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Zhuravleva OA, Ryabova TR, Vrublevsky AV, Svyazova NN, Margolis NY, Boshchenko AA. Stress Echocardiography by the ABCDE Protocol ln the Assessment of Prognosis of Stable Coronary Heart Disease. KARDIOLOGIIA 2024; 64:22-30. [PMID: 38742512 DOI: 10.18087/cardio.2024.4.n2572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 10/23/2023] [Indexed: 05/16/2024]
Abstract
AIM To assess the role of clinical indicators and parameters of stress echocardiography performed according to an extended protocol as predictors for the occurrence of a composite cardiovascular endpoint (CCVEP) in IHD. MATERIAL AND METHODS The study included 186 patients (60.2% men, mean age 60.6±9.9 years) with an established (n=73; 39.2%) and suspected (60.8%) diagnosis of IHD. Stress EchoCG with adenosine triphosphate (38.2%), transesophageal pacing (15.1%), dobutamine (2.6%), and bicycle ergometry on a recumbent ergometer (44.1%) was performed. The stress EchoCG protocol included assessment of regional wall motion abnormalities (WMA), B-lines, LV contractile reserve (CTR), coronary reserve (CR), and heart rate reserve. The median follow-up period was 13 [9; 20] months. The composite CCVEP included death from cardiovascular diseases and their complications, acute coronary syndrome, and revascularization and was defined at the first of these events. Statistical analysis was performed with the Statistica 16.0 and SPSS Statistics 23.0 software packages. Differences were considered statistically significant at p<0.05. RESULTS Invasive or noninvasive coronary angiography was performed in 90.3% of patients; obstructive coronary disease (stenosis ≥50%) was detected in 67.9% of cases. During the follow-up period, 58 (31.2%) patients had cardiovascular complications. The risk of developing CCVEP was associated with the pretest probability (PTP) of ischemic heart disease (odds ratio, OR, 1.05; 95% confidence interval, CI, 1.02-1.08), dyslipidemia (DLP) (OR 0.40; 95% CI 0.20-0.82), carotid atherosclerosis (OR 0.39; 95% CI 0.18-0.86), LV ejection fraction (OR 0.96; 95% CI 0.93-0.99), appearance at peak stress of new significant (2 LV segments or more) regional WMAs (OR 0.32; 95% CI 0.18-6.55), decreased LV CTR (OR 0.46; 95% CI 0.27-0.79) and CR (OR 0.33; 95% CI 0.18-0.61); p<0.05 for all. In a multivariate analysis with Cox regression, the model with clinical indicators included PTP of IHD (OR 1.04; 95% CI 1.01-1.07; p=0.01) and DLP (OR 0.14; 95% CI 0.02-1.01; p=0.05) as predictors. The model with stress EchoCG parameters included the appearance of new significant WMAs (OR 0.33, 95% CI 0.16-0.65; p=0.001) and reduced <2.0 CR (OR 0.44; 95% CI 0.24-0.82; p=0.01). A comparative analysis of Kaplan-Meier curves confirmed statistically significant differences in the dynamics of the CCVEP occurrence depending on the absence or presence of hemodynamically significant WMAs and/or reduced CR during stress EchoCG (p<0.01). CONCLUSION Reduced LV CR and WMA during stress EchoCG in patients with suspected or confirmed IHD are significant independent predictors for the CCVEP occurrence. Among clinical indicators, PTP of IHD and DLP are of the greatest importance for prognosis.
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Affiliation(s)
- O A Zhuravleva
- Research Institute of Cardiology, Tomsk National Research Medical Center
| | - T R Ryabova
- Research Institute of Cardiology, Tomsk National Research Medical Center
| | - A V Vrublevsky
- Research Institute of Cardiology, Tomsk National Research Medical Center
| | - N N Svyazova
- Research Institute of Cardiology, Tomsk National Research Medical Center
| | - N Y Margolis
- Research Institute of Cardiology, Tomsk National Research Medical Center
| | - A A Boshchenko
- Research Institute of Cardiology, Tomsk National Research Medical Center
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Hanyu Y, Hoshino M, Usui E, Sugiyama T, Kanaji Y, Hada M, Nagamine T, Nogami K, Ueno H, Sakamoto T, Yonetsu T, Sasano T, Kakuta T. Combined Assessment of Fractional Flow Reserve and Coronary Flow Velocity Reserve after Drug-Eluting Stent Implantation. J Am Soc Echocardiogr 2024; 37:428-438. [PMID: 38122836 DOI: 10.1016/j.echo.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Coronary flow velocity reserve (CFVR) can be measured noninvasively using stress transthoracic Doppler echocardiography (S-TDE). The prognostic significance of S-TDE-derived CFVR after percutaneous coronary intervention (PCI) remains unknown. The aim of this study was to investigate the prognostic value of post-PCI CFVR and its additional efficacy to fractional flow reserve (FFR) in patients undergoing elective PCI. METHODS A retrospective study was conducted involving 187 consecutive patients with chronic coronary syndrome who underwent elective PCI guided by FFR for the left anterior descending coronary artery. Pre- and post-PCI wire-based FFR and CFVR assessments of the left anterior descending coronary artery using S-TDE were performed in all patients. The association between post-PCI clinical and physiologic parameters and major adverse cardiac events (MACE), defined as a composite of cardiac death, myocardial infarction, heart failure, and unplanned remote target vessel revascularization, was evaluated. RESULTS Three-quarters of patients exhibited CFVR increase after PCI, while all patients showed FFR improvement. During a median follow-up period of 1.5 years, MACE occurred in 21 patients (11.2%). Among clinical demographics, patients with MACE had higher levels of N-terminal pro-brain natriuretic peptide compared with those without MACE (median, 615 pg/mL [interquartile range, 245-1,500 pg/mL] vs 180 pg/mL [interquartile range, 70-559 pg/mL]; P = .010). Post-PCI S-TDE-derived CFVR was lower in patients with MACE, while post-PCI FFR showed a nonsignificant tendency to be lower in patients with MACE. In a multivariable analysis, higher NT-proBNP (adjusted hazard ratio, 1.33; 95% CI, 1.02-1.74; P = .038), post-PCI CFVR ≤ 2.0 (adjusted hazard ratio, 2.93; 95% CI, 1.16-7.40; P = .023), and post-PCI FFR ≤ 0.82 (adjusted hazard ratio, 3.93; 95% CI, 1.52-10.18; P = .005) were independently associated with MACE. CONCLUSIONS In patients with chronic coronary syndrome who underwent successful elective PCI for left anterior descending coronary artery, the combined assessment of S-TDE-derived post-PCI CFVR and post-PCI FFR provided a significant association with the occurrence of MACE.
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Affiliation(s)
- Yoshihiro Hanyu
- Division of Cardiovascular Medicine, Hiratsuka Kyosai Hospital, Hiratsuka, Japan
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Eisuke Usui
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tomoyo Sugiyama
- Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Masahiro Hada
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tatsuhiro Nagamine
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Kai Nogami
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Hiroki Ueno
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Tatsuya Sakamoto
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan
| | - Taishi Yonetsu
- Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Japan.
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Gaibazzi N, Cortigiani L, Rigo F, Porter TR, Guerra E, Ciampi Q. Reversible ischaemia and outcome after adjustment for coronary artery disease severity: a multicentre stress-echocardiography registry. Eur Heart J Cardiovasc Imaging 2024; 25:510-519. [PMID: 37950913 DOI: 10.1093/ehjci/jead304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/28/2023] [Accepted: 11/07/2023] [Indexed: 11/13/2023] Open
Abstract
AIMS To assess the potential association of reversible ischaemia and Doppler coronary flow velocity reserve in the left anterior descending coronary artery (CFVR-LAD) during stress echocardiography (SE) with all-cause mortality and non-fatal myocardial infarction (MI), after correction for anatomic coronary artery disease (CAD) burden and other significant clinical variables. METHODS AND RESULTS We selected 3191 patients (mean age 66 ± 12 years) from our multicentre SE registry, who underwent both high-dose dipyridamole SE (comprehensive of CFVR-LAD measurement) and coronary angiography within 2 months. All-cause mortality and non-fatal MI were the primary end points. The association of the primary end point with ischaemia severity and CFVR-LAD was assessed, after multivariable adjustment for all other significant clinical and imaging variables, including anatomic CAD severity by the modified Duke Prognostic Index. The primary end point occurred in 767 (24%) patients (death in 409 and non-fatal MI in 375 patients) during a median follow-up of 42 months. Multivariable Cox regression analyses indicated that, among other significant variables, anatomic CAD severity, reversible ischaemia, and CFVR-LAD were all independently associated with the primary end point; reversible ischaemia was also associated with subsequent MI, while CFVR-LAD with mortality, independent of anatomic CAD severity. CONCLUSION Our study suggests that reversible ischaemia by wall motion assessment and CFVR-LAD on dipyridamole SE are independently associated with dismal outcome in patients with suspected or known stable CAD, even after accounting for angiographic anatomic CAD severity and also independently from which coronary artery is diseased.
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Affiliation(s)
- Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, Viale Antonio Gramsci 14, 43126 Parma, Italy
| | | | - Fausto Rigo
- Division of Cardiology, Villa Salus Hospital Foundation/IRCCS San Camillo Venice, Italy
| | - Thomas R Porter
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Nebraska Medical Center, 982265 Nebraska Medical Center, Omaha, NE 68198, USA
| | - Emiliano Guerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico Di Modena, Modena, Italy
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Li D, Zhao X, Xiao Q, Yang R, Li Z, Xie Y, Mao X, Li X, Hu W, Deng Y. Evaluation of left ventricular flow field changes after stress in patients with nonobstructive coronary artery disease using ultrasonic flow vector imaging. Front Cardiovasc Med 2024; 11:1340289. [PMID: 38576423 PMCID: PMC10991677 DOI: 10.3389/fcvm.2024.1340289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/08/2024] [Indexed: 04/06/2024] Open
Abstract
Purpose Vector flow mapping and treadmill exercise stress echocardiography were used to evaluate and explore changes in the left ventricular (LV) flow field of patients with nonobstructive coronary artery disease. Methods Overall, 34 patients with nonobstructive (<50%) left anterior descending coronary artery stenosis (case group) and 36 patients with no coronary artery stenosis (control group) were included. Apical four-, three-, and two-chamber echocardiographic images were collected at rest and during early recovery from treadmill exercise. LV flow field, vortex area, and circulation (cir) changes were recorded in different phases: isovolumetric systole (S1), rapid ejection (S2), slow ejection (S3), isovolumetric diastole (D1), rapid filling (D2), slow filling (D3), and atrial systole (D4). Intra- and inter-group differences were compared before and after exercise loading. Results The control and case groups demonstrated regular trends of eddy current formation and dissipation at rest and under stress. Compared with the control group, the case group had irregular streamline distributions. Abnormal vortices formed in the S1 and D3 apical segments and D1 left ventricular middle segment in the resting group. Compared with the control group, the resting group had decreased left ventricular S1 vortex areas and increased S3 vortex areas. The post-stress D1 and D3 vortex areas and D1 and D2 cir increased. Compared with at rest, after stress, the control group had decreased S1, S3, D2, and D3 vortex areas; increased S2, D1, D3, and D4 cir; and decreased D2 cir. After stress, the case group had decreased S3 and D2 vortex areas, increased D1 vortex areas, and increased S2, D1, D3, and D4 cir (P all < 0.001). Logistic regression and ROC curve analyses show that increased D1 vortex area after stress is an independent risk factor for stenosis in nonobstructive stenosis of coronary arteries (OR: 1.007, 95% CI: 1.005-1.010, P < 0.05). A D1 vortex area cutoff value of 82.26 had an AUC, sensitivity, and specificity of 0.67, 0.655, and 0.726, respectively. Conclusion The resting left ventricular flow field changed in patients with nonobstructive left anterior descending coronary artery stenosis. Both groups had more disordered left ventricular blood flow after stress. The increased D1 vortex area after stress is an independent risk factor for mild coronary stenosis and may contribute to the assessment of nonobstructive coronary stenosis. VFM combined with treadmill stress is useful in evaluating left ventricular flow field changes in patients with nonobstructive coronary artery disease, which is valuable in the early evaluation of coronary heart disease.
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Affiliation(s)
- Dongmei Li
- School of Medicine, University of Electronic Science and Technology, Chengdu, China
| | - Xin Zhao
- Department of Ultrasound Medicine, School of Medicine, Chengdu Second People’s Hospital, Chengdu, China
| | - Qiuyu Xiao
- School of Medicine, University of Electronic Science and Technology, Chengdu, China
| | - Rui Yang
- School of Medicine, University of Electronic Science and Technology, Chengdu, China
| | - Zizhuo Li
- School of Medicine, Chengdu Medical College, Chengdu, China
| | - Yuanyuan Xie
- School of Medicine, Chengdu Medical College, Chengdu, China
| | - Xinyue Mao
- School of Medicine, North Sichuan Medical College, Nanchong, China
| | - Xi Li
- School of Medicine, North Sichuan Medical College, Nanchong, China
| | - Wenhan Hu
- School of Medicine, North Sichuan Medical College, Nanchong, China
| | - Yan Deng
- Department of Cardiovascular Ultrasound and Cardiac Function, Affiliated Hospital of University of Electronic Science and Technology, Sichuan Provincial People’s Hospital Sichuan Provincial Key Laboratory of Ultrasonic Cardiac Electrophysiology and Biomechanics Sichuan Clinical Medical Research Center for Cardiovascular Disease National Clinical Medical Research Center for Cardiovascular Diseases Branch Center, Chengdu, China
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Cortigiani L, Gaibazzi N, Ciampi Q, Rigo F, Rodríguez‐Zanella H, Wierzbowska‐Drabik K, Kasprzak JD, Arbucci R, Lowenstein J, Zagatina A, Bartolacelli Y, Gregori D, Carerj S, Pepi M, Pellikka PA, Picano E. High Resting Coronary Flow Velocity by Echocardiography Is Associated With Worse Survival in Patients With Chronic Coronary Syndromes. J Am Heart Assoc 2024; 13:e031270. [PMID: 38362899 PMCID: PMC11010105 DOI: 10.1161/jaha.123.031270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 11/14/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND Resting coronary flow velocity (CFV) in the mid-distal left anterior descending coronary artery can be easily assessed with transthoracic echocardiography. In this observational study, the authors sought to assess the relationship between resting CFV, CFV reserve (CFVR), and outcome in patients with chronic coronary syndromes. METHODS AND RESULTS In a prospective multicenter study design, the authors retrospectively analyzed 7576 patients (age, 66±11 years; 4312 men) with chronic coronary syndromes and left ventricular ejection fraction ≥50% referred for dipyridamole stress echocardiography. Recruitment (years 2003-2021) involved 7 accredited laboratories, with interobserver variability <10% for CFV measurement at study entry. Baseline peak diastolic CFV was obtained by pulsed-wave Doppler in the mid-distal left anterior descending coronary artery. CFVR (abnormal value ≤2.0) was assessed with dipyridamole. All-cause death was the only end point. The mean CFV of the left anterior descending coronary artery was 31±12 cm/s. The mean CFVR was 2.32±0.60. During a median follow-up of 5.9±4.3 years, 1121 (15%) patients died. At multivariable analysis, resting CFV ≥32 cm/s was identified by a receiver operating curve as the best cutoff and was independently associated with mortality (hazard ratio [HR], 1.24 [95% CI, 1.10-1.40]; P<0.0001) together with CFVR ≤2.0 (HR, 1.78 [95% CI, 1.57-2.02]; P<0.0001), age, diabetes, history of coronary surgery, and left ventricular ejection fraction. When both CFV and CFVR were considered, the mortality rate was highest in patients with resting CFV ≥32 cm/s and CFVR ≤2.0 and lowest in patients with resting CFV <32 cm/s and CFVR >2.0. CONCLUSIONS High resting CFV is associated with worse survival in patients with chronic coronary syndromes and left ventricular ejection fraction ≥50%. The value is independent and additive to CFVR. The combination of high resting CFV and low CFVR is associated with the worst survival.
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Affiliation(s)
| | | | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli HospitalBeneventoItaly
| | - Fausto Rigo
- Cardiology Division, Villa Salus HospitalMestreItaly
| | | | | | | | - Rosina Arbucci
- Cardiodiagnosticos, Investigaciones Medicas CenterBuenos AiresArgentina
| | - Jorge Lowenstein
- Cardiodiagnosticos, Investigaciones Medicas CenterBuenos AiresArgentina
| | - Angela Zagatina
- Saint Petersburg State Pediatric Medical UniversitySaint PetersburgRussian Federation
| | - Ylenia Bartolacelli
- Paediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio‐Thoracic and Vascular Medicine IRCCS Azienda Ospedaliero‐Universitaria di BolognaPoliclinico S. Orsola‐Malpighi HospitalBolognaItaly
| | - Dario Gregori
- Biostatistics, Epidemiology and Public Health UnitPadova UniversityPadovaItaly
| | - Scipione Carerj
- Divisione di Cardiologia, Policlinico UniversitarioUniversità di MessinaMessinaItaly
| | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCSMilanItaly
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Picano E, Pierard L, Peteiro J, Djordjevic-Dikic A, Sade LE, Cortigiani L, Van De Heyning CM, Celutkiene J, Gaibazzi N, Ciampi Q, Senior R, Neskovic AN, Henein M. The clinical use of stress echocardiography in chronic coronary syndromes and beyond coronary artery disease: a clinical consensus statement from the European Association of Cardiovascular Imaging of the ESC. Eur Heart J Cardiovasc Imaging 2024; 25:e65-e90. [PMID: 37798126 DOI: 10.1093/ehjci/jead250] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023] Open
Abstract
Since the 2009 publication of the stress echocardiography expert consensus of the European Association of Echocardiography, and after the 2016 advice of the American Society of Echocardiography-European Association of Cardiovascular Imaging for applications beyond coronary artery disease, new information has become available regarding stress echo. Until recently, the assessment of regional wall motion abnormality was the only universally practiced step of stress echo. In the state-of-the-art ABCDE protocol, regional wall motion abnormality remains the main step A, but at the same time, regional perfusion using ultrasound-contrast agents may be assessed. Diastolic function and pulmonary B-lines are assessed in step B; left ventricular contractile and preload reserve with volumetric echocardiography in step C; Doppler-based coronary flow velocity reserve in the left anterior descending coronary artery in step D; and ECG-based heart rate reserve in non-imaging step E. These five biomarkers converge, conceptually and methodologically, in the ABCDE protocol allowing comprehensive risk stratification of the vulnerable patient with chronic coronary syndromes. The present document summarizes current practice guidelines recommendations and training requirements and harmonizes the clinical guidelines of the European Society of Cardiology in many diverse cardiac conditions, from chronic coronary syndromes to valvular heart disease. The continuous refinement of imaging technology and the diffusion of ultrasound-contrast agents improve image quality, feasibility, and reader accuracy in assessing wall motion and perfusion, left ventricular volumes, and coronary flow velocity. Carotid imaging detects pre-obstructive atherosclerosis and improves risk prediction similarly to coronary atherosclerosis. The revolutionary impact of artificial intelligence on echocardiographic image acquisition and analysis makes stress echo more operator-independent and objective. Stress echo has unique features of low cost, versatility, and universal availability. It does not need ionizing radiation exposure and has near-zero carbon dioxide emissions. Stress echo is a convenient and sustainable choice for functional testing within and beyond coronary artery disease.
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Affiliation(s)
- Eugenio Picano
- Institute of Clinical Physiology of the National Research Council, CNR, Via Moruzzi 1, 56124 Pisa, Italy
| | - Luc Pierard
- University of Liège, Walloon Region, Belgium
| | - Jesus Peteiro
- CHUAC-Complexo Hospitalario Universitario A Coruna, CIBER-CV, University of A Coruna, 15070 La Coruna, Spain
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, University Clinical Centre of Serbia, Medical School, University of Belgrade, 11000 Belgrade, Serbia
| | - Leyla Elif Sade
- University of Pittsburgh Medical Center UPMC Heart & Vascular Institute, Pittsburgh, PA, USA
| | | | | | - Jelena Celutkiene
- Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, 43100 Parma, Italy
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy
| | - Roxy Senior
- Imperial College, UK
- Royal Brompton Hospital Imperial College London, UK
- Northwick Park Hospital, London, UK
| | - Aleksandar N Neskovic
- Department of Cardiology, University Clinical Hospital Center Zemun-Belgrade Faculty of Medicine, University of Belgrade, Serbia
| | - Michael Henein
- Department of Public Health and Clinical Medicine Units: Section of Medicine, Umea University, Umea, Sweden
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Caiati C, Pollice P, Iacovelli F, Sturdà F, Lepera ME. Accelerated stenotic flow in the left anterior descending coronary artery explains the causes of impaired coronary flow reserve: an integrated transthoracic enhanced Doppler study. Front Cardiovasc Med 2023; 10:1186983. [PMID: 37745100 PMCID: PMC10515222 DOI: 10.3389/fcvm.2023.1186983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 08/10/2023] [Indexed: 09/26/2023] Open
Abstract
Background Accelerated stenotic flow (AsF) in the entire left anterior descending coronary artery (LAD), assessed by transthoracic enhanced color Doppler (E-Doppler TTE), can reveal coronary stenosis (CS) and its severity, enabling a distinction between the microcirculatory and epicardial causes of coronary flow reserve (CFR) impairment. Methods Eighty-four consecutive patients with a CFR <2.0 (1.5 ± 0.4), as assessed by E-Doppler TTE, scheduled for coronary angiography (CA) and eventually intracoronary ultrasounds (IVUS), were studied. CFR was calculated by the ratio of peak diastolic flow velocities: during i.v. adenosine (140 mcg/Kg/m) over resting; AsF was calculated as the percentage increase of localized maximal velocity in relation to a reference velocity. Results CA showed ≥50% lumen diameter narrowing of the LAD (critical CS) in 68% of patients (57/84) vs. non-critical CS in 32% (27/84). Based on the established CA/IVUS criteria, the non-critical CS subgroup was further subdivided into 2 groups: subcritical/diffuse [16/27 pts (57%)] and no atherosclerosis [11/27 pts (43%)]. CFR was similar in the three groups: 1.4 ± 0.3 in critical CS, 1.5 ± 0.4 in subcritical/diffuse CS, and 1.6 ± 0.4 in no atherosclerosis (p = ns). Overall, at least one segment of accelerated stenotic flow in the LAD was found in 73 patients (87%), while in 11 (13%) it was not. The AsF was very predictive of coronary segmental narrowing in both angio subgroups of atherosclerosis but as expected with the usage of different cutoffs. On the basis of the ROC curve, the optimal cutoff was 109% and 16% AsF % increment to successfully distinguish critical from non-critical CS (area under the curve [AUC] = 0.99, p < 0.001) and diffuse/subcritical from no CS (AUC = 0.91%, p < 0.001). Sensitivity and specificity were 96% and 100% and 82% and 100%, respectively. Conclusion E-Doppler TTE is highly feasible and reliable in detecting the CS of any grade of severity, distinguishing epicardial athero from microvascular causes of a severe CFR reduction.
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Affiliation(s)
- Carlo Caiati
- Unit of Cardiovascular Diseases, Department of Interdisciplinary Medicine, University of Bari “Aldo Moro”, Bari, Italy
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Al-Mohaissen MA. Echocardiographic assessment of primary microvascular angina and primary coronary microvascular dysfunction. Trends Cardiovasc Med 2023; 33:369-383. [PMID: 35192927 DOI: 10.1016/j.tcm.2022.02.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 01/16/2023]
Abstract
There is an increasing interest in the role of echocardiography in the evaluation of primary microvascular angina, which is attributed to primary coronary microvascular dysfunction. Valid echocardiographic techniques are expected to facilitate the diagnosis and follow-up of these patients and would be valuable for research purposes and therapy evaluation. However, adequate echocardiographic data are lacking, and the interpretation of the limited available literature is hindered by the previous addition of microvascular angina under more inclusive entities, such as cardiac syndrome X. In experienced hands, the assessment of primary coronary microvascular dysfunction in patients with suspected primary microvascular angina, using multiple echocardiographic techniques is feasible, relatively inexpensive, and safe. Exclusion of obstructive epicardial coronary artery disease is, however, a prerequisite for diagnosis. Two-dimensional transthoracic echocardiography, routine stress echocardiography, and speckle-tracking echocardiography indirectly assess primary coronary microvascular dysfunction by evaluating potential impairment in myocardial function and lack diagnostic sensitivity and specificity. Conversely, certain echocardiographic techniques, including Doppler-derived coronary flow velocity reserve and myocardial contrast echocardiography, assess some coronary microvascular dysfunction parameters and have exhibited diagnostic and prognostic potentials. Doppler-derived coronary flow velocity reserve is the best studied and only guideline-approved echocardiographic technique for documenting coronary microvascular dysfunction in patients with suspected microvascular angina. Myocardial contrast echocardiography, by comparison, can detect heterogeneous and patchy myocardial involvement by coronary microvascular dysfunction, which is an advantage over the common practice of coronary flow velocity reserve assessment in a single vessel (commonly the left anterior descending artery) which only reflects regional microvascular function. However, there is no consensus regarding the diagnostic criteria, and expertise performing this technique is limited. Echocardiography remains underexplored and inadequately utilized in the setting of microvascular angina and coronary microvascular dysfunction. Appraisal of the current echocardiographic literature regarding coronary microvascular dysfunction and microvascular angina is important to stay current with the progress in its clinical recognition and create a basis for future research and technological advancements.
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Affiliation(s)
- Maha A Al-Mohaissen
- Department of Clinical Sciences (Cardiology), College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh, Saudi Arabia.
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Garber L, Khodaei S, Maftoon N, Keshavarz-Motamed Z. Impact of TAVR on coronary artery hemodynamics using clinical measurements and image-based patient-specific in silico modeling. Sci Rep 2023; 13:8948. [PMID: 37268642 DOI: 10.1038/s41598-023-31987-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 03/21/2023] [Indexed: 06/04/2023] Open
Abstract
In recent years, transcatheter aortic valve replacement (TAVR) has become the leading method for treating aortic stenosis. While the procedure has improved dramatically in the past decade, there are still uncertainties about the impact of TAVR on coronary blood flow. Recent research has indicated that negative coronary events after TAVR may be partially driven by impaired coronary blood flow dynamics. Furthermore, the current technologies to rapidly obtain non-invasive coronary blood flow data are relatively limited. Herein, we present a lumped parameter computational model to simulate coronary blood flow in the main arteries as well as a series of cardiovascular hemodynamic metrics. The model was designed to only use a few inputs parameters from echocardiography, computed tomography and a sphygmomanometer. The novel computational model was then validated and applied to 19 patients undergoing TAVR to examine the impact of the procedure on coronary blood flow in the left anterior descending (LAD) artery, left circumflex (LCX) artery and right coronary artery (RCA) and various global hemodynamics metrics. Based on our findings, the changes in coronary blood flow after TAVR varied and were subject specific (37% had increased flow in all three coronary arteries, 32% had decreased flow in all coronary arteries, and 31% had both increased and decreased flow in different coronary arteries). Additionally, valvular pressure gradient, left ventricle (LV) workload and maximum LV pressure decreased by 61.5%, 4.5% and 13.0% respectively, while mean arterial pressure and cardiac output increased by 6.9% and 9.9% after TAVR. By applying this proof-of-concept computational model, a series of hemodynamic metrics were generated non-invasively which can help to better understand the individual relationships between TAVR and mean and peak coronary flow rates. In the future, tools such as these may play a vital role by providing clinicians with rapid insight into various cardiac and coronary metrics, rendering the planning for TAVR and other cardiovascular procedures more personalized.
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Affiliation(s)
- Louis Garber
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada
| | - Seyedvahid Khodaei
- Department of Mechanical Engineering (Mail to JHE-310), McMaster University, Hamilton, ON, L8S 4L7, Canada
| | - Nima Maftoon
- Department of Systems Design Engineering, University of Waterloo, Waterloo, ON, Canada
- Centre for Bioengineering and Biotechnology, University of Waterloo, Waterloo, ON, Canada
| | - Zahra Keshavarz-Motamed
- School of Biomedical Engineering, McMaster University, Hamilton, ON, Canada.
- Department of Mechanical Engineering (Mail to JHE-310), McMaster University, Hamilton, ON, L8S 4L7, Canada.
- School of Computational Science and Engineering, McMaster University, Hamilton, ON, Canada.
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10
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Xiao Q, Zhao X, Yang R, Li Z, Li D, Xie Y, Mao X, Wang Y, Yin L, Li C, Zuo M, Meng Q, Li W, Liu X, Li Z, Zhang Q, Deng Y. Assessment of left ventricular energy loss in patients with mild coronary artery stenosis by using vector flow mapping combined with exercise stress echocardiography. Echocardiography 2023. [PMID: 37178387 DOI: 10.1111/echo.15591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 03/20/2023] [Accepted: 05/02/2023] [Indexed: 05/15/2023] Open
Abstract
OBJECTIVES To evaluate the left ventricular energy loss (EL), energy loss reserve (EL-r), and energy loss reserve rate in patients with mild coronary artery stenosis by using vector flow mapping (VFM) combined with exercise stress echocardiography. METHODS A total of 34 patients (case group) with mild coronary artery stenosis and 36 sex and age matched patients (control group) without coronary artery stenosis according to coronary angiogram were prospectively enrolled. The total energy loss (ELt), basal segment energy loss (ELb), middle segment energy loss (ELm), apical segment energy loss (ELa), energy loss reserve (EL-r), and energy loss reserve rate were recorded in the isovolumic systolic period (S1), rapid ejection period (S2), slow ejection period (S3), isovolumic diastolic period (D1), rapid filling period (D2), slow filling period (D3), and atrial contraction period (D4). RESULTS Compared with the control group, some of the EL in the resting case group were higher; some of the EL in the case group were lower after exercise, and those during D1 ELb and D3 ELb were higher. Compared with the resting state, the total EL and the EL within the time segment in the control group were higher after exercise, except during D2 ELb. In the case group, except for during D1 ELt, ELb and D2 ELb, the total and segmental EL of each phase was mostly higher after exercise (p < .05). Compared with the control group, most of the EL-r and EL reserve rates in the case group were lower (p < .05). CONCLUSION The EL, EL-r, and energy loss reserve rate have a certain value in the evaluation of cardiac function in patients with mild coronary artery stenosis.
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Affiliation(s)
- Qiuyu Xiao
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Xin Zhao
- Department of Ultrasound, Chengdu Second People's Hospital, Chengdu, China
| | - Rui Yang
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | - Zizhuo Li
- Chengdu Medical College, Chengdu, China
| | - Dongmei Li
- School of Medicine, University of Electronic Science and Technology of China, Chengdu, China
| | | | - Xinyue Mao
- North Sichuan Medical University, Nanchong, China
| | - Yi Wang
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Lixue Yin
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Chunmei Li
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Mingliang Zuo
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Qingguo Meng
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Wenhua Li
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Xuebing Liu
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Zhaohuan Li
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Qingfeng Zhang
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Yan Deng
- Ultrasound in Cardiac Electrophysiology and Biomechanics Key Laboratory of Sichuan Province, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China
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11
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Ciampi Q, Cortigiani L, Rivadeneira Ruiz M, Barbieri A, Manganelli F, Mori F, D’Alfonso MG, Bursi F, Villari B. ABCDEG Stress Echocardiography in Aortic Stenosis. Diagnostics (Basel) 2023; 13:1727. [PMID: 37238211 PMCID: PMC10217228 DOI: 10.3390/diagnostics13101727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/06/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Rest and stress echocardiography (SE) plays a pivotal role in the evaluation of valvular heart disease. The use of SE is recommended in valvular heart disease when there is a mismatch between resting transthoracic echocardiography findings and symptoms. In aortic stenosis (AS), rest echocardiographic analysis is a stepwise approach that begins with the evaluation of aortic valve morphology and proceeds to the measurement of the transvalvular aortic gradient and aortic valve area (AVA) using continuity equations or planimetry. The presence of the following three criteria suggests severe AS: AVA < 1.0 cm2, a peak velocity > 4.0 m/s, or a mean gradient > 40 mmHg. However, in approximately one in three cases, we can observe a discordant AVA < 1 cm2 with a peak velocity < 4.0 m/s or a mean gradient <40 mmHg. This is due to reduced transvalvular flow associated with LV systolic dysfunction (LVEF < 50%) defined as "classical" low-flow low-gradient (LFLG) AS or normal LVEF "paradoxical" LFLG AS. SE has an established role in evaluating LV contractile reserve (CR) patients with reduced LVEF. In classical LFLG AS, LV CR distinguished pseudo-severe AS from truly severe AS. Some observational data suggest that long-term prognosis in asymptomatic severe AS may not be as favorable as previously thought, offering a window of opportunity for intervention prior to the onset of symptoms. Therefore, guidelines recommend evaluating asymptomatic AS with exercise stress in physically active patients, particularly those younger than 70 years, and symptomatic classical LFLG severe AS with low-dose dobutamine SE. A comprehensive SE assessment includes evaluating valve function (gradients), the global systolic function of the LV, and pulmonary congestion. This assessment integrates considerations of blood pressure response, chronotropic reserve, and symptoms. StressEcho 2030 is a prospective, large-scale study that employs a comprehensive protocol (ABCDEG) to analyze the clinical and echocardiographic phenotypes of AS, capturing various vulnerability sources which support stress echo-driven treatment strategies.
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Affiliation(s)
- Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
| | | | | | - Andrea Barbieri
- Department of Biomedical, Cardiology Division, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41121 Modena, Italy;
| | - Fiore Manganelli
- Cardiology Division, San Giuseppe Moscati Hospital, 83100 Avellino, Italy;
| | - Fabio Mori
- Cardiology Division, Careggi Hospital, 50134 Florence, Italy; (F.M.); (M.G.D.)
| | | | - Francesca Bursi
- Department of Health Science, University of Milan, Cardiology Division, San Paolo Hospital, ASST Santi Paolo e Carlo, 20142 Milano, Italy;
| | - Bruno Villari
- Cardiology Division, Fatebenefratelli Hospital, 82100 Benevento, Italy;
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12
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Picano E, Ciampi Q, Arbucci R, Cortigiani L, Zagatina A, Celutkiene J, Bartolacelli Y, Kane GC, Lowenstein J, Pellikka P. Stress Echo 2030: the new ABCDE protocol defining the future of cardiac imaging. Eur Heart J Suppl 2023; 25:C63-C67. [PMID: 37125276 PMCID: PMC10132595 DOI: 10.1093/eurheartjsupp/suad008] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Functional testing with stress echocardiography is based on the detection of regional wall motion abnormality with two-dimensional echocardiography and is embedded in clinical guidelines. Yet, it under-uses the unique versatility of the technique, ideally suited to describe the different functional abnormalities underlying the same wall motion response during stress. Five parameters converge conceptually and methodologically in the state-of-the-art ABCDE protocol, assessing multiple vulnerabilities of the ischemic patient. The five steps of the ABCDE protocol are (1) step A: regional wall motion; (2) step B: B-lines by lung ultrasound assessing extravascular lung water; (3) step C: left ventricular contractile reserve by volumetric two-dimensional echocardiography; (4) step D: coronary flow velocity reserve in mid-distal left anterior descending coronary with pulsed-wave Doppler; and (5) step E: assessment of heart rate reserve with a one-lead electrocardiogram. ABCDE stress echo offers insight into five functional reserves: epicardial flow (A); diastolic (B), contractile (C), coronary microcirculatory (D), and chronotropic reserve (E). The new format is more comprehensive and allows better functional characterization, risk stratification, and personalized tailoring of therapy. ABCDE protocol is an 'ecumenic' and 'omnivorous' functional test, suitable for all stresses and all patients also beyond coronary artery disease. It fits the need for sustainability of the current era in healthcare, since it requires universally available technology, and is low-cost, radiation-free, and nearly carbon-neutral.
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Affiliation(s)
- Eugenio Picano
- CNR, Istituto Fisiologia Clinica—Dipartimento di Biomedicina—Consiglio Nazionale delle Ricerche, CNR Research Campus, Via Moruzzi 1, Building C- Room 130, Pisa 56124, Italy
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Viale Principe di Napoli 14A, Benevento 82100, Italy
| | - Rosina Arbucci
- Cardiodiagnosticos, Investigaciones Medicas Center, Pichincha 69, Buenos Aires C1082, Argentina
| | - Lauro Cortigiani
- Cardiology Department, San Luca Hospital, Via Guglielmo Lippi Francesconi, Località San Filippo, Lucca 55100, Italy
| | - Angela Zagatina
- Cardiology Department, Saint Petersburg State Pediatric Medical University, Litovkaya St 2, Saint Petersburg 194100, Russian Federation
| | - Jelena Celutkiene
- Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Faculty of Medicine, Institute of Clinical Medicine, Vilnius LT-03101, Lithuania
| | - Ylenia Bartolacelli
- Paediatric Cardiology and Adult Congenital Heart Disease Program, Department of Cardio-Thoracic and Vascular Medicine IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna 40138, Italy
| | - Garvan C Kane
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Jorge Lowenstein
- Cardiodiagnosticos, Investigaciones Medicas Center, Pichincha 69, Buenos Aires C1082, Argentina
| | - Patricia Pellikka
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
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13
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Gaibazzi N, Rigo F, Lorenzoni V, Pasqualetto C, Foà A, Cagliari E, Cavasin N, Botti A, Martini C, Tuttolomondo D. Association of Coronary Computed Tomography Angiography and Stress Echocardiography with Long-Term Cardiac Outcome: A Comparison Study. J Clin Med 2023; 12:903. [PMID: 36769550 PMCID: PMC9917407 DOI: 10.3390/jcm12030903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/16/2023] [Accepted: 01/19/2023] [Indexed: 01/25/2023] Open
Abstract
AIMS This study aimed to assess which variables on coronary computed tomography angiography (CTA) and vasodilator stress-echocardiography (SE) are best associated with long-term cardiac outcome in patients presenting for suspected chronic coronary syndrome (CCS) who performed both tests. METHODS We identified 397 patients with suspected CCS who, between 2007 and 2019, underwent both SE and CTA within 30 days. Coronary artery calcium score (CACS) and the number of coronary arteries with diameter stenosis >50% were assessed on CTA. The presence of reversible regional wall motion abnormalities (RWMA) and reduced Doppler coronary flow velocity reserve in the left-anterior descending coronary artery (CFVR) were assessed on SE. The association of SE and CTA variables with cardiac outcome (cardiac death or myocardial infarction) was evaluated using Fine and Gray competing risk models. RESULTS During a median follow-up of 10 years, 38 (9.6%) patients experienced a nonfatal myocardial infarction and 19 (4.8%) died from a cardiac cause. RWMA (HR 7.189, p < 0.001) and a lower CFVR (HR 0.034, p < 0.001) on SE, along with CACS (HR 1.004, p < 0.001) and the number of >50% stenosed coronary vessels (HR 1.975, p < 0.001) on CTA, were each associated with cardiac events. After adjusting for covariates, only CACS and CFVR remained associated (both p < 0.001) with cardiac outcome. CONCLUSION Our data suggest that only CFVR on vasodilatory SE and CACS on CTA are independently and strongly associated with long-term cardiac outcome, unlike RWMA or the number of stenosed coronary arteries, usually considered the hallmarks of coronary artery disease on each test.
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Affiliation(s)
- Nicola Gaibazzi
- Department of Cardiology, Parma University Hospital, 43126 Parma, Italy
| | - Fausto Rigo
- Division of Cardiology, Villa Salus Hospital Foundation/IRCCS San Camillo, 30126 Venice, Italy
| | | | - Cristina Pasqualetto
- Department of Cardiology, Ospedale Civile di Dolo, ULSS 3 Serenissima, 30174 Venice, Italy
| | - Alberto Foà
- Unit of Cardiology, Department of Experimental, Diagnostic and Specialty Medicine—DIMES, University of Bologna, 40126 Bologna, Italy
| | - Enrico Cagliari
- Neuroradiology Department, Mestre Hospital, ULSS3 Serenissima, 30174 Mestre, Italy
| | - Nicola Cavasin
- Neuroradiology Department, Mestre Hospital, ULSS3 Serenissima, 30174 Mestre, Italy
| | - Andrea Botti
- Department of Cardiology, Parma University Hospital, 43126 Parma, Italy
| | - Chiara Martini
- Department Diagnostic, Parma University Hospital, 43126 Parma, Italy
- Department of Medicine and Surgery, University of Parma, 43121 Parma, Italy
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14
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Jovanovic I, Tesic M, Djordjevic-Dikic A, Giga V, Beleslin B, Aleksandric S, Boskovic N, Petrovic O, Marjanovic M, Vratonjic J, Paunovic I, Ivanovic B, Trifunovic-Zamaklar D. Role of different echocardiographic modalities in the assessment of microvascular function in women with ischemia and no obstructive coronary arteries. JOURNAL OF CLINICAL ULTRASOUND : JCU 2022; 50:1134-1142. [PMID: 36218210 DOI: 10.1002/jcu.23313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 08/19/2022] [Accepted: 08/21/2022] [Indexed: 06/16/2023]
Abstract
This review summarizes current knowledge about echocardiographic modalities used to assess microvascular function and left ventricular (LV) systolic function in women with ischemia and no obstructive coronary arteries (INOCA). Although the entire pathophysiological background of this clinical entity still remains elusive, it is primarily linked to microvascular dysfunction which can be assessed by coronary flow velocity reserve. Subtle impairments of LV systolic function in women with INOCA are difficult to assess by interpretation of wall motion abnormalities. LV longitudinal function impairment is considered to be an early marker of subclinical systolic dysfunction and can be assessed by global longitudinal strain quantification.
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Affiliation(s)
- Ivana Jovanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Milorad Tesic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Vojislav Giga
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Srdjan Aleksandric
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nikola Boskovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Olga Petrovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Marija Marjanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Jelena Vratonjic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Ivana Paunovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
| | - Branislava Ivanovic
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Danijela Trifunovic-Zamaklar
- Clinic for Cardiology, University clinical center of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
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15
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Machine Learning Algorithms for Prediction of Survival by Stress Echocardiography in Chronic Coronary Syndromes. J Pers Med 2022; 12:jpm12091523. [PMID: 36143307 PMCID: PMC9504503 DOI: 10.3390/jpm12091523] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 09/13/2022] [Accepted: 09/13/2022] [Indexed: 11/28/2022] Open
Abstract
Stress echocardiography (SE) is based on regional wall motion abnormalities and coronary flow velocity reserve (CFVR). Their independent prognostic capabilities could be better studied with a machine learning (ML) approach. The study aims to assess the SE outcome data by conducting an analysis with an ML approach. We included 6881 prospectively recruited and retrospectively analyzed patients with suspected (n = 4279) or known (n = 2602) coronary artery disease submitted to clinically driven dipyridamole SE. The outcome measure was all-cause death. A random forest survival model was implemented to model the survival function according to the patient’s characteristics; 1002 patients recruited by a single, independent center formed the external validation cohort. During a median follow-up of 3.4 years (IQR 1.6−7.5), 814 (12%) patients died. The mortality risk was higher for patients aged >60 years, with a resting ejection fraction < 60%, resting WMSI, positive stress-rest WMSI scores, and CFVR < 3.The C-index performance was 0.79 in the internal and 0.81 in the external validation data set. Survival functions for individual patients were easily obtained with an open access web app. An ML approach can be fruitfully applied to outcome data obtained with SE. Survival showed a constantly increasing relationship with a CFVR < 3.0 and stress-rest wall motion score index > Since processing is largely automated, this approach can be easily scaled to larger and more comprehensive data sets to further refine stratification, guide therapy and be ultimately adopted as an open-source online decision tool.
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16
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Morrone D, Gentile F, Aimo A, Cameli M, Barison A, Picoi ME, Guglielmo M, Villano A, DeVita A, Mandoli GE, Pastore MC, Barillà F, Mancone M, Pedrinelli R, Indolfi C, Filardi PP, Muscoli S, Tritto I, Pizzi C, Camici PG, Marzilli M, Crea F, Caterina RD, Pontone G, Neglia D, Lanza G. Perspectives in noninvasive imaging for chronic coronary syndromes. Int J Cardiol 2022; 365:19-29. [PMID: 35901907 DOI: 10.1016/j.ijcard.2022.07.038] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/05/2022] [Accepted: 07/21/2022] [Indexed: 11/26/2022]
Abstract
Both the latest European guidelines on chronic coronary syndromes and the American guidelines on chest pain have underlined the importance of noninvasive imaging to select patients to be referred to invasive angiography. Nevertheless, although coronary stenosis has long been considered the main determinant of inducible ischemia and symptoms, growing evidence has demonstrated the importance of other underlying mechanisms (e.g., vasospasm, microvascular disease, energetic inefficiency). The search for a pathophysiology-driven treatment of these patients has therefore emerged as an important objective of multimodality imaging, integrating "anatomical" and "functional" information. We here provide an up-to-date guide for the choice and the interpretation of the currently available noninvasive anatomical and/or functional tests, focusing on emerging techniques (e.g., coronary flow velocity reserve, stress-cardiac magnetic resonance, hybrid imaging, functional-coronary computed tomography angiography, etc.), which could provide deeper pathophysiological insights to refine diagnostic and therapeutic pathways in the next future.
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Affiliation(s)
- Doralisa Morrone
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy.
| | - Francesco Gentile
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Maria Elena Picoi
- Azienda Tutela Salute Sardegna, Ospedale Giovanni Paolo II, Unità di terapia intensiva Cardiologica, Olbia, Sardegna, Italy
| | - Marco Guglielmo
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | - Angelo Villano
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio DeVita
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Maria Concetta Pastore
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Francesco Barillà
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Policlinico Umberto I, Roma, Italy
| | - Massimo Mancone
- Dipartimento di Scienze Cliniche, Internistiche, Anestesiologiche e Cardiovascolari, Sapienza Università di Roma, Policlinico Umberto I, Roma, Italy
| | - Roberto Pedrinelli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Ciro Indolfi
- Istituto di Cardiologia, Dipartimento di Scienze Mediche e Chirurgiche, Università degli Studi "Magna Graecia", Catanzaro - Mediterranea Cardiocentro, Napoli, Italy
| | - Pasquale Perrone Filardi
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Italy, Mediterranea Cardiocentro, Naples, Italy
| | - Saverio Muscoli
- U.O.C. Cardiologia, Fondazione Policlinico "Tor Vergata", Roma, Italy
| | - Isabella Tritto
- Università di Perugia, Dipartimento di Medicina, Sezione di Cardiologia e Fisiopatologia Cardiovascolare, Perugia, Italy
| | - Carmine Pizzi
- Università di Bologna, Alma Mater Studiorum, Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Bologna, Italy
| | - Paolo G Camici
- Vita-Salute University and IRCCS San Raffaele Hospital, Milan, Italy
| | - Mario Marzilli
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Filippo Crea
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | - Raffaele De Caterina
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine-Cardiology Division, University Hospital of Pisa, Italy
| | - Gianluca Pontone
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan 20138, Italy
| | | | - Gaetano Lanza
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
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17
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Liu T, Ding M, Sun D, Zhang H, Guo L, Li Y, Zhao H, Zhu F. The association between heart rate reserve and impaired coronary flow velocity reserve: a study based on adenosine stress echocardiography. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2022; 38:1037-1046. [PMID: 34919164 DOI: 10.1007/s10554-021-02480-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 11/20/2021] [Indexed: 10/19/2022]
Abstract
This study was to explore the correlation between heart rate reserve (HRR) to coronary flow velocity reserve (CFVR), using adenosine stress echocardiography (SE), in patients with angina and no obstructive coronary artery disease (ANOCA). 111 ANOCA patients underwent adenosine SE were enrolled, which were divided into two groups, impaired CFVR group (CFVR < 2) and control groups (CFVR ≥ 2). The relationships between HRR and impaired CFVR were explored in total and subgroup to sex. A reduced HRR during adenosine infusion was seen in ANOCA patients with impaired CFVR (25.73 ± 8.39 vs. 34.30 ± 19.93, P < 0.001). Compared to respective controls, the blunted HRR to adenosine was more pronounced in female patients (women: 27.21 ± 8.01 vs. 39.48 ± 10.57, P < 0.001; men: 24.05 ± 8.70 vs. 29.12 ± 8.69, P = 0.041). A strong association between CFVR and a blunted HRR was observed in women (r = 0.46, P < 0.001), while no association in men (r = 0.18, P = 0.199). In female, a multivariate logistic regression identified HRR as the strongest negative predictor of impaired CFVR [HR (95% CI) = 0.854 (0.764-0.956), P = 0.006]. Based on the ROC curve, HRR < 35% was a strong indicator of impaired CFVR, with AUC of 0.838, sensitivity of 70%, and specificity of 87% in females. A blunted HRR was seen in patients with impaired CFVR, with a most pronounced effect being seen in female patients. The blunted HRR < 35% is intricately linked to impaired CFVR in women with ANOCA beyond the value of traditional risk factors, which could ultimately contribute to risk stratification of impaired CFVR in such patients.
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Affiliation(s)
- Tingting Liu
- Faculty of Medical Imaging and Nuclear Medicine, Graduate School of Dalian Medical University, Dalian, 116044, China
- Department of Cardiac Function, People's Hospital of Liaoning Province, Building 1, No.33, Wenyi Road, Shenhe District, Shenyang, 110000, China
| | - Mingyan Ding
- Department of Cardiac Function, People's Hospital of Liaoning Province, Building 1, No.33, Wenyi Road, Shenhe District, Shenyang, 110000, China
| | - Dandan Sun
- Department of Cardiac Function, People's Hospital of Liaoning Province, Building 1, No.33, Wenyi Road, Shenhe District, Shenyang, 110000, China
| | - Huihui Zhang
- Department of Cardiac Function, People's Hospital of Liaoning Province, Building 1, No.33, Wenyi Road, Shenhe District, Shenyang, 110000, China
| | - Lijuan Guo
- Department of Cardiac Function, People's Hospital of Liaoning Province, Building 1, No.33, Wenyi Road, Shenhe District, Shenyang, 110000, China
| | - Ying Li
- Department of Cardiac Function, People's Hospital of Liaoning Province, Building 1, No.33, Wenyi Road, Shenhe District, Shenyang, 110000, China
| | - Hanzhang Zhao
- Department of Cardiac Function, People's Hospital of Liaoning Province, Building 1, No.33, Wenyi Road, Shenhe District, Shenyang, 110000, China
| | - Fang Zhu
- Department of Cardiac Function, People's Hospital of Liaoning Province, Building 1, No.33, Wenyi Road, Shenhe District, Shenyang, 110000, China.
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18
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Association between Resting Global Longitudinal Strain and Clinical Outcome of Patients Undergoing Stress Echocardiography. J Am Soc Echocardiogr 2022; 35:1018-1027.e6. [DOI: 10.1016/j.echo.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 05/07/2022] [Accepted: 05/10/2022] [Indexed: 11/22/2022]
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Kelshiker MA, Seligman H, Howard JP, Rahman H, Foley M, Nowbar AN, Rajkumar CA, Shun-Shin MJ, Ahmad Y, Sen S, Al-Lamee R, Petraco R. Coronary flow reserve and cardiovascular outcomes: a systematic review and meta-analysis. Eur Heart J 2022; 43:1582-1593. [PMID: 34849697 PMCID: PMC9020988 DOI: 10.1093/eurheartj/ehab775] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 09/07/2021] [Accepted: 10/26/2021] [Indexed: 01/04/2023] Open
Abstract
AIMS This meta-analysis aims to quantify the association of reduced coronary flow with all-cause mortality and major adverse cardiovascular events (MACE) across a broad range of patient groups and pathologies. METHODS AND RESULTS We systematically identified all studies between 1 January 2000 and 1 August 2020, where coronary flow was measured and clinical outcomes were reported. The endpoints were all-cause mortality and MACE. Estimates of effect were calculated from published hazard ratios (HRs) using a random-effects model. Seventy-nine studies with a total of 59 740 subjects were included. Abnormal coronary flow reserve (CFR) was associated with a higher incidence of all-cause mortality [HR: 3.78, 95% confidence interval (CI): 2.39-5.97] and a higher incidence of MACE (HR 3.42, 95% CI: 2.92-3.99). Each 0.1 unit reduction in CFR was associated with a proportional increase in mortality (per 0.1 CFR unit HR: 1.16, 95% CI: 1.04-1.29) and MACE (per 0.1 CFR unit HR: 1.08, 95% CI: 1.04-1.11). In patients with isolated coronary microvascular dysfunction, an abnormal CFR was associated with a higher incidence of mortality (HR: 5.44, 95% CI: 3.78-7.83) and MACE (HR: 3.56, 95% CI: 2.14-5.90). Abnormal CFR was also associated with a higher incidence of MACE in patients with acute coronary syndromes (HR: 3.76, 95% CI: 2.35-6.00), heart failure (HR: 6.38, 95% CI: 1.95-20.90), heart transplant (HR: 3.32, 95% CI: 2.34-4.71), and diabetes mellitus (HR: 7.47, 95% CI: 3.37-16.55). CONCLUSION Reduced coronary flow is strongly associated with increased risk of all-cause mortality and MACE across a wide range of pathological processes. This finding supports recent recommendations that coronary flow should be measured more routinely in clinical practice, to target aggressive vascular risk modification for individuals at higher risk.
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Affiliation(s)
- Mihir A Kelshiker
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Henry Seligman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - James P Howard
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Haseeb Rahman
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Michael Foley
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Alexandra N Nowbar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Christopher A Rajkumar
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Matthew J Shun-Shin
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Yousif Ahmad
- Yale School of Medicine, Yale University, 333 Cedar St, New Haven, Connecticut 06510, USA
| | - Sayan Sen
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Rasha Al-Lamee
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
| | - Ricardo Petraco
- National Heart and Lung Institute, Imperial College London, Hammersmith Campus, 72 Du Cane Road, London W12 0HS, UK
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20
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Tona F, Osto E, Kerkhof PLM, Montisci R, Famoso G, Lorenzoni G, De Michieli L, Cecere A, Zanetti I, Civieri G, Iliceto S, Piaserico S. Multiparametric analysis of coronary flow in psoriasis using a coronary flow reserve companion. Eur J Clin Invest 2022; 52:e13711. [PMID: 34780064 PMCID: PMC9286413 DOI: 10.1111/eci.13711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/05/2021] [Accepted: 11/06/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coronary microvascular dysfunction (CMD) is usually evaluated measuring coronary flow velocity reserve (CFVR). A more comprehensive analysis of CFVR including additional consideration of the associated logical companion-CFVR, where hyperemic diastolic coronary flow velocity may act as surrogate, was applied in this study to elucidate the mechanism of CMD in psoriasis. METHODS AND RESULTS Coronary flow velocity reserve was analysed using transthoracic echocardiographs of 127 psoriasis patients (age 36 ± 8 years; 104 males) and of 52 sex- and age-matched healthy controls. CFVR determination was repeated in the patient subgroup (n = 78) receiving anti-inflammatory therapy. Baseline and hyperemic microvascular resistance (MR) were calculated. CMD was defined as CFVR ≤ 2.5. Four endotypes of CMD were identified referring to concordant or discordant impairments of hyperemic flow or CFVR. We evaluated the companion-CFVR, as derived from the quadratic mean of hyperemic and diastolic flow velocity at rest. Coronary flow parameters, including CFVR (p = 0.01), were different among the two endotypes having CFVR > 2.5. Specifically, all 11 (14%) patients with CFVR deterioration despite therapy, belonged to endotype 1, and had higher baseline and hyperemic MR (p < 0.0001, both). Interestingly, while CFVR was comparable in patients with worsened versus those with improved CFVR, the companion-CFVR could discriminate by being lower in patients with worsened CFVR (p = 0.01). CONCLUSIONS The reduced CFVR in psoriasis is driven by decreased companion-CFVR, combined with increased hyperemic MR. Adoption of the mandatory companion-CFVR enables a personalized characterization superior to that achieved by exclusive consideration of CFVR.
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Affiliation(s)
- Francesco Tona
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Elena Osto
- University Heart Center, University Hospital Zurich & University of Zurich, Zurich, Switzerland.,Institute of Clinical Chemistry, University Hospital Zurich & University of Zurich, Zurich, Switzerland
| | - Peter L M Kerkhof
- Amsterdam University Medical Centers, VUmc, Radiology and Nuclear Medicine, Amsterdam, The Netherlands
| | - Roberta Montisci
- Clinical Cardiology, Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
| | - Giulia Famoso
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Giulia Lorenzoni
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Laura De Michieli
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Annagrazia Cecere
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Irene Zanetti
- Dermatology Unit, Department of Medicine, University of Padova, Padova, Italy
| | - Giovanni Civieri
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Stefano Piaserico
- Dermatology Unit, Department of Medicine, University of Padova, Padova, Italy
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21
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Cotrim CA, Café H, João I, Cotrim N, Guardado J, Cordeiro P, Cotrim H, Baquero L. Exercise stress echocardiography: Where are we now? World J Cardiol 2022; 14:64-82. [PMID: 35316975 PMCID: PMC8900523 DOI: 10.4330/wjc.v14.i2.64] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 07/04/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
Exercise stress echocardiography (ESE) is a widely used diagnostic test in cardiology departments. ESE is mainly used to study patients with coronary artery disease; however, it has increasingly been used in other clinical scenarios including valve pathology, congenital heart disease, hypertrophic and dilated cardiomyopathies, athlete evaluations, diastolic function evaluation, and pulmonary circulation study. In our laboratories, we use an established methodology in which cardiac function is evaluated while exercising on a treadmill. After completing the exercise regimen, patients remain in a standing position or lie down on the left lateral decubitus, depending on the clinical questions to be answered for further evaluation. This method increases the quality and quantity of information obtained. Here, we present the various methods of exercise stress echocardiography and our experience in many clinical arenas in detail. We also present alternatives to ESE that may be used and their advantages and disadvantages. We review recent advances in ESE and future directions for this established method in the study of cardiac patients and underline the advantage of using a diagnostic tool that is radiation-free.
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Affiliation(s)
| | - Hugo Café
- Faculdade de Medicina, Algarve University, Faro 8005-139, Portugal
| | - Isabel João
- Department of Cardiology, Garcia de Orta Hospital, Almada 2805-267, Portugal
| | - Nuno Cotrim
- Department of Medicine, Garcia de Orta Hospital, Almada 2805-267, Portugal
| | - Jorge Guardado
- Cardiovascular Unit, UCARDIO, Centro Clinico, Riachos 2350-325, Portugal
| | - Pedro Cordeiro
- Department of Cardiology, Hospital Particular do Algarve, Faro 8005-226, Portugal
| | - Hortense Cotrim
- Faculdade de Medicina, Algarve University, Faro 8005-139, Portugal
| | - Luis Baquero
- Heart Center, Hospital da Cruz Vermelha Portuguesa, Lisboa 1549-008, Portugal
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22
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Yamaguchi M, Hoshino M, Sugiyama T, Kanaji Y, Nogami K, Nagamine T, Misawa T, Hada M, Araki M, Hamaya R, Usui E, Murai T, Lee T, Yonetsu T, Sasano T, Kakuta T. Preprocedural transthoracic Doppler echocardiography to identify stenosis associated with increased coronary flow after revascularisation. Sci Rep 2022; 12:1667. [PMID: 35102261 PMCID: PMC8803832 DOI: 10.1038/s41598-022-05683-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 01/17/2022] [Indexed: 11/09/2022] Open
Abstract
AbstractThe benefit of percutaneous coronary intervention (PCI) has been reported to be associated with functional stenosis severity defined by fractional flow reserve (FFR). This study aimed to investigate the predictive ability of preprocedural transthoracic Doppler echocardiography (TDE) for increased coronary flow. A total of 50 left anterior descending arteries (LAD) that underwent TDE examinations were analysed. Hyperaemic LAD diastolic peak velocity (hDPV) was used as a surrogate of volumetric coronary flow. The increase in coronary flow was evaluated by the metric of % hDPV-increase defined by 100× (post-PCI hDPV-pre-PCI hDPV)/pre-PCI hDPV. The two groups divided by the median value of % hDPV-increase were compared, and the determinants of a significant coronary flow increase defined as more than the median % hDPV-increase were explored. After PCI, FFR values improved in all cases. hDPV significantly increased from 53.0 to 76.0 mm/s (P < 0.01) and the median % hDPV-increase was 45%, while hDPV decreased in 10 patients. On multivariable analysis, pre-PCI FFR and hDPV were independent predictors of a significant coronary flow increase. Preprocedural TDE-derived hDPV provided significant improvement of identification of lesions that benefit from revascularisation with respect to significant coronary flow increase.
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23
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Vasodilator Strain Stress Echocardiography in Suspected Coronary Microvascular Angina. J Clin Med 2022; 11:jcm11030711. [PMID: 35160163 PMCID: PMC8836360 DOI: 10.3390/jcm11030711] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/25/2022] [Indexed: 12/19/2022] Open
Abstract
Background: In patients with Ischemia and non-obstructive coronary artery stenosis (INOCA) wall motion is rarely abnormal during stress echocardiography (SE). Our aim was to determine if patients with INOCA and reduced coronary flow velocity reserve (CVFR) have altered cardiac mechanics using two-dimensional speckle-tracking echocardiography (2DSTE) during SE. Methods: In a prospective, multicenter, international study, we recruited 135 patients with INOCA. Overall, we performed high dose (0.84 mg/kg) dipyridamole SE with combined assessment of CVFR and 2DSTE. The population was divided in patients with normal CVFR (>2, group 1, n = 95) and abnormal CVFR (≤2, group 2, n = 35). Clinical and 2DSTE parameters were compared between groups. Results: Feasibility was high for CFVR (98%) and 2DSTE (97%). A total of 130 patients (mean age 63 ± 12 years, 67 women) had complete flow and strain data. The two groups showed similar 2DSTE values at rest. At peak SE, Group 1 patients showed lower global longitudinal strain (p < 0.007), higher mechanical dispersion (p < 0.0005), lower endocardial (p < 0.001), and epicardial (p < 0.0002) layer specific strain. Conclusions: In patients with INOCA, vasodilator SE with simultaneous assessment of CFVR and strain is highly feasible. Coronary microvascular dysfunction is accompanied by an impairment of global and layer-specific deformation indices during stress.
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24
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Gaibazzi N, Tuttolomondo D, Guaricci AI, De Marco F, Pontone G. Stress-echocardiography or coronary computed tomography in suspected chronic coronary syndrome after the 2019 European Guidelines? A practical guide. J Cardiovasc Med (Hagerstown) 2022; 23:12-21. [PMID: 34366402 DOI: 10.2459/jcm.0000000000001235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Stress-echocardiography can rightly be considered one of the champions of cardiac functional imaging, thanks to its real-time imaging, high temporal resolution, high safety and very low cost. When stress-echocardiography is performed at top technical quality, hence taking advantage of ultrasound contrast media for endocardial border delineation at least for suboptimal cases, subjectivity is minimized, and with the routine use of coronary flow reserve measurement (left anterior descending coronary artery, stress/rest ratio reduced or normal, i.e. <>2.0) diagnostic sensitivity is strengthened. The true competitor of any type of functional imaging, stress-echocardiography included, is nowadays coronary computed tomography angiography, which is instead a diagnostic method directly, noninvasively assessing coronary anatomy, apparently the holy grail for any cardiologist. The new 2019 Guidelines on chronic coronary syndrome of the European Society of Cardiology change the existing landscape and clinical practice, while they probably cannot clarify which type of test, functional or anatomic, should be first chosen in different clinical scenarios of suspected chronic coronary syndrome. We review the existing data and the authors' personal view in order to assess how functional stress-echocardiography compares with coronary computed tomography angiography regarding three main aspects: diagnosis of coronary artery disease, guidance of therapy (coronary revascularization versus medical therapy) and risk stratification.
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Affiliation(s)
| | | | | | - Federico De Marco
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, San Donato Milanese
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25
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Cortigiani L, Carpeggiani C, Meola L, Djordjevic-Dikic A, Bovenzi F, Picano E. Reduced Sympathetic Reserve Detectable by Heart Rate Response after Dipyridamole in Anginal Patients with Normal Coronary Arteries. J Clin Med 2021; 11:jcm11010052. [PMID: 35011796 PMCID: PMC8745735 DOI: 10.3390/jcm11010052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Revised: 12/16/2021] [Accepted: 12/21/2021] [Indexed: 12/28/2022] Open
Abstract
Background. Patients with ischemia and normal coronary arteries (INOCA) may show abnormal cardiac sympathetic function, which could be unmasked as a reduced heart rate reserve (HRR) during dipyridamole stress echocardiography (SE). Objectives. To assess whether HRR during dipyridamole SE predicts outcome. Methods. Dipyridamole SE was performed in 292 patients with INOCA. HRR was measured as peak/rest heart rate and considered abnormal when ≤1.22 (≤1.17 in presence of permanent atrial fibrillation). All-cause death was the only endpoint. Results. HRR during SE was normal in 183 (63%) and abnormal in 109 patients (37%). During a follow-up of 10.4 ± 5.5 years, 89 patients (30%) died. The 15-year mortality rate was 27% in patients with normal and 54% in those with abnormal HRR (p < 0.0001). In a multivariable analysis, a blunted HRR during SE was an independent predictor of outcome (hazard ratio 1.86, 95% confidence intervals 1.20–2.88; p = 0.006) outperforming inducible ischemia. Conclusions. A blunted HRR during dipyridamole SE predicts a worse survival in INOCA patients, independent of inducible ischemia.
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Affiliation(s)
- Lauro Cortigiani
- Cardiology Division, San Luca Hospital, 55100 Lucca, Italy; (L.M.); (F.B.)
- Correspondence: ; Tel.: +39-0583970449; Fax: +39-0583970445
| | - Clara Carpeggiani
- CNR Institute of Clinical Physiology, 56125 Pisa, Italy; (C.C.); (E.P.)
| | - Laura Meola
- Cardiology Division, San Luca Hospital, 55100 Lucca, Italy; (L.M.); (F.B.)
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, Medical School, University of Belgrade, 11000 Belgrade, Serbia;
| | - Francesco Bovenzi
- Cardiology Division, San Luca Hospital, 55100 Lucca, Italy; (L.M.); (F.B.)
| | - Eugenio Picano
- CNR Institute of Clinical Physiology, 56125 Pisa, Italy; (C.C.); (E.P.)
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26
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Blanken CPS, Schrauben EM, Peper ES, Gottwald LM, Coolen BF, van Wijk DF, Piek JJ, Strijkers GJ, Planken RN, van Ooij P, Nederveen AJ. Coronary Flow Assessment Using Accelerated 4D Flow MRI With Respiratory Motion Correction. Front Bioeng Biotechnol 2021; 9:725833. [PMID: 34869250 PMCID: PMC8634777 DOI: 10.3389/fbioe.2021.725833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/02/2021] [Indexed: 11/29/2022] Open
Abstract
Magnetic resonance imaging (MRI) can potentially be used for non-invasive screening of patients with stable angina pectoris to identify probable obstructive coronary artery disease. MRI-based coronary blood flow quantification has to date only been performed in a 2D fashion, limiting its clinical applicability. In this study, we propose a framework for coronary blood flow quantification using accelerated 4D flow MRI with respiratory motion correction and compressed sensing image reconstruction. We investigate its feasibility and repeatability in healthy subjects at rest. Fourteen healthy subjects received 8 times-accelerated 4D flow MRI covering the left coronary artery (LCA) with an isotropic spatial resolution of 1.0 mm3. Respiratory motion correction was performed based on 1) lung-liver navigator signal, 2) real-time monitoring of foot-head motion of the liver and LCA by a separate acquisition, and 3) rigid image registration to correct for anterior-posterior motion. Time-averaged diastolic LCA flow was determined, as well as time-averaged diastolic maximal velocity (VMAX) and diastolic peak velocity (VPEAK). 2D flow MRI scans of the LCA were acquired for reference. Scan-rescan repeatability and agreement between 4D flow MRI and 2D flow MRI were assessed in terms of concordance correlation coefficient (CCC) and coefficient of variation (CV). The protocol resulted in good visibility of the LCA in 11 out of 14 subjects (six female, five male, aged 28 ± 4 years). The other 3 subjects were excluded from analysis. Time-averaged diastolic LCA flow measured by 4D flow MRI was 1.30 ± 0.39 ml/s and demonstrated good scan-rescan repeatability (CCC/CV = 0.79/20.4%). Time-averaged diastolic VMAX (17.2 ± 3.0 cm/s) and diastolic VPEAK (24.4 ± 6.5 cm/s) demonstrated moderate repeatability (CCC/CV = 0.52/19.0% and 0.68/23.0%, respectively). 4D flow- and 2D flow-based diastolic LCA flow agreed well (CCC/CV = 0.75/20.1%). Agreement between 4D flow MRI and 2D flow MRI was moderate for both diastolic VMAX and VPEAK (CCC/CV = 0.68/20.3% and 0.53/27.0%, respectively). In conclusion, the proposed framework of accelerated 4D flow MRI equipped with respiratory motion correction and compressed sensing image reconstruction enables repeatable diastolic LCA flow quantification that agrees well with 2D flow MRI.
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Affiliation(s)
- Carmen P S Blanken
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Eric M Schrauben
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Eva S Peper
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Lukas M Gottwald
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Bram F Coolen
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | | | - Jan J Piek
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Gustav J Strijkers
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - R Nils Planken
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Pim van Ooij
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Aart J Nederveen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, Netherlands
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27
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Schroder J, Prescott E. Doppler Echocardiography Assessment of Coronary Microvascular Function in Patients With Angina and No Obstructive Coronary Artery Disease. Front Cardiovasc Med 2021; 8:723542. [PMID: 34778394 PMCID: PMC8585781 DOI: 10.3389/fcvm.2021.723542] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/22/2021] [Indexed: 01/18/2023] Open
Abstract
Echocardiographic evaluation is an essential part of the diagnostic work-up in patients with known or suspected cardiovascular disease. Transthoracic Doppler echocardiography (TTDE) enables straightforward and reliable visualization of flow in the left anterior descending artery. In the absence of obstructive coronary artery disease, low TTDE-derived coronary flow velocity reserve (CFVR) is considered a marker of coronary microvascular dysfunction (CMD). TTDE CFVR is free from ionizing radiation and widely available, utilizing high-frequency transducers, pharmacologic vasodilator stress, and pulsed-wave Doppler quantification of diastolic peak flow velocities. European Society of Cardiology guidelines recommend TTDE CFVR evaluation only following preceding anatomic invasive or non-invasive coronary imaging excluding obstructive CAD. Accordingly, clinical use of TTDE CFVR is limited and CMD frequently goes undiagnosed. An evolving body of evidence underlines that low CFVR is an important and robust predictor of adverse prognosis and continuing symptoms in angina patients both with and without obstructive CAD. The majority of angina patients have no obstructive CAD, particularly among women. This has led to the suggestion that there may be a gender-specific female atherosclerotic phenotype with less epicardial obstruction, and a low CFVR signifying CMD instead. Nevertheless, available evidence indicates low CFVR is an equally important prognostic marker in both men and women. In this review, TTDE CFVR was evaluated regarding indication, practical and technical aspects, and interpretation of results. Association with symptoms and prognosis, comparison with alternative invasive and non-invasive imaging modalities, and possible interventions in angina patients with low CFVR were discussed, and key research questions were proposed.
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Affiliation(s)
- Jakob Schroder
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
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Tesic M, Beleslin B, Giga V, Jovanovic I, Marinkovic J, Trifunovic D, Petrovic O, Dobric M, Aleksandric S, Juricic S, Boskovic N, Tomasevic M, Ristic A, Orlic D, Stojkovic S, Vukcevic V, Stankovic G, Ostojic M, Djordjevic Dikic A. Prognostic Value of Transthoracic Doppler Echocardiography Coronary Flow Velocity Reserve in Patients With Asymmetric Hypertrophic Cardiomyopathy. J Am Heart Assoc 2021; 10:e021936. [PMID: 34634920 PMCID: PMC8751885 DOI: 10.1161/jaha.120.021936] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Microvascular dysfunction might be a major determinant of clinical deterioration and outcome in patients with hypertrophic cardiomyopathy (HCM). However, long‐term prognostic value of transthoracic Doppler echocardiography (TDE) coronary flow velocity reserve (CFVR) on clinical outcome is uncertain in HCM patients. Therefore, the aim of our study was to assess long‐term prognostic value of CFVR on clinical outcome in HCM population. Methods and Results We prospectively included 150 HCM patients (82 women; mean age 48±15 years). Patients’ clinical characteristics, echocardiographic and CFVR findings (both for left anterior descending [LAD] and posterior descending artery [PD]), were assessed in all patients. The primary outcome was a composite of: HCM related death, heart failure requiring hospitalization, sustained ventricular tachycardia and ischemic stroke. Patients were stratified into 2 subgroups depending on CFVR LAD value: Group 1 (CFVR LAD>2, [n=87]) and Group 2 (CFVR LAD≤2, [n=63]). During a median follow‐up of 88 months, 41/150 (27.3%) patients had adverse cardiac events. In Group 1, there were 8/87 (9.2%), whereas in Group 2 there were 33/63 (52.4%, P<0.001 vs. Group 1) adverse cardiac events. By Kaplan‐Meier analysis, patients with preserved CFVR LAD had significantly higher cumulative event‐free survival rate compared to patients with impaired CFVR LAD (96.4% and 90.9% versus 66.9% and 40.0%, at 5 and 8 years, respectively: log‐rank 37.2, P<0.001). Multivariable analysis identified only CFVR LAD≤2 as an independent predictor for adverse cardiac outcome (HR 6.54; 95% CI 2.83–16.30, P<0.001), while CFVR PD was not significantly associated with outcome. Conclusions In patients with HCM, impaired CFVR LAD (≤2) is a strong, independent predictor of adverse cardiac outcome. When the aim of testing is HCM risk stratification and CFVR LAD data are available, the evaluation of CFVR PD is redundant.
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Affiliation(s)
- Milorad Tesic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Branko Beleslin
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Vojislav Giga
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Ivana Jovanovic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia
| | - Jelena Marinkovic
- Institute for Medical Statistics and Informatics School of Medicine University of Belgrade
| | - Danijela Trifunovic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Olga Petrovic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Milan Dobric
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Srdjan Aleksandric
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Stefan Juricic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia
| | - Nikola Boskovic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia
| | - Miloje Tomasevic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Kragujevac Kragujevac Serbia
| | - Arsen Ristic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Dejan Orlic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Sinisa Stojkovic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Vladan Vukcevic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
| | - Goran Stankovic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia.,Serbian Academy of Sciences and Arts Belgrade Serbia
| | - Miodrag Ostojic
- School of Medicine University of Belgrade Belgrade Serbia.,Serbian Academy of Sciences and Arts Belgrade Serbia
| | - Ana Djordjevic Dikic
- Clinic for CardiologyClinical Center of Serbia Belgrade Serbia.,School of Medicine University of Belgrade Belgrade Serbia
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Zhang J, Liu Y, Deng Y, Zhu Y, Sun R, Lu S. Non-invasive Global and Regional Myocardial Work Predicts High-Risk Stable Coronary Artery Disease Patients With Normal Segmental Wall Motion and Left Ventricular Function. Front Cardiovasc Med 2021; 8:711547. [PMID: 34651024 PMCID: PMC8505723 DOI: 10.3389/fcvm.2021.711547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 09/01/2021] [Indexed: 01/22/2023] Open
Abstract
Background: Previous studies suggested that myocardial work (MW) may identify abnormalities in the left ventricular (LV) function and establish a more sensitive index for LV dysfunction at the early stage. This study aimed to explore the value of global and regional MW parameters in predicting high-risk stable coronary artery disease (SCAD) patients with normal wall motion and preserved LV function. Patients and Methods: A total of 131 patients, who were clinically diagnosed as SCAD with normal wall motion and LV function, were finally included in this study. Global MW parameters, including global work index (GWI), global constructive work (GCW), global waste work (GWW), and global work efficiency (GWE) were measured with non-invasive LV pressure-strain loops constructed from speckle-tracking echocardiography. Regional myocardial work index (RWI) and work efficiency (RWE) were also calculated according to the perfusion territory of each major coronary artery. All patients underwent coronary angiography and were divided into the high-risk SCAD group, the non-high-risk SCAD group, and the No SCAD group according to the range and degrees of coronary arteries stenosis. Results: The global longitudinal strain (GLS), GWI and GCW were statistically different (P < 0.001) among the three groups. In the high-risk SCAD group, GLS, GWI, and GCW were significantly lower than the other two groups (P < 0.05). Receiver operating characteristic analysis demonstrated GWI and GCW could predict high-risk SCAD at a cutoff value of 1,808 mm Hg% (sensitivity, 52.6%; specificity, 87.8%; predictive positive value, 76.3%; predictive negative value, 69.9%) and 2,308 mm Hg% (sensitivity, 80.7%; specificity, 64.9%; predictive positive value, 63.3%; predictive negative value, 80.0%), respectively. Multivariate analyses showed that carotid plaque, decreased GWI, and GCW was independently related to high-risk SCAD. The cutoff values of RWILAD, RWILCX, and RWIRCA were 2,156, 1,929, and 1,983 mm Hg% in predicting high-risk SCAD, respectively (P < 0.001). When we combined RWI in two or three perfusion regions, the diagnostic performance of SCAD was improved (P < 0.001). Conclusions: Both global and regional MW parameters have great potential in non-invasively predicting high-risk SCAD patients with normal wall motion and preserved LV function, contributing to the early identification of high-risk patients who may benefit from revascularization therapy.
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Affiliation(s)
- Jun Zhang
- Department of Medical Ultrasound, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yani Liu
- Department of Medical Ultrasound, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Youbin Deng
- Department of Medical Ultrasound, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Ying Zhu
- Department of Medical Ultrasound, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Ruiying Sun
- Department of Medical Ultrasound, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Shirui Lu
- Department of Medical Ultrasound, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
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The evolving role of cardiac imaging in patients with myocardial infarction and non-obstructive coronary arteries. Prog Cardiovasc Dis 2021; 68:78-87. [PMID: 34600948 DOI: 10.1016/j.pcad.2021.08.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 08/29/2021] [Indexed: 01/02/2023]
Abstract
Myocardial infarction (MI) with non-obstructive coronary arteries (MINOCA) represents a heterogeneous clinical conundrum accounting for about 6%-8% of all acute MI who are referred for coronary angiography. Current guidelines and consensus documents recommend that these patients are appropriately diagnosed, uncovering the causes of MINOCA, so that specific therapies can be prescribed. Indeed, there are a variety of causes that can result in this clinical condition, and for this reason diagnostic cardiac imaging has an emerging critical role in the assessment of patients with suspected or confirmed MINOCA. In last years, different cardiac imaging techniques have been evaluated in this context, and the comprehension of their strengths and limitations is of the utmost importance for their effective use in clinical practice. Moreover, recent evidence is clearly suggesting that a multimodality cardiac imaging approach, combining different techniques, seems to be crucial for a proper management of MINOCA. However, great variability still exists in clinical practice in the management of patients with suspected MINOCA, also depending on the availability of diagnostic tools and local expertise. Herein, we review the current knowledge supporting the use of different cardiac imaging techniques in patients with MINOCA, underscoring the importance of a comprehensive multimodality cardiac imaging approach and proposing a practical diagnostic algorithm to properly identify and treat the specific causes of MINOCA, in order to improve prognosis and the quality of life in these patients.
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31
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Ciampi Q, Zagatina A, Cortigiani L, Wierzbowska-Drabik K, Kasprzak JD, Haberka M, Djordjevic-Dikic A, Beleslin B, Boshchenko A, Ryabova T, Gaibazzi N, Rigo F, Dodi C, Simova I, Samardjieva M, Barbieri A, Morrone D, Lorenzoni V, Prota C, Villari B, Antonini-Canterin F, Pepi M, Carpeggiani C, Pellikka PA, Picano E. Prognostic value of stress echocardiography assessed by the ABCDE protocol. Eur Heart J 2021; 42:3869-3878. [PMID: 34449837 PMCID: PMC8486488 DOI: 10.1093/eurheartj/ehab493] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 05/04/2021] [Accepted: 07/19/2021] [Indexed: 12/20/2022] Open
Abstract
AIM The aim of this study was to assess the prognostic value of ABCDE-SE in a prospective, large scale, multicentre, international, effectiveness study. Stress echocardiography (SE) was recently upgraded to the ABCDE protocol: step A, regional wall motion abnormalities; step B, B lines; step C, left ventricular contractile reserve; step D, Doppler-based coronary flow velocity reserve in left anterior descending coronary artery; and step E, electrocardiogram-based heart rate reserve. METHODS AND RESULTS From July 2016 to November 2020, we enrolled 3574 all-comers (age 65 ± 11 years, 2070 males, 58%; ejection fraction 60 ± 10%) with known or suspected chronic coronary syndromes referred from 13 certified laboratories. All patients underwent clinically indicated ABCDE-SE. The employed stress modality was exercise (n = 952, with semi-supine bike, n = 887, or treadmill, n = 65 with adenosine for step D) or pharmacological stress (n = 2622, with vasodilator, n = 2151; or dobutamine, n = 471). SE response ranged from score 0 (all steps normal) to score 5 (all steps abnormal). All-cause death was the only endpoint. Rate of abnormal results was 16% for A, 30% for B, 36% for C, 28% for D, and 37% for E steps. During a median follow-up of 21 months (interquartile range: 13-36), 73 deaths occurred. Global X2 was 49.5 considering clinical variables, 50.7 after step A only (P = NS (not significant)) and 80.6 after B-E steps (P < 0.001 vs. step A). Annual mortality rate ranged from 0.4% person-year for score 0 up to 2.7% person-year for score 5. CONCLUSION ABCDE-SE allows an effective prediction of survival in patients with chronic coronary syndromes.
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Affiliation(s)
- Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Angela Zagatina
- Cardiology Department, Saint Petersburg State University Hospital, Russian Federation
| | | | | | | | - Maciej Haberka
- Department of Cardiology, SHS, Medical University of Silesia, Katowice, Poland
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Alla Boshchenko
- Cardiology Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Tamara Ryabova
- Cardiology Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, Parma, Italy
| | - Fausto Rigo
- Cardiology Department, Ospedale di Dolo-Venice, Venice, Italy
| | - Claudio Dodi
- Cardiology Department, Ospedale di Cremona, Cremona, Italy
| | - Iana Simova
- Cardiology Department, Heart and Brain Center of Excellence, University Hospital, Pleven, Sofia, Bulgaria
| | - Martina Samardjieva
- Cardiology Department, Heart and Brain Center of Excellence, University Hospital, Pleven, Sofia, Bulgaria
| | | | | | | | | | - Bruno Villari
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Francesco Antonini-Canterin
- Highly Specialized Rehabilitation Hospital Motta di Livenza, Cardiac Prevention and Rehabilitation Unit, Treviso, Italy.,Italian Society of Echocardiography and Cardiovascular Imaging, Milano, Italy
| | - Mauro Pepi
- Italian Society of Echocardiography and Cardiovascular Imaging, Milano, Italy.,Cardiology Division, Fondazione Cardiologica Monzino, Milano, Italy
| | - Clara Carpeggiani
- Biomedicine Department, CNR, Institute of Clinical Physiology, Via Moruzzi 1, Building C- Room 130, 56124 Pisa, Italy
| | | | - Eugenio Picano
- Biomedicine Department, CNR, Institute of Clinical Physiology, Via Moruzzi 1, Building C- Room 130, 56124 Pisa, Italy
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32
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Picano E. Coronary flow velocity reserve with transthoracic echocardiography: a game changer. Acta Cardiol 2021; 78:491-494. [PMID: 34565288 DOI: 10.1080/00015385.2021.1980957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Zagatina A, Zhuravskaya N, Caprnda M, Shiwani HA, Gazdikova K, Rodrigo L, Kruzliak P, Shmatov D. Should we routinely assess coronary artery Doppler in daily echocardiography practice? Acta Cardiol 2021; 77:573-579. [PMID: 34538214 DOI: 10.1080/00015385.2021.1973771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
A lot of people with coronary artery disease do not have specific symptoms, and myocardial infarction or death are the first manifestation of the disease. New accurate, non-invasive and safe screening methods are required that can assess the prognosis of patients during routine examinations performed on millions of people. The aim of this review was to discuss the current literature regarding the utility of non-invasive ultrasound imaging of the coronary artery in assessing a patient's prognosis in daily practice. Assessment of coronary artery flow during common stress echocardiography or echocardiography can provide additive incremental prognostic information without the burden of radiation. Exercise or pharmacologic stress echocardiography tests combined with coronary flow velocity reserve assessment has advantages over stress tests based only on regional wall motion abnormalities. Scanning of main coronary arteries as an addition to routine echocardiography can reveal patients at high risk of adverse cardiac events in the near future.
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Affiliation(s)
- Angela Zagatina
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
| | - Nadezhda Zhuravskaya
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
| | - Martin Caprnda
- 1st Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovakia
| | - Haaris A. Shiwani
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Trust, Lancaster, United Kingdom
| | - Katarina Gazdikova
- Department of Nutrition, Faculty of Nursing and Professional Health Studies, Slovak Medical University, Bratislava, Slovakia
- Department of General Medicine, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia
| | - Luis Rodrigo
- Faculty of Medicine, University of Oviedo, Central University Hospital of Asturias (HUCA), Oviedo, Spain
| | - Peter Kruzliak
- 2nd Department of Surgery, Faculty of Medicine, Masaryk University and St. Annés University Hospital, Brno, Czech Republic
| | - Dmitry Shmatov
- Department of Cardiology, Saint Petersburg State University, Saint Petersburg, Russian Federation
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Cortigiani L, Carpeggiani C, Landi P, Raciti M, Bovenzi F, Picano E. Prognostic Value of Heart Rate Reserve during Dipyridamole Stress Echocardiography in Patients With Abnormal Chronotropic Response to Exercise. Am J Cardiol 2021; 154:106-110. [PMID: 34233833 DOI: 10.1016/j.amjcard.2021.05.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Abstract
Heart rate reserve (HRR) during physical or pharmacological stress is a sign of cardiac autonomic function and sympathetic reserve, but it can be reduced during exercise for confounders such as poor motivation, drugs or physical fitness. In this study we sought to assess the prognostic meaning of HRR during dipyridamole stress echocardiography (DSE) in patients with abnormal chronotropic response to exercise. From 2004 to 2019, we prospectively acquired and retrospectively analyzed 379 patients (age 62 ± 11 years; ejection fraction 60 ± 5%) with suspected (n = 243) or known (n = 136) chronic coronary syndromes, referred to DSE for chronotropic incompetence during upright bicycle exercise-electrocardiography test defined as HRR used [(peak HR - rest HR) / (220 - age) - rest HR] ≤80% in patients off and ≤62% in patients on beta-blockers. All patients were in sinus rhythm and underwent DSE (0.84 mg/kg) within 3 months of exercise testing. During DSE, age-independent HRR (peak/rest HR) ≤1.22 was considered abnormal. All patients were followed-up. All-cause death was the only outcome measure. HRR during DSE was normal in 275 (73%) and abnormal in 104 patients (27%). During a follow-up of 9.0 ± 4.2 years, 67 patients (18%) died. The 15-year mortality rate was 23% in patients with normal and 61% in patients with abnormal HRR (p < 0.0001). At multivariable analysis a blunted HRR during DSE was an independent predictor of outcome (hazard ratio 2.01, 95% confidence intervals 1.23-3.29; p = 0.005) with age and diabetes, while neither inducible ischemia nor ongoing beta-blocker therapy were significant predictors. In conclusion, a blunted HRR during DSE predicts a worse survival in patients with chronotropic incompetence during exercise test. HRR during DSE is an appealingly simple biomarker of cardiac autonomic dysfunction independent of imaging, exercise and beta-blocker therapy.
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Affiliation(s)
| | | | | | - Mauro Raciti
- CNR Institute of Clinical Physiology, Pisa, Italy
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Stress Echo 2030: The Novel ABCDE-(FGLPR) Protocol to Define the Future of Imaging. J Clin Med 2021; 10:jcm10163641. [PMID: 34441937 PMCID: PMC8397117 DOI: 10.3390/jcm10163641] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 08/12/2021] [Accepted: 08/13/2021] [Indexed: 02/06/2023] Open
Abstract
With stress echo (SE) 2020 study, a new standard of practice in stress imaging was developed and disseminated: the ABCDE protocol for functional testing within and beyond CAD. ABCDE protocol was the fruit of SE 2020, and is the seed of SE 2030, which is articulated in 12 projects: 1-SE in coronary artery disease (SECAD); 2-SE in diastolic heart failure (SEDIA); 3-SE in hypertrophic cardiomyopathy (SEHCA); 4-SE post-chest radiotherapy and chemotherapy (SERA); 5-Artificial intelligence SE evaluation (AI-SEE); 6-Environmental stress echocardiography and air pollution (ESTER); 7-SE in repaired Tetralogy of Fallot (SETOF); 8-SE in post-COVID-19 (SECOV); 9: Recovery by stress echo of conventionally unfit donor good hearts (RESURGE); 10-SE for mitral ischemic regurgitation (SEMIR); 11-SE in valvular heart disease (SEVA); 12-SE for coronary vasospasm (SESPASM). The study aims to recruit in the next 5 years (2021–2025) ≥10,000 patients followed for ≥5 years (up to 2030) from ≥20 quality-controlled laboratories from ≥10 countries. In this COVID-19 era of sustainable health care delivery, SE2030 will provide the evidence to finally recommend SE as the optimal and versatile imaging modality for functional testing anywhere, any time, and in any patient.
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Hada M, Hoshino M, Wakasa N, Sugiyama T, Kanaji Y, Yamaguchi M, Misawa T, Nagamine T, Nogami K, Yasui Y, Yonetsu T, Sasano T, Kakuta T. Early effect of percutaneous coronary intervention of non-left anterior descending artery on coronary flow velocity reserve of left anterior descending artery assessed by transthoracic Doppler echocardiography. PLoS One 2021; 16:e0256161. [PMID: 34388217 PMCID: PMC8363006 DOI: 10.1371/journal.pone.0256161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 07/30/2021] [Indexed: 11/19/2022] Open
Abstract
Background Limited data are available regarding the influence of percutaneous coronary intervention (PCI) of non-totally occluded lesions (non-CTO) on the coronary flow of non-target vessels. We sought to investigate the short-term impact of the non-left anterior descending artery (non-LAD) PCI on the coronary flow physiology of LAD using transthoracic Doppler echocardiography (TDE). Methods and results We consecutively studied 50 patients who underwent successful PCI of non-LAD and non-CTO lesions and a coronary flow velocity assessment of LAD at rest and maximal hyperemia before and at 2 days after the procedure by TDE. Coronary flow velocity reserve (CFVR) was calculated as the ratio of hyperemic to resting diastolic peak velocity (hDPV/bDPV). We evaluated the changes in LAD coronary flow characteristics after PCI of non-LAD and explored the determinants of the change in LAD-CFVR. The median fractional flow reserve (FFR) of the culprit lesion and the LAD quantitative flow ratio (QFR) were 0.67 and 0.88, respectively. After non-LAD PCI, LAD-CFVR was decreased in 33 patients (66.0%). LAD-CFVR significantly decreased (pre-PCI: 2.41, post-PCI: 2.03, p = 0.001) due to a significant decrease in LAD-hDPV (P = 0.007). The prevalence of impaired LAD-CFVR (≤2.0) significantly increased (pre: 30%, post: 48%, P = 0.027). Multivariable linear regression analysis showed that pre-PCI LAD-CFVR was independent predictor of the change in LAD-CFVR after PCI. Conclusions LAD-CFVR significantly decreased after successful non-LAD PCI due to the postprocedural reduction of coronary flow assessed by LAD-hDPV.
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Affiliation(s)
- Masahiro Hada
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Masahiro Hoshino
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Nobutaka Wakasa
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Tomoyo Sugiyama
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Yoshihisa Kanaji
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Masao Yamaguchi
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Toru Misawa
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Tatsuhiro Nagamine
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Kai Nogami
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Yumi Yasui
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
| | - Taishi Yonetsu
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Bunkyo, Tokyo, Japan
| | - Tsunekazu Kakuta
- Division of Cardiovascular Medicine, Tsuchiura Kyodo General Hospital, Tsuchiura, Ibaraki, Japan
- * E-mail:
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D’Andrea A, Ciampi Q, Russo A, Forni A, Mangia C, Picano E. The effects of lockdown-induced air quality changes on the results of cardiac functional stress testing in coronary artery disease and heart failure patients. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2021; 28:41423-41430. [PMID: 33786763 PMCID: PMC8009465 DOI: 10.1007/s11356-021-13622-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/18/2021] [Indexed: 05/05/2023]
Abstract
In vulnerable subjects, the increase in air pollution worsens the signs of myocardial ischemia. Lockdown during COVID-19 pandemics substantially cleaned the air. The objective of this is to assess the effects of air cleaning due to lockdown on stress echocardiography (SE) results. We enrolled 19 patients with chronic coronary artery disease and/or heart failure referred to SE (semi-supine bicycle exercise, n = 8, or dipyridamole, n = 11). Before and soon after lockdown, we assessed regional wall motion abnormalities (abnormal value: worsening of ≥ 2 segments), B-lines (a sign of pulmonary congestion, 4-site simplified scan, abnormal value ≥ 2), and coronary flow velocity reserve in left anterior descending artery (CFVR, abnormal value < 2.0). Local air quality indicators (same day of SE) of fine particulate matter (PM2.5) and nitrogen dioxide (NO2) were obtained from publicly available data sets of the regional authority of environmental protection. After lockdown, NO2 concentration decreased from 19 ± 10 to 10 ± 4 μg/m3 (p = 0.006). After lockdown, abnormal responses remained unchanged for ischemia (21% vs 16%, p = ns) and decreased for B-lines (42% vs 5%, p = 0.008) and CFVR (84 vs 42%, p = 0.007). Changes in coronary flow velocity reserve (CFVR) were correlated to same-day variations in NO2 (r = -0.578, p = 0.010) and preceding 30-day changes in PM2.5 (r = -0.518, p = 0.023). After lockdown, air cleaning was associated with a beneficial effect on coronary small vessel dysfunction and alveolar-capillary barrier distress mirrored by improvement of CFVR and B-lines during SE in vulnerable patients. ClinicalTrials.gov Identifier: NCT 030.49995.
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Affiliation(s)
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Antonello Russo
- Association for Public Health “Salute Pubblica”, Brindisi, Italy
| | - Alberto Forni
- Cardiology Division, Nocera Inferiore Hospital, Nocera Inferiore, Italy
| | - Cristina Mangia
- ISAC-Institute of Sciences of Atmosphere and Climate, CNR, Lecce, Italy
| | - Eugenio Picano
- Institute of Clinical Physiology, Biomedicine Department, CNR, Pisa, Italy
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Coronary Flow, Left Ventricular Contractile and Heart Rate Reserve in Non-Ischemic Heart Failure. J Clin Med 2021; 10:jcm10153405. [PMID: 34362186 PMCID: PMC8347234 DOI: 10.3390/jcm10153405] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 07/14/2021] [Accepted: 07/24/2021] [Indexed: 12/14/2022] Open
Abstract
Background: Left ventricular contractile reserve (LVCR), coronary flow velocity reserve (CFVR), and heart rate reserve (HRR) affect outcome in heart failure (HF). They can be simultaneously measured during dipyridamole stress echocardiography (DSE). Aim: To assess the value of comprehensive DSE in patients with non-ischemic HF. Methods: We evaluated 610 patients with HF, no history of coronary artery disease, and no inducible regional wall motion abnormalities: 270 patients with preserved ejection fraction (≥50%), 146 patients with mid-range ejection fraction (40–49%), and 194 patients with reduced ejection fraction (<40%). All underwent DSE (0.84 mg/kg in 6′) in 7 accredited laboratories. We measured LVCR (abnormal value ≤ 1.1), CFVR in left anterior descending artery (abnormal value: ≤2.0), and HRR (peak/rest heart rate; abnormal value: ≤1.22). All patients were followed up. Results: Abnormal CFVR, LVCR, and HRR occurred in 29%, 45%, and 47% of patients, respectively (p < 0.001). After a median follow-up time of 20 months (interquartile range: 12–32 months), 113 hard events occurred in 105 patients with 41 deaths, 8 myocardial infarctions, 61 admissions for acute HF, and 3 strokes. The annual mortality rates were 0.8% in 200 patients with none abnormal criteria, 1.8% in 184 patients with 1 abnormal criterion, 7.1% in 130 patients with 2 abnormal criteria, 7.5% in 96 patients with 3 abnormal criteria. Conclusions: Abnormal LVCR, CFVR, and HRR were frequent during DSE in non-ischemic HF patients. They target different pathophysiological vulnerabilities (myocardial function, coronary microcirculation, and cardiac autonomic balance) and are useful for outcome prediction.
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Imaging Quality Control, Methodology Harmonization and Clinical Data Management in Stress Echo 2030. J Clin Med 2021; 10:jcm10143020. [PMID: 34300186 PMCID: PMC8305320 DOI: 10.3390/jcm10143020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 06/18/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023] Open
Abstract
Stress echo (SE) 2030 study is an international, prospective, multicenter cohort study that will include >10,000 patients from ≥20 centers from ≥10 countries. It represents the logical and chronological continuation of the SE 2020 study, which developed, validated, and disseminated the “ABCDE protocol” of SE, more suitable than conventional SE to describe the complex vulnerabilities of the contemporary patient within and beyond coronary artery disease. SE2030 was started with a recruitment plan from 2021 to 2025 (and follow-up to 2030) with 12 subprojects (ranging from coronary artery disease to valvular and post-COVID-19 patients). With these features, the study poses particular challenges on quality control assurance, methodological harmonization, and data management. One of the significant upgrades of SE2030 compared to SE2020 was developing and implementing a Research Electronic Data Capture (REDCap)-based infrastructure for interactive and entirely web-based data management to integrate and optimize reproducible clinical research data. The purposes of our paper were: first, to describe the methodology used for quality control of imaging data, and second, to present the informatic infrastructure developed on RedCap platform for data entry, storage, and management in a large-scale multicenter study.
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Human coronary inflammation by computed tomography: Relationship with coronary microvascular dysfunction. Int J Cardiol 2021; 336:8-13. [PMID: 34052238 DOI: 10.1016/j.ijcard.2021.05.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/21/2021] [Accepted: 05/24/2021] [Indexed: 11/22/2022]
Abstract
Background A new imaging metric using coronary computed tomography angiography (CCTA), addressing the peri-coronary adipose tissue (PCAT) computed tomography (CT) attenuation, has been clinically validated. This method provides information regarding coronary inflammation. It is unclear how coronary inflammation affects microvascular function. The non-invasive evaluation of coronary flow velocity reserve is widely used in clinical practice using Doppler measurement on the left anterior descending coronary artery (CFVR-lad) during stress-echocardiography (SE). We hypothesize that coronary inflammation affects CFVR-lad and, in the absence of overt CAD, they are significantly correlated. Methods We evaluated the relationship between coronary inflammation (by PCAT CT attenuation) and coronary microvascular function (by CFVR-lad) in subjects with no or non-obstructive (diameter stenosis <70%) coronary artery disease (CAD). Results Two-hundred and two subjects were enrolled in the study. The relationship between PCAT CT attenuation and CFVR-lad show a significant inverse relationship in the entire group of subjects enrolled in the study (r = -0.32, p < 0.001). Correlation between PCAT CT attenuation and CFVR-lad was significant in subjects with no or mild CAD-lad, while this was not the case in subjects with intermediate CAD-lad. The R and R2 were respectively -0.40, -0.16 in subjects without CAD (p < 0.001) and - 0.35 and - 0.12 in subjects with mild CAD-lad (p = 0.001). Conclusions The main finding of the current study is the independent relationship between coronary microvascular function, by Doppler CFVR-lad during SE, in subjects without severely obstructive CAD in the left anterior descending coronary artery, and the level of local coronary inflammation, by PCAT attenuation measurement on CCTA.
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41
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Schroder J, Michelsen MM, Mygind ND, Suhrs HE, Bove KB, Bechsgaard DF, Aziz A, Gustafsson I, Kastrup J, Prescott E. Coronary flow velocity reserve predicts adverse prognosis in women with angina and no obstructive coronary artery disease: results from the iPOWER study. Eur Heart J 2021; 42:228-239. [PMID: 33477168 DOI: 10.1093/eurheartj/ehaa944] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 08/28/2020] [Accepted: 11/02/2020] [Indexed: 01/09/2023] Open
Abstract
AIMS Many patients with angina, especially women, do not have obstructive coronary artery disease (CAD) yet have impaired prognosis. We investigated whether routine assessment of coronary microvascular dysfunction (CMD) is feasible and predicts adverse outcome in women with angina and no obstructive CAD. METHODS AND RESULTS After screening 7253, we included 1853 women with angina and no obstructive CAD on angiogram who were free of previous CAD, heart failure, or valvular heart disease in the prospective iPOWER (Improving Diagnosis and Treatment of Women with Angina Pectoris and Microvascular Disease) study. CMD was assessed by Doppler echocardiography in the left anterior descending artery as coronary flow velocity reserve (CFVR). Patients were followed for a composite outcome of cardiovascular death, myocardial infarction (MI), heart failure, stroke, and coronary revascularization. CFVR was obtained in 1681 patients (91%) and the median CFVR was 2.33 (quartiles 1-3: 2.00-2.74). During a median follow-up of 4.5 years, 96 events occurred. In univariate Cox regression, CFVR was associated with the composite outcome {hazard ratio (HR) 1.07 [95% confidence interval (CI) 1.03-1.11] per 0.1 unit decrease in CFVR; P < 0.001}, primarily driven by an increased risk of MI and heart failure. Results remained significant in multivariate analysis [HR 1.05 (95% CI 1.01-1.09) per 0.1 unit decrease in CFVR; P = 0.01]. In exploratory analyses, CFVR was also associated with the risk of repeated hospital admission for angina and all-cause mortality. CONCLUSION Assessment of CFVR by echocardiography is feasible and predictive of adverse outcome in women with angina and no obstructive CAD. Results support a more aggressive preventive management of these patients and underline the need for trials targeting CMD.
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Affiliation(s)
- Jakob Schroder
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Marie M Michelsen
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Naja D Mygind
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.,Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Hannah E Suhrs
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Kira B Bove
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Daria Frestad Bechsgaard
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark.,Department of Cardiology, Hvidovre Hospital, Kettegaard Alle 30, 2650 Hvidovre Odense Hospital, J.B. Winsloews Vej 4, 5000 Odense, Denmark
| | - Ahmed Aziz
- Department of Cardiology, Odense University Hospital, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
| | - Jens Kastrup
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg Frederiksberg Hospital, University of Copenhagen, Bispebjerg Bakke 23, 2400 Copenhagen, Denmark
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Carbone A, D'Andrea A, Sperlongano S, Tagliamonte E, Mandoli GE, Santoro C, Evola V, Bandera F, Morrone D, Malagoli A, D'Ascenzi F, Bossone E, Cameli M. Echocardiographic assessment of coronary microvascular dysfunction: Basic concepts, technical aspects, and clinical settings. Echocardiography 2021; 38:993-1001. [PMID: 33948990 PMCID: PMC8252466 DOI: 10.1111/echo.15059] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 03/15/2021] [Accepted: 04/06/2021] [Indexed: 01/06/2023] Open
Abstract
Coronary flow reserve is the capacity of the coronary circulation to augment the blood flow in response an increase in myocardial metabolic demands and has a powerful prognostic significance in different clinical situations. It might assess with invasive and noninvasive technique. Transthoracic echocardiography Doppler is an emerging diagnostic technique, noninvasive, highly feasible, safe for patient and physician, without radiation, and able to detect macrovascular and microvascular anomalies in the coronary circulation. This review aims to describe the benefit and limits of echocardiographic assessment of coronary flow reserve.
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Affiliation(s)
- Andreina Carbone
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Antonello D'Andrea
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Simona Sperlongano
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Ercole Tagliamonte
- Department of Cardiology and Intensive Coronary Unit, "Umberto I" Hospital, Nocera Inferiore (SA), Italy
| | - Giulia Elena Mandoli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Ciro Santoro
- Department of Advanced Biomedical Sciences, University of Naples "Federico II", Naples, Italy
| | - Vincenzo Evola
- Department of Clinical and Experimental Medicine, University of Palermo, Palermo, Italy
| | - Francesco Bandera
- Heart Failure Unit, Chair of Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy.,Department of Biomedical Health Science, University of Milan, Milan, Italy
| | - Doralisa Morrone
- Cardiothoracic Department, Cisanello Hospital, University of Pisa, Pisa, Italy
| | | | - Flavio D'Ascenzi
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | | | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
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Cortigiani L, Ciampi Q, Carpeggiani C, Lisi C, Bovenzi F, Picano E. Additional prognostic value of heart rate reserve over left ventricular contractile reserve and coronary flow velocity reserve in diabetic patients with negative vasodilator stress echocardiography by regional wall motion criteria. Eur Heart J Cardiovasc Imaging 2020; 23:209-216. [PMID: 33313642 DOI: 10.1093/ehjci/jeaa307] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/05/2020] [Indexed: 12/20/2022] Open
Abstract
AIMS In diabetic patients, a blunted left ventricular contractile reserve (LVCR) and/or a reduced coronary flow velocity reserve (CFVR) identify patients at higher risk in spite of stress echocardiography (SE) negative for ischaemia. Cardiac autonomic dysfunction contributes to risk profile independently of inducible ischaemia and can be assessed with heart rate reserve (HRR). We sought to assess the added prognostic value of HRR to LVCR and CFVR in diabetic patients with non-ischaemic SE. METHODS AND RESULTS Six-hundred and thirty-six diabetic patients (age 68 ± 9 years, 396 men, ejection fraction 58 ± 10%) with sinus rhythm on resting electrocardiogram underwent dipyridamole SE in a two-centre prospective study with assessment of wall motion, force-based LVCR (stress/rest ratio, normal value > 1.1), CFVR of the left anterior descending coronary artery (stress/rest ratio, normal value >2.0), and HRR (stress/rest ratio, normal value >1.22). All-cause death was the only considered endpoint. During a median follow-up of 39 months, 94 (15%) patients died. Independent predictors of death were abnormal CFVR [hazard ratio (HR) 1.59, 95% confidence interval (CI) 1.0-2.52, P = 0.05], reduced LVCR (HR 1.76, 95% CI 1.15-2.69, P = 0.009), and blunted HRR (HR 1.92, 95% CI 1.24-2.96, P = 0.003). Eight-year death rate was 9% for patients with triple negativity (n = 252; 40%), 18% for those with single positivity (n = 216; 34%), 36% with double positivity (n = 124; 19%), and 64% for triple positivity (n = 44; 7%) (P < 0.0001). CONCLUSION Diabetic patients with dipyridamole SE negative for ischaemia still may have a significant risk in presence of an abnormal LVCR and/or CFVR and/or HRR, which assess the underlying myocardial, microvascular, and cardiac autonomic dysfunction. CLINICAL TRIALS Gov Identifier NCT 030.49995.
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Affiliation(s)
- Lauro Cortigiani
- Ospedale San Luca, Department of Cardiology, Via Guglielmo Lippi Francesconi, 55100 Lucca, Italy
| | - Quirino Ciampi
- Ospedale Fatebenefratelli, Department of Cardiology, Benevento, Italy
| | | | - Cristiano Lisi
- Ospedale San Luca, Department of Cardiology, Via Guglielmo Lippi Francesconi, 55100 Lucca, Italy
| | - Francesco Bovenzi
- Ospedale San Luca, Department of Cardiology, Via Guglielmo Lippi Francesconi, 55100 Lucca, Italy
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Bechsgaard DF, Hove JD, Michelsen MM, Mygind ND, Pena A, Hansen PR, Hansen HS, Kastrup J, Høst N, Gustafsson I, Prescott E. Myocardial CT perfusion compared with transthoracic Doppler echocardiography in evaluation of the coronary microvascular function: An iPOWER substudy. Clin Physiol Funct Imaging 2020; 41:85-94. [PMID: 33030280 DOI: 10.1111/cpf.12669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 08/20/2020] [Accepted: 09/30/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND A significant number of women with angina and no obstructive coronary artery disease (CAD; <50% stenosis) have coronary microvascular dysfunction (CMD) which carries an adverse cardiovascular prognosis. Coronary microvascular function can be evaluated by transthoracic Doppler echocardiography (TTDE) as a coronary flow velocity reserve (CFVR) and by static CT myocardial perfusion (CTP) as a myocardial perfusion reserve (MPR). Whether these methods are correlated is not known. We assessed the correlation between CFVR and MPR and investigated whether women with angina, CMD and no obstructive CAD have reduced MPR compared with asymptomatic women. METHODS Static CTP with adenosine-induced vasodilation and TTDE of the left anterior descending artery with dipyridamole-induced vasodilation were successfully performed and analysed in 99 women with stable angina and no obstructive CAD and 33 asymptomatic women with no obstructive CAD. CMD was defined as CFVR < 2. RESULTS Correlation between rate-pressure product corrected MPR and CFVR was weak but significant (r = .23; p = .007). MPR was highest among asymptomatic women with normal CFVR (median [interquartile range; IQR] 158 [145-181] %). Symptomatic women with normal CFVR had reduced MPR (148 [134-162] %; age-adjusted p < .001); however, the lowest MPR was found in symptomatic women with CMD (140 [129-164] %; age-adjusted p < .001), independent of cardiovascular risk factors and haemodynamic parameters (p = .017). CONCLUSION Women with angina, CMD and no obstructive CAD had markedly diminished MPR compared with asymptomatic women. Correlation between CFVR and MPR was weak, suggesting that CTP and TTDE are not interchangeable for detection of CMD.
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Affiliation(s)
- Daria F Bechsgaard
- Department of Cardiology, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jens D Hove
- Department of Cardiology, Hvidovre University Hospital, University of Copenhagen, Copenhagen, Denmark.,Center for Functional and Diagnostic Imaging, Hvidovre University Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Marie M Michelsen
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Naja D Mygind
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Adam Pena
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Peter R Hansen
- Department of Cardiology, Herlev-Gentofte Hospital, University of Copenhagen, Hellerup, Denmark
| | - Henrik S Hansen
- Department of Cardiology, Odense University Hospital, Odense C, Denmark
| | - Jens Kastrup
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Nis Høst
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Ida Gustafsson
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Eva Prescott
- Department of Cardiology, Bispebjerg University Hospital, University of Copenhagen, Copenhagen, Denmark
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45
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Morrone D, Arbucci R, Wierzbowska-Drabik K, Ciampi Q, Peteiro J, Agoston G, Varga A, Camarozano AC, Boshchenko A, Ryabova T, Dekleva M, Simova I, Lowenstein Haber DM, Tesic M, Boskovic N, Djordjevic-Dikic A, Beleslin B, D'Alfonso MG, Mori F, Rodrìguez-Zanella H, Kasprzak JD, Cortigiani L, Lattanzi F, Scali MC, Torres MAR, Daros CB, de Castro E Silva Pretto JL, Gaibazzi N, Zagatina A, Zhuravskaya N, Amor M, Mieles PEV, Merlo PM, Monte I, D'Andrea A, Re F, Di Salvo G, Merli E, Lorenzoni V, De Nes M, Paterni M, Limongelli G, Prota C, Citro R, Colonna P, Villari B, Antonini-Canterin F, Carpeggiani C, Lowenstein J, Picano E. Feasibility and functional correlates of left atrial volume changes during stress echocardiography in chronic coronary syndromes. Int J Cardiovasc Imaging 2020; 37:953-964. [PMID: 33057991 DOI: 10.1007/s10554-020-02071-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 10/09/2020] [Indexed: 10/23/2022]
Abstract
An enlarged left atrial volume index (LAVI) at rest mirrors increased LA pressure and/or impairment of LA function. A cardiovascular stress may acutely modify left atrial volume (LAV) within minutes. Aim of this study was to assess the feasibility and functional correlates of LAV-stress echocardiography (SE) Out of 514 subjects referred to 10 quality-controlled labs, LAV-SE was completed in 490 (359 male, age 67 ± 12 years) with suspected or known chronic coronary syndromes (n = 462) or asymptomatic controls (n = 28). The utilized stress was exercise in 177, vasodilator in 167, dobutamine in 146. LAV was measured with the biplane disk summation method. SE was performed with the ABCDE protocol. The intra-observer and inter-observer LAV variability were 5% and 8%, respectively. ∆-LAVI changes (stress-rest) were negatively correlated with resting LAVI (r = - 0.271, p < 0.001) and heart rate reserve (r = -.239, p < 0.001). LAV-dilators were defined as those with stress-rest increase ≥ 6.8 ml/m2, a cutoff derived from a calculated reference change value above the biological, analytical and observer variability of LAVI. LAV dilation occurred in 56 patients (11%), more frequently with exercise (16%) and dipyridamole (13%) compared to dobutamine (4%, p < 0.01). At multivariable logistic regression analysis, B-lines ≥ 2 (OR: 2.586, 95% CI = 1.1293-5.169, p = 0.007) and abnormal contractile reserve (OR: 2.207, 95% CI = 1.111-4.386, p = 0.024) were associated with LAV dilation. In conclusion, LAV-SE is feasible with high success rate and low variability in patients with chronic coronary syndromes. LAV dilation is more likely with reduced left ventricular contractile reserve and pulmonary congestion.
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Affiliation(s)
| | - Rosina Arbucci
- Cardiodiagnosticos, Investigaciones Medicas, Buenos Aires, Argentina
| | | | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Jesus Peteiro
- CHUAC- Complexo Hospitalario Universitario A Coruna- University of A Coruna, La Coruna, Spain
| | - Gergely Agoston
- Institute of Family Medicine, University of Szeged, Szeged, Hungary
| | - Albert Varga
- Institute of Family Medicine, University of Szeged, Szeged, Hungary
| | - Ana Cristina Camarozano
- Hospital de Clinicas UFPR, Medicine Department, Federal University of Paranà, Curitiba, Brazil
| | - Alla Boshchenko
- Cardiology Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Tamara Ryabova
- Cardiology Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Milica Dekleva
- Clinical Cardiology Department, Clinical Hospital Zvezdara, Medical School, University of Belgrade, Belgrade, Serbia
| | - Iana Simova
- Head of Cardiology Department, Acibadem City Clinic Cardiovascular Center, University Hospital, Sofia, Bulgaria
| | | | - Milorad Tesic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Nikola Boskovic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Maria Grazia D'Alfonso
- SOD Diagnostica Cardiovascolare, DAI Cardio-Toraco-Vascolare, Azienda Ospedaliera-Universitaria Careggi, Firenze, Italy
| | - Fabio Mori
- SOD Diagnostica Cardiovascolare, DAI Cardio-Toraco-Vascolare, Azienda Ospedaliera-Universitaria Careggi, Firenze, Italy
| | | | | | | | - Fabio Lattanzi
- Cardiothoracic Department, University of Pisa, Pisa, Italy
| | | | - Marco A R Torres
- Hospital de Clinicas de Porto Alegre - Universidade Federal Do Rio Grande Do Sul, Porto Alegre, Brazil
| | | | | | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, Parma, Italy
| | - Angela Zagatina
- Cardiology Department, Saint Petersburg State University Clinic, Saint Petersburg State University, St Petersburg, Russian Federation
| | - Nadezhda Zhuravskaya
- Cardiology Department, Saint Petersburg State University Clinic, Saint Petersburg State University, St Petersburg, Russian Federation
| | - Miguel Amor
- Cardiology Department, Ramos Mejia Hospital, Buenos Aires, Argentina
| | | | | | - Ines Monte
- Echocardiography Lab, Cardio-Thorax-Vascular Department, "Policlinico Vittorio Emanuele", Catania University, Catania, Italy
| | | | - Federica Re
- Cardiology Division, Ospedale San Camillo, Rome, Italy
| | - Giovanni Di Salvo
- Cardiology Division, Pediatric Cardiology Department, Brompton Hospital, Imperial College of London, London, UK
| | - Elisa Merli
- Department of Cardiology, Ospedale per gli Infermi, Faenza, Ravenna, Italy
| | | | - Michele De Nes
- Biomedicine Department, Institute of Clinical Physiology, CNR, Pisa, Italy
| | - Marco Paterni
- Biomedicine Department, Institute of Clinical Physiology, CNR, Pisa, Italy
| | | | - Costantina Prota
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Rodolfo Citro
- Cardiology Department and Echocardiography Lab, University Hospital "San Giovanni Di Dio e Ruggi D'Aragona", Salerno, Italy.,Italian Society of Echocardiography and Cardiovascular Imaging, Rome, Italy
| | - Paolo Colonna
- Italian Society of Echocardiography and Cardiovascular Imaging, Rome, Italy.,Cardiology Hospital, Policlinico University Hospital of Bari, Bari, Italy
| | - Bruno Villari
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | - Francesco Antonini-Canterin
- Italian Society of Echocardiography and Cardiovascular Imaging, Rome, Italy.,Cardiac Prevention and Rehabilitation Unit, Highly Specialized Rehabilitation Hospital Motta Di Livenza, Treviso, Italy
| | - Clara Carpeggiani
- Biomedicine Department, Institute of Clinical Physiology, CNR, Pisa, Italy
| | - Jorge Lowenstein
- Cardiodiagnosticos, Investigaciones Medicas, Buenos Aires, Argentina
| | - Eugenio Picano
- Biomedicine Department, Institute of Clinical Physiology, CNR, Pisa, Italy.
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Koilpillai P, Aggarwal NR, Mulvagh SL. State of the Art in Noninvasive Imaging of Ischemic Heart Disease and Coronary Microvascular Dysfunction in Women: Indications, Performance, and Limitations. Curr Atheroscler Rep 2020; 22:73. [PMID: 33009953 DOI: 10.1007/s11883-020-00894-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Establishing a diagnosis of ischemic heart disease (IHD) in women, including assessment for coronary microvascular dysfunction (CMD) when indicated, can be challenging. Access to performance of invasive testing when appropriate may be limited, and noninvasive imaging assessments have evolved. This review will summarize the various noninvasive imaging modalities available for the diagnosis of IHD and CMD in women, outlining indications, performance modalities, advantages, and limitations. RECENT FINDINGS While stress echocardiography and single photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI) are widely available and can detect IHD in women, their ability to specifically identify CMD is limited. Novel developments in cardiac magnetic resonance (CMR) imaging, including spectroscopy, and positron emission tomography (PET) have changed the diagnostic landscape. Coronary computed tomographic angiography (CCTA), while unable to diagnose CMD, is developing an emerging role in the risk stratification of ischemic syndromes. Despite the discovery of increased CMD prevalence in symptomatic women and technological advances in diagnostic imaging, practitioners are limited by user expertise and center availability when choosing a diagnostic imaging modality. Knowledge of this evolving field is imperative as it highlights the need for sex-specific assessment of cardiovascular syndromes.
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Affiliation(s)
- Priya Koilpillai
- Department of Internal Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Niti R Aggarwal
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sharon L Mulvagh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA. .,Division of Cardiology, Department of Medicine, Queen Elizabeth II Health Sciences Center, Halifax Infirmary Site, Dalhousie University, 1796 Summer Street, Suite 2148.5, Halifax, NS, B3H 3A7, Canada.
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Sustainability and Versatility of the ABCDE Protocol for Stress Echocardiography. J Clin Med 2020; 9:jcm9103184. [PMID: 33008112 PMCID: PMC7601661 DOI: 10.3390/jcm9103184] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 09/23/2020] [Accepted: 09/28/2020] [Indexed: 12/19/2022] Open
Abstract
For the past 40 years, the methodology for stress echocardiography (SE) has remained basically unchanged. It is based on two-dimensional, black and white imaging, and is used to detect regional wall motion abnormalities (RWMA) in patients with known or suspected coronary artery disease (CAD). In the last five years much has changed and RWMA is not enough on its own to stratify patient risk and dictate therapy. Patients arriving at SE labs often have comorbidities and are undergoing full anti-ischemic therapy. The SE positivity rate based on RWMA fell from 70% in the eighties to 10% in the last decade. The understanding of CAD pathophysiology has shifted from a regional hydraulic disease to a systemic biologic disease. The conventional view of CAD encouraged the use of coronary anatomic imaging for diagnosis and the oculo-stenotic reflex for the deployment of therapy. This has led to a clinical oversimplification that ignores the lessons of pathophysiology and epidemiology, and in fact, CAD is not synonymous with ischemic heart disease. Patients with CAD may also have other vulnerabilities such as coronary plaque (step A of ABCDE-SE), alveolar-capillary membrane and pulmonary congestion (step B), preload and contractile reserve (step C), coronary microcirculation (step D) and cardiac autonomic balance (step E). The SE methodology based on two-dimensional echocardiography is now integrated with lung ultrasound (step B for B-lines), volumetric echocardiography (step C), color- and pulsed-wave Doppler (step D) and non-imaging electrocardiogram-based heart rate assessment (step E). In addition, qualitative assessment based on the naked eye has now become more quantitative, has been improved by contrast and based on cardiac strain and artificial intelligence. ABCDE-SE is now ready for large scale multicenter testing in the SE2030 study.
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The obesity paradox in the stress echo lab: fat is better for hearts with ischemia or coronary microvascular dysfunction. Int J Obes (Lond) 2020; 45:308-315. [PMID: 32830196 DOI: 10.1038/s41366-020-00655-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 07/10/2020] [Accepted: 08/11/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Obesity is an independent risk factor for coronary artery disease (CAD), but once CAD has developed it has been associated with improved survival ("obesity paradox"). AIM To assess how obesity affects prognosis in patients with or without inducible ischemic regional wall motion abnormalities (RWMA) and/or abnormal coronary flow velocity reserve (CFVR) during stress echocardiography (SE). METHODS In an observational retrospective two- center study design, we analyzed 3249 consecutive patients (1907 men; age 66 ± 12 years; body mass index, BMI, 26.9 ± 4.1 kg/m2) with known (n = 1306) or suspected (n = 1943) CAD who underwent dipyridamole SE with simultaneous evaluation of RWMA and CFVR. All-cause death was the outcome end-point. RESULTS 1075 patients were lean (BMI 18.5-24.9 kg/m2), 1523 overweight (BMI 25.0-29.9 kg/m2), and 651 obese (≥30.0 kg/m2). Ischemic test result for RWMA occurred in 28 (3%) lean, 69 (4%) overweight, and 28 (4%) obese patients (p = 0.03). An abnormal CFVR (≤2.0) was found in 281 (26%) lean, 402 (26%) overweight and 170 (26%) obese patients (p = 0.99). During 68 ± 44 months of follow-up, 496 (15%) patients died. At multivariable Cox analysis, BMI ≥ 30 was an independent predictor of reduced mortality in the 878 patients with stress-induced (≥2 segments) RWMA and/or CFVR abnormality (HR 0.58, 95% CI 0.40-0.84; p = 0.003), while showed no effect at univariate analysis in the 2371 patients with no RWMA and normal CFVR (HR 1.04, 95% CI 0.74-1.46; p = 0.84). CONCLUSIONS Obesity exerts a "paradoxical" protective effect in patients with stress-induced ischemia and/ or coronary microvascular dysfunction, and shows a neutral effect in patients with normal CFVR and no stress-induced RWMA.
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Dobric M, Beleslin B, Tesic M, Djordjevic Dikic A, Stojkovic S, Giga V, Tomasevic M, Jovanovic I, Petrovic O, Rakocevic J, Boskovic N, Sobic Saranovic D, Stankovic G, Vukcevic V, Orlic D, Simic D, Nedeljkovic MA, Aleksandric S, Juricic S, Ostojic M. Prompt and consistent improvement of coronary flow velocity reserve following successful recanalization of the coronary chronic total occlusion in patients with viable myocardium. Cardiovasc Ultrasound 2020; 18:29. [PMID: 32693812 PMCID: PMC7374915 DOI: 10.1186/s12947-020-00211-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 07/16/2020] [Indexed: 11/20/2022] Open
Abstract
Background Coronary chronic total occlusion (CTO) is characterized by the presence of collateral blood vessels which can provide additional blood supply to CTO-artery dependent myocardium. Successful CTO recanalization is followed by significant decrease in collateral donor artery blood flow and collateral derecruitment, but data on coronary hemodynamic changes in relation to myocardial function are limited. We assessed changes in coronary flow velocity reserve (CFVR) by echocardiography in collateral donor and recanalized artery following successful opening of coronary CTO. Methods Our study enrolled 31 patients (60 ± 9 years; 22 male) with CTO and viable myocardium by SPECT scheduled for percutaneous coronary intervention (PCI). Non-invasive CFVR was measured in collateral donor artery before PCI, 24 h and 6 months post-PCI, and 24 h and 6 months in recanalized artery following successful PCI of CTO. Results Collateral donor artery showed significant increase in CFVR 24 h after CTO recanalization compared to pre-PCI values (2.30 ± 0.49 vs. 2.71 ± 0.45, p = 0.005), which remained unchanged after 6-months (2.68 ± 0.24). Baseline blood flow velocity of the collateral donor artery significantly decreased 24 h post-PCI compared to pre-PCI (0.28 ± 0.06 vs. 0.24 ± 0.04 m/s), and remained similar after 6 months, with no significant difference in maximum hyperemic blood flow velocity pre-PCI, 24 h and 6 months post-PCI. CFVR of the recanalized coronary artery 24 h post-PCI was 2.55 ± 0.35, and remained similar 6 months later (2.62 ± 0.26, p = NS). Conclusions In patients with viable myocardium, prompt and significant CFVR increase in both recanalized and collateral donor artery, was observed within 24 h after successful recanalization of CTO artery, which maintained constant during the 6 months. Trial registration ClinicalTrials.gov (Number NCT04060615).
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Affiliation(s)
- Milan Dobric
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia. .,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia.
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Milorad Tesic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Ana Djordjevic Dikic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Sinisa Stojkovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Vojislav Giga
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Miloje Tomasevic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Department of Internal Medicine, Faculty of Medical Sciences, University of Kragujevac, 69 Svetozara Markovica Street, Kragujevac, 34000, Serbia
| | - Ivana Jovanovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Olga Petrovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia
| | - Jelena Rakocevic
- Institute of Histology and Embryology, Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Nikola Boskovic
- Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Dragana Sobic Saranovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Goran Stankovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Vladan Vukcevic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Dejan Orlic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Dragan Simic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Milan A Nedeljkovic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Srdjan Aleksandric
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia.,Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
| | - Stefan Juricic
- Cardiology Clinic, Clinical Center of Serbia, 26 Visegradska Street, Belgrade, 11000, Serbia
| | - Miodrag Ostojic
- Faculty of Medicine, University of Belgrade, 6 Dr Subotica Street, Belgrade, 11000, Serbia
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50
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Scali MC, Zagatina A, Ciampi Q, Cortigiani L, D'Andrea A, Daros CB, Zhuravskaya N, Kasprzak JD, Wierzbowska-Drabik K, Luis de Castro E Silva Pretto J, Djordjevic-Dikic A, Beleslin B, Petrovic M, Boskovic N, Tesic M, Monte I, Simova I, Vladova M, Boshchenko A, Vrublevsky A, Citro R, Amor M, Vargas Mieles PE, Arbucci R, Merlo PM, Lowenstein Haber DM, Dodi C, Rigo F, Gligorova S, Dekleva M, Severino S, Lattanzi F, Morrone D, Galderisi M, Torres MAR, Salustri A, Rodrìguez-Zanella H, Costantino FM, Varga A, Agoston G, Bossone E, Ferrara F, Gaibazzi N, Celutkiene J, Haberka M, Mori F, D'Alfonso MG, Reisenhofer B, Camarozano AC, Miglioranza MH, Szymczyk E, Wejner-Mik P, Wdowiak-Okrojek K, Preradovic-Kovacevic T, Bombardini T, Ostojic M, Nikolic A, Re F, Barbieri A, Di Salvo G, Merli E, Colonna P, Lorenzoni V, De Nes M, Paterni M, Carpeggiani C, Lowenstein J, Picano E. Lung Ultrasound and Pulmonary Congestion During Stress Echocardiography. JACC Cardiovasc Imaging 2020; 13:2085-2095. [PMID: 32682714 DOI: 10.1016/j.jcmg.2020.04.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/22/2020] [Accepted: 04/30/2020] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The purpose of this study was to assess the functional and prognostic correlates of B-lines during stress echocardiography (SE). BACKGROUND B-profile detected by lung ultrasound (LUS) is a sign of pulmonary congestion during SE. METHODS The authors prospectively performed transthoracic echocardiography (TTE) and LUS in 2,145 patients referred for exercise (n = 1,012), vasodilator (n = 1,054), or dobutamine (n = 79) SE in 11 certified centers. B-lines were evaluated in a 4-site simplified scan (each site scored from 0: A-lines to 10: white lung for coalescing B-lines). During stress the following were also analyzed: stress-induced new regional wall motion abnormalities in 2 contiguous segments; reduced left ventricular contractile reserve (peak/rest based on force, ≤2.0 for exercise and dobutamine, ≤1.1 for vasodilators); and abnormal coronary flow velocity reserve ≤2.0, assessed by pulsed-wave Doppler sampling in left anterior descending coronary artery and abnormal heart rate reserve (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators). All patients completed follow-up. RESULTS According to B-lines at peak stress patients were divided into 4 different groups: group I, absence of stress B-lines (score: 0 to 1; n = 1,389; 64.7%); group II, mild B-lines (score: 2 to 4; n = 428; 20%); group III, moderate B-lines (score: 5 to 9; n = 209; 9.7%) and group IV, severe B-lines (score: ≥10; n = 119; 5.4%). During median follow-up of 15.2 months (interquartile range: 12 to 20 months) there were 38 deaths and 28 nonfatal myocardial infarctions in 64 patients. At multivariable analysis, severe stress B-lines (hazard ratio [HR]: 3.544; 95% confidence interval [CI]: 1.466 to 8.687; p = 0.006), abnormal heart rate reserve (HR: 2.276; 95% CI: 1.215 to 4.262; p = 0.010), abnormal coronary flow velocity reserve (HR: 2.178; 95% CI: 1.059 to 4.479; p = 0.034), and age (HR: 1.031; 95% CI: 1.002 to 1.062; p = 0.037) were independent predictors of death and nonfatal myocardial infarction. CONCLUSIONS Severe stress B-lines predict death and nonfatal myocardial infarction. (Stress Echo 2020-The International Stress Echo Study [SE2020]; NCT03049995).
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Affiliation(s)
- Maria Chiara Scali
- Cardiothoracic Department, University of Pisa, and Nottola Cardiology Division, Montepulciano, Siena, Italy
| | - Angela Zagatina
- Cardiology Department, Saint Petersburg University Clinic, Saint Petersburg, Russian Federation
| | - Quirino Ciampi
- Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy
| | | | - Antonello D'Andrea
- Cardiology Department, Echocardiography Lab and Rehabilitation Unit, Monaldi Hospital, Second University of Naples, Naples, Italy
| | | | - Nadezhda Zhuravskaya
- Cardiology Department, Saint Petersburg University Clinic, Saint Petersburg, Russian Federation
| | | | | | | | - Ana Djordjevic-Dikic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Branko Beleslin
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Marija Petrovic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Nikola Boskovic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Milorad Tesic
- Cardiology Clinic, Clinical Center of Serbia, Medical School, University of Belgrade, Belgrade, Serbia
| | - Ines Monte
- Cardio-Thorax-Vascular Department, Echocardiography lab, "Policlinico Vittorio Emanuele", Catania University, Catania, Italy
| | - Iana Simova
- Head of Cardiology Department, Acibadem City Clinic Cardiovascular Center, University Hospital, Sofia, Bulgaria
| | - Martina Vladova
- Head of Cardiology Department, Acibadem City Clinic Cardiovascular Center, University Hospital, Sofia, Bulgaria
| | - Alla Boshchenko
- Cardiology Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Alexander Vrublevsky
- Cardiology Research Institute, Tomsk National Research Medical Centre of the Russian Academy of Sciences, Tomsk, Russian Federation
| | - Rodolfo Citro
- Cardiology Department and Echocardiography Lab, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Miguel Amor
- Cardiology Department, Ramos Mejia Hospital, Buenos Aires, Argentina
| | | | - Rosina Arbucci
- Cardiodiagnosticos, Investigaciones Medicas, Buenos Aires, Argentina
| | | | | | - Claudio Dodi
- Casa di Cura Figlie di San Camillo, Cremona, Italy
| | - Fausto Rigo
- Cardiology Department, Ospedale dell'Angelo Mestre-Venice, Venice, Italy
| | | | - Milica Dekleva
- Clinical Cardiology Department, Clinical Hospital Zvezdara, Medical School, University of Belgrade, Belgrade, Serbia
| | - Sergio Severino
- Cardiology Department, Coronary Care Unit, Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Fabio Lattanzi
- Cardiothoracic Department, University of Pisa, and Nottola Cardiology Division, Montepulciano, Siena, Italy
| | - Doralisa Morrone
- Cardiothoracic Department, University of Pisa, and Nottola Cardiology Division, Montepulciano, Siena, Italy
| | - Maurizio Galderisi
- Department of Advanced Biomedical Sciences, Federico II University Hospital, Naples, Italy
| | - Marco A R Torres
- Hospital de Clinicas de Porto Alegre - Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Alessandro Salustri
- Non-invasive Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | | | | | - Albert Varga
- Institute of Family Medicine, University of Szeged, Szeged, Hungary
| | - Gergely Agoston
- Institute of Family Medicine, University of Szeged, Szeged, Hungary
| | - Eduardo Bossone
- Azienda Ospedaliera Rilevanza Nazionale A. Cardarelli Hospital, Naples, Italy
| | - Francesco Ferrara
- Azienda Ospedaliera Rilevanza Nazionale A. Cardarelli Hospital, Naples, Italy
| | - Nicola Gaibazzi
- Cardiology Department, Parma University Hospital, Parma, Italy
| | - Jelena Celutkiene
- Centre of Cardiology and Angiology, Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Maciej Haberka
- Department of Cardiology, SHS, Medical University of Silesia, Katowice, Poland
| | - Fabio Mori
- SOD Diagnostica Cardiovascolare, DAI Cardio-Toraco-Vascolare, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
| | - Maria Grazia D'Alfonso
- SOD Diagnostica Cardiovascolare, DAI Cardio-Toraco-Vascolare, Azienda Ospedaliera-Universitaria Careggi, Florence, Italy
| | - Barbara Reisenhofer
- Cardiology Division, Pontedera-Volterra Hospital, ASL Toscana Nord-Ovest, Italy
| | - Ana Cristina Camarozano
- Hospital de Clinicas UFPR, Medicine Department, Federal University of Paranà, Curitiba, Brazil
| | | | - Ewa Szymczyk
- Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland
| | - Paulina Wejner-Mik
- Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland
| | | | | | - Tonino Bombardini
- School of Medicine, University Clinical Center of The Republic of Srpska, Banja-Luka, Bosnia-Herzegovina
| | - Miodrag Ostojic
- School of Medicine, Institute for Cardiovascular Disease Dedinje, Belgrade, Serbia
| | - Aleksandra Nikolic
- School of Medicine, Institute for Cardiovascular Disease Dedinje, Belgrade, Serbia
| | - Federica Re
- Ospedale San Camillo, Cardiology Division, Rome, Italy
| | - Andrea Barbieri
- Cardiology Division, Policlinico University Hospital of Modena, Modena, Italy
| | - Giovanni Di Salvo
- Pediatric Cardiology Department, Cardiology Division, Brompton Hospital, Imperial College of London, London, United Kingdom
| | - Elisa Merli
- Department of Cardiology, Ospedale per gli Infermi, Faenza, Ravenna, Italy
| | - Paolo Colonna
- Cardiology Hospital, Policlinico University Hospital of Bari, Bari, Italy
| | | | - Michele De Nes
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
| | - Marco Paterni
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
| | - Clara Carpeggiani
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy
| | - Jorge Lowenstein
- Cardiodiagnosticos, Investigaciones Medicas, Buenos Aires, Argentina
| | - Eugenio Picano
- CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy.
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