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Berg CJ, Patel B, Reynolds M, Tuzovic M, Chew KW, Sico JJ, Bhattacharya D, Butt AA, Lim JK, Bedimo RJ, Brown ST, Gottdiener JS, Warner AL, Freiberg MS, So-Armah KA, Nguyen KL. Left Atrial Mechanics and Diastolic Function Among People Living With Human Immunodeficiency Virus (from the Veterans Aging Cohort Study). Am J Cardiol 2023; 186:50-57. [PMID: 36343446 PMCID: PMC10193525 DOI: 10.1016/j.amjcard.2022.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 09/27/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
Human immunodeficiency virus (HIV) infection is associated with subclinical cardiomyopathy, diastolic dysfunction, and increased risk of cardiovascular death. However, the relationship between left atrial (LA) mechanics and left ventricular (LV) diastolic function has not been evaluated in people living with HIV (PLWH) relative to HIV-uninfected (HIV-) controls. This is a multicenter, cross-sectional cohort analysis using the HIV Cardiovascular Disease substudy of the Veterans Aging Cohort Study database, which aimed to examine a cohort of PLWH and HIV- veterans without known cardiovascular disease. A total of 277 subjects (180 PLWH, 97 HIV-) with echocardiograms were identified. LV and LA phasic strain were derived and diastolic function was evaluated. Relationship between LA strain, LV strain, and the degree of diastolic dysfunction were assessed using analysis of variance and ordinal logistic regression with propensity weighting. In the PLWH cohort, 91.7% were on antiretroviral therapy and 86.1% had HIV viral loads <500 copies/ml. The mean (± SD) duration of infection was 9.7 ± 4.9 years. Relative to HIV- veterans, PLWH did not differ in LA mechanics and proportion of diastolic dysfunction (p = 0.31). Using logistic regression with propensity weighting, we found no association between HIV status and degree of diastolic dysfunction. In both cohorts, LA reservoir strain and LA conduit strain were inversely and independently associated with the degree of diastolic dysfunction. Compared with HIV- veterans, PLWH who are primarily virally suppressed and antiretroviral-treated did not differ in LA strain or LV diastolic dysfunction. If confirmed in other cohorts, HIV viral suppression may curtail adverse alterations in cardiac structure and function.
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Affiliation(s)
- Christopher J Berg
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Bobby Patel
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Maxwell Reynolds
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Mirela Tuzovic
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University School of Medicine, Stanford, California
| | - Kara W Chew
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Jason J Sico
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut; Center for Neuroepidemiology and Clinical Neurologic Research, Yale School of Medicine, New Haven, Connecticut; Neurology Service, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Debika Bhattacharya
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Adeel A Butt
- Weill Cornell Medical College, Doha Qatar and New York, New York; VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joseph K Lim
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Roger J Bedimo
- Department of Medicine, UT Southwestern Medical Center, Dallas, Texas; VA North Texas Healthcare System, Dallas, Texas
| | - Sheldon T Brown
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York; James J. Peters VA Medical Center, Bronx, New York
| | | | - Alberta L Warner
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Matthew S Freiberg
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee; GRECC VA Tennessee Valley Healthcare System, Nashville, Tennessee
| | | | - Kim-Lien Nguyen
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California.
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Tuzovic M, Tang X, Francisco N, Sell A, Drew R, Paloma A, Chow J, Liang D, Heidenreich P, Salerno M, Schnittger I, Haddad F. Reference change value of global longitudinal strain in clinical practice: A test-rest quality implementation project. Echocardiography 2022; 39:1522-1531. [PMID: 36376263 DOI: 10.1111/echo.15482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 09/26/2022] [Accepted: 10/16/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Reference change value (RCV) is used to assess the significance of the difference between two measurements after accounting for pre-analytic, analytic, and within-subject variability. The objective of the current study was to define the RCV for global longitudinal strain (GLS) using different semi-automated software in standard clinical practice. METHODS Using a test-retest study design, we quantified the median coefficient of variation (CV) for GLS using AutoStrain and Automated Cardiac Motion Quantification (aCMQ) by Philips. Triplane left-ventricular ejection fraction (LVEF) was measured for comparison. Multivariable regression analysis was performed to determine factors influencing test-retest CV including image quality and the presence of segmental wall motion abnormalities (WMA). RCV was reported using a standard formula assuming two standard deviations for repeated measurements; results were also translated into Bayesian probability. Total measurement variation was described in terms of its three different components: pre-analytic (acquisition), analytic (measuring variation), and within-subject (biological) variation. RESULT Of the 44 individuals who were screened, 41 had adequate quality for strain quantification. The mean age of the cohort was 56.4 ± 16.8 years, 41% female, LVEF was 55.8 ± 9.8% and the median and interquartile range for LV GLS was -17.2 [-19.3 to -14.8]%. Autostrain was more time efficient (80% less analysis time) and had a lower total median CV than aCMQ (CV = 7.4% vs. 17.6%, p < .001). The total CV was higher in patients with WMA (6.4% vs. 13.2%, p = .035). In non-segmental disease, the CV translates to a RCV of 15% (corresponding to a probability of real change of 80%). Assuming a within-subject variability of 4.0%, the component analysis identified that inter-reader variability accounts for 3.7% of the CV, while acquisition variability accounts for 4.0%. CONCLUSION Using test-retest analysis and CVs, we find that an RCV of 15% for GLS represents an optimistic estimate in routine clinical practice. Based on our results, a higher RCV of 17%-21% is needed in order to provide a high probability of clinically meaningful change in GLS in all comers. The methodology presented here for determining measurement reproducibility and RCVs is easily translatable into clinical practice for any imaging parameter.
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Affiliation(s)
- Mirela Tuzovic
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Xiu Tang
- Echocardiography Imaging Center, Cardiovascular Heath, Stanford Health Care, Stanford, California, USA
| | - Nadia Francisco
- Echocardiography Imaging Center, Cardiovascular Heath, Stanford Health Care, Stanford, California, USA
| | - April Sell
- Echocardiography Imaging Center, Cardiovascular Heath, Stanford Health Care, Stanford, California, USA
| | - Robert Drew
- Echocardiography Imaging Center, Cardiovascular Heath, Stanford Health Care, Stanford, California, USA
| | - Allan Paloma
- Echocardiography Imaging Center, Cardiovascular Heath, Stanford Health Care, Stanford, California, USA
| | - Judy Chow
- Echocardiography Imaging Center, Cardiovascular Heath, Stanford Health Care, Stanford, California, USA
| | - David Liang
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Paul Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA.,Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Michael Salerno
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
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Berg C, Patel B, Reynolds M, Tuzovic M, Chew K, Sico J, Bhattacharya D, Butt AA, Lim JK, Bedimo RJ, Brown ST, Gottdiener J, Warner A, Freiberg M, So-Armah K, Nguyen KL. LEFT ATRIAL STRAIN AND DIASTOLIC DYSFUNCTION AMONGST HIV-POSITIVE INDIVIDUALS: INSIGHTS FROM THE VETERANS AGING COHORT STUDY. J Am Coll Cardiol 2021. [DOI: 10.1016/s0735-1097(21)02780-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Tuzovic M, Brown SA, Yang EH, West BH, Bassi NS, Park S, Guha A, Ghosh AK, Ganatra S, Hayek SS, Moslehi J, Jahangir E. Implementation of Cardio-Oncology Training for Cardiology Fellows. JACC CardioOncol 2020; 2:795-799. [PMID: 34396296 PMCID: PMC8352041 DOI: 10.1016/j.jaccao.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Mirela Tuzovic
- Division of Cardiovascular Medicine, Department of Medicine, Stanford Medical Center, Stanford, California, USA
| | - Sherry-Ann Brown
- Cardio-oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric H Yang
- University of California Los Angeles Cardio-oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Brian H West
- Division of Cardiovascular Medicine, Department of Medicine, University of California San Diego School of Medicine, La Jolla, California, USA
| | - Nikhil S Bassi
- University of California Los Angeles Cardio-oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Sandy Park
- University of California Los Angeles Cardio-oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Avirup Guha
- Cardio-oncology Program, Division of Cardiology, Department of Medicine, The Ohio State University, Columbus, Ohio, USA.,Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Arjun K Ghosh
- Cardio-oncology Services, Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom.,University College London Hospital, London, United Kingdom.,Hatter Cardiovascular Institute, University College London, London, United Kingdom
| | - Sarju Ganatra
- Cardio-Oncology Program, Landsman Heart and Vascular Center, Division of Cardiology, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts, USA
| | - Salim S Hayek
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Javid Moslehi
- Cardio-oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Eiman Jahangir
- Cardio-oncology Program, Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Barrett CD, Dobos K, Liedtke M, Tuzovic M, Haddad F, Kobayashi Y, Lafayette R, Fowler MB, Arai S, Schrier S, Witteles RM. A Changing Landscape of Mortality for Systemic Light Chain Amyloidosis. JACC: Heart Failure 2019; 7:958-966. [DOI: 10.1016/j.jchf.2019.07.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 11/28/2022]
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Tuzovic M, Yang EH, Sevag Packard RR, Ganz PA, Fonarow GC, Ziaeian B. National Outcomes in Hospitalized Patients With Cancer and Comorbid Heart Failure. J Card Fail 2019; 25:516-521. [PMID: 30769035 PMCID: PMC7659987 DOI: 10.1016/j.cardfail.2019.02.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 02/03/2019] [Accepted: 02/07/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure (HF) and cancer are a significant cause of morbidity and mortality in the US. Due to overlapping risk factors, these two conditions often coexist. METHODS We sought to describe the national burden of HF for hospitalized patients with cancer. We identified adults admitted with a primary oncologic diagnosis in 2014 included in the National Inpatient Sample (NIS). Patient hospitalizations were divided based on presence or absence of comorbid HF. Primary outcomes included cost, length of stay (LOS), and inpatient mortality. Logistic regression analysis with cluster adjustment was performed to determine predictors of inpatient mortality. RESULTS There were 834,900 admissions for a primary oncologic diagnosis in patients without comorbid HF, and 64,740 (7.2%) admissions for patients with comorbid HF. Patients with HF were on average older and had more comorbidities. Patients with HF had significantly higher mean hospitalization cost ($22,571 vs $20,234, p-value <0.001), age-standardized LOS (12.7 vs 8.2 days, p-value <0.001), and age-standardized inpatient mortality (12.2% vs 4.5%, p-value <0.001). Presence of HF predicted inpatient mortality after adjusting for age, race, insurance payer, and comorbidity index (OR 1.12, 95% CI 1.04-20, p-value = 0.002). CONCLUSION Patients with cancer hospitalized with comorbid HF represent a high-risk population with increased costs and high inpatient mortality rates. More data is needed to determine what screening and treatment measures may improve outcomes.
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Affiliation(s)
- Mirela Tuzovic
- Division of Cardiology, UCLA Cardio-Oncology Program, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Eric H Yang
- VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - RenÉ R Sevag Packard
- Division of Cardiology, UCLA Cardio-Oncology Program, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California
| | - Patricia A Ganz
- Division of Hematology and Oncology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California
| | - Gregg C Fonarow
- Division of Cardiology, UCLA Cardio-Oncology Program, David Geffen School of Medicine at UCLA, Los Angeles, California; Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, UCLA Medical Center, Los Angeles, California
| | - Boback Ziaeian
- Division of Cardiology, UCLA Cardio-Oncology Program, David Geffen School of Medicine at UCLA, Los Angeles, California; VA Greater Los Angeles Healthcare System, Los Angeles, California.
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7
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Boralkar KA, Kobayashi Y, Moneghetti KJ, Pargaonkar VS, Tuzovic M, Krishnan G, Wheeler MT, Banerjee D, Kuznetsova T, Horne BD, Knowlton KU, Heidenreich PA, Haddad F. Improving risk stratification in heart failure with preserved ejection fraction by combining two validated risk scores. Open Heart 2019; 6:e000961. [PMID: 31217994 PMCID: PMC6546198 DOI: 10.1136/openhrt-2018-000961] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 03/18/2019] [Indexed: 02/06/2023] Open
Abstract
Introduction The Intermountain Risk Score (IMRS) was developed and validated to predict short-term and long-term mortality in hospitalised patients using demographics and commonly available laboratory data. In this study, we sought to determine whether the IMRS also predicts all-cause mortality in patients hospitalised with heart failure with preserved ejection fraction (HFpEF) and whether it is complementary to the Get with the Guidelines Heart Failure (GWTG-HF) risk score or N-terminal pro-B-type natriuretic peptide (NT-proBNP). Methods and results We used the Stanford Translational Research Integrated Database Environment to identify 3847 adult patients with a diagnosis of HFpEF between January 1998 and December 2016. Of these, 580 were hospitalised with a primary diagnosis of acute HFpEF. Mean age was 76±16 years, the majority being female (58%), with a high prevalence of diabetes mellitus (36%) and a history of coronary artery disease (60%). Over a median follow-up of 2.0 years, 140 (24%) patients died. On multivariable analysis, the IMRS and GWTG-HF risk score were independently associated with all-cause mortality (standardised HRs IMRS (1.55 (95% CI 1.27 to 1.93)); GWTG-HF (1.60 (95% CI 1.27 to 2.01))). Combining the two scores, improved the net reclassification over GWTG-HF alone by 36.2%. In patients with available NT-proBNP (n=341), NT-proBNP improved the net reclassification of each score by 46.2% (IMRS) and 36.3% (GWTG-HF). Conclusion IMRS and GWTG-HF risk scores, along with NT-proBNP, play a complementary role in predicting outcome in patients hospitalised with HFpEF.
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Affiliation(s)
- Kalyani Anil Boralkar
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Yukari Kobayashi
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Kegan J Moneghetti
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Vedant S Pargaonkar
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Mirela Tuzovic
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Gomathi Krishnan
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Matthew T Wheeler
- Department of Medicine, Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Dipanjan Banerjee
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology KU Leuven, Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Benjamin D Horne
- Intermountain Heart Institute, Intermountain Medical Center, Salt Lake City, Utah, USA
| | - Kirk U Knowlton
- Cardiovascular Diseases, Intermountain Medical Center, Murray, Utah, USA
| | - Paul A Heidenreich
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
| | - Francois Haddad
- Cardiovascular Institute, Stanford University School of Medicine, Stanford, California, USA
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Abstract
PURPOSE OF REVIEW Due to advancements in oncologic treatment strategies and techniques, the number of survivors who have undergone hematopoetic stem cell transplant (HCT) continues to increase in the United States; this number is projected to reach 502,000 by the year 2030. There is significant interest within the field of cardio-oncology to identify cardiotoxicity and cardiovascular disease in the HCT population. Epidemiologic studies analyzing both short- and long-term cardiovascular effects, risk stratification modeling, cardioprotective strategies, and expert consensus documents for cardiotoxicity surveillance recommendations are reviewed. RECENT FINDINGS Patients who have undergone HCT are at increased risk of cardiovascular events and mortality compared to matched controls. The type of cardiotoxicity and the incidence rates vary based on specific therapeutic regimens and pre-existing cardiovascular risk factors. Life-threatening cardiotoxicity can present during HCT as acute heart failure, arrhythmias, pericardial tamponade, or cardiac arrest; or it can present late after treatment as cardiomyopathy, ischemic heart disease, vascular disease, stroke, or comorbid conditions, such as hypertension and diabetes mellitus that are associated with cardiac events. HCT is associated with excess cardiovascular risk partially due to exposure to cardiotoxic chemotherapy and radiation, as well as indirect and direct detrimental effects on cardiovascular reserve. This review discusses the epidemiology and the known cardiotoxic effects of historical chemoradiation agents in addition to newer targeted therapies. Recent expert consensus statements from cardiology and hematology/oncology societies are reviewed in regard to risk stratification of the cancer patient based on the type of treatments. Finally, gaps in knowledge are identified with proposed avenues of research that will allow for more accurate risk assessment, prediction, and potential treatment of the HCT patient in attenuating the risk of developing both short- and long-term cardiovascular comorbidities.
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Affiliation(s)
- Mirela Tuzovic
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Monica Mead
- Division of Hematology and Oncology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Patricia A Young
- Division of Hematology and Oncology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Gary Schiller
- Division of Hematology and Oncology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
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9
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Kobayashi Y, Moneghetti KJ, Boralkar K, Amsallem M, Tuzovic M, Liang D, Yang PC, Narayan S, Kuznetsova T, Wu JC, Schnittger I, Haddad F. Challenging the complementarity of different metrics of left atrial function: insight from a cardiomyopathy-based study. Eur Heart J Cardiovasc Imaging 2018; 18:1153-1162. [PMID: 27638850 DOI: 10.1093/ehjci/jew121] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Accepted: 05/16/2016] [Indexed: 12/22/2022] Open
Abstract
Aims Left ventricular (LV) strain provides incremental values to LV ejection fraction (LVEF) in predicting outcome. We sought to investigate if similar relationship is observed between left atrial (LA) emptying fraction and LA strain. Methods and results In this study, we selected 50 healthy subjects, 50 patients with dilated, 50 hypertrophic, and 50 infiltrative (light-chain (AL) amyloidosis) cardiomyopathy (CMP). Echocardiographic measures included LVEF and LA emptying fraction as well as LV and LA longitudinal strain (LVLS and LALS). After regression analysis, comparison of least square means of LA strain among aetiologies was performed. Intraclass correlation coefficient (ICC) and coefficient of variation (COV) were used in the assessment of variability and reproducibility of LV and LA metrics. The mean LVLS and all LA metrics were impaired in patients with all CMP compared with healthy subjects. In contrast to the moderate relationship between LVEF and LVLS (r = -0.51, P < 0.001), there was a strong linear relationship between LA emptying fraction and LA strain (r = 0.87, P < 0.001). In multiple regression analysis, total LA strain was associated with LVLS (β = -0.48, P < 0.001), lateral E/e' (β = -0.24, P < 0.001), age (β = -0.21, P < 0.001), and heart rate (β = -0.14, P = 0.02). The least square mean of LA strain adjusted for the parameters was not different among aetiologies (ANOVA P = 0.82). The ICC (>0.77) and COV (<13) were acceptable. Conclusion In contrast to LV measures, there is a strong linear relationship between volumetric and longitudinal deformation indices of left atrium irrespective of CMP aetiology. Either LA emptying fraction or LA strain could be used as an important parameter in predictive models.
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Affiliation(s)
- Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Kegan J Moneghetti
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Kalyani Boralkar
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Myriam Amsallem
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Mirela Tuzovic
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - David Liang
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Phillip C Yang
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Sanjiv Narayan
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Tatiana Kuznetsova
- Research Unit Hypertension and Cardiovascular Epidemiology, KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Joseph C Wu
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Ingela Schnittger
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford School of Medicine, 300 Pasteur Drive, Stanford, CA 94305, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA 94305, USA
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10
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Abstract
PURPOSE OF REVIEW Cancer is a common cause of morbidity and mortality in the USA. While the association between venous thrombosis and malignancy is well established, arterial thrombosis has more recently been recognized as a serious complication of cancer and certain chemotherapeutic agents. This review aims to summarize the most recent literature regarding the incidence and risk factors for cancer-related arterial thrombosis, understand the pathophysiologic mechanisms of thrombosis, and highlight the specific diagnostic and treatment considerations relevant to cancer patients. RECENT FINDINGS Based on a recent study looking at the Surveillance, Epidemiology, and End Results (SEER) database, the incidence of arterial thromboembolic events (ATEs) in patients with cancer at 6 months is 4.7%; the presence of an ATE is predictive of worse outcomes. Certain drugs such as platinum-based agents, vascular endothelial growth factor inhibitors, tyrosine kinase inhibitors, and taxanes have been associated with high rates of ATEs. Increased platelet reactivity appears crucial to development of arterial thrombosis in cancer patients. Cancer patients have an increased risk of arterial thrombosis that is likely due to both a cancer-associated procoagulant state as well as the adverse effects of certain chemotherapeutic agents. Treatment of arterial thromboembolism in cancer patients typically requires a multidisciplinary approach in part due to high rates of thrombocytopenia and stent thrombosis in the setting of percutaneous interventions. More studies are needed to investigate optimal prophylaxis, surveillance strategies, and treatments of cancer-related arterial thromboembolic disease.
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Affiliation(s)
- Mirela Tuzovic
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA
| | - Joerg Herrmann
- Division of Cardiovascular Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Cezar Iliescu
- Division of Cardiology, Department of Medicine, MD Anderson Cancer Center, University of Texas at Houston, Houston, TX, USA
| | | | - Boback Ziaeian
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA
| | - Eric H Yang
- UCLA Cardio-Oncology Program, Division of Cardiology, Department of Medicine, University of California at Los Angeles, 100 Medical Plaza, Suite 630, Los Angeles, CA, 90095, USA.
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11
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Tuzovic M, Wu PT, Kianmahd S, Nguyen KL. Natural history of myocardial deformation in children, adolescents, and young adults exposed to anthracyclines: Systematic review and meta-analysis. Echocardiography 2018; 35:922-934. [PMID: 29603386 DOI: 10.1111/echo.13871] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Anthracyclines are widely used to treat solid and hematologic malignancies, but are known to cause cardiotoxicity. As more childhood cancer survivors reach adulthood due to improvements in oncologic treatments, they become susceptible to late and progressive anthracycline-induced cardiotoxicity. Nonetheless, diagnostic criteria for early detection of cardiac dysfunction are not well defined in children, adolescent, and young adults (CAYA, ages 1-40 years). We present a natural history of the changes in myocardial deformation in CAYA patients after anthracycline therapy. METHODS We performed a literature review search between 2001 and 2016 using PubMed with the following search terms: strain (or deformation), torsion (or twist), children (or adolescent or young adult), cardiotoxicity (or dysfunction), and anthracyclines (or doxorubicin). A total of 23 articles were reviewed. Fourteen articles were incorporated in the meta-analysis. RESULTS Strain abnormalities are observed at both short-term and long-term follow-up. Global longitudinal strain (GLS) abnormalities are common during or early after chemotherapy, whereas changes in global circumferential strain (GCS) are more significant and consistent on long-term follow-up. Although global radial strain and torsional parameters are also often abnormal late after chemotherapy, there are few studies evaluating these parameters. CONCLUSION There are significant abnormalities in GLS and GCS following anthracycline therapy acutely and late after treatment. The prognostic value of these strain abnormalities warrants further investigation.
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Affiliation(s)
- Mirela Tuzovic
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Pei-Tzu Wu
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Samuel Kianmahd
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA.,School of Medicine, Stony Brook University, New York, NY, USA
| | - Kim-Lien Nguyen
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,Division of Cardiology, VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
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Abstract
Cardiac amyloidosis in the United States is most often due to myocardial infiltration by immunoglobulin protein, such as in AL amyloidosis, or by the protein transthyretin, such as in hereditary and senile amyloidosis. Cardiac amyloidosis often portends a poor prognosis especially in patients with systemic AL amyloidosis. Despite better understanding of the pathophysiology of amyloid, many patients are still diagnosed late in the disease course. This review investigates the current understanding and new research on the diagnosis and treatment strategies in patients with cardiac amyloidosis. Myocardial amyloid infiltration distribution occurs in a variety of patterns. Structural and functional changes on echocardiography can suggest presence of amyloid, but CMR and nuclear imaging provide important complementary information on amyloid burden and the amyloid subtype, respectively. While for AL amyloid, treatment success largely depends on early diagnosis, for ATTR amyloid, new investigational agents that reduce production of transthyretin protein may have significant impact on clinical outcomes. Advancements in the non-invasive diagnostic detection and improvements in early disease recognition will undoubtedly facilitate a larger proportion of patients to receive early therapy when it is most effective.
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Affiliation(s)
- Mirela Tuzovic
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Eric H Yang
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Arnold S Baas
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Eugene C Depasquale
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Mario C Deng
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Daniel Cruz
- Ahmanson-UCLA Cardiomyopathy Center, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Gabriel Vorobiof
- Division of Cardiology, Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA. .,Cardiovascular Center, 100 Medical Plaza, Suite 545, 100 UCLA Medical Plaza, Los Angeles, CA, 90095, USA.
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Tuzovic M, Yang EH, Packard R, Ziaeian B. NATIONAL OUTCOMES IN HOSPITALIZED CANCER PATIENTS WITH CO-MORBID HEART FAILURE. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31238-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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14
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Boralkar K, Kobayashi Y, Pargaonkar V, Moneghetti K, Tuzovic M, Krishnan G, Amsallem M, Kouznetsova T, Horne B, Knowlton K, Heidenreich P, Haddad F. THE COMPLEMENTARY VALUE OF THE GET WITH THE GUIDELINES: HEART FAILURE RISK SCORE AND LABORATORY MARKERS AT DISCHARGE IN PREDICTING MORTALITY IN PATIENTS HOSPITALIZED WITH HEART FAILURE WITH PRESERVED EJECTION FRACTION. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31380-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tuzovic M, Kobayashi Y, Wheeler M, Barrett C, Liedtke M, Lafayette R, Schrier S, Haddad F, Witteles R. Functional Cardiac Recovery and Hematologic Response to Chemotherapy in Patients With Light-Chain Amyloidosis (from the Stanford University Amyloidosis Registry). Am J Cardiol 2017; 120:1381-1386. [PMID: 28844519 DOI: 10.1016/j.amjcard.2017.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/27/2017] [Accepted: 07/07/2017] [Indexed: 11/19/2022]
Abstract
Cardiac involvement is common in patients with light-chain (AL) amyloidosis and portends a poor prognosis, although little is known about the changes in cardiac mechanics after chemotherapy. We sought to explore the relation between amyloidosis staging and baseline cardiac mechanics and to investigate short-term changes in cardiac mechanics after chemotherapy. We identified 41 consecutive patients from the Stanford Amyloid Center who had echocardiograms and free light-chain values before and after chemotherapy, along with 40 age- and gender-matched controls. Echocardiographic assessment included left ventricular global longitudinal strain, E/e' ratio, and left atrial (LA) stiffness. Hematologic response to chemotherapy was defined as ≥50% reduction in the difference between the involved and the uninvolved free light chain (dFLC). The mean age was 66.9 ± 8.4 years and 66% were men. Before chemotherapy, global longitudinal strain, E/e' ratio, and LA stiffness were impaired in patients with amyloidosis compared with controls, and the severity of impairment worsened with advanced staging. After chemotherapy, hematologic response was observed in 30 (73%) patients. There was a significant association between the change in dFLC and cardiac function (E/e' ratio: r = -0.43, p = 0.01; LA stiffness: r = -0.35, p = 0.05). There was no significant improvement in cardiac mechanics in patients without a hematologic response to chemotherapy. In conclusion, amyloidosis stage correlated with noninvasive measurements of cardiac mechanics, and improvement in dFLC correlated with cardiac improvement on short-term follow-up echocardiography.
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Affiliation(s)
- Mirela Tuzovic
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthew Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Christopher Barrett
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Michaela Liedtke
- Division of Hematology, Stanford University School of Medicine, Stanford, California
| | - Richard Lafayette
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Stanley Schrier
- Division of Hematology, Stanford University School of Medicine, Stanford, California
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald Witteles
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
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Vijayasekaran S, Tuzovic M, deKemp RA, Canty J, Fallavollita J. PET REVERSE MISMATCH IS COMMON IN ISCHEMIC CARDIOMYOPATHY AND NOT LIMITED TO LEFT BUNDLE BRANCH BLOCK. J Am Coll Cardiol 2011. [DOI: 10.1016/s0735-1097(11)60790-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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