Multiple Phenotypes of Chronic Coronary Syndromes Identified by ABCDE Stress Echocardiography

BACKGROUND

Regional wall motion abnormality is considered a sensitive and specific marker of ischemia during stress echocardiography (SE). However, ischemia is a multifaceted entity associated with either coronary artery disease (CAD) or angina with normal coronary arteries, a distinction difficult to make using a single sign. The aim of this study was to evaluate the diagnostic potential of the five-step ABCDE SE protocol for CAD detection.

METHODS

From the 2016-2022 Stress Echo 2030 study data bank, 3,229 patients were selected (mean age, 66 ± 12 years; 2,089 men [65%]) with known CAD (n = 1,792) or angina with normal coronary arteries (n = 1,437). All patients were studied using both the ABCDE SE protocol and coronary angiography, within 3 months. In step A, regional wall motion abnormality is assessed; in step B, B-lines and diastolic function; in step C, left ventricular contractile reserve; in step D, coronary flow velocity reserve in the left anterior descending coronary artery; and in step E, heart rate reserve.

RESULTS

SE response ranged from a score of 0 (all steps normal) to a score of 5 (all steps abnormal). For CAD, rates of abnormal results were 347 for step A (19.4%), 547 (30.5%) for step B, 720 (40.2%) for step C, 615 (34.3%) for step D, and 633 (35.3%) for step E. For angina with normal coronary arteries, rates of abnormal results were 81 (5.6%) for step A, 429 (29.9%) for step B, 432 (30.1%) for step C, 354 (24.6%) for step D, and 445 (31.0%) for step E. The dominant "solitary phenotype" was step B in 109 patients (9.1%).

CONCLUSIONS

Stress-induced ischemia presents with a wide range of diagnostic phenotypes, highlighting its complex nature. Using a comprehensive approach such as the advanced ABCDE score, which combines multiple markers, proves to be more valuable than relying on a single marker in isolation.

Treatment adherence in patients without ST-elevation acute coronary syndrome

BACKGROUND

Despite progress during the last decades, patients with coronary artery disease (CAD) remain with a high residual risk due to multiple reasons. Optimal medical treatment (OMT) provides a decrease of recurrent ischemic events after acute coronary syndrome (ACS). Therefore, treatment adherence results crucial to reduce further outcomes after the index event. No recent data are available in Argentinian population; the main objective of our study was to evaluate the adherence at 6 and 15 months in post non-ST elevation acute coronary syndrome (NST-ACS) consecutive patients. Secondary objective was to evaluate the relationship of adherence with 15-month events.

METHODS

A prespecified sub-analysis in the prospective registry Buenos Aires I was performed. The adherence was evaluated using the modified Morisky-Green Scale.

RESULTS

A number of 872 patients had information about adherence profile. Of them 76.4% were classified as adherents at month 6 and 83.6% at 15 (P=0.06). We did not find any difference in baseline characteristic between the adherent and non-adherent patients at 6 months. The adjusted analysis showed that non-adherent patients had a rate of ischemic events at 15th month of 20% (27/135) vs. 11.5% (52/452) in adherent patients (P=0.001). The bleeding events defined were of 3.6% in the non-adherent group vs. 5% in the adherent group without a statistical difference (P=0.238).

CONCLUSIONS

Adherence to treatment is still a major issue as almost 25% of patients should be considered as non-adherent to OMT. No clinical predictor of this phenomenon was identified but our criteria were not exhaustive. Good adherence to treatment was highly associated to a reduction of ischemic events, whereas no impact on bleeding events was found. These data support a better network and collaboration with shared decision between healthcare professionals with patients and family members to improve acceptance and adherence to optimal medical strategies.

High Resting Coronary Flow Velocity by Echocardiography Is Associated With Worse Survival in Patients With Chronic Coronary Syndromes

BACKGROUND

Resting coronary flow velocity (CFV) in the mid-distal left anterior descending coronary artery can be easily assessed with transthoracic echocardiography. In this observational study, the authors sought to assess the relationship between resting CFV, CFV reserve (CFVR), and outcome in patients with chronic coronary syndromes.

METHODS AND RESULTS

In a prospective multicenter study design, the authors retrospectively analyzed 7576 patients (age, 66±11 years; 4312 men) with chronic coronary syndromes and left ventricular ejection fraction ≥50% referred for dipyridamole stress echocardiography. Recruitment (years 2003-2021) involved 7 accredited laboratories, with interobserver variability <10% for CFV measurement at study entry. Baseline peak diastolic CFV was obtained by pulsed-wave Doppler in the mid-distal left anterior descending coronary artery. CFVR (abnormal value ≤2.0) was assessed with dipyridamole. All-cause death was the only end point. The mean CFV of the left anterior descending coronary artery was 31±12 cm/s. The mean CFVR was 2.32±0.60. During a median follow-up of 5.9±4.3 years, 1121 (15%) patients died. At multivariable analysis, resting CFV ≥32 cm/s was identified by a receiver operating curve as the best cutoff and was independently associated with mortality (hazard ratio [HR], 1.24 [95% CI, 1.10-1.40]; P<0.0001) together with CFVR ≤2.0 (HR, 1.78 [95% CI, 1.57-2.02]; P<0.0001), age, diabetes, history of coronary surgery, and left ventricular ejection fraction. When both CFV and CFVR were considered, the mortality rate was highest in patients with resting CFV ≥32 cm/s and CFVR ≤2.0 and lowest in patients with resting CFV <32 cm/s and CFVR >2.0.

CONCLUSIONS

High resting CFV is associated with worse survival in patients with chronic coronary syndromes and left ventricular ejection fraction ≥50%. The value is independent and additive to CFVR. The combination of high resting CFV and low CFVR is associated with the worst survival.

Rest and Stress Left Atrial Dysfunction in Patients with Atrial Fibrillation

BACKGROUND

Left atrial (LA) myopathy with paroxysmal and permanent atrial fibrillation (AF) is frequent in chronic coronary syndromes (CCS) but sometimes occult at rest and elicited by stress.

AIM

This study sought to assess LA volume and function at rest and during stress across the spectrum of AF.

METHODS

In a prospective, multicenter, observational study design, we enrolled 3042 patients [age = 64 ± 12; 63.8% male] with known or suspected CCS: 2749 were in sinus rhythm (SR, Group 1); 191 in SR with a history of paroxysmal AF (Group 2); and 102 were in permanent AF (Group 3). All patients underwent stress echocardiography (SE). We measured left atrial volume index (LAVI) in all patients and LA Strain reservoir phase (LASr) in a subset of 486 patients.

RESULTS

LAVI increased from Group 1 to 3, both at rest (Group 1 = 27.6 ± 12.2, Group 2 = 31.6 ± 12.9, Group 3 = 43.3 ± 19.7 mL/m2, p < 0.001) and at peak stress (Group 1 = 26.2 ± 12.0, Group 2 = 31.2 ± 12.2, Group 3 = 43.9 ± 19.4 mL/m2, p < 0.001). LASr progressively decreased from Group 1 to 3, both at rest (Group 1 = 26.0 ± 8.5%, Group 2 = 23.2 ± 11.2%, Group 3 = 8.5 ± 6.5%, p < 0.001) and at peak stress (Group 1 = 26.9 ± 10.1, Group 2 = 23.8 ± 11.0 Group 3 = 10.7 ± 8.1%, p < 0.001). Stress B-lines (≥2) were more frequent in AF (Group 1 = 29.7% vs. Group 2 = 35.5% vs. Group 3 = 57.4%, p < 0.001). Inducible ischemia was less frequent in SR (Group 1 = 16.1% vs. Group 2 = 24.7% vs. Group 3 = 24.5%, p = 0.001).

CONCLUSIONS

In CCS, rest and stress LA dilation and reservoir dysfunction are often present in paroxysmal and, more so, in permanent AF and are associated with more frequent inducible ischemia and pulmonary congestion during stress.

Stress Echo 2030: the new ABCDE protocol defining the future of cardiac imaging

Functional testing with stress echocardiography is based on the detection of regional wall motion abnormality with two-dimensional echocardiography and is embedded in clinical guidelines. Yet, it under-uses the unique versatility of the technique, ideally suited to describe the different functional abnormalities underlying the same wall motion response during stress. Five parameters converge conceptually and methodologically in the state-of-the-art ABCDE protocol, assessing multiple vulnerabilities of the ischemic patient. The five steps of the ABCDE protocol are (1) step A: regional wall motion; (2) step B: B-lines by lung ultrasound assessing extravascular lung water; (3) step C: left ventricular contractile reserve by volumetric two-dimensional echocardiography; (4) step D: coronary flow velocity reserve in mid-distal left anterior descending coronary with pulsed-wave Doppler; and (5) step E: assessment of heart rate reserve with a one-lead electrocardiogram. ABCDE stress echo offers insight into five functional reserves: epicardial flow (A); diastolic (B), contractile (C), coronary microcirculatory (D), and chronotropic reserve (E). The new format is more comprehensive and allows better functional characterization, risk stratification, and personalized tailoring of therapy. ABCDE protocol is an 'ecumenic' and 'omnivorous' functional test, suitable for all stresses and all patients also beyond coronary artery disease. It fits the need for sustainability of the current era in healthcare, since it requires universally available technology, and is low-cost, radiation-free, and nearly carbon-neutral.

Myocardial Wringing and Rigid Rotation in Cardiac Amyloidosis

Background

The motion of the heart is a result of the helicoidal arrangement of the myofibers in the organ's wall. We aimed to study the relationship between the wringing motion state and the degree of ventricular function in patients with cardiac amyloidosis (CA).

Methods

Fifty patients with CA and decreased global longitudinal strain (LS) were evaluated using 2-dimensional speckle-tracking echocardiography. We have expressed LS as positive values to facilitate understanding. Normal twist, which occurs when basal and apical rotations occur in opposite directions, was coded as positive. When the apex and base rotate in the same direction (rigid rotation), twist was coded as negative. Left ventricular (LV) wringing (calculated as twist/LS, which takes into account actions that occur simultaneously during LV systole [ie, longitudinal shortening and twist]) was evaluated according to LV ejection fraction (LVEF).

Results

Most of the patients (66%) who participated in the study were diagnosed with transthyretin amyloidosis. A positive relationship was observed between wringing and LVEF (r = 0.75, P < 0.0001). In advanced stages of ventricular dysfunction, rigid rotation appeared in 66.6% of patients with LVEF ≤ 40%, in whom negative values of twist and wringing were observed. LV wringing proved to be a good discriminator of LVEF (area under the curve 0.90, P < 0.001, 95% confidence interval 0.79-0.97); for example, wringing < 1.30°/% detected LVEF < 50% with 85.7% sensibility and 89.7% specificity.

Conclusions

Wringing, which integrates twist and simultaneous LV longitudinal shortening, is a conditioning rotational parameter of the degree of ventricular function in patients with CA.

Left atrial volume, function and B-lines at rest and during vasodilator stress echocardiography

Background

Left atrial volume index (LAVi), left atrial reservoir function assessed with global peak amplitude longitudinal strain (PALS), and B-lines at lung ultrasound are supplementary markers of left ventricular filling pressures.

Aim

To assess the relationship between LAVi, PALS and B-lines at rest and peak vasodilator stress.

Methods

A comprehensive dipyridamole stress echo was completed in 266 patients (187 male, 71%, age 65±10 years) with chronic coronary syndromes. LAVi was measured with the biplane disk summation method. PALS was measured from a single vendor with 2-dimensional speckle tracking echocardiography and expressed in % values as the mean of the 12 atrial segments from 4- and 2-chamber values. B-lines were assessed with the simplified 4-site scan in the third intercostal space, with global score from 0 to 40, and considered significant with global score ≥2 units.

Results

During dipyridamole, LAVi decreased (rest= 26±14 ml/m2 vs stress= 24±12 ml/m2, p&lt;0.001), PALS increased (rest= 33±8 vs stress= 38±10%, p&lt;0.001), and B-lines were more frequent (rest= 0.4, median interquartile range 0–30, vs stress= 0.7, median interquartile range 0–30, units, p&lt;0.001). There was a significant, linear, inverse correlation between LAVi and PALS both at rest (r=−0.301, p&lt;0.001) and at peak stress (r=−0.279, p&lt;0.001, see figure). At group analysis, peak B-lines were directly correlated with peak LAVi (r=0.151, p=0.017) and inversely correlated with peak PALS (r=−0.234, p&lt;0.001). At individual patient analysis, 4/93 patients (4.3%) showed stress B-lines (black dots in figure) with normal LAVi (&lt;34 ml/m2) and preserved PALS (&gt;42%).

Conclusion

Vasodilator stress echocardiography with combined assessment of left atrial volume, function and pulmonary congestion is feasible with high success rate in patients with chronic coronary syndromes. Pulmonary congestion is more frequent with dilated left atrium with reduced atrial contractile reserve, but it may occur in a minority of patients with normal LAVi and normal PALS.

Funding Acknowledgement

Type of funding sources: None.

Heart rate reserve complements regional wall motion abnormality for predicting outcome in hypertensives during stress echocardiography

Background

Stress echocardiography (SE) was recently upgraded to include imaging-independent heart rate reserve (HRR) which assesses cardiac sympathetic balance and is simply based on one-lead electrocardiogram present in the echo monitor. The value of HRR for risk stratification of hypertensive patients remains undetermined.

Aim

To assess the prognostic value of SE with HRR in hypertensive patients in a prospective, large scale, multicenter, international, effectiveness study.

Methods

From July 2016 to December 2020, we enrolled 2747 hypertensives (age 66±10 years, 1599 males, 58.2%; ejection fraction 61±8%) referred from 12 certified laboratories. All patients underwent clinically indicated SE. The employed stress modality was exercise (n=754) or pharmacological stress (n=1993). Exercise modality was either semi-supine bike (n=674) or treadmill (n=80). Pharmacological stress was either vasodilator (n=1695, 1661 with dipyridamole and 34 with adenosine) or dobutamine (n=298). SE response included the evaluation of regional wall motion abnormality (RWMA) and non-imaging HRR (peak/rest heart rate), with stress-specific cutoff values abnormal response &lt;1.80 for exercise or dobutamine, &lt;1.22 for dipyridamole or adenosine. All-cause death was the only end-point.

Results

Rate of abnormal results was 17% for RWMA and 40% for HRR. During a median follow-up of 624 days (interquartile range: 380–1037 days), 60 deaths occurred. Global X2 was 25.0 considering clinical and resting echocardiographic variables, with no change after stress-induced RWMA and a significant increase after HRR (Figure 1). Annual mortality rate was 0.7% person/year for patients (n=1496) with normal HRR and absence of stress-induced RMWA, 0.4% for patients (n=151) with RWMA and normal HRR, up to 2.1% person/year for patients (n=1101) with abnormal HRR with (n=321) or without (n=780) RWMA. At multivariable analysis, only age (HR: 1.070, 95% CI: 1.039–1.101, p&lt;0.001) and abnormal HRR 2.651 (HR: 2.651, 95% CI: 1.550–4.543, p&lt;0.001) showed independent value in predicting survival.

Conclusion

SE with either exercise or pharmacological stress allows an effective prediction of survival in hypertensive patients with chronic coronary syndromes, but only when the conventional criterion of RWMA is complemented with imaging-independent HRR.

Funding Acknowledgement

Type of funding sources: None.

Prognostic value of rest B-lines with the simplified 4-site scan for predicting survival: incremental value over transthoracic echocardiography

Background

Lung ultrasound (LUS) detects pulmonary congestion as B-lines at rest.

Methods

After preliminary exclusion of 154 patients lost to follow-up, we analyzed transthoracic echocardiography (TTE) plus LUS (4-site simplified scan) data in 5165 subjects (age 64±11 years) referred to 19 certified centers of 9 countries for known or suspected coronary artery disease (n=3891, 75%), dyspnea (n=591, 12%), or screening in asymptomatic patients with risk factors (n=667, 13%). We analyzed the anterior and lateral hemi-thoraces, scanning from mid-axillary to mid-clavicular lines on the third intercostal space. B-lines score ranged from 0 (normal) to 40 (severely abnormal). By selection, follow-up information was available in all. All-cause death was the predetermined end-point.

Results

Feasibility of B-lines was 100% in all subjects. B-lines (median) were 0.1 [0–1]. Rest B-lines (≥2) were present in 863 patients (16.7%). Ejection fraction was 61±10%. After a median follow-up of 690 (Interquartile range 420–1065) days, 96 all-cause deaths occurred. Two-year mortality was 3.6% in patients with and 1.5% in patients without B-lines (p&lt;0.001) and increased progressively with the increasing number of B-lines, from 2.4% in mild (2–4, n=630), 5.0% in moderate (5–9, n=160) and 8.2% in patients with severe (≥10, n=73) B-lines (see figure). At multivariable analysis, rest B lines (HR 1.812, 95% CI: 1.165–2.916, p=0.008) and ejection fraction (HR 0.987, 95% CI: 0.976–0.998, p=0.020) were independent predictors of all-cause death, in addition to age (HR 1.045, 95% CI: 1.023–01.067, p&lt;0.001) and diabetes (HR 1.643, 95% CI: 1.079–2.503, p=0.021).

Conclusion

In all-comers referred for TTE, resting B-lines assessed by focused LUS with the simplified 4-site scan are detected in 1 out of 4 patients with symptos or coronary risk factors and are associated with worse survival. The severity of pulmonary congestion predicts the severity of outcomes. The prognostic value of resting B-lines is independent and additive over standard clinical and TTE predictors such as diabetes and ejection fraction. Focused LUS for pulmonary congestion can easily be incorporated in standard TTE examination.

Funding Acknowledgement

Type of funding sources: None.

Pulmonary Congestion During Exercise Stress Echocardiography in Ischemic and Heart Failure Patients

BACKGROUND

Lung ultrasound detects pulmonary congestion as B-lines at rest, and more frequently, during exercise stress echocardiography (ESE).

METHODS

We performed ESE plus lung ultrasound (4-site simplified scan) in 4392 subjects referred for semi-supine bike ESE in 24 certified centers in 9 countries. B-line score ranged from 0 (normal) to 40 (severely abnormal). Five different populations were evaluated: control subjects (n=103); chronic coronary syndromes (n=3701); heart failure with reduced ejection fraction (n=395); heart failure with preserved ejection fraction (n=70); ischemic mitral regurgitation ≥ moderate at rest (n=123). In a subset of 2478 patients, follow-up information was available.

RESULTS

During ESE, B-lines increased in all study groups except controls. Age, hypertension, abnormal ejection fraction, peak wall motion score index, and abnormal heart rate reserve were associated with B-lines in multivariable regression analysis. Stress B lines (hazard ratio, 2.179 [95% CI, 1.015-4.680]; P=0.046) and ejection fraction <50% (hazard ratio, 2.942 [95% CI, 1.268-6.822]; P=0.012) were independent predictors of all-cause death (n=29 after a median follow-up of 29 months).

CONCLUSIONS

B-lines identify the pulmonary congestion phenotype at rest, and more frequently, during ESE in ischemic and heart failure patients. Stress B-lines may help to refine risk stratification in these patients.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03049995.

PRECISE SCORE VALIDATION IN BUENOS AIRES 1 REGISTRY

The PRECISE-DAPT score predicts the bleeding risk in patients treated with dual antiplatelet treatment after PCI. We asess the prediction power of the score in patients suffering from non-ST elevation acute coronary syndromes. Our cohort included 862 patients from Buenos Aires 1 registry. The PRECISE-DAPT score was calculated upon admission and the follow up period was 15 months. The score as a continuous variable had low to moderate ability to predict bleeding events BARC 2, 3 or 5 (c-statistics 0.58 [95% CI, 0.52-0.61]); moderate at BARC 3 or 5 (c-statistics 0.72 [95% CI, 0.64-0.78]), and poor for MACE (c-statistics 0.49 [95% CI, 0,45-0.51]). PRECISE-DAPT score as a dichotomous variable (≥25, n= 210 [24%]) was associated with very high risk of bleeding (HR 2.1) and ischemic events (HR 1.9, 95% CI 1.8-2.1). As conclusion, PRECISE-DAPT score ≥25 was able to identify a subgroup of patients with high bleeding, and thrombotic events.

HIGH-SENSITIVITY TROPONIN T FOR THE RISK ASSESSMENT OF PATIENTS WITH ACUTE ATRIAL FIBRILLATION

Elevations of high-sensitivity troponin T (Hs-TnT) in the setting of acute atrial fibrillation (AF) are not clearly understood. This study evaluated factors associated with these elevations and its prognostic implication. We prospectively included 413 consecutive patients who presented to our institution with acute AF. The median Hs-TnT on admission was 12 ng/l and 39.4% had values above the 99th percentile. At one-year, AF recurrence occurred in 38.3% of patients and MACE in 5.6%. Hs-TnT levels were not associated with AF reversion (p 0.869) or with one-year AF recurrence (p 0.132) but they were with MACE (12 vs 24 ng/l, p 0.001). Thus, Hs-TnT was a strong predictor of MACE (HR 3.486, 95% CI 1.256-5.379, p 0.009) in this population. In conclusion, Hs-TnT elevation was frequently observed in patients with acute AF, and although it was not associated with AF reversion or recurrence, it was highly predictive of MACE at one-year.

Pulmonary congestion during exercise stress echocardiography in ischaemic, heart failure and valvular patients

Background

Lung ultrasound (LUS) detects pulmonary congestion as B-lines at rest and exercise stress echocardiography (ESE).

Aim

To assess the prevalence of B-lines during ESE in different cardiovascular diseases.

Methods

We performed ESE plus LUS (4-site simplified scan) in 4419 subjects referred for semi-supine bike ESE in 28 certified centers. B-lines score ranged from 0 (normal) to 40 (severely abnormal). Stress B-lines abnormal result was ≥2 units. Six different populations were evaluated: healthy controls (n=103); chronic coronary syndromes (CCS, n=3701); heart failure with reduced ejection fraction (HFrEF, n=395); heart failure with preserved ejection fraction (HFpEF, n=70); valvular heart disease (VHD) for ischemic mitral regurgitation ≥moderate at rest (n=123); repaired tetralogy of Fallot (ToF, n=27).

Results

Feasibility of B-lines was 100% at rest and peak ESE in all subjects. Imaging and analysis time were &lt;1 minute. B-lines (median) were not detectable in healthy subjects (rest=0.1 [0–1] vs 0.1 [0–1], p=ns) and TOF (rest=0.2 [0–2] vs 0.3 [0–4], p=ns), but were present in all other groups: see figure. During ESE, B-lines increased in CCS (rest=0.5 [0–24] vs ESE=1.3 [0–28], p&lt;0.001); HFrEF (rest=1.4 [0–35] vs ESE=2.9 [0–40], p&lt;0.001); HFpEF (rest=0.3 [0–2] vs ESE=3.4 [0–12], p&lt;0.001), VHD (rest=1.7 [0–12] vs ESE=4.3 [0–23], p&lt;0.001). Stress B-lines were correlated with stress-rest change in wall motion score index in CCS (r=0.325, p&lt;0.001), contractile reserve in HFrEF (r=−0.266, p&lt;0.001) and in VHD (r=−.0300, p=0.001), left atrial volume stress-rest change in HFpEF (r=0.287, p=0.043).

Conclusion

B-lines identify the pulmonary congestion phenotype at rest and more frequently during ESE in patients with different coronary, myocardial or valvular heart disease, all sharing the final common pathway of acute backward left heart failure through different disease-specific mechanisms. B-lines are absent in healthy subjects and in conditions inducing a mostly right-sided overload such as repaired ToF.

Funding Acknowledgement

Type of funding sources: None. Figure 1. B-lines at rest and during stress. Percentage (%) of rest (empty bar) and stress (full bar) B-lines abnormality (≥2 units) in six different study groups.

Comprehensive diastolic exercise stress echocardiography in heart failure with preserved ejection fraction

Background

In heart failure with preserved ejection fraction (HFpEF), diastolic exercise stress echocardiography (ESE) is currently recommended with E/e' and systolic pulmonary artery pressure (SPAP) from tricuspid regurgitant jet velocity (TRV).

Purpose

To evaluate conventional and advanced ESE parameters in patients with HFpEF.

Methods

We prospectively screened 124 patients with suspected HFpEF (dyspnea, resting EF &gt;50%, increased natriuretic peptide levels) and HFA-PEFF score ≥1. Of these 124, 10 patients were excluded for history of coronary artery disease, 3 for severe mitral regurgitation (MR), 12 for inducible ischemia. The final study population consisted of 99 patients (mean age 63±7 yrs, 57 females). All underwent ESE, with semi-supine bike (n=35), upright bike (n=20) or treadmill (n=44 patients) in 11 accredited labs from 9 countries (Argentina, Brazil, Bulgaria, Hungary, Italy, Lithuania, Mexico, Russia and Spain). In addition to E/e' average (abnormal stress response ≥15 units) and TRV (abnormal stress response &gt;3.4 m/s), we measured 8 additional criteria: B-lines (4-site simplified scan, abnormal stress value ≥2); cardiac index (CI) reserve (increase from rest to stress, abnormal &lt;1.63 l/min/m2), ejection fraction (EF, abnormal increase &lt;5%), global longitudinal strain (GLS, abnormal increase &lt;2%), end-diastolic volume (EDV, abnormal stress &lt; rest); heart rate reserve (HRR, abnormal &lt;1.80); left atrial volume index, (LAVI, abnormal increase &gt;6.8 ml/m2); MR (abnormal, stress value more than mild).

Results

Technical success rate during stress ranged from 100% for B-lines to 75% for GLS: see Table. At individual criteria analysis, positivity rate in interpretable studies ranged from 67% of HRR to 10% of peak MR: see table. At individual patient analysis, an abnormal response in 1 ESE criterion occurred in 4 pts (4%), of 2 to 4 criteria in 71 pts (72%) and of ≥5 criteria in 24 (24%).

Conclusion

In suspected HFpEF, ESE is helpful in the screening phase to identify extra-diastolic causes of dyspnea such as myocardial ischemia or severe MR. In the diagnostic phase, a comprehensive ESE captures the functional heterogeneity of HFpEF, with variable association of multiple phenotypes, the most frequent represented by reduced chronotropic, cardiac or contractile reserve and pulmonary congestion.

Funding Acknowledgement

Type of funding sources: None.

Hemodynamic Heterogeneity of Reduced Cardiac Reserve Unmasked by Volumetric Exercise Echocardiography

Background: Two-dimensional volumetric exercise stress echocardiography (ESE) provides an integrated view of left ventricular (LV) preload reserve through end-diastolic volume (EDV) and LV contractile reserve (LVCR) through end-systolic volume (ESV) changes. Purpose: To assess the dependence of cardiac reserve upon LVCR, EDV, and heart rate (HR) during ESE. Methods: We prospectively performed semi-supine bicycle or treadmill ESE in 1344 patients (age 59.8 ± 11.4 years; ejection fraction = 63 ± 8%) referred for known or suspected coronary artery disease. All patients had negative ESE by wall motion criteria. EDV and ESV were measured by biplane Simpson rule with 2-dimensional echocardiography. Cardiac index reserve was identified by peak-rest value. LVCR was the stress-rest ratio of force (systolic blood pressure by cuff sphygmomanometer/ESV, abnormal values ≤2.0). Preload reserve was defined by an increase in EDV. Cardiac index was calculated as stroke volume index * HR (by EKG). HR reserve (stress/rest ratio) <1.85 identified chronotropic incompetence. Results: Of the 1344 patients, 448 were in the lowest tertile of cardiac index reserve with stress. Of them, 303 (67.6%) achieved HR reserve <1.85; 252 (56.3%) had an abnormal LVCR and 341 (76.1%) a reduction of preload reserve, with 446 patients (99.6%) showing ≥1 abnormality. At binary logistic regression analysis, reduced preload reserve (odds ratio [OR]: 5.610; 95% confidence intervals [CI]: 4.025 to 7.821), chronotropic incompetence (OR: 3.923, 95% CI: 2.915 to 5.279), and abnormal LVCR (OR: 1.579; 95% CI: 1.105 to 2.259) were independently associated with lowest tertile of cardiac index reserve at peak stress. Conclusions: Heart rate assessment and volumetric echocardiography during ESE identify the heterogeneity of hemodynamic phenotypes of impaired chronotropic, preload or LVCR underlying a reduced cardiac reserve.

Influence of Ventricular Wringing on the Preservation of Left Ventricular Ejection Fraction in Cardiac Amyloidosis

BACKGROUND

The purpose of this work was to determine the influence of myocardial wringing on ventricular function in patients with cardiac amyloidosis (CA).

METHODS

Fifteen healthy volunteers (group 1) and 34 patients with CA (17 with left ventricular ejection fractions [LVEFs] ≥ 53% [group 2] and 17 with LVEFs < 53% [group 3]) were evaluated using two-dimensional speckle-tracking echocardiography. A control group of mass-matched patients (n = 20) with left ventricular (LV) hypertrophy and LVEFs ≥ 53% was also included. Longitudinal strain (LS), circumferential strain, and LV twist and torsion were calculated. Deformation index (DefI), a new parameter of wringing, calculated as twist/LS, that takes into account actions that occur simultaneously during LV systole (i.e., longitudinal shortening and twist), was evaluated. Torsional and wringing parameters were calculated according to LVEF.

RESULTS

Lower global values of LS and circumferential strain were observed among patients with CA (LS: group 1, -20.6 ± 2.5%; group 2, -11.6 ± 4.1%; group 3, -9.0 ± 3.1%; circumferential strain: group 1, -22.7 ± 4.9%; group 2, -14.4 ± 8.0%; group 3, -13.6 ± 3.8%; P < .001 for both). Torsion did not vary between group 2 and group 1 (2.5 ± 1.1°/cm vs 2.7 ± 0.8°/cm, P = NS). In contrast, DefI was greater in group 2 than in group 1 (-1.8 ± 0.8°/% vs -1.0 ± 0.3°/%, P < .01). Torsion and DefI were lower in group 3 (1.2 ± 0.7°/cm and -1.1 ± 0.6°/%, respectively, P < .001 for both) than in group 2. DefI was similar in patients with LV hypertrophy (-1.7 ± 0.6°/%, P = NS) and group 2.

CONCLUSIONS

In patients with CA, preservation of LVEF depends on greater ventricular wringing. DefI, a parameter that integrates the twist and the simultaneous longitudinal shortening of the left ventricle, is a more accurate indicator of the efficacy of this mechanism.

The spectrum of functional responses during ABCDE stress echocardiography

Background

The new methodological standard in stress echo (SE) is the comprehensive approach with ABCDE protocol: step A for regional wall motion abnormalities (RWMA); step B for B-lines by lung ultrasound; step C for left ventricular contractile reserve (LVCR); step D for Doppler-based coronary flow velocity reserve (CFVR) in left anterior descending coronary artery; and step E for imaging-independent EKG-based heart rate reserve (HRR).

Purpose

To assess the feasibility of ABCDE-SE in a prospective, large scale, multicenter, international, effectiveness study.

Methods

From September 2016 to December 2019, we enrolled 4,585 all-comers patients (age 63±11 years, 2,566 males, 56%; ejection fraction 61±9%) with known or suspected chronic coronary artery disease referred to clinically-driven SE with exercise (n=1,774, 38.7%), dipyridamole (n=2,403, 52.4%), dobutamine (n=375, 8.2%) or adenosine (n=33, 0.7%). Recruitment involved 13-certified laboratories of 7 countries. All patients underwent ABCDE-SE. The same transducer was used for cardiac and lung scan. Criteria for abnormal response were: stress-induced changes in RWMA in 2 contiguous segments for step A; stress-rest increase in B-lines ≥2 for step B (4-site simplified scan, each site scored from 0= A-lines or black lung to 10= white lung for coalescing B-lines); LVCR ≤2.0 for exercise and dobutamine (≤1.1 for vasodilators) for step C; CFVR in LAD ≤2.0 for step D; HRR (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators) for step E.

Results

Success rate was 98%, 100%, 99%, 86% and 100% for A, B, C, D and E steps, respectively. The positivity rate was 19% for A, 27% for B, 35% for C, 27% for D and 37% for E. All 5 parameters were normal in 1,496 patients (32.6%), all 5 were abnormal in 183 patients (4.0%). Most patients had abnormal response of 1 (n=1,356, 29.6%), 2 (n=788, 17.2%), 3 (n=477, 9.7%) or 4 (n=315, 6.9%) criteria (see Figure).

Conclusions

ABCDE-SE is extremely feasible, user-friendly, with minimal increase in imaging and off-line analysis time. It allows a comprehensive and personalized functional stratification assessing different vulnerabilities: epicardial coronary artery stenosis (step A), pulmonary congestion (step B), global myocardial dysfunction (step C), coronary microcirculatory dysfunction (step D), and cardiac autonomic nervous system imbalance (step E). The SE response is not only black and white with step A but can be effectively titrated from benign green code (all steps negative) to more functionally malignant red code (at least 3 steps positive).

Figure 1

Funding Acknowledgement

Type of funding source: None

Left atrial volume stress echocardiography in chronic coronary syndromes

Background

An enlarged left atrial volume index (LAVI) at rest mirrors increased LA pressure and/or impairment of LA function. A cardiovascular stress may acutely modify LAVI within minutes.

Purpose

To assess the feasibility and functional correlates of LAVI-stress echocardiography (SE)

Methods

Out of 514 subjects referred to 10 quality-controlled labs, LAVI-SE was completed in 490 (359 male, age 67±12 yrs, ejection fraction 60±10%) with suspected or known chronic coronary syndromes (n=462) or asymptomatic controls (n=28). The utilized stress was exercise in 177, vasodilator in 167, dobutamine in 146. LAVI was measured with the biplane disk summation method. SE was performed with the ABCDE protocol. In a single center sub-study in 50 subjects, including 28 controls and 22 patients, also peak longitudinal atrial strain (PALS, %) was measured as an index of LA reservoir function.

Results

The intra-observer and inter-observer LAVI variability were 5% and 8%, respectively. Δ-LAVI changes (stress-rest) were negatively correlated with resting LAVI (r=−0.271, p&lt;0.001), heart rate reserve (r=−0.239, p&lt;0.001), and Δ-PALS (n=50, r=−0.374, p=0.007).LAVI-dilators were defined as those with stress-rest increase ≥6.8 ml/m2, a cutoff derived from a calculated reference change value above the biological, analytical and observer variability of LAVI. LAVI dilation (see figure) occurred in 56 patients (11%). At multivariable logistic regression analysis, B-lines ≥2 (OR: 2.586, 95% CI =1.1293–5.169, p=0.007) and abnormal left ventricular contractile reserve (OR: 2.207, 95% CI=1.111–4.386, p=0.024) were associated with LAVI dilation.

Conclusion

LAVI-SE is feasible, with high success rate and low variability, in patients with chronic coronary syndromes. A wet (increased B-lines) and weak (reduced LV contractile reserve and LA reservoir function) heart frequently portends LAVI dilation during stress.

Figure 1

Funding Acknowledgement

Type of funding source: None

Feasibility and functional correlates of left atrial volume changes during stress echocardiography in chronic coronary syndromes

An enlarged left atrial volume index (LAVI) at rest mirrors increased LA pressure and/or impairment of LA function. A cardiovascular stress may acutely modify left atrial volume (LAV) within minutes. Aim of this study was to assess the feasibility and functional correlates of LAV-stress echocardiography (SE) Out of 514 subjects referred to 10 quality-controlled labs, LAV-SE was completed in 490 (359 male, age 67 ± 12 years) with suspected or known chronic coronary syndromes (n = 462) or asymptomatic controls (n = 28). The utilized stress was exercise in 177, vasodilator in 167, dobutamine in 146. LAV was measured with the biplane disk summation method. SE was performed with the ABCDE protocol. The intra-observer and inter-observer LAV variability were 5% and 8%, respectively. ∆-LAVI changes (stress-rest) were negatively correlated with resting LAVI (r = - 0.271, p < 0.001) and heart rate reserve (r = -.239, p < 0.001). LAV-dilators were defined as those with stress-rest increase ≥ 6.8 ml/m², a cutoff derived from a calculated reference change value above the biological, analytical and observer variability of LAVI. LAV dilation occurred in 56 patients (11%), more frequently with exercise (16%) and dipyridamole (13%) compared to dobutamine (4%, p < 0.01). At multivariable logistic regression analysis, B-lines ≥ 2 (OR: 2.586, 95% CI = 1.1293-5.169, p = 0.007) and abnormal contractile reserve (OR: 2.207, 95% CI = 1.111-4.386, p = 0.024) were associated with LAV dilation. In conclusion, LAV-SE is feasible with high success rate and low variability in patients with chronic coronary syndromes. LAV dilation is more likely with reduced left ventricular contractile reserve and pulmonary congestion.

Lung Ultrasound and Pulmonary Congestion During Stress Echocardiography

OBJECTIVES

The purpose of this study was to assess the functional and prognostic correlates of B-lines during stress echocardiography (SE).

BACKGROUND

B-profile detected by lung ultrasound (LUS) is a sign of pulmonary congestion during SE.

METHODS

The authors prospectively performed transthoracic echocardiography (TTE) and LUS in 2,145 patients referred for exercise (n = 1,012), vasodilator (n = 1,054), or dobutamine (n = 79) SE in 11 certified centers. B-lines were evaluated in a 4-site simplified scan (each site scored from 0: A-lines to 10: white lung for coalescing B-lines). During stress the following were also analyzed: stress-induced new regional wall motion abnormalities in 2 contiguous segments; reduced left ventricular contractile reserve (peak/rest based on force, ≤2.0 for exercise and dobutamine, ≤1.1 for vasodilators); and abnormal coronary flow velocity reserve ≤2.0, assessed by pulsed-wave Doppler sampling in left anterior descending coronary artery and abnormal heart rate reserve (peak/rest heart rate) ≤1.80 for exercise and dobutamine (≤1.22 for vasodilators). All patients completed follow-up.

RESULTS

According to B-lines at peak stress patients were divided into 4 different groups: group I, absence of stress B-lines (score: 0 to 1; n = 1,389; 64.7%); group II, mild B-lines (score: 2 to 4; n = 428; 20%); group III, moderate B-lines (score: 5 to 9; n = 209; 9.7%) and group IV, severe B-lines (score: ≥10; n = 119; 5.4%). During median follow-up of 15.2 months (interquartile range: 12 to 20 months) there were 38 deaths and 28 nonfatal myocardial infarctions in 64 patients. At multivariable analysis, severe stress B-lines (hazard ratio [HR]: 3.544; 95% confidence interval [CI]: 1.466 to 8.687; p = 0.006), abnormal heart rate reserve (HR: 2.276; 95% CI: 1.215 to 4.262; p = 0.010), abnormal coronary flow velocity reserve (HR: 2.178; 95% CI: 1.059 to 4.479; p = 0.034), and age (HR: 1.031; 95% CI: 1.002 to 1.062; p = 0.037) were independent predictors of death and nonfatal myocardial infarction.

CONCLUSIONS

Severe stress B-lines predict death and nonfatal myocardial infarction. (Stress Echo 2020-The International Stress Echo Study [SE2020]; NCT03049995).

Feasibility and value of two-dimensional volumetric stress echocardiography

BACKGROUND

Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV).

METHODS

We enrolled 4735 patients (age 63.6±11.3 years, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (N.=1992 patients) and adenosine (N.=18); ≤2.0 for exercise (N.=2087) or dobutamine (N.=638).

RESULTS

Force-based LVCR was obtained in all 4735 patients. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57% of patients with abnormal LVCR nevertheless showed increase in stroke volume.

CONCLUSIONS

Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

Feasibility and value of two-dimensional volumetric stress echocardiography

BACKGROUND

Stroke volume response during stress is a major determinant of functional status in heart failure and can be measured by two-dimensional (2-D) volumetric stress echocardiography (SE). The present study hypothesis is that SE may identify mechanisms underlying the change in stroke volume by measuring preload reserve through end-diastolic volume (EDV) and left ventricular contractile reserve (LVCR) with systolic blood pressure and end-systolic volume (ESV).

METHODS

We enrolled 4,735 patients (age 63.6 ± 11.3 yrs, 2800 male) referred to SE for known or suspected coronary artery disease (CAD) and/or heart failure (HF) in 21 SE laboratories in 8 countries. In addition to regional wall motion abnormalities (RWMA), force was measured at rest and peak stress as the ratio of systolic blood pressure by cuff sphygmomanometer/ESV by 2D with Simpson's or linear method. Abnormal values of LVCR (peak/rest) based on force were ≤1.10 for dipyridamole (n=1,992 patients) and adenosine (n=18); ≤2.0 for exercise (n=2,087) or dobutamine (n=638).

RESULTS

Force-based LVCR was obtained in all 4,735 pts. Lack of stroke volume increase during stress was due to either abnormal LVCR and/or blunted preload reserve, and 57 % of patients with abnormal LVCR nevertheless showed increase in stroke volume.

CONCLUSIONS

Volumetric SE is highly feasible with all stresses, and more frequently impaired in presence of ischemic RWMA, absence of viability and reduced coronary flow velocity reserve. It identifies an altered stroke volume response due to reduced preload and/or contractile reserve.

P971 The echocardiographic phenotype in patients with cardiac amyloidosis and heart failure with preserved ejection fraction

BACKGROUND

New echocardiographic phenotypes of heart failure (HF) are focused on myocardial systolic involvement of the left ventricle (LV), either endocardial and/or transmural.

PURPOSE.

To study the pattern of myocardial involvement in patients (p) with HF with preserved left ventricular ejection fraction (pLVEF) and cardiac amyloidosis (CA).

METHODS.

Comparative study of 16 p with CA and HF with pLVEF, considering as cut point LVEF &gt; 50%, in NYHA class ≥ II / IV, and a control group of 16 healthy people. Longitudinal Strain (LS) and Circumferential Strain (CS) were calculated using 2D speckle-tracking echocardiography, along with Mitral Annulus Plane Systolic Excursion (MAPSE) and Base-Apex distance (B-A). Also, the following indexes were calculated: Twist (apical rotation + basal rotation, º); Classic Torsion (TorC): (twist/B-A, º/cm); Torsion Index (Tor.I): (twist/MAPSE, º/cm) and Deformation Index (Def.I): (twist/LS, º).

We suggest the introduction of these dynamic torsion indexes as Tor.I and Def.I that include twist per unit of longitudinal systolic shortening of the LV instead of using TorC which is the normalisation of twist to the end-diastolic longitudinal diameter of the LV.

RESULTS

There were no differences of age between the groups (68.2 ± 11.5 vs 63.7 ± 2.8 years, p = 0.14). Global values of LS and CS were lower in p with CA indicating endocardial and transmural deterioration during systole, while TorC and Twist of the LV remained conserved in p with CA.

However, there is an increase of dynamic torsion parameters such as Tor.I and Def.I that show an increased Twist per unit of longitudinal shortening of the LV in the CA group (Table).

CONCLUSIONS

In p with CA and HF with pLVEF, the impairment of LS and CS indicates endocardial and transmural systolic dysfunction. In these conditions, LVEF would be preserved at the expense of a greater dynamic torsion of the LV.

Table LS (%) CS (%) Twist (º) TorC (º/cm) Tor.I (º/cm) Def.I (º/%) CA pLVEF (n = 16) -11.7 ± 4.2 17.2 ± 4.8 19.8 ± 8.3 2.5 ± 1.1 27.7 ± 13.5 -1.8 ± 0.9 Control Group (n = 15) -20.6 ± 2.5 22.7 ± 4.9 21.7 ± 6.1 2.7 ± 0.8 16.4 ± 4.7 -1.0 ± 0.3 p &lt; 0.001 &lt; 0.01 0.46 0.46 &lt; 0.01 &lt; 0.01 Dynamic Torsion Indexes and Classic Torion Parameters in pLVEF CA patients vs Control group.

P1402 The behavior of regional longitudinal strain depends on the coronary reserve in a simultaneous analysis during Dipyridamol Stress Echocardiography Test

Objectives

Compare the behavior of the Apical LS and GLS with the value of the CFR in the LADA and as a secondary objective to compare these responses with a simultaneous visual analysis of the motility during EchoDipi.

Materials and methods

179 patients (p) were included (age 68.7 ± 7 years). Of them, 113p(65%) were men. At the peak of the effect of Dipi(0.84mg/kg in 4m) the CFR was measured in the distal region of the LADA(Normal Value≥2). The subjects were divided into 2 groups(G): G1: p with CFR of the LAD≥2 and G2 p with LADA CFR &lt; 2. ApRLS was defined as the average of the 4 apical segments, in 4, 3 and 2 apical views, considering any increase in the percentage of deformation as normal. The LGS and wall motility of the 17 segments were evaluated; p with LBBB or wall motion abnormalities were excluded.

Results

Of 179 p, 113p(63.12%) were included in G1 and 66p(36.87%) in G2. G1 were older(65.9 ± 10.27 vs 72.2 ± 9.31,p &lt; 0.02), without significant differences in other clinical characteristics. No differences in the values of LGS and the Ap RLS at rest between G1 and G2 (GLS: G1: -19.8 ± 4.8 vs G2: -20.27 ± 2.6 p = NS; Ap RLS G1: -25.41 ± 4.75 vs G2: -26.73 ± 7.6 p = NS). During EchoDipi GLS and Ap RLS increased in the pts of G1 with a significant worsening in the G2 (SLG: G1: -22.98 ± 4.31 vs G2: -17.82 ± 2.70, p &lt; 0.0001; Ap SLR G1: -28.43 ± 5.6 vs. G2: -22.78 ± 7.41, p &lt; 0.0001). We observed that in 96.7% of p G1 the ApRLS increased strain with the stress meanwhile 95.31% of the G2 decrease(p &lt; 0.0001). Negative predictive value (NPV) :95.6%(CI = 87.8-98.5%), positive predictive value (PPV) =96.8%(CI = 89.0-99.1%).Specificity(E): 97%(CI = 89.9-99.2%),Sensibility(S): 95.2%(CI = 86.9-98.4%). Area Under the ROC curve(AUC)=0.92. The behavior of the GLS showed that 82.8% of the pts of the G1 during EchoDipi increased their Strain values in contrast with 78.8% p of the G2 decrease p &lt; 0.01).NPV 78.8%(CI = 67.5-86.9%),PPV:90.8%(CI = 83.9-94.9%),E:83.9% (CI = 72.8-91.0%),S:87.6%(CI = 80.3-92.5%).AUC ROC= 0.84. The analysis of wall motility showed that 96.46%(109p) of G1 had preserved wall motility, 1 p showed contractility abnormalities and decreased ApRLS. Of the G2, 36p showed conserved contractility during the stress.

Conclusions.There was a close correlation between LADA coronary flow reserve and the contractile reserve evaluated by regional longitudinal strain of the 4 apical segments, which was superior to the use of global longitudinal strain. The Apical Strain showed a better correlation with the LADA coronary flow reserve than with the visual analysis of wall motion.

P308 Changes in the echocardiographic phenotype during the evolution of cardiac amyloidosis from preserved to reduced left ventricle ejection fraction

Introduction

Cardiomyopaties like Cardiac Amyloidosis (CA), are an important cause of Heart Failure (HF). They can cause endocardial or transmural involvement. It is possible to characterize the kind of affectation thanks to different phenotypes identified by 2D speckle tracking echocardiography. Purpose: To study the pattern of myocardial involvement in patients (p) affected by CA and HF. Methods: Comparative study of 30 p with CA and HF, in NYHA class ≥II/IV, of which 16 had preseved left ventricle ejection fraction (pLVEF) and 14 had reduced LVEF (rLVEF), considering as cut point a LVEF &gt; 50%. There was a control group (CG) of 16 healthy subjects. Twist, radial strain (RS), circunferential strain (CS) and longitudinal strain (LS) were determined using 2D speckle-tracking echocardiography, along with mitral annulus plane systolic excursion (MAPSE) and basal-apex distance (B-A). The following indexes were calculated: Twist (apical rotation + basal rotation, °); Torsion (twist/B-A, °/cm); Torsion Index (TorI: twist/MAPSE, °/cm), and Deformation Index (DefI:twist/LS,°). The last indexes are dynamic parameters that allow for a more realistic assessment of LV torsion, since they include longitudinal shortening measures such as MAPSE and LS, describing in a more complete and physiological way the global LV systolic movement.

Results

There were differences of age between the three gropus, being older the p with rLVEF and younger the ones in the CG (63,7 ± 2,8; 68,2 ± 11,5; y 73,9 ± 12,9 years respectively). LS and CS were lower in rLVEF group when compared with pLVEF group, as well as in pLVEF group compared with the CG. The p with pLVEF showed increased values of the dynamic torsion parameters (DefI and TorI), indicating a compensatory increase of LV twist that disappears in p with rLVEF. Twist and Torsion are significantly lower only in the rLVEF group (see table).

Conclusions

In both CA groups, LS and CS deterioration indicates endocardial and transmural involvement. The loss of compensation given by the increased LV twist, reflected by DefI and TorI, marks the transition to the deterioration of LVEF.

Results Table LVEF (%) LS (%) CS (%) TWIST (°) Torsion (°/cm) TorI (°/cm) DefI (°/%) Control Group (n = 15) 68.2 ± 6.3 -20.6 ± 2.5 -22.7 ± 4.9 21.7 ± 6.1 2.7± 0.8 16.4 ± 4.7 -1.0 ± 0.3 CA pLVEF (n = 16) 60,6 ± 5.4* -11.7 ± 4.2* -17.2 ± 4.8* 19.8 ± 8.3 2.5± 1.1 27.7 ±13.5* -1.8 ± 0.9* CA rLVEF (n = 14) 37.2 ± 8.8** -8.7 ± 3.2** -13.0 ± 3.4** 8.3 ± 5.6** 1.0 ± 1.7** 13.4 ± 9.6** -1.0 ± 0.7** *:p value &lt;0,01 between CG and pLVEF group; **:p value &lt;0,01 between pLVEF and rLVEF

The HEART score in the era of the European Society of Cardiology 0/1-hour algorithm

Background:

The European Society of Cardiology’s 0/1-hour algorithm improves the early triage of patients towards “rule-out” or “rule-in” of non-ST-segment elevation myocardial infarction. The HEART score is a risk stratification tool for patients with undifferentiated chest pain. We sought to evaluate the performance of the European Society of Cardiology 0/1-hour algorithm and the HEART score to evaluate chest pain patients in the emergency department.

Methods:

In this prospective study, we applied the European Society of Cardiology 0/1-hour algorithm and the HEART score in 1355 consecutive patients who presented to the emergency department with symptoms suggestive of acute coronary syndrome without ST-segment elevation. Patients were followed for non-ST-segment elevation myocardial infarctions and major adverse cardiac events at 30 days: death, non-ST-segment elevation myocardial infarction, or unplanned coronary revascularization.

Results:

The European Society of Cardiology 0/1-hour algorithm classified 921 (68.0%) patients as “rule-out” and the HEART score classified 686 (50.6%) patients as “low-risk”. The 30-day incidence of non-ST-segment elevation myocardial infarctions was 0.32% in the European Society of Cardiology 0/1-hour algorithm “rule-out” patients versus 0.29% in the HEART score “low-risk” patients ( p=0.75). The rate of major adverse cardiac events was 7.7% in the European Society of Cardiology 0/1-hour algorithm “rule-out” patients versus 1.1% in the HEART score “low-risk” patients ( p<0.001).

Conclusion:

The European Society of Cardiology 0/1-hour algorithm identified more patients with low risk of non-ST-segment elevation myocardial infarctions at 30 days whereas for major adverse cardiac events, the HEART score had a greater capacity to detect low-risk patients.

3297Real-world outcome of applying the ESC 0/1-hour algorithm in clinical routine

Background

The European Society of Cardiology (ESC) recommends the use of a 0/1h-algorithm for rapid triage of patients with suspected non-ST-elevation myocardial infarction (NSTEMI). To date, its impact on patient management and ultimately also safety when routinely applied in emergency departments (ED) is unknown. We therefore aimed to determine these important real-world outcome data.

Methods

In a prospective international multicenter study enrolling unselected patients presenting with suspected NSTEMI to the ED, we assessed the real-world feasibility, adherence, efficacy, effectiveness, and safety of the ESC 0/1h-algorithm using high-sensitivity cardiac troponin T embedded in routine clinical care. Patients with ST-segment elevation myocardial infarctions were excluded. Safety was quantified by the 30-day incidence of major adverse cardiac events (MACE, defined as the composite of cardiovascular death and myocardial infarction including the index event) in the rule-out group and in outpatients.

Results

Among 2296 patients, NSTEMI prevalence was 9.8% (224/2296). Feasibility was very high with a median time to the “1h-draw” of 65 minutes [q1 61, q3 72]. Adherence was very high with 94% (95% confidence interval [CI], 93–95) of patients managed without protocol violations. Effectiveness was very high: 98% (95% CI, 97–98) of patients triaged towards rule-out by the ESC 0/1h-algorithm did not require additional cardiac investigations including hs-cTnT measurements at later time points (e.g. 3–12h) or coronary CT-angiography in the ED. Median time to discharge from the ED was 150 [q1134, q3235] minutes in the overall population. The ESC 0/1h-algorithm triaged 62% (95% CI, 60–64) of patients towards rule-out and 13% (95% CI, 12–14) towards rule-in of NSTEMI. Overall, 71% (95% CI, 69–72) of patients underwent outpatient management (Figure 1). Safety of rule-out and outpatient management were very high with a 30-day MACE incidence of 0.2% (95% CI, 0–0.5) and 0.1% (95% CI, 0–0.2), respectively. These findings were consistent in several predefined subgroups.

Figure 1

Conclusions

These real-world data document the excellent feasibility, adherence, effectiveness, efficacy and safety of the ESC 0/1h-algorithm for the rapid management of patients presenting with suspected NSTEMI to the ED when applied in routine clinical practice.

P1881High-sensitivity cardiac troponin T in patients with acute atrial fibrillation

Background

Atrial Fibrillation (AF) is the most common sustained cardiac arrhythmia encountered in clinical practice and confers a significant burden to morbidity and mortality. High-sensitivity cardiac troponin T (hs-cTnT) levels have provided a significant contribution in the early diagnosis of cardiovascular events; however, the significance of hs-cTnT elevation in the setting of acute AF is not clearly understood.

Purpose

The aim of this study was to evaluate the factors associated with hs-cTnT elevation and its prognostic implication in patients with acute AF.

Methods

This single-center prospective study included 406 consecutive patients who presented to the emergency department (ED) with acute AF. Acute AF was defined as a rapid, irregular, and chaotic atrial activity of <48 hours' duration including both the first symptomatic onset of chronic or persistent AF, and episodes of paroxysmal AF. The association between hs-cTnT and outcomes were evaluated using multivariate analyses.

Results

The mean age of the population was 67.3±12.2 and 74% were male. The median time from the onset of symptoms to ED consultation was 230 minutes (interquartile range: 123–450 minutes). The median hs-cTnT value was 12 ng/L, with 39% of patients with values above the 99 thpercentile. AF was reverted to sinus rhythm in 76% of the patients (83% attempted cardioversion). At one-year, AF recurrence was observed in 38% of the patients and major adverse cardiovascular events (MACE) (death, myocardial infarction, acute coronary syndrome or stroke) were observed in 6% of the patients. After adjusting for demographic and clinical characteristics in multivariate analysis, hs-cTnT elevation was associated with increasing age and left atrial area (p=0.001). Hs-cTnT levels were not associated with 1-year AF recurrence (p=0.132) or with AF reversion (p=0.869). Hs-cTnT levels were significantly higher in patients who experienced MACE at 1-year (12 ng/L vs 24 ng/L, p=0.001) and hs-cTnT was a predictor of MACE on multivariate analysis (OR 3.486, 95% CI 1.256–5.379, p=0.009).

Variable Result AF rate 110 (90–118) Atrial area, cm2 22 (19–27) Cardioversion attemped 82.5%

Conclusions

Hs-cTnT elevation accounted for a large proportion of patients with acute AF. Elevated levels of hs-cTnT were not associated with AF reversion or with 1-year AF recurrence, however hs-cTnT was highly predictive of MACE at 1-year.

248Real-world Outcome of the ESC 0/1-hour Algorithm when Routinely Applied in Early Presenters

Background

The European Society of Cardiology (ESC) recommends the use of a 0/1h-algorithm for rapid triage of patients with suspected non-ST-elevation myocardial infarction (NSTEMI) using high-sensitivity cardiac troponin (hs-cTn). Concerns were articulated about its efficacy and particularly safety when applied in patients presenting early (≤3 hours) after chest pain onset, as hs-cTn concentrations might still be very low or even undetectable in these high-risk patients.

Purpose

We aimed to assess the real-world effectiveness, efficacy, and ultimately safety of the ESC 0/1h-algorithm when routinely applied in early presenters.

Methods

In a prospective international multicenter study enrolling unselected patients presenting with suspected NSTEMI to the ED, patients were assessed according to the ESC 0/1h-algorithm using high-sensitivity cardiac troponin T embedded in routine clinical care. Patients with ST-segment elevation myocardial infarctions were excluded. Safety was quantified by the 30-day incidence of major adverse cardiac events (MACE, defined as the composite of cardiovascular death and myocardial infarction including the index event) in the rule-out group and in outpatients.

Results

Among 2296 patients, 819 (36%) were early presenters. NSTEMI prevalence in early presenters was 11%. Effectiveness was very high as 97% of patients triaged towards rule-out by the ESC 0/1h-algorithm did not require additional cardiac investigations including hs-cTnT measurements at later time points (e.g. 3–12h) or coronary CT-angiography in the ED. Median time to discharge or transfer from the ED was 150 minutes [q1130, q3215]. Efficacy of the ESC 0/1h-algorithm was very high: 67% of patients were triaged towards rule-out and 14% towards rule-in of NSTEMI. Overall, 75% of early presenters underwent outpatient management. Safety of rule-out and outpatient management were excellent in early presenters with a 30-day MACE incidence of both 0% and comparable with 0.3% and 0.1% in late presenters, respectively (p=ns).

Conclusions

These real-world data document for the first time the excellent effectiveness, efficacy and particularly safety of the ESC 0/1h-algorithm when routinely applied in early presenters. No differences in safety could be observed when compared with late presenters.