HFA-PEFF score as a prognostic factor in patients with liver cirrhosis

Introduction

Cardiovascular complications of liver cirrhosis which are frequently referred to as cirrhotic cardiomyopathy (CCM), include high cardiac output, reduced afterload and diastolic dysfunction. However, there are only scarce or even conflicting data about the prognostic significance of CCM. HFA-PEFF score is a diagnostic score for heart failure with preserved ejection fraction (HFpEF), which has prognostic value in HFpEF patients. It has functional, morphological and biomarker domains and the score may vary from 0 to 6. Score of 5 or 6 is diagnostic of HFpEF in symptomatic patients. No study has calculated HFA-PEFF score in cirrhotic patients to date.

Purpose

The purpose of this prospective study was to calculate HFA-PEFF score in cirrhotic patients, correlate it with disease severity and determine its prognostic significance.

Methods

A total number of 92 consecutive cirrhotic outpatients were prospectively examined and 72 fulfilled the inclusion criteria. Patients older than 75 years old or patients with ejection fraction (LVEF) <50%, coronary artery disease, moderate or severe valvular heart disease, atrial fibrillation, ongoing alcohol consumption, hepatocellular carcinoma and poor acoustic window were excluded. In all patients a thorough echocardiographic examination was performed, BNP or NT-pro-BNP levels were measured and subsequently HFA-PEFF score was calculated. MELD score was used to define the severity of cirrhosis. The median follow-up was 20 months and the study end-point was defined as the composite of all-cause death.

Results

Mean age was 58.5±8.3 years, 52 (72.2%) were males, median Meld score was 12.9 (8.5–16.3) and mean LVEF was 61.1±5.4%. HFA-PEFF score was 5 or 6 in 38 (52.8%), 2–4 in 27 (37.5%) and 0 or 1 in 9 (9.7%) patients. According to Spearman's coefficient analysis, HFA-PEFF score was correlated with MELD score (rho=0.566, p<0.001), but not with age, systolic blood pressure (SBP) and heart rate. The survival analysis stratified by the HFA-PEFF score [low, score 0–4 (N=34) vs. high, score 5–6 (N=38)] indicated that the HFA-PEFF score successfully predicted all cause two-year survival (log-rank test p<0.001). According to the Cox-regression proportion hazard models HFA-PEFF score as a continuous variable correlated with six-month, one year and two year survival. When HFA-PEFF was treated as a categorical variable, hazard models were significant for the one and two-year survival. The multivatiate COX regression survival analysis showed that the increased HFA-PEFF score (low: score 0–4, N=34 vs high: score 5–6, N=38) was significantly associated with decreased two-year survival when patient age, gender and MELD score are taken into account [HR=3.659 (1.068–12.536), p=0.039].

Conclusions

HFA-PEFF score is high among patients with liver cirrhosis, especially those with increased disease severity. HFA-PEFF score is associated with survival even when adjusting for the severity of the cirrhosis.

Funding Acknowledgement

Type of funding sources: None.

Changes of RV-PC coupling during negative for myocardial ischemia dobutamine stress echocardiography

Background

Coupling between RV contractile function and pulmonary circulation (PC) reflects the comprehensive performance of the RV by integrating afterload and contractility. RV-PC coupling is nowadays frequently expressed by the non-invasively measured ratios TAPSE/RVSP and RVFWLS/RVSP. It has been shown that it decreases slightly during exercise, whereas no known data exist on how dobutamine does affect it.

Purpose

The aim of this study was to evaluate the changes in RV-PC coupling and RV mechanics during the different stages of dobutamine stress echocardiography (DSE) in cases without known coronary artery disease (CAD) and negative for myocardial ischemia DSE.

Methods

Patients with a low-to-intermediate risk for CAD were referred for and underwent DSE. RV systolic function was evaluated with TAPSE, S' and RV Free Wall (RVFW) Strain. The non-invasively measured RV-PC coupling was evaluated by indexing TAPSE and RV free wall longitudinal strain to right ventricular systolic pressure (RVSP) during baseline echocardiogram, low dose (inotropic dobutamine effect) and peak dose (chronotropic effect) stages of DSE.

Results

Initially, a total of 53 patients underwent DSE. Eight patients had a positive for ischemia response and were excluded.

The remaining 45 patients {mean age 65±8.7, 28 (63%) male}, 24 (53%) had hypertension, 24 (53%) were smokers, 33 (74%) had dyslipidemia, 15 (34%) had family history of CAD and 7 (15%) had diabetes mellitus. TAPSE, S' and RVFW Strain increased from baseline to peak dose [23.55±2.91 vs 28.76±1.9 (p<0.001), 13.13±1.79 vs 23.83±4.87 (p<0.001) and 19.7±5.87 vs 23.46±5.42 (p=0.044) respectively].

TAPSE/RVSP showed a significant steady decrease between baseline and low dose (0.88±0.14 vs 0.79±0.19) and peak dose (0.88±0.14 vs 0.74±0.12) stages with a difference of 0.09 (p value 0.013) and 0.14 (p value 0.000) respectively. On the other hand, RVFW Strain/ RVSP exhibited a significant decrease (0.60±0.15, p value 0.000) only between baseline and peak dose.

There was no significant correlation of the change in TAPSE/RVSP with the change in E/E' or change in Systolic Blood Pressure.

Conclusions

RV-PC coupling decreases during negative for ischemia DSE independently of LV dynamic changes and therefore, future studies should be oriented to evaluate the incremental role of this novel index not only for the assessment and evaluation of myocardial ischemia and RV disease that affects RV coupling, but also as a prognostic marker for patients with no evident ischemia.

Funding Acknowledgement

Type of funding sources: None.

Deformation analysis in post-hospitalised patients with moderate SARS-CoV-2 infection

Funding Acknowledgements

Type of funding sources: None.

Background

SARS-CoV-2 infection is associated with multiple cardiac manifestations (1,2). Global longitudinal strain (GLS) by speckle tracking echocardiography (STE) is a novel transthoracic echocardiography (TTE) measure of myocardial deformation, which could early recognize subclinical cardiac injury in COVID-19 patients (3,4).

Purpose

We aimed to explore GLS profiles in post-hospitalized COVID-19 patients to identify features of eventual subclinical cardiac injury and to investigate the possible correlation with the severity of infection.

Methods

We enrolled 33 patients (mean age 59.2 ± 13, 64% men) with positive SARS-CoV-2 RT-PCR, hospitalized for moderate COVID-19 disease, with no admission to intensive care unit. Patients were submitted to TTE 1-2 months after discharge.  Images were anonymised and analysed offline by two accredited cardiologists. Clinical parameters and laboratory findings from hospitalization were also collected.  Acute myocardial infarction and pulmonary embolism were exclusion criteria.

Results

Mean duration of hospitalization was 12.9 ± 8.0 days. Study population had normal systolic function with a mean LV ejection fraction 58.6% (±3.6) while the majority of patients had relative low values of LV global longitudinal strain, mean 15.2% (±2.3). Arterial hypertension was present in 51.5% of patients and a history of previous myocardial infarction was referred in 6.1% of the population. Only 24.2% of patients had elevated troponin levels during the previous in-hospital period (mean maximal value of hs-troponin  was 18.1 ±16.6 pg/mL) whereas  81.8% had abnormal D-Dimers values (mean 2424 μg /L, range ±2825) and 93.1% had high hs-CRP values (138.2 ±92.0 mg/L) . Duration of hospitalization had strong significant correlation with D-Dimers (rho: 0.708, p: <0.001) and hs CRP (rho:0383, p:0.028) and  marginal association with troponin ( rho: 0.335, p:0.056). Moreover, global longitudinal strain showed significant association with duration of hospitalization (rho:-0.545, p: 0.007). Traditional systolic indices as LVEF and the various diastolic parameters  showed no significant association with severity of disease reflected by the duration of hospitalization and the other clinical and laboratory biomarkers.

Conclusion

Cardiac manifestations of SARS-CoV-2 infections could be present in mild to moderate disease and seems to associate with the severity of infection. The novel echocardiographic parameters such as GLS could add valuable information and identify  possible subclinical cardiac injury often unrecognized by traditional TTE examination.

The prognostic value of left atrial strain in patients with end stage renal disease on dialysis

Funding Acknowledgements

Type of funding sources: None.

Background

Chronic kidney disease (CKD) is associated with higher incidence of cardiovascular death especially as the disease progresses and the patients undergo long term dialysis treatment (1). Left ventricular (LV) dysfunction evaluated by cardiac deformation measurements with speckle tracking echocardiography seems to have an important prognostic role in several different specific populations (2-4).

Purpose

Τhe prognostic value of strain analysis measurements, including the novel diastolic parameters such as left atrial (LA) strain, in patients with end-stage renal disease on dialysis (stage 5 CKD).

Methods

 67 patients (mean age 62.3 ± 11.8, 65.7% men) with stage 5 CKD (45 on hemodialysis and 22 on peritoneal dialysis) were enrolled in the study protocol. The mean duration of dialysis was 102.48 ± 84.98 months. Patients were submitted to a transthoracic echocardiogram at rest and dobutamine stress contrast echo (DSCE) protocol. Mean follow-up lasted five years.

Results

The majority of the study population had normal or mildly impaired systolic function with a mean LV ejection fraction 49.17% (±10.41) while 70% of the patients had impaired LV global longitudinal strain, (mean 14.35%, ±4.49). Regarding LA strain parameters the mean LA reservoir, LA conduit, and LA contractile reserve were 24.11%(±12.61), 10.56% (±5.88) and 13.60% (±9.15) respectively. Thus 50% of the population had impaired LA strain. DSCE was positive for ischemia in 55.7%. The 5-year cumulative event-free survival was 58.2% (±6.7), while 30% of major events happened during the first 2 years after DSCE (see Figure). Logistic regression analysis showed that of the various echocardiographic parameters LV ejection fraction, LV global longitudinal strain, and the conduit phase of LA strain were significantly associated with DSCE result and total prognosis (p = 0.009, p = 0.007, p = 0.05, and p = 0.005, p = 0.049, p = 0.043, respectively). The conduit element of LA strain notably was the strongest predictor among them(OR = 0.76 p = 0.05 and OR = 0.72 p = 0.043, respectively).

Conclusion

 Left ventricular diastolic dysfunction is an important prognostic factor among patients with advanced CKD under long-term dialysis.  The novel echocardiographic parameters such as LA strain couldadd valuable information to the overall cardiac evaluation of this specific population. Abstract Figure.

Dobutamine stress echocardiography during covid-19 pandemic: impact on volume and positivity rates in a tertiary hospital

Funding Acknowledgements

Type of funding sources: None.

Introduction

The emergence of coronavirus 2019 infection (covid-19) was accompanied by severe social and economic restrictions and applied significant pressure to the healthcare systems. The first pandemic wave started in March to May 2020 and was characterized by the peak of confinement measures and lockdown application. The second wave started in September and peaked in November to December 2020 and was characterized by improved healthcare organization but significant burden for the hospitals and intensive care units. Dobutamine stress echocardiography (DSE) is used for evaluation of ischemia in patients with known or suspected coronary artery disease.

Purpose

To compare DSE volume and positivity rates between 2019 and 2020 time periods in a department of a public tertiary hospital.

Methods

We retrospectively analysed DSE studies performed in our department in 2020 including the peak of covid-19 restrictions and compared the data to the 2019.

Results

Volume of DSE studies decreased from 1516 in 2019 to 996 in 2020 (-34.3%). The study volume reduction was greater in April (-93.7%) and May (-54.5%) when the covid-19 restrictions were at the peak. Great decreases were also recorded in November (-46.8%) and December (-53.5%) when the second wave of covid-19 disease emerged. Conversely, small increases were recorded in September (7.1%) and October (10.6%) (figure 1). Regarding positivity rates, a statistically non-significant increase was recorded (33.6% vs 34.2% in 2019 and 2020 respectively, p = 0.73). Interestingly a statistically significant increase in positivity levels was recorded during the period March to May 2020 compared to the same period of 2019 (44.7% vs 36.9%, p = 0.029). On the contrary, positivity rates were decreased at the period September to December (27.1% vs 34.2%, p = 0.019) (figure 2).

Conclusions

Volume of DSE studies was significantly reduced in 2020 when compared to 2019 during respective peaks of the pandemic and the accompanying restriction measures. Positivity rates were higher during the first pandemic wave, possibly due to decreased hospital attendance of mildly symptomatic patients in combination with stricter admission criteria at the emergency department. Lower positivity rates during the second pandemic wave possibly reflect an adjustment of both healthcare systems and patients to the new conditions imposed by the covid-19 pandemic. Abstract Figure 1  Abstract Figure 2