Sex differences on new-onset heart failure in patients with known or suspected chronic coronary syndrome

Background

The impact of sex in patients with chronic coronary syndrome (CCS) has been widely reported, but little is known about the influence of sex on the risk of new-onset HF in patients with CCS.

Objectives

We aimed to examine sex-related differences and new-onset heart failure (HF) risk in patients with known or suspected CCS undergoing vasodilator stress cardiac magnetic resonance (CMR).

Methods

We prospectively evaluated 5,899 consecutive HF-free patients submitted to stress CMR for known or suspected CCS. Ischemic burden (number of segments with stress-induced perfusion deficit) and left ventricular ejection fraction (LVEF) were assessed by CMR. The association between sex and new-onset HF (including outpatient diagnosis or acute HF hospitalization) was evaluated using a Cox proportional-hazards regression model adjusted for competing events (death, myocardial infarction, and non-CMR-related revascularization).

Results

A total of 2,289 (38.8%) patients were women, and 539 (9.1%) underwent CMR-related revascularization. During a median follow-up of 4.5 years, 610 (10.3%) patients died, 191 (3.2%) suffered a myocardial infarction, 420 (7.1%) underwent CMR-non-related revascularization, and 314 (5.3%) developed new-onset HF. Unadjusted new-onset HF rates were higher in women than in men (1.25 vs 0.83 per 100 person/years, p=0.002) (Figure 1). After comprehensive multivariate adjustment, women showed an increased risk of new-onset HF (HR=1.61, 95% CI: 1.21–2.13, p=0.001). Compared with men, the risk of new-onset HF was higher in women with LVEF >53%.

Conclusions

Compared with men, women with CCS are at a higher risk of new-onset HF. Further studies are needed to unravel the mechanisms behind these sex-related differences.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III and Fondo Europeo de Desarrollo Regional (FEDER) Figure 1

Prognostic value of vasodilator stress CMR in elderly patients with known or suspected chronic coronary syndrome

Background

In recent guidelines, non-invasive imaging techniques play a pivotal role in the management of chronic coronary syndrome (CCS). The elderly represent a large percentage of our routine CCS population and risk stratification in this scenario is challenging. The potential of vasodilator stress cardiovascular magnetic resonance (vs-CMR) for this purpose is unknown.

Purpose

We explored the prognostic value of the ischemic burden, as derived from vs-CMR, in elderly patients with known or suspected CCS.

Methods

From the general cohort of 6389 patients with known or suspected CCS submitted to undergo vs-CMR in our health department from 2001 to 2016, we performed a subanalysis of the 1225 patients >70 year-old (mean age 77±5 years, 51% male). Clinical and vs-CMR characteristics were prospectively recorded. The ischemic burden (at stress first-pass perfusion imaging) was computed (using the 17-segment model). The occurrence of major adverse cardiac events (MACE) defined as all-cause death and/or non-fatal myocardial infarction (whichever occurred first) was retrospectively revised using the electronic regional health system registry.

Results

During a median follow-up of 2.7 years, 203 MACEs were registered (17%). Age (77±4 vs. 76±5 years) was not significantly different in patients with and without MACE. Larger left ventricular (LV) end-diastolic and end-systolic volume indexes, more depressed LV ejection fraction, more extensive areas with late gadolinium enhancement and ischemic burden were detected in patients with MACE (p<0.001 for all comparisons). In non-revascularized patients (n=1118), the MACE rate ranged from 13% (in patients with 0–1 ischemic segments) to 35% (in those with >8 ischemic segments, p<0.001 for the trend). In the small subset of revascularized patients (n=107), revascularization exerted a non-significant protective effect only in patients with extensive ischemic burden (>5 segments).

Conclusions

Vasodilator stress CMR represents a valuable tool to stratify risk in elderly patients with known or suspected CCS and might be helpful to guide decision-making.

Figure 1

Funding Acknowledgement

Type of funding source: None

A novel clinical and stress cardiac magnetic resonance score to predict long-term all-cause mortality in patients with known or suspected chronic coronary syndrome

Background

Vasodilator stress cardiac magnetic resonance (stressCMR) has shown robust diagnostic and prognostic value in patients with known or suspected chronic coronary syndrome (CCS). However, it is unknown whether integration of several prognostic stressCMR parameters, such as the ischemic burden (number of segments with first-pass stress-induced perfusion defects -PD-) and left ventricular ejection fraction (LVEF), with clinical variables can improve risk prediction in this population.

Purpose

We aim to explore the usefulness of a clinical-stressCMR score to predict the risk of all-cause mortality in patients with known or suspected CCS submitted to undergo a stressCMR.

Methods

We included 6187 patients in a large prospective multicenter registry (mean age 65.18±11.51 years, 37.3% female) which underwent stressCMR for known or suspected CCS. Several clinical and stressCMR variables were collected, such as LVEF, end-diastolic and end-systolic volume indices, ischemic burden and segments with necrosis (with late gadolinium enhancement imaging).

Results

During a mean and median follow-up of 5.85±3.82 years we registered 682 (11%) all-cause deaths. Several clinical and all stressCMR variables were associated with all-cause mortality in univariate analysis. However, the only independent predictors of all-cause mortality in multivariate analysis were age (HR 1.07 [1.06–1.08] per year, p<0.001), male sex (HR 1.36 [1.15–1.61], p<0.001), diabetes mellitus (HR 1.6 [1.37–1.87], p<0.001), LVEF (0.98 [0.97–0.98] per %, p<0.001) and ischemic burden (HR 1.04 [1.02–1.06] per segment with stress-induced PD, p=0.001). By means of the chi-square increase at each step of the stepwise multiparametric Cox regression we created a clinical-stressCMR score that included these variables (age, male sex, diabetes mellitus, LVEF and ischemic burden) kept in their continuous state if possible. This score showed a good performance to predict all-cause mortality (area under the curve = 0.716 [0.697–0.735], p<0.001). Dividing the population into quintiles according to the clinical-stressCMR score allowed for a stratification of the annualized risk of all-cause mortality (0.39%/year, 0.94%/year, 1.62%/year, 2.63%/year and 3.83%/year, respectively; log-rank 420.33 and p<0.001 for Kaplan-meier curves).

Conclusions

A novel clinical-stressCMR, which includes clinical (age, male sex, and diabetes mellitus) and stressCMR (LVEF and ischemic burden) variables, can provide robust prediction and stratification of the risk of all-cause mortality in a population of patients with know or suspected CCS.

Figure 1. Clinical-stress CMR score

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and by Generalitat Valenciana (GV/2018/116).

Chest pain of unknown coronary origin: can exercise ECG testing contribute to long-term risk prediction on top of vasodilator stress cardiac magnetic resonance?

Background

The prognostic value of both exercise ECG testing (ExECG) and vasodilator stress cardiac magnetic resonance (VS-CMR) is well-known in patients with chest pain of unknown coronary origin. However, it is unknown whether performing both techniques can improve the risk stratification of these patients.

Purpose

We aim to confirm the additive prognostic value of ExECG and VS-CMR in a real-world cohort of patients with chest pain of unknown coronary origin.

Methods

We retrospectively included 288 patients in which ExECG and VS-CMR had been subsequently performed within one year. Clinical, ExECG and VS-CMR variables were registered. We performed univariate and multivariate analysis to check for the association of variables with the risk of MACE, defined as a combined endpoint of acute coronary syndrome (ACS), admission for heart failure (aHF) or all-cause death.

Results

During a mean follow-up of 4.2±2.15 years, we registered 27 MACE (15 ACS, 8 aHF and 8 all-cause deaths). The history of hypertension, previous coronary artery disease and/or coronary artery bypass grafting, lower maximal heart rate during ExECG (maxHR) and more extensive ischemic burden (segments with perfusion defects -PD- on stress first-pass perfusion) and myocardial necrosis (number of segments with necrosis at late gadolinium enhancement imaging) associated with the MACE endpoint. However, the only independent predictors of MACE were maxHR during ExECG (HR 0.98 [0.96–0.99], p=0.01) and more extensive segments with PD in the VS-CMR (HR 1.2 [1.07–1.34], p=0.002). We identified the best cut-off using the Youden index derived from receiver operating characteristics (ROC) analysis to predict MACE - it was ≤130bpm for maxHR during ExECG and ≥2 segments with PD on VS-CMR. These cathegories allowed us to stratify the annualized rate of MACE, which was very low (0.97%/year) in patients with normal maxHR and no PD on VS-CMR, intermediate in patients with only abnormal maxHR (1.98%/year) or PD on VS-CMR (3.24%/year) and high in patients with both abnormal maxHR and segments with PD (6.26%/year). Adding maxHR to the multivariable model including stress-induced PD by VS-CMR significantly improved the predictive power of MACE as derived from the continuous reclassification improvement index (0.47 [0.10–0.81], p<0.05).

Conclusions

ExECG and VS-CMR can have an additive prognostic value to predict the long-term risk of MACE in patients with chest pain of unknown coronary origin. Patients with maxHR during ExECG ≤130bpm and ≥2 segments with PD on VS-CMR are at the highest risk of MACE.

Figure 1. MACE risk stratification.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants) and by Generalitat Valenciana (GV/2018/116).

Impact of the dynamics of ejection fraction on risk stratification in a large multicenter registry of STEMI patients using sequential CMR

Background

Left ventricular ejection fraction (LVEF) has traditionally been used as the cornerstone for risk stratification after ST-segment elevation myocardial infarction (STEMI) and it can be accurately quantified by cine cardiovascular magnetic resonance (CMR). In recent years, the additional prognostic value of contrast CMR-derived infarct size (IS) and microvascular obstruction (MVO) has been demonstrated.

Purpose

We explored the impact of sequential assessment of CMR-derived LVEF on dynamic risk stratification after STEMI.

Methods

Data were obtained from three prospective registries of reperfused STEMI patients (n=1036) in whom LVEF, IS and MVO were sequentially quantified by CMR (at least at 1 week and at 6 months). Major adverse cardiac events (MACE) were defined as a combined clinical end-point: death or re-admission for acute heart failure (HF), whichever occurred first. Late events were regarded as those occurring after the 6-month CMR.

Results

During a mean and median follow-up of 5 years, 105 first MACE (10%, 36 deaths and 69 HF) and 82 late MACE (8%, 35 deaths and 47 HF) were registered. From 1-week to 6-month CMR, LVEF improved (49±12 vs. 53±12%), IS decreased (21±14 vs 17±12% of LV mass) and MVO vanished (1.3±1.9 vs. 0.1±0.7% of LV mass), p<0.001 for all comparisons. At 1-week CMR, 207 patients (20%) displayed reduced LVEF (r-LVEF, <40%), 328 (32%) mid-range LVEF (mr-LVEF, 40–50%) and 501 (48%) preserved LVEF (p-LVEF, >50%). At 6-month CMR, 144 patients (14%) displayed r-LVEF, 247 (24%) mr-LVEF and 645 (62%) p-LVEF. The total MACE rate was higher (p<0.001) only in patients with r-LVEF at 1 week (22%) vs. 7% in those with mr-LVEF and 7% in those with p-LVEF. Similarly, the late MACE rate was higher (p<0.001) only in patients with r-LVEF at 6 months (20%) vs. 7% in those with mr-LVEF and 5% in those with p-LVEF. The late MACE rate was very low in patients with sustained mr- or p-LVEF (41/794, 5%), intermediate in those with improved LVEF from r-LVEF at 1 week to mr- or p-LVEF at 6 months (12/98, 12%) and high in patients with sustained r-LVEF (22/109, 20%) or worsened LVEF from mr- or p-LVEF at 1 week to r-LVEF at 6 months (7/35, 20%), p<0.001 for the trend. Using a Markov approach, only r-LVEF (at any time assessed) significantly related to a higher MACE rate.

Conclusions

Of available CMR parameters, LVEF persists as the pivotal index for simple post-STEMI risk stratification. Mid-range or preserved LVEF in acute phase associates with excellent long-term outcome. Changes in LVEF provide valuable dynamic prognostic information. Maintenance of mid-range or preserved LVEF in chronic phase occurs in the majority of patients and associates with a very low risk of late clinical events. Whereas late improvement reaching at least mid-range LVEF exerts salutary effects, detection of reduced LVEF at this point identifies the small subset of patients at high risk in the long term.

Figure 1

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants).

Risk stratification in patients discharged for STEMI. Ejection fraction by echocardiography as the gatekeeper for a selective use of cardiac magnetic resonance

Background

CMR permits robust risk stratification of discharged STEMI patients but an indiscriminate use in all cases is unfeasible.

Purpose

We evaluated the usefulness of left ventricular ejection fraction (LVEF) by echocardiography (Echo) as the gatekeeper for identifying those patients discharged for ST-segment elevation myocardial infarction (STEMI) who benefit most from cardiac magnetic resonance (CMR) for prognostic purposes.

Methods

Echo and CMR were performed in 1119 patients discharged for STEMI included in a multicenter registry. The prognostic power of CMR beyond Echo-LVEF was assessed using C-statistic, net reclassification index (NRI) and integrated discrimination improvement index (IDI).

Results

During a 4.8-year median follow-up, 136 (12%) first major adverse cardiac events (MACE) occurred (47 cardiovascular deaths and 89 re-admissions for acute heart failure). Lesser Echo-LVEF and CMR-LVEF associated with the occurrence of MACE but only CMR-LVEF and microvascular obstruction were independent predictors. The MACE rate significantly increased only in patients with CMR-LVEF <40% (≥50%: 7%, 40–49%: 9%, <40%: 27%, p<0.001). The majority of patients (629, 56%) displayed Echo-LVEF ≥50% and most of them (94%) were at the “safe zone” (CMR-LVEF >40%). On the other hand, 490 patients (44%) exhibited Echo-LVEF <50% and 33% of them were incorrectly classified either in the “safe zone” (CMR-LVEF ≥40%) or in the “risk zone” (CMR-LVEF <40%). C-statistic, NRI and IDI demonstrated potent reclassification for MACE prediction by CMR in patients with Echo-LVEF <50% but not in those with Echo-LVEF ≥50%.

Conclusions

Echo-LVEF <50% identifies the subset of discharged STEMI patients who may benefit most from CMR in terms of long-term risk prediction.

Figure 1. LVEF reclassification

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was funded by “Instituto de Salud Carlos III” and “Fondos Europeos de Desarrollo Regional FEDER” (PIE15/00013, PI17/01836, and CIBERCV16/11/00486 grants).

Comparison of cardiac MR feature tracking and myocardial MR tagging for assessment of regional ventricular function

Background

Quantification of regional myocardial function allows risk stratification in heart disease. CMR tagging (TAG) enables the evaluation of segmental cardiac deformation, but it has not reached clinical routine due to the long acquisition and post-processing times. Conversely, CMR feature-tracking (FT) is a post-processing method based on standard cine-MR imaging.

Purpose

To compare myocardial strain and torsion obtained with CMR-TAG and CMR-FT in healthy volunteers and myocardial infarction (MI).

Methods

42 subjects (18 healthy; 24 MI) underwent CMR (1.5T, cine/TAG sequences). Global and segmental (16-segment) circumferential strain (CS), and torsion were measured using FT (CVI42, Canada) and tagging (InTag, France). Inter-method agreement was assessed using 2-way-mixed intraclass correlation coefficient (ICC).

Results

The agreement for segmental and global CS measurements was good to excellent in both groups (Table). Torsion angle showed excellent (0.763) and good (0.697) agreement for healthy and MI.

Conclusion

CMR-FT strain and torsion measurements showed high agreement with CMR-tagging. Thus, CMR-FT provides a potential clinical alternative in the assessment of regional ventricular function.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Carlos III Health Institute, Spanish Ministry of Economy and Competiveness; Agencia Valenciana de la Innovaciόn, Generalitat Valenciana

P5445PCSK9 and 6-month Left Ventricular Ejection Fraction after ST-segment Elevation Myocardial Infarction. A Pilot Study

Background

Proprotein convertase subtilisin/kexin type 9 (PCSK9) has emerged as a therapeutic target for reducing plasma LDL. Beyond lipid control, recent findings suggest a deleterious effect of this protein in the pathogenesis of post-myocardial infarction left ventricle remodeling and heart failure-related complications. The aim of this work was to assess the relationship between circulating PCSK9 and 6-month cardiac magnetic resonance (CMR) imaging-derived left ventricle ejection fraction (LVEF) after a first ST-segment elevation myocardial infarction (STEMI).

Methods

We prospectively evaluated 40 patients with a first STEMI treated with primary percutaneous coronary intervention (PPCI) and LVEF<50% in which PCSK9 was measured 24h post-reperfusion. All patients underwent CMR imaging 1 week and 6 months after STEMI. The association between serum PCSK9 and 6-month LVEF was evaluated by ANCOVA. The following covariates were included in the final model; 1-week CMR-derived LVEF, age, gender, 1-week CMR-infarct size, plasma suppression of tumorigenicity-2 (ST2), low density lipoprotein-cholesterol, ante treatment with statins.

Results

The mean age of the sample was 60±12 years and 33 patients (82.5%) were male. Mean 1-week and 6-month LVEF were 41±7% and 48±10%, respectively. The mean±SD of PCSK9 was 1.93±0.38 U/mL. PCSK9 values were inversely related with 6-month LVEF (r=−0.35, p=0.028). The mean values of PCSK9 were significantly higher in patients with LVEF<50% at 6 months (2.06±0.29 vs. 1.80±0.41 U/mL, p=0.028). After a multivariate adjustment, circulating PCSK9 remained significant and inversely associated with 6-month LVEF (p=0.001).

Figure 1

Conclusions

In patients with a first STEMI treated with PCCI and reduced ejection fraction, circulating PCSK9 was associated with lower LVEF at 6 months.