). The overall mortality rate for the STEMI patients was 8% (PHL = 4 [8.3%], PPCI = 8 [5%], medical therapy = 7 [35%]). There were 154 PHENST patients, 44% later diagnosed with acute coronary syndrome. The mortality rate for PHENST was 14%.

Conclusions

Through a model of EMS prehospital ECG interpretation, digital transmission, direct communication with a physician, and rapid coordinated service, we demonstrate that benchmark reperfusion times in STEMI can be achieved.     

Arrhythmias in patients with acute coronary syndrome in the first 24 hours of hospitalization

Objectives

In patients with acute coronary syndrome (ACS), we sought to: 1) describe arrhythmias during hospitalization, 2) explore the association between arrhythmias and patient outcomes, and 3) explore predictors of the occurrence of arrhythmias.

Methods

In a prospective sub-study of the IMMEDIATE AIM study, we analyzed electrocardiographic (ECG) data from 278 patients with ACS. On emergency department admission, a Holter recorder was attached for continuous 12-lead ECG monitoring.

Results

Approximately 22% of patients had more than 50 premature ventricular contractions (PVCs) per hour. Non-sustained ventricular tachycardia (VT) occurred in 15% of patients. Very few patients (≤1%) had a malignant arrhythmia (sustained VT, asystole, torsade de pointes, or ventricular fibrillation). Only more than 50 PVCs/hour independently predicted an increased length of stay (p < .0001). No arrhythmias predicted mortality. Age greater than 65 years and a final diagnosis of acute myocardial infarction independently predicted more than 50 PVCs per hour (p = .0004).

Conclusions

Patients with ACS seem to have fewer serious arrhythmias today, which may have implications for the appropriate use of continuous ECG monitoring.     

Prevalence and predictors of worsened left ventricular diastolic dysfunction after catheter ablation of atrial fibrillation

Background

The interactions between atrial fibrillation (AF) and left ventricular diastolic dysfunction (LVDD) are complex and not well defined. Despite the high prevalence of LVDD in the AF population, therapies for LVDD remain limited. Previous studies have suggested that restoration of sinus rhythm with catheter ablation has a positive effect on LVDD, but the prevalence and predictors for worsened LVDD are unknown.

Methods

70 consecutive patients included in prospective AF catheter ablation registry (61 ± 10 years, 66% male) with paroxysmal (n = 40) or persistent AF (n = 30) were examined by transthoracic echocardiography, before and 12 months after ablation. LVDD was classified according to current guidelines. Rhythm outcome of the ablation was verified by serial 7-day Holter ECG.

Results

LVDD was present in 27 patients (38%) at baseline and in 33 patients (47%) at 12 months follow-up (p = .327). An improvement of LVDD was observed in 13 patients (19%), an aggravation was found in 19 (27%), while it was unchanged in the remaining 38 patients (54%). In uni- and multivariable regression analysis, total ablation time (OR 1.611 per 10 min ablation time, 95% CI 1.088 – 2.386, p = .017) was associated with LVDD progression, while neither baseline characteristics nor rhythm during follow-up influenced LVDD alterations. There was no association between echocardiographic deterioration and symptoms.

Conclusions

Catheter ablation of AF can worsen LVDD in a substantial proportion of patients with more aggressive ablation leading to aggravation of LVDD. While there are no apparent negative short-term effects, long-term consequences need to be determined.     

Isolated hypertrophy of the basal ventricular septum: Characteristics of patients with and without outflow tract obstruction

Background

Isolated basal septal hypertrophy (IBSH) of the left ventricle (LV) is not a well understood phenomenon, particularly in the presence of concomitant left ventricular outflow tract obstruction (LVOTO). We evaluated the prevalence of IBSH and compared those with and without LVOTO.

Methods

Retrospective observational study of 4104 consecutive patients undergoing echocardiography at a community cardiology practice and a hospital without specialized Hypertrophic Cardiomyopathy (HCM) service to determine prevalence of IBSH, defined as isolated hypertrophy (> 15 mm) of the basal LV septum (BS) without hypertrophy elsewhere. Clinical, ECG and echocardiographic characteristics were compared in IBSH with and without LVOTO.

Results

Prevalence of IBSH was 5.8% (240/4104): mean (SD) age was 76.0y (10.4) with equal gender distribution. Prevalence increased with age (p < 0.001 for trend), reaching 7.8% over 70y. None had a family history of HCM, and HCM-associated ECG changes were uncommon. Mean BS thickness (SD) was 17.8 mm (0.24) with a BS/posterior wall ratio (SD) of 1.76 (0.31). Resting peak LVOT gradient (> 20 mm Hg) was present in 8/240 (3.3%), mean (SD) 69.6mm Hg (59.3). Patients with LVOTO had hypercontractile LV function (fractional shortening [SD] 51.8% [9.5] vs. 40.5% [10.9], p = 0.012) compared to those without LVOTO, but had similar BS thickness [SD] (17.8 mm [3.0] vs. 17.8 mm [2.8], p = 0.996) and ECG characteristics. Greater apical and septal displacements of the mitral valve co-aptation point characterized those with IBSH and LVOTO.

Conclusions

IBSH is common in elderly patients referred for echocardiography. LVOTO occurs only when concomitant mitral valve co-aptation and LV hypercontractility facilitate development of a gradient, rather than through differences in the degree of BS myocardial hypertrophy.     

Progression and regression of women with biopsy-confirmed normal cervical epithelium or cervical intraepithelial neoplasia grade 1: a 15-year population-based cohort study in China

Background

The long-term risk of progression or regression in women with biopsy-confirmed normal cervical epithelium or cervical intraepithelial neoplasia grade 1 (CIN1) is unclear. The aim of the study was to assess the rates of progression and regression of women with histological CIN1 or normal cervical epithelium in rural China.

Impact of new task force criteria in the diagnosis of arrhythmogenic right ventricular cardiomyopathy

Background

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy that can lead to sudden cardiac death. The diagnostic criterion has recently been revised and through the use of cardiac magnetic resonance (CMR) imaging this study aimed to assess the clinical impact of comparing the original 1994 task force (TF) criterion to the revised 2010 criterion.

Methods

We evaluated 173 consecutive CMR scans of patients referred with clinical suspicion of ARVC between 2008 and 2011. We then compared the prevalence of major and minor CMR criteria by applying the two criteria.

Results

Using the 1994 TF criterion, 13 (7.5%) patients had definite, 11 (6.4%) had borderline, and 39 (22.5%) had possible ARVC. Using the 2010 TF criterion, 10 (5.8%) patients had definite, 1 had borderline, and 7 had (0.04%) possible ARVC. With the 1994 criterion, 81 patients satisfied CMR criterion, of which 36 (44%) had major and 45 (56%) had minor criteria. Upon reclassification with the revised criterion, 61 of the 81 patients were not assigned any criteria, even though many patients had significant risk factors. The negative predictive values (NPV) for both CMR criteria were 100% but the positive predictive values (PPV) for combined CMR major or minor criteria improved from 23% to 55%.

Conclusions

Revision of the criterion has enhanced the diagnostic capabilities of CMR but has resulted in a large cohort of patients not classified. In these patients, there is presently no official consensus on imaging or clinical strategy for surveillance of the evolution of pathology over time.     

Comparative prognostic value of myocardial strain derived from DENSE CMR: the British Heart Foundation MR-MI study

Background

Infarct size assessed early after acute ST-segment elevation myocardial infarction (STEMI) can overestimate the true extent of infarction, limiting its usefulness as a prognostic biomarker. Myocardial strain derived from displacement encoding with stimulated echoes (DENSE) cardiovascular magnetic resonance (CMR) provides information on myocardial contractility with high precision and accuracy. We hypothesised that the prognostic value of peak circumferential strain is higher than infarct size.

Quantitative ST-depression in Acute Coronary Syndromes: the PLATO Electrocardiographic Substudy

Background

We evaluated whether electrocardiogram (ECG) characteristics were aligned with clinical outcomes and the effect of ticagrelor within the diverse spectrum of non-ST-elevation acute coronary syndrome patients enrolled in the PLATelet inhibition and patient Outcomes (PLATO) trial.

Methods

There were 8884 PLATO patients who had baseline ECGs assessed by a core laboratory; of these, 4935 had an ECG at hospital discharge that also was assessed. Associations with study treatment on vascular death or myocardial infarction within 1 year were examined.

Results

At baseline, most patients had either no or ≤0.5 mm of ST-segment depression (57%); 26% had 1.0 mm, and 17% had more extensive depression (>1.0 mm). Across the baseline ST-segment depression strata, there was a consistent treatment benefit with ticagrelor versus clopidogrel on vascular death/myocardial infarction. The extent of residual ST-segment depression at discharge was similar in the treatment groups, and the treatment effect did not differ by the extent of discharge ST-segment depression. There was a progressive increase in vascular death/myocardial infarction with increasing extent of baseline ST-segment depression (1.0 mm [vs no/0.5 mm]: hazard ratio [HR] 1.22; 95% confidence interval [CI], 1.03-1.45; >1.0 mm: HR 1.49; 95% CI, 1.24-1.78; P <.001) and at discharge (HR 1.28; 95% CI, 1.02-1.61; HR 2.13; 95% CI, 1.54-2.95; P <.001).

Conclusion

The treatment effect of ticagrelor among non-ST-segment-elevation acute coronary syndrome patients was consistently expressed across all baseline ST-segment depression strata. There was no indication of an anti-ischemic benefit of ticagrelor as reflected on the discharge ECG. Our data affirm the independent prognostic relationship of both baseline and hospital discharge ST-segment depression on outcomes within 1 year in non-ST-segment-elevation acute coronary syndrome patients.     

Cardiovascular magnetic resonance imaging in asymptomatic patients with connective tissue disease and recent onset left bundle branch block

Background–aim

Recent LBBB in connective tissue diseases (CTDs) is challenging, due to high incidence of underlying pathology that may remain undetected, due to limitations of imaging tests. We hypothesized that cardiovascular magnetic resonance (CMR) may be of diagnostic value in CTDs with recent LBBB and normal echocardiogram.

Patients–methods

26 CTDs, aged 32 ± 7 yrs (19 F) and 26 controls without CTDs, aged 60 ± 4 yrs (10 F) with recent LBBB and normal echo were evaluated by CMR. The CTDs included 6 sarcoidosis (SRC), 4 systemic sclerosis (SSc), 6 systemic lupus erythematosus (SLE), 6 rheumatoid arthritis (RA) and 4 inflammatory myopathies (IM). CMR was performed by 1.5 T. LVEF, T2 ratio (oedema imaging) and late gadolinium enhancement (LGE) (fibrosis imaging) were evaluated. Acute and chronic lesions were characterised by T2 > 2 and positive LGE and T2 < 2 and positive LGE, respectively. According to LGE, lesions were characterised as diffuse subendo-, subepicardial/intramural not following and subendocardial/transmural following the distribution of coronaries, indicative of vasculitis, myocarditis and myocardial infarction, respectively.

Results

CTDs were younger (p < 0.001), with higher incidence of abnormal CMR (42.31 vs 30.77%, p = NS), including dilated cardiomyopathy (11.54%), diffuse subendocardial fibrosis (11.54%), myocardial infarction (7.69%) and acute myocarditis (11.54%) vs dilated cardiomyopathy (19.23%), myocardial infarction (7.69%) and acute myocarditis (3.85%), detected in non-CTDs.

Conclusions

In CTDs with recent LBBB, CMR documented acute and chronic cardiac pathology, particularly myocarditis. CMR should be considered as an adjunct to conventional diagnostic workup in both patient groups, more so in CTDs.