Discrepancies in Assessing Diastolic Function in Pre-Clinical Heart Failure Using Different Algorithms-A Primary Care Study

Echocardiographic markers of early alcoholic cardiomyopathy: Six-month longitudinal study in heavy drinking patients

BACKGROUND

The development of alcoholic cardiomyopathy (ACM) is related to chronic excessive alcohol use. However, features of early-stage ACM are still unclear. We assessed echocardiographic characteristics of patients with alcohol dependence (DSM-IV criteria) during a six-month treatment period.

METHODS

Active drinking patients, heavy alcohol users, without heart disease, referred to our Alcohol Addiction Unit were enrolled in the study. After signing informed consent, patients started outpatient treatment program. Echocardiography was performed at enrollment, then three and six months afterwards, by cardiologists blinded to drinking status.

RESULTS

Forty-three patients (36 males, 7 females) were enrolled. At six months, 20 patients (46.5%) reduced alcohol consumption below heavy drinking levels. Although within normal range, baseline mean IVS thickness and mean LVDD were significantly higher (p < 0.001) and mean EF significantly reduced (p = 0.009), as compared to age-matched mean references. Mean E/A ratio, DcT and LA diameter were significantly different (p < 0.001) from mean references, but within normal range. Baseline mean E/e' ratio was significantly higher than the mean reference (p < 0.001) and out of the normal range. A significant correlation between the number of drinks per drinking days in the 7 days before baseline assessment and E/e' ratio was observed (p = 0.028). After six months, a trend-level reduction of mean E/e' ratio (p = 0.051) was found in the whole sample; this reduction was statistically significant (p = 0.041) among patients reducing drinking, compared to baseline.

CONCLUSIONS

Altered E/e' ratio may characterize early-ACM before the occurrence of relevant echocardiographic alterations. The reduction of alcohol consumption could restore this alteration after six months.

Performance of non-invasive myocardial work to predict the first hospitalization for de novo heart failure with preserved ejection fraction

AIMS

Non-invasive myocardial work (MW) is a validated index of left ventricular (LV) systolic performance, incorporating afterload and myocardial metabolism. The role of MW in predicting the first hospitalization for de novo heart failure with preserved ejection fraction (HFpEF) is still unknown. We aim to investigate the diagnostic performance of MW to predict the first de novo HFpEF hospitalization in ambulatory individuals with preserved LV ejection fraction.

METHODS AND RESULTS

Twenty-nine patients with transthoracic echocardiography performed at least 6 months before the first HFpEF hospitalization were compared with 29 matched controls. MW was derived as the area of pressure-strain loop using speckle-tracking and brachial artery blood pressure. Global work index, global constructive work, global wasted work (GWW), and global work efficiency (GWE) were collected. First HFpEF hospitalization and its combination with cardiovascular death [major adverse cardiovascular events (MACE)] and all-cause of death [major adverse events (MAE)] were assessed. At baseline, future HFpEF patients showed lower global work index, global constructive work, GWE, and higher GWW than controls (all P < 0.05). At admission vs. baseline, GWE significantly decreased, and GWW increased in the HFpEF group (P < 0.05), whereas no significant difference was observed in the controls over time. GWW, with a cut-off of 170 mmHg%, showed the largest area under the curve (AUC) to predict first HFpEF hospitalization [AUC = 0.80, 95% confidence interval (CI) 0.69-0.91, P < 0.001], MACE (AUC = 0.80, 95% CI 0.66-0.90, P < 0.001), and MAE (AUC = 0.79, 95% CI 0.62-0.88, P = 0.001). GWW > 170 mmHg% was associated with a 4-fold increase of MACE (HR = 4.5, 95% CI 1.59-13.12, P = 0.005) and a 3-fold higher risk of MAE (HR = 2.9, 95% CI 1.24-6.6, P = 0.014).

CONCLUSIONS

In ambulatory patients with preserved LV ejection fraction and risk factors, GWW showed high accuracy to predict the first HFpEF hospitalization and its combination with mortality. The GWW routine assessment may be clinically helpful in patients with dyspnoea.

Left atrial ejection fraction is an indicator of left ventricular diastolic function

Left atrial ejection fraction (LAEF) has been previously shown to accurately distinguish between patients with and without clearly defined left ventricle diastolic dysfunction (LVDD) by ASE/EACVI criteria, but indeterminate cases were excluded. We sought to determine if LAEF could accurately distinguish between normal, indeterminate and LVDD patients. A retrospective cohort of 125 patients who underwent transthoracic echocardiography was studied. Comprehensive echocardiographic study was performed with measurement of validated diastolic parameters. Subjects were assigned LVDF ASE/EACVI categories. ANOVA test was used to compare means between groups and binary logistic regression and ROC curves to assess diagnostic accuracy. Mean LAEF was statistically different between groups (p < 0.001): 56.3% ± 4.5 for normal patients, 50.2% ± 5.5 for indeterminate patients and 44% ± 8.5 for patients with LVDD. LAEF distinguished LVDD from patients without diastolic dysfunction (OR = 0.73, 95% CI 0.63-0.65, p < 0.001) and ROC curve reveals excellent discriminative power (AUC 0.91, 95% CI 0.84-0.97, p < 0.001). LAEF also distinguished indeterminate patients from LVDD (OR = 0.9, 95% CI 0.83-0.95, p < 0.001) and ROC curve revealed good discriminative power (AUC 0.72, 95% CI 0.62-0.82, p < 0.001). LAEF can accurately differentiate between normal, indeterminate and LVDD patients and could be considered as an additional parameter in the study of diastolic function.

Left Atrial Volumetric/Mechanical Coupling Index: A Novel Predictor of Outcome in Heart Failure With Reduced Ejection Fraction

BACKGROUND

Left atrial assessment is complex, particularly in heart failure with reduced ejection fraction due to interactions with functional mitral regurgitation (FMR). Pilot data suggest that left atrial volumetric/mechanical coupling index (LACI) may be useful, but large outcome data are lacking.

METHODS

We enrolled a comprehensively characterized cohort of patients in sinus rhythm with heart failure with reduced ejection fraction diagnosis at Mayo Clinic from 2007 to 2011. Routinely measured left atrial volume index and tissue-doppler-imaging a' allowed LACI calculation as (left atrial volume index)/(tissue-doppler-imaging a'). Survival was the outcome measured.

RESULTS

The cohort's 4196 patients (69 [58-77] years, ejection fraction 40 [31-45]%) had mild FMR in 1505 and moderate-severe FMR in 1068. LACI was overall 5.06 (3.50-8.10) and increased with each FMR grade (3.86 [2.94-5.29] without FMR, 5.38 [3.80-8.02] with mild, 5.45 [1.49-8.07] with moderate/severe FMR; P<0.0001). At diagnosis, higher LACI was independently determined by more severe FMR and by higher left ventricular mass index, lower ejection fraction, higher E/e', and lower glomerular filtration rate (all P<0.0001). During follow-up 1588 (38%) patients died. In spline modeling, excess mortality appeared around LACI=6 and steeply increased thereafter (5-year survival 72±1% with LACI<6 and 49±2% with LACI ≥6, P<0.0001). Multivariable comprehensive adjustment showed LACI strong association with excess mortality (adjusted hazard ratio, 1.41 [1.23-1.61], P<0.0001 for LACI ≥6). Independent link to mortality persistent across FMR grades (adjusted hazard ratio, 1.45 [1.13-1.86], P=0.004 without FMR, 1.42 [1.16-1.77], P=0.0008 with mild FMR, and 1.38 [1.01-1.66], P=0.04 with moderate/severe FMR) without interaction (P=0.3). LACI independent impact on outcome was incremental to that of left atrial volume index, tissue-doppler-imaging a', or any other characteristic including the Meta-Analysis Global Group in Chronic-score (least significant P=0.02).

CONCLUSIONS

In this large cohort, left atrial volumetric/mechanical coupling measured by LACI in routine practice integrates the influence of several morphological/hemodynamic determinants but displays progressive deterioration with increasing FMR severity in heart failure with reduced ejection fraction. About outcome, higher LACI is strongly, independently, and incrementally associated with excess mortality, irrespective of FMR grade and in all subsets. Hence, LACI is a novel and critical measure in heart failure with reduced ejection fraction, quantifiable in routine practice, which should be integrated in prognostication and decision-making.