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Zhang Y, Zhu Y, Wang D, Xu L, Jiang W, Wang J, Sun X, Kang L, Song L. Cardiac index: A superior parameter of cardiac function than left ventricular ejection fraction in risk stratification of hypertrophic cardiomyopathy. Heart Rhythm 2023:S1547-5271(23)00212-6. [PMID: 36870381 DOI: 10.1016/j.hrthm.2023.02.028] [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: 08/28/2022] [Revised: 02/18/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND An appropriate indicator of cardiac function in the risk stratification of hypertrophic cardiomyopathy (HCM) patients is urgently needed. Cardiac index that reflects cardiac pumping function may be suitable. OBJECTIVE The purpose of this study was to investigate the clinical significance of reduced cardiac index in HCM patients. METHODS A total of 927 HCM patients were enrolled. The primary endpoint was cardiovascular death. The secondary endpoints were sudden cardiac death (SCD) and all-cause death. Combination models were constructed by adding reduced cardiac index and reduced left ventricular ejection fraction (LVEF) to the HCM risk-SCD model. Predictive accuracy was determined by C-statistics. RESULTS Reduced cardiac index was defined as cardiac index ≤2.42 L/min/m2. During median follow-up of 4.3 years, 51 patients reached the endpoint. Reduced cardiac index independently increased the risk of cardiovascular death (adjusted hazard ratio [aHR] 2.976; P = .007), SCD (aHR 6.385; P = .001), and all-cause death (aHR 2.428; P = .010). By adding reduced cardiac index to the HCM risk-SCD model, the model C-statistic increased from 0.691 to 0.762, with an integrated discrimination improvement of 0.021 (P = .018) and a net reclassification improvement of 0.560 (P = .007). The addition of reduced LVEF failed to improve the original model. Better predictive accuracy for all endpoints was also indicated in reduced cardiac index than in reduced LVEF. CONCLUSION Reduced cardiac index is an independent predictor of poor prognoses in HCM patients. Combining reduced cardiac index rather than reduced LVEF improved the HCM risk-SCD stratification strategy. The reduced cardiac index showed better predictive accuracy than reduced LVEF for all endpoints.
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Affiliation(s)
- Yu Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuming Zhu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Dong Wang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Lianjun Xu
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Wen Jiang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jizheng Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xiaolu Sun
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Lianming Kang
- Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Lei Song
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; Cardiomyopathy Ward, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China; National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Hori M, Imamura T, Oshima A, Onoda H, Kinugawa K. Novel Ramp Test to Optimize Pressure Setting of Adaptive Servo-Ventilation Using Non-Invasive Lung Fluid Level Quantification. Am J Case Rep 2022; 23:e935086. [PMID: 35839152 PMCID: PMC9295190 DOI: 10.12659/ajcr.935086] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Optimal patient selection and device pressure settings are key to successful adaptive servo-ventilation therapy, but there is no established strategy thus far. Adaptive servo-ventilation therapy at an inappropriately high pressure setting for those without pulmonary congestion decreases cardiac output and worsens clinical outcomes. The remote dielectric sensing system (ReDS) is a novel noninvasive tool to estimate the lung fluid amount. The ReDS might be a promising tool for successful adaptive servo-ventilation therapy if appropriately utilized for optimal patient selection and device pressure setting. CASE REPORT An 83-year-old woman was admitted to our hospital to treat acute decompensated heart failure with preserved ejection fraction that was refractory to conventional medical therapy. Following the confirmation that she had significant pulmonary congestion with 47% of the ReDS value (normal range, 20-35%), we performed a "ramp test" to optimize device pressure, by measuring ReDS values and noninvasively estimating the cardiac output and stroke volume at each pressure setting. The device pressure setting was finally determined to minimize pulmonary congestion and maximize cardiac output. Following the continuous adaptive servo-ventilation therapy with the optimized pressure setting, the patient's hospitalization was uneventful and she was discharged. CONCLUSIONS We propose performing a ramp test to optimize the pressure setting of adaptive servo-ventilation by utilizing ReDS technology for each patient, instead of using a default or inappropriately higher pressure setting. However, further studies including large patient populations are warranted to validate the prognostic implication of this customized ramp test protocol.
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Affiliation(s)
- Masakau Hori
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Akira Oshima
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Hiroshi Onoda
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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Kabutoya T, Imai Y, Okuyama T, Watanabe H, Yokota A, Kamioka M, Watanabe T, Komori T, Kario K. Usefulness of Optimization of Interventricular Delay Using an Electrical Cardiometry Method in Patients with Cardiac Resynchronization Therapy Implantation. Int Heart J 2022; 63:241-246. [PMID: 35354746 DOI: 10.1536/ihj.21-711] [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] [Indexed: 11/18/2022]
Abstract
There are no studies examining interventricular (VV) delay optimization by an electrical cardiometry method in relation to subsequent cardiac function in cardiac resynchronization therapy (CRT) -implanted patients. This study aimed to compare the VV delay in CRT-implanted patients by the dp/dt and electrical cardiometry and to examine the optimization of VV delay and improvement of cardiac function. We examined 19 consecutive CRT-implanted patients. The protocol included biventricular stimulation with either simultaneous or sequential pacing, and we evaluated systolic volume (SV) using an electrical cardiometry and the dp/dt of the left ventricle. The optimal VV delay was determined by the maximum SV using the electrical cardiometry. Two groups were defined, those whose increase in SV was at or above the median and those whose SV increase was below the median; changes in left ventricular ejection fraction (LVEF). The correlation between the VV delay optimized by the electrical cardiometry and dp/dt methods was high (R = 0.61, P = 0.006). Compared to the baseline SV (43.4 mL), the SV increased to 47.8 mL with simultaneous biventricular pacing (versus baseline P = 0.008) and further increased to 49.8 mL with optimized VV delay (versus simultaneous biventricular pacing P = 0.020). LVEF after 6 months significantly improved in the above-median SV increase group (37.6 versus 28.2%, P = 0.041), but not in the below-median SV increase group (26.5 versus 26.5%, P = 0.985). In conclusion, the optimal VV delay by electrical cardiometry method was almost concordant with that by the dp/dt method. Cardiac function significantly improved in the group with the above-median SV increase.
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Affiliation(s)
- Tomoyuki Kabutoya
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Yasushi Imai
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Takafumi Okuyama
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Hiroaki Watanabe
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Ayako Yokota
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Masashi Kamioka
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Tomonori Watanabe
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Takahiro Komori
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
| | - Kazuomi Kario
- Division of Cardiovascular Medicine, Department of Medicine, Jichi Medical University School of Medicine
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Imamura T, Kinugawa K. Doppler Echocardiography-Guided Heart Rate Modulation Therapy Using Ivabradine in a Patient with Systolic Heart Failure. Medicina (B Aires) 2022; 58:medicina58020164. [PMID: 35208489 PMCID: PMC8879967 DOI: 10.3390/medicina58020164] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/15/2022] [Accepted: 01/19/2022] [Indexed: 11/16/2022] Open
Abstract
Heart rate reduction using ivabradine, a selective If channel blocker that purely decreases heart rate without affecting hemodynamics, improves clinical outcomes in patients with systolic heart failure. However, the ideal heart rate that should be a target remains unknown. Our team recently proposed a methodology using Doppler echocardiography to estimate ideal heart rate, at which E-wave and A-wave stand adjacent without overlap. However, the implication of Doppler echocardiography-guided heart rate modulation therapy using ivabradine remains uncertain. We had a 72-year-old man with systolic heart failure and sinus tachycardia who initiated ivabradine therapy. Ivabradine dose was adjusted between 5.0 mg/day and 10.0 mg/day and continued for 12 weeks to minimize the overlap between the two echocardiography waves, accompanying improvement in cardiac output, left ventricular ejection fraction, plasma B-type natriuretic peptide, and six-minute walk distance. Doppler echocardiography-guided heart rate regulation therapy using ivabradine may be a promising strategy to improve cardiac function and clinical outcomes in patients with systolic heart failure, although further studies are required to validate this hypothesis.
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Imamura T, Narang N, Kinugawa K. Adaptive Servo-Ventilation as a Novel Therapeutic Strategy for Chronic Heart Failure. J Clin Med 2022; 11:jcm11030539. [PMID: 35159990 PMCID: PMC8836600 DOI: 10.3390/jcm11030539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/19/2022] [Accepted: 01/20/2022] [Indexed: 02/01/2023] Open
Abstract
The introduction of new therapeutics for patients with chronic heart failure, including sacubitril/valsartan, sodium-glucose cotransporter 2 inhibitors, and ivabradine, in addition to beta-blockers, angiotensin converting enzyme inhibitors, and mineralocorticoid receptor antagonists, lends an opportunity for significant clinical risk reduction compared to what was available just one decade ago. Further clinical options are needed, however, for patients with residual clinical congestion refractory to these therapies. Adaptive servo-ventilation is a novel therapeutic option to address significant clinical volume in cases resistant to medical therapy. The aggregate benefit of these additional therapeutic strategies in addition to foundational medical therapy may be a promising option in the selected candidates who do not achieve acceptable clinical and quality-of-life improvements with oral medical therapy alone. Now is the era to reconsider the implication of an adaptive servo-ventilation-therapy-incorporated medical therapeutic strategy for patients with congestive heart failure.
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Affiliation(s)
- Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan;
- Correspondence: ; Tel.: +81-76-434-2281; Fax: +81-76-434-5026
| | - Nikhil Narang
- Advocate Christ Medical Center, Oak Lawn, IL 60453, USA;
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani, Toyama 930-0194, Japan;
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Hori M, Imamura T, Narang N, Kinugawa K. Pressure Ramp Testing for Optimization of End-Expiratory Pressure Settings in Adaptive Servo-Ventilation Therapy. Circ Rep 2022; 4:17-24. [PMID: 35083384 PMCID: PMC8710634 DOI: 10.1253/circrep.cr-21-0132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 10/14/2021] [Accepted: 10/19/2021] [Indexed: 11/09/2022] Open
Affiliation(s)
- Masakazu Hori
- Second Department of Internal Medicine, Toyama University
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Abstract
Heart rate modulation therapy using ivabradine improves mortality and morbidity in patients with systolic dysfunction. However, a target heart rate remains uncertain. Echocardiography-guided ivabradine therapy, in which we attempt to approach zero overlap between two diastolic filling inflow waves, has recently been proposed to maximize cardiac output, facilitate reverse remodeling, and reduce mortality and morbidity, instead of using an absolute value for the target heart rate. Prospective studies are needed to validate the clinical implication of these therapeutic strategies. Also, this concept should be expanded to other clinical scenarios.
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Affiliation(s)
- Teruhiko Imamura
- The Second Department of Internal Medicine, University of Toyama
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Nakayama A, Nakao T, Fujiu K, Daimon M, Morita H, Komuro I. Safety Monitoring for Obstructive Hypertrophic Cardiomyopathy During Exercise. CJC Open 2020; 2:732-734. [PMID: 33305240 PMCID: PMC7711023 DOI: 10.1016/j.cjco.2020.08.006] [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: 07/10/2020] [Accepted: 08/12/2020] [Indexed: 11/20/2022] Open
Abstract
Patients with hypertrophic cardiomyopathy (HCM) are prohibited from engaging in intensive exercise, to avoid sudden death. Given that patients with HCM, even those without left-ventricular outflow tract obstruction at rest, potentially have exercise-induced obstruction, reasonable monitoring methods during exercise are required. We present the case of a woman with HCM with exercise-induced obstruction whose hemodynamics during stress echocardiography were under observation using noninvasive cardiac output monitoring. Stroke volume declined during exercise before the manifest elevation of the left-ventricular outflow tract pressure gradient. As shown here, a noninvasive monitoring method can be useful in monitoring hemodynamics during exercise in HCM patients.
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