Imaging-Guided Cardioprotective Treatment in a Community Elderly Population of Stage B Heart Failure

Incident HFpEF and time-dependent changes in markers of LVDD severity in women and men with preclinical LVDD

BACKGROUND

The progression of left ventricular diastolic dysfunction (LVDD) over time may lead to the development of heart failure with preserved ejection fraction (HFpEF). HFpEF is twice as common in women compared with men; however, the sex-specific progression from LVDD towards HFpEF is poorly described. Therefore, we aim to evaluate changes over time in markers of LVDD severity and HFpEF in women and men with preclinical LVDD.

METHODS AND RESULTS

We reassessed 146 participants from the HELPFul study (58% women and 42% men) with preclinical LVDD after a median follow-up of 4.3 (IQR: 3.9-4.7) years. The follow-up measurements mirrored baseline measurements, encompassing clinical examination, blood draw for biomarkers and echocardiography. We determined HFpEF incidence and report changes over time in echocardiography. Additionally, we studied how blood pressure and kidney function affected LVDD progression, including plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, using generalised mixed models. All analyses were performed for women and men combined, and sex stratified. Out of 146 participants, 15 (10%) developed HF of whom 13 had HFpEF (9 women and 4 men). Over time, mean kidney function (estimated glomerular filtration rate, eGFR) declined from 89±14.4 to 81±16.9 mL/min/1.73 m2 and median NT-proBNP plasma levels increased from 71 (IQR: 44-120) to 100 (IQR: 51-157) pg/mL. In women, a higher systolic and in men a higher diastolic blood pressure were associated with an increase in NT-proBNP plasma levels over time. Lower eGFR levels were related to increased NT-proBNP plasma levels over time in both men and women.

CONCLUSIONS

Our study demonstrates that only a small proportion of women and men with preclinical LVDD develop incident HF over a roughly 5-year follow-up period. High blood pressure and decreased kidney function were associated with higher levels of NT-proBNP. This highlights the need to further explore cardiorenal protection as a method to prevent HFpEF.

Cardiac Function and Functional Capacity in Patients With Long COVID: A Comparison to Propensity-Matched Community Controls

BACKGROUND

Cardiac impairment has been associated with acute COVID-19 since the earliest reports of the pandemic. However, its role in postacute sequelae of COVID-19 ("long COVID") is undefined, and many existing observations about cardiovascular involvement in postacute sequelae of COVID-19 are uncontrolled.

OBJECTIVE

To compare the prevalence of cardiac dysfunction in patients with long COVID and noninfected controls from the same community and explore their association with functional capacity.

METHODS

Echocardiography was used to assess cardiac structure and function, including the measurement of global longitudinal strain (GLS), in 190 participants with long COVID. All underwent assessment of functional impairment by subjective (Duke Activity Status Index) and objective tests (6-minute walk test). The 190 participants from the long COVID group were matched with those from 979 patients who underwent the same tests in the pre-COVID-19 era, using a propensity score.

RESULTS

The 190 patients with long COVID had similar age and risk factor profiles to those of their matched controls. Left ventricular dimensions and geometry, but not diastolic parameters, were significantly altered in the long COVID group. The long COVID group had subclinical systolic dysfunction (GLS 18.5% ± 2.6% vs 19.3% ± 2.7%, P = .005), and more long COVID patients had abnormal (<16%) GLS (13% vs 8%, P = .035). The association of long COVID with abnormal GLS (odds ratio, 1.49 [1.04, 2.45]) was independent of-and had a similar or greater effect size than-age and risk factors. There was no interaction of long COVID with the association of risk factors with GLS. As expected, the long COVID group had significant subjective (<85% predicted METS; 72% vs 5%, P < .001) and objective functional impairment (29% vs 24%, P = .026), but GLS was only weakly associated with both subjective (r = 0.30, P = .005) and objective (r = 0.21, P = .05) functional impairment. The presence of long COVID was independently associated with subjective (odds ratio = 159.7 [95% CI, 61.6-414.2]) and objective functional impairment (odds ratio = 2.8 [95% CI, 1.5-5.2]).

CONCLUSIONS

Impaired GLS and left ventricular dimensions are the echocardiographic features that are overrepresented in long COVID, and this association is similar to and independent of other risk factors. Impaired GLS is weakly associated with functional impairment.

Use of Clinical and Echocardiographic Evaluation to Assess the Risk of Heart Failure

BACKGROUND

Clinical and echocardiographic features predict incident heart failure (HF), but the optimal strategy for combining them is unclear.

OBJECTIVES

This study sought to define an effective means of using echocardiography in HF risk evaluation.

METHODS

The same clinical and echocardiographic evaluation was obtained in 2 groups with HF risk factors: a training group (n = 926, followed to 7 years) and a validation group (n = 355, followed to 10 years). Clinical risk was categorized as low, intermediate, and high using 4-year ARIC (Atherosclerosis Risk In Communities) HF risk score cutpoints of 9% and 33%. A risk stratification algorithm based on clinical risk and echocardiographic markers of stage B HF (SBHF) (abnormal global longitudinal strain [GLS], diastolic dysfunction, or left ventricular hypertrophy) was developed using a classification and regression tree analysis and was validated.

RESULTS

HF developed in 12% of the training group, including 9%, 18%, and 73% of low-, intermediate-, and high-risk patients. HF occurred in 8.6% of stage A HF and 19.4% of SBHF (P < 0.001), but stage A HF with clinical risk of ≥9% had similar outcome to SBHF. Abnormal GLS (HR: 2.92 [95% CI: 1.95-4.37]; P < 0.001) was the strongest independent predictor of HF. Normal GLS and diastolic function reclassified 61% of the intermediate-risk group into the low-risk group (HF incidence: 12%). In the validation group, 11% developed HF over 4.5 years; 4%, 17%, and 39% of low-, intermediate-, and high-risk groups. Similar results were obtained after exclusion of patients with known coronary artery disease. The echocardiographic parameters also provided significant incremental value to the ARIC score in predicting new HF admission (C-statistic: 0.78 [95% CI: 0.71-0.84] vs 0.83 [95% CI: 0.77-0.88]; P = 0.027).

CONCLUSIONS

Clinical risk assessment is adequate to classify low and high HF risk. Echocardiographic evaluation reclassifies 61% of intermediate-risk patients.

Associations between symptoms and functional capacity in patients after COVID-19 infection and community controls

BACKGROUND

Post-acute sequelae of COVID-19 (PASC or 'long COVID') reflect ongoing symptoms, but these are non-specific and common in the wider community. Few reports of PASC have been compared with a control group.

AIMS

To compare symptoms and objective impairment of functional capacity in patients with previous COVID-19 infection with uninfected community controls.

METHODS

In this community-based, cross-sectional study of functional capacity, 562 patients from Western Melbourne who had recovered from COVID-19 infections in 2021 and 2022 were compared with controls from the same community and tested for functional capacity pre-COVID-19. Functional impairment (<85% of the predicted response) was assessed using the Duke Activity Status Index (DASI) and 6-min walk distance (6MWD) test. A subgroup underwent cardiopulmonary exercise testing before and after exercise training.

RESULTS

Of 562 respondents (age 54 ± 12 years, 69% women), 389 were symptomatic. Functional impairment (<85% predicted metabolic equivalent of tasks) was documented by DASI in 149 participants (27%), and abnormal 6MWD (<85% predicted) was observed in 14% of the symptomatic participants. Despite fewer risk factors and younger age, patients with COVID-19 had lower functional capacity by 6MWD (P < 0.001) and more depression (P < 0.001) than controls. In a pilot group of seven participants (age 58 ± 12 years, two women, VO2 18.9 ± 5.7 mL/kg/min), repeat testing after exercise training showed a 20% increase in peak workload.

CONCLUSIONS

Although most participants (69%) had symptoms consistent with long COVID, significant subjective functional impairment was documented in 27% and objective functional impairment in 14%. An exercise training programme might be beneficial for appropriately selected patients.

Echocardiographic detection of heart valve disease in a community cohort of asymptomatic Australians > 65 years with cardiovascular risk factors

BACKGROUND

Valvular heart disease is becoming an increasingly prevalent with population ageing. We sought to define the current prevalence of valvular heart disease in Australia.

METHODS

The TasELF and VicELF studies prospectively recruited 962 asymptomatic participants ≥65 years, with at least one cardiovascular risk factor, from the Tasmanian and Victorian communities. People were excluded if they had a previous diagnosis of heart failure, or a life expectancy <1 year. All underwent baseline echocardiography. Those with moderate or severe valvular disease were identified. The current prevalence of clinically significant valve disease was applied to the Australian Bureau of Statistics population projections.

RESULTS

Echocardiograms were interpretable in 943 participants (98%). Clinically significant valve disease was present in 5% of the population, and mitral regurgitation was the most common overall valvular lesion, present in 36% of the population. The projected numbers of people with clinically significant valvular disease is expected to increase significantly across all age groups by the year 2060.

CONCLUSIONS

Clinically significant yet asymptomatic valvular disease was prevalent in a large community cohort of participants with at least one risk factor. The total burden of valvular heart disease is expected to increase dramatically over the coming decades.

Incidence of Preclinical Heart Failure in a Community Population

Background

A high prevalence of preclinical heart failure (HF) (Stages A and B) has previously been shown. The aim of this study was to explore factors associated with the incidence of preclinical HF in a community population.

Methods and Results

Retrospective review of 393 healthy community individuals aged ≥45 years from the Olmsted County Heart Function Study that returned for 2 visits, 4 years apart. At visit 2, individuals that remained normal were compared with those that developed preclinical HF. By the second visit, 191 (49%) developed preclinical HF (12.1 cases per 100 person‐years of follow‐up); 65 (34%) Stage A and 126 (66%) Stage B. Those that developed preclinical HF (n=191) were older (P=0.004), had a higher body mass index (P<0.001), and increased left ventricular mass index (P=0.006). When evaluated separately, increased body mass index was seen with development of Stage A (P<0.001) or Stage B (P=0.009). Echocardiographic markers of diastolic function were statistically different in those that developed Stage A [higher E/e’ (P<0.001), lower e’ (P<0.001)] and Stage B [higher left atrial volume index (P<0.001), higher E/e’ (P<0.001), lower e’ (P<0.001)]. NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) was higher at visit 2 in those that developed Stage A or B (P<0.001 for both). Hypertension (57%), obesity (34%), and hyperlipidemia (25%) were common in the development of Stage A. Of patients who developed Stage B, 71% (n=84) had moderate or severe diastolic dysfunction.

Conclusions

There is a high incidence of preclinical HF in a community population. Development of Stage A was driven by hypertension and obesity, while preclinical diastolic dysfunction was seen commonly in those that developed Stage B.

Cardiac Damage Staging Classification in Asymptomatic Moderate or Severe Primary Mitral Regurgitation

Background

Optimal timing for intervention remains uncertain in asymptomatic patients with primary mitral regurgitation (MR). We aimed to assess the prognostic value of a new cardiac damage staging classification in patients with asymptomatic moderate or severe primary MR.

Methods

Clinical, Doppler-echocardiographic, and outcome data prospectively collected in 338 asymptomatic patients (64 ± 15 years, 68% men) with at least moderate primary MR were retrospectively analyzed. Patients were hierarchically classified as per the following staging classification: no cardiac damage (stage 0), mild left ventricular or left atrial damage (stage 1), moderate or severe left ventricular or left atrial damage (stage 2), pulmonary vasculature or tricuspid valve damage (stage 3), or right ventricular damage (stage 4).

Results

There was a stepwise increase in 10-year mortality rates as per cardiac damage stage: 20.0% in stage 0, 25.6% in stage 1, 31.5% in stage 2, and 61.3% in stage 3-4 (p < 0.001). The staging classification was significantly associated with increased risk of mortality (hazard ratio = 1.41 per one-stage increase, 95% confidence interval: 1.07-1.85, p = 0.015) and the composite of cardiovascular mortality or hospitalization (hazard ratio = 1.51 per one-stage increase, 95% confidence interval: 1.07-2.15, p = 0.020) in multivariable analysis adjusted for EuroSCORE II, mitral valve intervention as a time-dependent variable, and other risk factors. The proposed scheme showed incremental value over several clinical variables (net reclassification index = 0.40, p = 0.03).

Conclusions

The new staging classification provides independent and incremental prognostic value in patients with asymptomatic moderate or severe MR.

Screening-Guided Spironolactone Treatment of Subclinical Left Ventricular Dysfunction for Heart Failure Prevention in At-risk Patients

BACKGROUND

Subclinical left ventricular dysfunction (LVD) is a prelude to symptomatic heart failure (HF). We hypothesised that screening-guided treatment with spironolactone would prevent incident HF in at-risk patients.

METHODS

We randomised asymptomatic, community-dwelling subjects aged ≥65 years old, with at least one non-ischaemic HF risk factor (hypertension, type 2 diabetes mellitus or obesity) to echocardiography-guided therapy or usual care. Spironolactone therapy was triggered by the detection of subclinical LVD (GLS ≤16% or diastolic abnormalities (at least one of E/e'>15, E/e' >10 with left atrial enlargement [LAE] or impaired relaxation [E/A <0.8, IR], LAE with IR), or borderline GLS (17%) with IR or borderline GLS with LAE. The primary outcome was incident HF at 24 months. Secondary outcomes were change in 6-minute walk test (6MWT) and change in LV function.

RESULTS

LVD was identified in 161 (46%) of 349 participants (age 70 years [68-73], 201 (58%) women). The trial was stopped because of a 55% rate of spironolactone discontinuation, due primarily to decline in renal function. Incident HF developed in 11 (3.5%) of 310 participants completing follow-up, with no difference between usual care and intervention (4 [2.5%] vs. 7 [4.7%], p=0.29), decline in 6MWT distance (p=0.28), persistent or new LVD (p=0.58), nor change in GLS with intervention (p=0.15). A per-protocol analysis of 131 patients with baseline LVD and a follow-up echocardiogram, showed resolution of LVD with spironolactone therapy (61% vs 33%, p=0.01).

CONCLUSION

The study was underpowered to determine whether screening-guided spironolactone therapy reduced incident HF because spironolactone was frequently discontinued due to renal function criteria. However, LVD resolved in more patients treated with spironolactone than in untreated patients. Future trials should use less conservative renal criteria for spironolactone discontinuation.

Incremental Value of Global Longitudinal Strain in the Long-Term Prediction of Heart Failure among Patients with Coronary Artery Disease

BACKGROUND

Heart failure (HF) remains a common complication for patients with coronary artery disease (CAD), especially after acute myocardial infarction. Although left ventricular ejection fraction (LVEF) is conventionally used to assess cardiac function for risk stratification, it has been shown in other settings to underestimate the risk of HF compared with global longitudinal strain (GLS). Moreover, most evidence pertains to early-onset HF. We sought the clinical and myocardial predictors for late-onset HF in patients with CAD.

METHODS

We analyzed echocardiograms (including GLS) in 334 patients with CAD (ages 65 ± 11 years, 77% male) who were enrolled in the Nurse-Led Intervention for Less Chronic Heart Failure trial, a prospective, randomized controlled trial that compared standard care with nurse-led intervention to prevent HF in individuals at risk of incident HF. Long-term (9 years) follow-up was obtained via data linkage. Analysis was performed using a competing-risk model.

RESULTS

Baseline LVEF values were normal or mildly impaired (LVEF ≥ 40%) in all subjects. After a median of 9 years of follow-up, 50 (15%) of the 334 patients had new HF admissions, and 68 (20%) died. In a competing-risk model, HF was associated with GLS (hazard ratio = 1.15 [1.05-1.25], P = .001), independent of estimated glomerular filtration rate (hazard ratio = 0.98 [0.97-0.99], P = .045), Charlson comorbidity score (hazard ratio = 1.64 [1.25-2.15], P < .001), or E/e' (hazard ratio = 1.08 [1.02-1.14], P = .01). Global longitudinal strain-but not conventional echocardiographic measures-added incremental value to a clinical model based on age, gender, and Charlson score (area under the curve, 0.78-0.83, P = .01). Global longitudinal strain was still associated with HF development in patients taking baseline angiotensin convertase enzyme inhibitors (hazard ratio = 1.21 [1.11-1.31], P < .01) and baseline beta-blockers (1.17 [1.09, 1.26]; P < .01). Mortality was associated with older men, risk factors (hypertension or diabetes), and comorbidities (AF and chronic kidney disease).

CONCLUSIONS

Global longitudinal strain is independently associated with risk of incident HF in patients admitted with CAD and provides incremental prognostic value to standard markers. Identifying an at-risk subgroup using GLS may be the focus of future randomized controlled trails to enable targeted therapeutic intervention.

Machine Learning of ECG Waveforms to Improve Selection for Testing for Asymptomatic Left Ventricular Dysfunction Prompt

OBJECTIVES

To identify whether machine learning from processing of continuous wave transforms (CWTs) to provide an "energy waveform" electrocardiogram (ewECG) could be integrated with echocardiographic assessment of subclinical systolic and diastolic left ventricular dysfunction (LVD).

BACKGROUND

Asymptomatic LVD has management implications, but routine echocardiography is not undertaken in subjects at risk of heart failure. Signal processing of the surface ECG with the use of CWT can identify abnormal myocardial relaxation.

METHODS

EwECG and echocardiography were undertaken in 398 participants at risk of heart failure (HF). Reduced global longitudinal strain (GLS ≤16%)), diastolic abnormalities (E/e' >15, left atrial enlargement with E/e' >10 or impaired relaxation) or LV hypertrophy defined LVD. EwECG feature selection and supervised machine-learning by random forest (RF) classifier was undertaken with 643 CWT-derived features and the Atherosclerosis Risk in Communities (ARIC) heart failure risk score.

RESULTS

The ARIC score and 18 CWT features were selected to build a RF predictive model for LVD in a training dataset (n = 287; 60% female, median age 71 [interquartile range: 68 to 74] years). Model performance was tested in an independent group (n = 111; 49% female, median age 61 years [59 to 66 years]), demonstrating 85% sensitivity and 72% specificity (area under the receiver-operating characteristic curve [AUC]: 0.83; 95% confidence interval [CI]: 0.74 to 0.92). With ARIC score removed, sensitivity was 88% and specificity, 70% (AUC: 0.78; 95% CI: 0.70 to 0.86). RF models for reduced GLS and diastolic abnormalities including similar features had sensitivities that were unsuitable for screening. Conventional candidates for LVD screening (ARIC score, N-terminal pro-B-type natriuretic peptide, and standard automated ECG analysis) had inferior discriminative ability. Integration of ewECG in screening of people at risk of HF would reduce need for echocardiography by 45% while missing 12% of LVD cases.

CONCLUSIONS

Machine learning applied to ewECG is a sensitive screening test for LVD, and its integration into screening of patients at risk for HF would reduce the number of echocardiograms by almost one-half.

Left ventricular global longitudinal strain predicts elevated cardiac pressures and poor clinical outcomes in patients with non-ischemic dilated cardiomyopathy

BACKGROUND

Risk stratification in patients with non-ischemic dilated cardiomyopathy (NI-DCM) is essential to treatment planning. Global longitudinal strain (GLS) predicts poor prognosis in various cardiac diseases, but it has not been evaluated in a cohort of exclusively NI-DCM. Although deformation parameters have been shown to reflect diastolic function, their association with other hemodynamic parameters needs further elucidation. We aimed to evaluate the association between GLS and E/GLS and invasive hemodynamic parameters and assess the prognostic value of GLS and E/GLS in a prospective well-defined pure NI-DCM cohort.

METHODS AND RESULTS

Forty-one patients with NI-DCM were enrolled in the study. They underwent a standard diagnostic workup, including transthoracic echocardiography and right heart catheterization. During a five-year follow-up, 20 (49%) patients reached the composite outcome measure: LV assist device implantation, heart transplantation, or cardiovascular death. Pulmonary capillary wedge pressure (PCWP), mean pulmonary artery pressure, pulmonary vascular resistance (PVR) correlated with GLS and E/GLS (p < 0.05). ROC analysis revealed that GLS and E/GLS could identify elevated PCWP (≥ 15 mmHg) and PVR (> 3 Wood units). Survival analysis showed GLS and E/GLS to be associated with short- and long-term adverse cardiac events (p < 0.05). GLS values above thresholds of -5.34% and -5.96% indicated 18- and 12-fold higher risk of poor clinical outcomes at one and five years, respectively. Multivariate Cox regression analysis revealed that GLS is an independent long-term outcome predictor.

CONCLUSION

GLS and E/GLS correlate with invasive hemodynamics parameters and identify patients with elevated PCWP and high PVR. GLS and E/GLS predict short- and long-term adverse cardiac events in patients with NI-DCM. Worsening GLS is associated with incremental risk of long-term adverse cardiac events and might be used to identify high-risk patients.

Progression of Preclinical Heart Failure: A Description of Stage A and B Heart Failure in a Community Population

BACKGROUND

The aims of this study are to evaluate the rate of progression of preclinical (Stage A and B) heart failure, identify associated characteristics, and evaluate long-term outcomes.

METHODS

Retrospective review of the Olmsted County Heart Function Study. Individuals categorized as Stage A or B heart failure at initial visit that returned for a second visit 4 years later were included. Logistic regression analyses evaluated group differences with adjustment for age and sex.

RESULTS

At visit 1, 413 (32%) individuals were classified as Stage A and 413 (32%) as Stage B. By visit 2, 146 (35%) individuals from Stage A progressed with the vast majority (n=142) progressing to Stage B. In comparison, a total of 23 (6%) individuals progressed from Stage B. A greater rate of progression was seen for Stage A compared with Stage B (8.7 per 100 person-years [95% CI, 7.4-10.2] versus 1.4 per 100 person-years [95% CI, 0.9-2.1]; P<0.001). NT-proBNP correlated with progression for Stage B (P=0.01), but not for Stage A (P=0.39). A multivariate model found female sex (odds ratio, 1.65 [95% CI, 1.05-2.58]; P=0.03), increased E/e' (odds ratio, 1.13 [95% CI, 1.02-1.26], P=0.02), and beta blocker use (odds ratio, 2.19 [95% CI, 1.25-3.82], P=0.006) were associated with progression for Stage A. There was a signal that cardiovascular mortality was higher in individuals who progressed, although not statistically significant (P=0.06 for Stage A and P=0.05 for Stage B).

CONCLUSIONS

There is significant progression of preclinical heart failure in a community population, with progression rates higher for Stage A. NT-proBNP correlated with progression for Stage B, but not for Stage A. No statistically significant differences in long-term outcomes were seen. Study results have clinical implications important to help guide future heart failure screening and prevention strategies.

Feasibility, Reproducibility, and Clinical Implications of the Novel Fully Automated Assessment for Global Longitudinal Strain

BACKGROUND

Despite evidence of its usefulness, measurement of global longitudinal strain (GLS) has not been widely accepted as a clinical routine, because it requires proficiency and is time consuming. Automated assessment of GLS may be the solution for this situation. The aim of this study was to investigate the feasibility, reproducibility, and predictive value of automated strain analysis compared with semiautomated and manual assessment of GLS.

METHODS

In this validation study, different methods for the assessment of GLS were applied to echocardiograms from 561 asymptomatic subjects (mean age, 71 ± 5 years) with heart failure risk factors, recruited from the community. All patients had both data on follow-up outcomes (new heart failure and cardiac death) and interpretable echocardiographic images for strain analysis. Measurement of GLS was repeated using the same apical images with three different measurement packages as follows: (1) fully automated GLS (AutoStrain), (2) semiautomated GLS (automated, corrected by a trained investigator), and (3) manual GLS (standard manual assessment by a trained investigator).

RESULTS

AutoStrain measurements were technically feasible in 99.5% of patients. Calculation times for automated (0.5 ± 0.1 min/patient) and semiautomated assessment (2.7 ± 0.6 min/patient) were significantly shorter than for manual assessment (4.5 ± 1.6 min/patient; P < .001 for both). Approximately 40% of patients were thought to need manual correction after automatic calculation of GLS. Therefore, there was considerable discordance between automated and semiautomated and manual GLS. Over a median of 12 months of follow-up, cardiovascular events (new heart failure and cardiac death) occurred in 66 patients (11.8%). Automated GLS showed the potential to correctly detect normal and abnormal systolic function and predict cardiac events; the predictive value was inferior to that of semiautomated GLS.

CONCLUSIONS

A novel fully automated assessment for GLS may provide a technically feasible, rapidly reproducible, and clinically applicable means of assessing left ventricular function, but a substantial number of automatic traces still need manual correction by experts. At the present stage, the semiautomated approach using this novel automated software seems to provide a better balance between feasibility and clinical relevance.

Investigation of early signs of systolic and diastolic dysfunction among persons with type 1 diabetes

Background

Persons with type 1 diabetes have a higher risk to develop heart failure than the general population, and the mechanism behind the increased risk is unclear. In epidemiological studies with hospitalisation for heart failure as endpoint HbA1c, body mass index and decreased kidney function are significant risk factors, but it is unclear how these risk factors influence the development of heart failure.

Methods

In this study, we investigated early signs of systolic and diastolic dysfunction with transthoracic echocardiography. Statistical analysis on correlation of risk factors and early signs of diastolic and systolic dysfunction was made.

Results

In this study population of 287 persons with type 1 diabetes, 160 were men and 127 were women with a mean age of 53.8 (SD 11.6) years and a mean diabetes duration of 36.2 (SD 13.5) years. There were 23 (8.2%) persons who fulfilled the definition of systolic dysfunction (ejection fraction <50% or regional wall motion abnormalities) and 24 persons (9%) the definition for diastolic dysfunction. When comparing the groups with either systolic or diastolic dysfunction to the rest of the population, the only significant risk factor was age in both groups and previous myocardial infarction in the systolic group.

Conclusion

In our study population with type 1 diabetes, we found signs of diastolic dysfunction in 9% and systolic dysfunction in 8.2%. Compared with published data from the general population, this rate is somewhat higher in a younger population. Only age was a significant risk factor in the study.

Global myocardial longitudinal strain in a general population-associations with blood pressure and subclinical heart failure: The Tromsø Study

The early detection of subclinical myocardial dysfunction can contribute to the treatment and prevention of heart failure (HF). The aim of the study was to (i) describe myocardial global longitudinal strain (GLS) patterns in a large general population sample from Norway and their relation to established cardiovascular disease (CVD) risk factors; (ii) to determine its normal thresholds in healthy individuals and (iii) ascertain the relation of myocardial GLS to stage A subclinical heart failure (SAHF). Participants (n = 1855) of the 7th survey of the population-based Tromsø Study of Norway (2015-2016) with GLS measurements were studied. Linear and logistic regression models were used for assessment of the associations between CVD risk factors and GLS. Mean GLS (SD) in healthy participants was - 15.9 (2.7) % in men and - 17.8 (3.1) % in women. Among healthy subjects, defined as those without known cardiovascular diseases and comorbidities, GLS declined with age. An increase of systolic blood pressure (SBP) of 10 mm Hg was associated with a 0.2% GLS reduction. Myocardial GLS in individuals with SAHF was 1.2% lower than in participants without SAHF (p < 0.001). Mean myocardial GLS declines with age in both sexes, both in a general population and in the healthy subsample. SBP increase associated with GLS decline in women. Our findings indicate high sensitivity of GLS for early subclinical stages of HF.

Prognostic implications of left ventricular strain by speckle-tracking echocardiography in the general population: a meta-analysis

PURPOSE

Left ventricular (LV) mechanics by speckle-tracking echocardiography (STE) is prognostic in patients with cardiovascular diseases, but evidence related to community-dwelling individuals is uncertain. We therefore performed a systematic review and meta-analysis of STE as a predictor of adverse outcomes in the general population.

METHODS

PRISMA guidelines were followed and MEDLINE and EMBASE were searched to identify eligible studies. Primary outcome was all-cause mortality and secondary outcomes were composite cardiac and cardiovascular end-point. Random effects meta-analysis was performed, and a modified Newcastle-Ottawa Assessment Scale was used for quality assessment.

RESULTS

Eight papers matched the predefined criteria (total number of individuals studied=11,744). All publications assessed global longitudinal strain (GLS) by two-dimensional speckle-tracking echocardiography (2D-STE), one assessed circumferential, radial and transverse strains, and one assessed GLS-derived post-systolic shortening. None assessed LV rotational measures in association with outcomes. Two studies reported associations between GLS and all-cause mortality and composite cardiovascular end-point. Six papers reported an association between GLS and composite cardiac end-point, three of which were from the same study. Four papers were suitable for meta-analysis. GLS predicted all-cause mortality (pooled minimally adjusted HR per unit strain (%)=1.07 [95% CI 1.03-1.11], p=0.001), and composite cardiovascular (pooled maximally adjusted HR=1.18 [1.09-1.28], p<0.0001) and cardiac (HR=1.08 [1.02-1.14], p=0.006) end-points. GLS also predicted coronary heart disease (HR=1.15 [1.03-1.29], p=0.017) and heart failure (HR=1.07 [1.02-1.13], p=0.012). The quality of all studies was good.

CONCLUSIONS

This study provides some evidence that STE may have utility as a measure of cardiac function and risk in the general population. 2D-STE-based GLS predicts total mortality, major adverse cardiac and cardiovascular end-points in community-dwelling individuals in a limited number of studies. Despite this, this systematic review also highlights important knowledge gaps in the current literature and further evidence is needed regarding the prognostic value of LV mechanics in unselected older populations.Registration number: CRD42018090302.

Asymptomatic Left Ventricular Diastolic Dysfunction: Predicting Progression to Symptomatic Heart Failure

Asymptomatic left ventricular diastolic dysfunction (ALVDD) (diastolic abnormalities and normal ejection fraction in the absence of symptoms) is associated with incident heart failure (HF) and decreased survival. Abnormalities of diastolic function might therefore be included in the definition of stage B HF, which denotes individuals at risk for the development of HF. Imaging techniques, especially echocardiography, are necessary for the recognition of preclinical left ventricular (LV) diastolic disturbances, as well as further tracking of pathological changes and responses to treatment. The transition of ALVDD to symptomatic HF is underlain by multiple factors, including both cardiovascular and noncardiovascular determinants. The initiation of management strategies targeting cardiovascular and systemic comorbidities in patients identified as having ALVDD may delay symptomatic progression and improve prognosis.

Noninvasive Cardiac Imaging and the Prediction of Heart Failure Progression in Preclinical Stage A/B Subjects

Heart failure (HF) continues to grow as a cause of morbidity and mortality in our community and presents a significant public health problem, predominantly in individuals ≥65 years of age. Early intervention in asymptomatic HF subjects (Stage A/B) at risk of progression to symptomatic HF (Stage C/D) may provide an opportunity to halt this epidemic. The ability of cardiac imaging to assess cardiac structure and function permits early identification of those at increased risk of developing symptomatic HF. Systolic, diastolic, and structural left ventricular parameters each predict symptomatic HF, but no single parameter has sufficient sensitivity for screening to identify individuals with Stage A/B HF who are at increased risk of disease progression. Transthoracic echocardiography (TTE) has the advantage over other imaging modalities in being able to measure systolic, diastolic, and structural left ventricular parameters, and it identified at least 1 abnormal parameter in >50% of individuals with Stage A/B HF ≥65 years of age. Moreover, identification of at least 1 abnormality according to TTE in individuals with Stage A/B HF ≥65 years of age had 72% to 82% sensitivity for detection of those who subsequently developed symptomatic HF. Therefore, a case can be made for cardiac imaging by using TTE for community-dwelling populations with Stage A/B HF ≥65 years of age to identify those with increased risk of symptomatic HF who can be offered preventative therapies. Further studies are required to determine the best strategy for identifying the risk of symptomatic HF in younger individuals.

Activin A and Late Postpartum Cardiac Dysfunction Among Women With Hypertensive Disorders of Pregnancy

Women with hypertensive disorders of pregnancy have an increased risk of subsequent heart failure and cardiovascular disease when compared with women with normotensive pregnancies. Although the mechanisms underlying these findings are unclear, elevated levels of the biomarker activin A are associated with myocardial dysfunction and may have predictive value. We hypothesized that elevated levels of antepartum activin A levels would correlate with postpartum cardiac dysfunction in women with hypertensive disorders of pregnancy. We prospectively studied 85 women to determine whether increased antepartum activin A levels were associated with cardiac dysfunction at 1 year postpartum as measured by global longitudinal strain. Thirty-two patients were diagnosed with preeclampsia, 28 were diagnosed with gestational or chronic hypertension, and the remainder were nonhypertensive controls. Activin A levels were measured with ELISA both in the third antepartum trimester and at 1 year postpartum. Comprehensive echocardiograms including measurement of global longitudinal strain were also performed at enrollment and at 1 year postpartum. Antepartum activin A levels correlated with worsening antepartum global longitudinal strain (r=0.70; P=0.0001). Across the entire cohort, elevated antepartum activin A levels were associated with the development of abnormal global longitudinal strain at 1 year (C statistic 0.74; P=0.004). This association remained significant after multivariable adjustment for clinically relevant confounders (C statistic 0.93; P=0.01). Postpartum activin A levels also correlated with increasing left ventricular mass index (P=0.02), increasing mean arterial pressures (P=0.02), and decreasing E' values (P=0.01). Activin A may be a useful tool for identifying and monitoring patients at risk for postpartum development of cardiovascular disease.