Change in minimum indexed left atrial volume predicts incident heart failure: the multi-ethnic study of atherosclerosis

Funding Acknowledgements

Type of funding sources: None.

Background and Purpose

Longitudinal change in the left atrium prior to the onset of heart failure has not been as well studied as left atrial (LA) dysfunction in pre-existing heart failure. This study used cardiac magnetic resonance (CMR) imaging to investigate the relationship between longitudinal change in LA volume and function and incident heart failure (HF), in a multi-ethnic population free of known cardiovascular disease at baseline.

Methods and Results

In the Multi-Ethnic Study of Atherosclerosis (MESA), 2470 participants (60±9 years, 47% males), free at baseline of clinically recognized cardiovascular disease, had LA volume, emptying fractions and peak longitudinal strain assessed with Multimodality Tissue Tracking (MTT; version 6.0 Toshiba, Japan) on CMR imaging at baseline (2000-02) and at follow-up 9.4±0.6 years later. Seventy three (3%) participants subsequently developed incident HF 7.1±2.1 years after the follow-up CMR exam. In cox regression models, an annualized change in all LA parameters were significantly associated with an increased risk of incident HF. An annual increase of 1ml/m2 in minimum indexed LA volumes (∆LAVimin) was most strongly associated with the risk of incident HF (Hazard Ratio(HR)=1.85, 95% confidence interval(CI) [1.49-2.29], P<0.001) and improved model reclassification and discrimination in predicting incident HF (c-statistic=0.80, 95%CI [0.75-0.86]; NRI=0.13, P=0.04; IDI=0.04, P=0.01; x2=6.52, P=0.69) adjusting for known risk factors (age, gender, systolic blood pressure, anti-hypertensive medication use, smoking status, diabetes mellitus, total cholesterol, previous atrial fibrillation) and baseline LA parameters.

Conclusion

In this multi-ethnic population free of clinical cardiovascular disease at baseline, ∆LAVimin was most strongly associated with, and incrementally predictive of incident HF, after adjusting for known risk factors and baseline LA measures.

Change in left atrial function and volume predicts heart failure with preserved and reduced ejection fraction: the multi-ethnic study of atherosclerosis

Aims

This study used cardiac magnetic resonance (CMR) imaging to investigate the relationship between longitudinal change in left atrial (LA) function and incident heart failure (HF), in a multi-ethnic population free of known cardiovascular disease at baseline.

Methods and results

In the Multi-Ethnic Study of Atherosclerosis (MESA), 2470 participants (60±9 years, 47% males), free at baseline of clinically recognized cardiovascular disease, had LA volume and function assessed with CMR imaging at baseline (2000–02) and 9.4±0.6 years later. Seventy three (3%) participants developed incident HF over 7.1±2.1 years; of these, 39 participants had preserved ejection fraction (HFpEF) and 34 participants had reduced ejection fraction (HFrEF). An annual decrease of 1-SD unit in peak LA strain (ΔLASmax) was most strongly associated with the risk of HFpEF (subdistribution HR=2.56, 95% confidence interval (CI) [1.34–4.90], P=0.004) and improved model reclassification and discrimination in predicting HFpEF (c-statistic=0.84, 95% CI [0.79–0.90]; NRI=0.34, P=0.01; IDI=0.02, P=0.02; x2=4.25, P=0.89) adjusting for event-specific risk factors and baseline LA parameters. An annual decrease of 1ml/m2 of pre-atrial LA volume index (ΔLAVipreA) was most strongly associated with the risk of HFrEF (subdistribution HR=1.88, 95% CI [1.44–2.45], P<0.001) and improved model reclassification and discrimination in predicting HFrEF (c-statistic=0.81, 95% CI (0.72–0.90); NRI=0.31, P=0.03; IDI=0.01, P=0.50; x2=15.4, P=0.08), adjusting for event-specific risk factors and baseline LA measures (Table 1).

Conclusion

In this multi-ethnic population free of clinical cardiovascular disease at baseline, ΔLASmax and ΔLAVipreA were associated with, and incrementally predictive of HFpEF and HFrEF respectively, after adjusting for event-specific risk factors and baseline LA measures.

Disclaimer

The views expressed in this abstract are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): National Heart, Lung and Blood InstituteNational Center for Advancing Translational Sciences

Machine-learning score using stress CMR for death prediction in patients with suspected or known CAD

Background

In patients with suspected or known coronary artery disease (CAD), traditional prognostic risk assessment is based upon a limited selection of clinical and imaging findings. Machine learning (ML) methods can take into account a greater number and complexity of variables.

Purpose

To investigate the feasibility and accuracy of ML using stress CMR and clinical data to predict 10-year all-cause mortality in patients with suspected or known CAD, and compared its performance to existing clinical or CMR scores.

Methods

Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (interquartile range: 5.0–8.0) included all consecutive patients referred for stress CMR. Twenty-three clinical and 11 stress CMR parameters were evaluated. Machine learning involved automated feature selection by random survival forest, model building with a multiple fractional polynomial algorithm, and 5 repetitions of 10-fold stratified cross-validation. The primary outcome was all-cause death based on the electronic National Death Registry. The external validation cohort of the ML score was performed in another center.

Results

Of 31,752 consecutive patients (mean age 63.7±12.1 years and 65.7% males), 2,679 (8.4%) died with 206,453 patient-years of follow-up. ML score (ranging 0 to 10 points) exhibited a higher area-under-the-curve compared with C-CMR-10-score, ESC-score, QRISK3-score, FRS and stress CMR data alone for prediction of 10-year all-cause mortality (ML: 0.76 vs. C-CMR-10-score: 0.68, ESC-score: 0.66, QRISK3-score: 0.64, FRS: 0.63, extent of inducible ischemia: 0.66, extent of LGE: 0.65, all p<0.001). The ML score exhibited also a good area-under-the-curve in the external cohort (AUC: 0.75).

Conclusions

The ML score including clinical and stress CMR data exhibited a higher prognostic value to predict 10-year death compared with all traditional clinical or CMR scores.

Funding Acknowledgement

Type of funding sources: None.

Incremental prognostic value of stress CMR in symptomatic patients with coronary stenosis on CCTA

Background

Noninvasive functional imaging is often performed in patients with obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA). However, the prognostic value of stress cardiovascular magnetic resonance (CMR) is unknown in patients with coronary stenosis of unknown significance on CCTA.

Purpose

To assess the prognostic value of stress CMR in symptomatic patients with obstructive CAD of unknown significance on CCTA.

Methods

Between 2008–2020, consecutive symptomatic patients without known CAD referred for CCTA were screened. Patients with obstructive CAD (at least 1 ≥50% stenosis on CCTA) were further referred for stress CMR and followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction.

Results

Of 2,210 patients who completed CMR, 2,038 (46.5% male, mean age 69.8±12.2 years) completed follow-up (median 6.8 [IQR 5.9–9.2] years); 281 experienced a MACE (13.8%). Inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with MACE (HR: 4.51, [95% CI: 3.55–5.74]; and HR: 3.32, [95% CI: 2.55–4.32], respectively; p<0.001). In multivariable Cox regression, number of segments with >70% stenosis, with noncalcified plaques and number of vessels with obstructive CAD were prognosticators (p<0.001). The presence of inducible ischemia and LGE were independent predictors of MACE (HR: 3.97, [95% CI: 3.43–5.13]; HR: 2.30, [95% CI: 1.52–3.33]; p<0.001). After adjustment, stress CMR showed the best improvement in model discrimination and reclassification above traditional risk factors and CCTA (C-statistic improvement: 0.04; NRI=0.421; IDI=0.047).

Conclusions

In symptomatic patients with obstructive CAD of unknown significance on CCTA, stress CMR had incremental prognostic value to predict MACE.

Funding Acknowledgement

Type of funding sources: None.

Regional strain score as prognostic marker of cardiovascular events. from the Multi-Ethnic Study of Atherosclerosis (MESA)

Background

Left ventricular (LV) circumferential strain (Ecc) is an accurate indicator of regional myocardial function, particularly using the regional Ecc or layer-specific strain.

Purpose

To investigate the prognostic value of a regional strain score (RSS) for predicting the incident of heart failure (HF) and coronary heart disease (CHD) in a population without a history of cardiovascular disease at baseline.

Methods

In Multi-Ethnic Study of Atherosclerosis (MESA), 1,506 study participants (63.3±9.4 years, 54.6% men) underwent tagged magnetic resonance imaging for left ventricular circumferential strain (Ecc) analysis. Using −17% and −10% as Ecc cut-offs, each segment was rated from 0–2 points according to the Ecc value of each layer. The endo-Ecc, mid-Ecc, and epi-Ecc values from the 16-segment model were used to calculate three RSS: Endo-, Mid-, and Epi-RSS, respectively, which were defined as a percentage of good LV regional function. The Intramyocardial-RSS was the sum of these three RSS. Cox proportional models were used to evaluate the association between RSS and cardiovascular outcomes.

Results

After a median [IQR] follow-up of 15.9 [12.9–16.6] years, 122 hard CHD and 91 HF were observed. After adjustment, Mid-, Epi-, and Intramyocardial-RSS values <50% were independently associated with HF (HR 1.43; 95% CI [1.08–2.87], p=0.004; HR 1.80; 95% CI [1.12–3.07], p<0.001; and HR 2.01; 95% CI [1.19–3.20], p<0.001). After adjustment, Endo-, Mid-, Epi-, and Intramyocardial-RSS <50% were also independently associated with hard CHD (HR 1.31; 95% CI [1.03–1.51], p=0.04; HR 1.79; 95% CI [1.26–2.57], p<0.001; HR 2.03; 95% CI [1.45–3.40], p<0.001; and HR 2.28; 95% CI [1.51–3.53], p<0.001).

Conclusion

Layer-specific regional Ecc, assessed by RSS, provides a robust, independent predictive value for incident HF and hard CHD in asymptomatic participants without any cardiovascular disease at baseline.

Funding Acknowledgement

Type of funding sources: None.

Efficacy of simulation-based training on transoesophageal echocardiography learning in a multicentre randomised controlled trial: SIMULATOR study

Background

Evidence on the impact of simulation-based training in transesophageal echocardiography (TEE) is scarce.

Purpose

We aimed to assess the efficacy of simulation-based versus traditional teaching on TEE knowledge and skills for cardiology residents.

Methods

Between November 2020 and November 2021, all consecutive cardiology residents inexperienced from TEE were randomised (1:1, n=324) through 42 French University Centers into two groups with or without simulation support (either a simulation group or a traditional group). The coprimary outcomes were the scores in the final theoretical and practical tests 3 months after the training. TEE duration and the feelings of residents were also assessed. An economic analysis was also performed.

Results

While the theoretical and practical test scores were similar between the two groups before the training (respectively P=0.80 and P=0.51), the residents in the simulation group displayed higher theoretical test and practical test scores after the training than those in the traditional group (respectively 47.2±15.6% vs. 38.3±19.8%, P<0.0001 and 74.5±17.7% vs. 59.0±25.1%, P<0.0001). Subgroups analyses showed that the efficacy of the simulation training was even greater when performed at the beginning of residency (P<0.0001). After the training, the duration to perform a complete TEE was significantly lower in the simulation group than in the traditional group (respectively 8.3±1.4 min vs. 9.4±1.2 min, P<0.0001). Finally, residents' feelings were better in the simulation group than in the traditional group across all components (P<0.0001). Compared to the traditional group, the average additional cost per resident of the simulation program was respectively €1,785, €942 or €662 for 20, 40 and 60 residents.

Conclusion

Simulation-based teaching on TEE showed a significant improvement in knowledge, skills, and feelings of cardiology residents as well as a reduction in the duration to complete the examination.

Funding Acknowledgement

Type of funding sources: None.

Determinants of left atrioventricular coupling index: the multi-ethnic study of atherosclerosis (MESA)

Background

Recent studies have described a novel left atrioventricular coupling index (LACI), which had a better prognostic value than individual left atrial (LA) or left ventricular (LV) parameters measured separately to predict cardiovascular events.

Purpose

To identify the determinants of the LACI and its 10-year annual change (ΔLACI), measured by cardiovascular magnetic resonance (CMR), and to better understand the parameters governing this left atrioventricular coupling.

Methods

In the Multi-Ethnic Study of Atherosclerosis (MESA), 2,112 study participants, free of cardiovascular disease at baseline, had LACI assessed by CMR imaging at baseline (LACIBaseline, 2000–2002) and 10 years later (2010–2012). The LACI was defined as the ratio of LA to LV end-diastolic volumes. Linear regression analyses were performed to identify independent determinants of LACIBaseline or ΔLACI.

Results

In the 2,112 participants (58.8±9.1 years, 46.6% male), after adjustment for all covariates, age was independently associated with both LACIBaseline (R2=0.10, slope=0.16) and ΔLACI (R2=0.15, slope=0.008, both p<0.001). African Americans had the highest LACIBaseline value (18.0±7.7%). Although there was no difference in LACIBaseline between women and men (p=0.19), ΔLACI was higher in women than in men (1.0±1.1 vs. 0.8±1.0%/year, p<0.001). Diabetes and a higher BMI were independently associated with LACIBaseline (both p<0.001). LACIBaseline was independently associated with LV myocardial fibrosis markers (native T1: R2=0.11, slope = 0.09, p=0.038; and extra-cellular volume: R2=0.08, slope = 0.28, p=0.035) and NT-proBNP levels (R2=0.10, slope = −1.11, p<0.001) but was not associated with IL-6 or hsCRP.

Conclusions

Age, sex, ethnicity, diabetes, and BMI were independent determinants of LACI. LACI was independently associated with LV myocardial fibrosis markers and NT-proBNP levels.

Funding Acknowledgement

Type of funding sources: None.

Incremental prognostic value of stress CMR for cardiovascular risk stratification after a cryptogenic ischemic stroke

Background

One-third of ischemic strokes are “cryptogenic” without clearly identified etiology. Although coronary artery disease (CAD) is the main cause of death after stroke, the interest of CAD screening in patients with cryptogenic stroke is still debated.

Purpose

The aim of the study was to assess the incremental prognostic value of stress cardiovascular magnetic resonance (CMR) beyond traditional risk factors for predicting cardiovascular events in patients with a prior cryptogenic ischemic stroke.

Methods

Between 2008 and 2021, consecutive patients with prior cryptogenic strokes referred for stress CMR were included and followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction (MI). Univariable and multivariable Cox regressions were performed to determine the prognostic value of unrecognized MI and silent ischemia.

Results

Of 542 patients (55.2% male, mean age 71.4±8.8 years) who completed the follow-up (median 5.9 years), 66 (12.2%) experienced MACE. Silent ischemia and unrecognized MI were detected in 18% and 17% of patients, respectively. Using Kaplan-Meier analysis, silent ischemia and unrecognized MI were associated with the occurrence of MACE (hazard ratio, HR: 8.43 [95% CI: 5.11–13.9]; HR: 7.87 [95% CI: 4.80–12.9]; respectively, p<0.001). In multivariable analysis, silent ischemia and unrecognized MI were independent predictors of MACE (HR: 8.08 [95% CI: 4.21–15.5]; HR: 6.65 [95% CI: 3.49–12.7]; respectively, p<0.001). After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors (C-statistic improvement: 0.13; NRI=0.428; IDI=0.048).

Conclusions

In patients with prior cryptogenic stroke, stress CMR findings have an incremental prognostic value to predict MACE over traditional risk factors.

Funding Acknowledgement

Type of funding sources: None.

Prevalence of illicit drugs use and association with in-hospital major adverse events in patients hospitalised for acute cardiac events: the ADDICT-ICCU Trial

Background

The prevalence and short-term cardiovascular consequences of illicit drug use in patients admitted to the intensive cardiac care unit (ICCU) for acute cardiovascular events are not well established.

Purpose

The Addiction in Intensive Cardiac Care Units (ADDICT-ICCU) study was designed to assess prospectively the prevalence of illicit drugs use, and their association with the occurrence of in-hospital major adverse events (MAEs) in consecutive patients admitted to ICCUs for acute cardiovascular events.

Methods

From 7 to 22 April 2021, screening for illicit drug was performed by systematic urinary testing in a prospective study including all consecutive patients admitted to ICCU in 39 centres throughout France. The primary outcome was the prevalence of the illicit drugs detected. The secondary clinical outcome was in-hospital Major Adverse cardiac Events (MAEs) defined by death, resuscitated cardiac arrest or cardiogenic shock.

Results

Among 1,499 consecutive patients screened (age 63.3±14.9 years, 69.6% male), 161 (10.7%) had a positive test for illicit drugs (cannabis: 9.1%, opioids: 2.1%, cocaine: 1.7%, amphetamines: 0.7%, 3,4-methylenedioxymethamphetamine: 0.6%). Patients who used illicit drugs were young (33.0% at age <40 vs. 5.9% at age ≥60 years), and more frequently male (11.9% vs. 8.1%, p<0.001). Self-reported current use was 56.5% in patients with a positive test. After a median duration of hospitalisation of five days, there were 61 in-hospital MAEs (4.1%).

The detection of illicit drugs was associated with a higher rate of MAEs after adjustment for known predictors of severity (OR=8.84; 95% CI: 4.68–16.7, p<0.001) or after using a propensity score adjustment (OR=5.81; 95% CI: 4.14–8.14, p<0.001). After adjustment for age and sex, detection of cannabis or cocaine was significantly associated with MAEs (OR=3.53; 95% CI: 1.25–9.95, p<0.001; OR=5.12; 95% CI: 1.48–17.2, p=0.004 respectively). Multiple drug detection (28% of positive patients) was associated with a higher incidence of MAEs than single drug detection.

Conclusions

The prevalence of illicit drugs use in patients hospitalised in the ICCUs for acute cardiovascular events was 10.7% and was under-reported. Illicit drugs detection was independently associated with a higher occurrence of in-hospital MAEs.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Fondation Coeur et Recherche

Prognostic value of a left atrioventricular coupling index (LACI) in pre- and post-menopausal women. from the multi-ethnic study of atherosclerosis (MESA)

Background

Endogenous sex hormones associated with both the left atrial (LA) and left ventricular (LV) structures in peri-menopausal women, but the association of menopause status with left atrioventricular coupling is not well established.

Purpose

To assess the prognostic value of a left atrioventricular coupling index (LACI) in pre- and post-menopausal women without a history of cardiovascular disease (CVD) at baseline in the Multi-Ethnic Study of Atherosclerosis (MESA).

Methods

In women participating in the MESA study, the LACI was measured as the ratio of the left atrial (LA) end-diastolic volume to the left ventricular (LV) end-diastolic volume using cardiovascular magnetic resonance (CMR). Cox proportional hazard models were used to assess the association between the LACI and the outcomes of atrial fibrillation (AF), heart failure (HF), and hard CVD defined by myocardial infarction, resuscitated cardiac arrest, stroke, or coronary heart disease death.

Results

Among the 2,087 women participants (61±10 years), 485 cardiovascular events were observed during the mean follow-up period of 13.2±3.3 years. A higher LACI was independently associated with AF (HR 1.70; 95% CI [1.51–1.90]), HF (HR 1.62; [1.33–1.97]), and hard CVD (HR 1.30; [1.13–1.51], all p<0.001). Adjusted models with the LACI showed significant improvement in model discrimination and reclassification when compared to currently used standard models used to predict the incidence of AF (C-statistic=0.82 vs. 0.79; NRI=0.325; IDI=0.036), HF (C-statistic=0.84 vs. 0.81; NRI=0.571; IDI=0.023), hard CVD (C-statistic=0.78 vs. 0.76; NRI=0.229; IDI=0.012).

Conclusion

In a multi-ethnic population of pre- and post-menopausal women, the LACI is an independent predictor of HF, AF, and hard CVD. In both pre- and post-menopausal women, the LACI has an incremental prognostic value for predicting cardiovascular events over traditional risk factors and sex hormone levels.

ClinicalTrials: gov Identifier: NCT00005487

Funding Acknowledgement

Type of funding sources: None.

Fully automatic AI-based valve motion parameter extraction on long axis CINE images - application on N=11000 patient datasets

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Research support from Siemens Healthineers GmbH.

Background

Mitral valve (MV) motion parameters, assessable using CMR [1, 2], have been shown to help the diagnosis of cardiac dysfunction. To extract valve motion parameters, we propose a fully automatic AI-based prototype system that tracks annulus and apex landmarks by the registration network on time-resolved two- and four-chamber CMR cine views. Parameters such as displacements, velocities, mitral annular plane systolic excursion (MAPSE), or longitudinal shortening (LS) are automatically extracted and evaluated on a large CMR dataset (N=11000).

Methods

The system consists of two sequential neural networks with a processing step in between (Fig. 1a) [3]. Initially, a 2D UNet is applied to localize both MV annulus insertion points as well as the apex. Based on these points, the image processing step consists of rotating, cropping, and interpolating the images, allowing a standardized image impression for both long axis views. Finally, the registration network (VoxelMorph framework [4]) is applied to the processed series and tracks the MV annulus insertion points and apex over the cardiac cycle by the deformation fields obtained by the network. The system was trained on (N=166) multivendor, multi-field strength, ground-truth annotated datasets [5].

A total of 11000 datasets, acquired on a 1.5T scanner (MAGNETOM Aera, Siemens Healthcare, Erlangen, Germany) from January 2016 to September 2017 [6], were used for parameter extraction. 200 of these datasets were additionally annotated semi-automatically for the performance evaluation of the system.

Five motion parameters were automatically derived by the system that are defined as follows (Fig. 1b): (1) The atrioventricular plane displacement (AVPD) as the distance of the plane spanned by the MV annulus points relative to the first frame, (2) the atrioventricular plane velocity (AVPV) as the discrete temporal derivate of the AVPD, (3) the diameter of the annulus as the maximum distance between the MV annulus points, (4) the lateral/inferior and septal/superior MAPSE, as the maximum MV points’ excursion, and (5) the LS as the percentage size difference of the distance between the mid valvular point and the apex point at end-systole and end-diastole.

Results

The accuracy of the system resulted in deviations on the annotated dataset of 1.02 ± 0.87 mm, 0.01 ± 0.02 mm/s, 1.54 ± 1.21 mm, 2.30 ± 1.35 mm, 2.1 ± 1.8 mm for AVPD, AVPV, diameter, MAPSE, and LS respectively. Initial statistics on all datasets (Fig. 2) revealed a mean lateral/inferior, septal/superior MAPSE and LS of 8.7 ± 2.7 mm, 10.5 ± 3.2 mm and 16.3 ± 4.2 % for two-chamber and 9.6 ± 2.6 mm, 8.7 ± 2.6 mm and 15.5 ± 3.9 % for four-chamber views, respectively.

Conclusions

The results demonstrate the versatility of the proposed system for automatic extraction of various MV motion parameters. The proposed system enables automatic extraction of clinically relevant parameters and can improve the automation of MV-based analyses. System overview & Parameter of interestsAnalysis of the extracted parameters

Cardiovascular manifestations secondary to COVID-19: A narrative review

The coronavirus disease 2019 (COVID-19) pandemic has spread rapidly, becoming a major threat to global health. In addition to having required the adaptation of healthcare workers for almost 2 years, it has been much talked about, both in the media and among the scientific community. Beyond lung damage and respiratory symptoms, the involvement of the cardiovascular system largely explains COVID-19 morbimortality. In this review, we emphasize that cardiovascular involvement is common and is associated with a worse prognosis, and that earlier detection by physicians should lead to better management. First, direct cardiac involvement will be discussed, in the form of COVID-19 myocarditis, then secondary cardiac involvement, such as myocardial injury, myocardial infarction and arrhythmias, will be considered. Finally, worsening of previous cardiovascular disease as a result of COVID-19 will be examined, as well as long-term COVID-19 effects and cardiovascular complications of COVID-19 vaccines.

Prognostic value of left atrioventricular coupling index (LACI) in pre- and post-menopausal women : from the multi-ethnic study of atherosclerosis (MESA)

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Although endogenous sex hormones influence both left atrial (LA) and left ventricular (LV) structure in peri-menopausal women, no study has ever evaluated the interaction between sex hormones levels and the left atrioventricular coupling.

PURPOSE

 This study aimed to assess the prognostic value of a left atrioventricular coupling index (LACI) in pre- and post-menopausal women without history of CVD at baseline.

METHODS

In all women participating in the Multi-Ethnic Study of Atherosclerosis (MESA) with baseline cardiovascular magnetic resonance (CMR) study, LACI was measured as the ratio of the LA end-diastolic volume divided by the LV end-diastolic volume. Cox proportional hazard models were used to assess the association between LACI and the outcomes of atrial fibrillation (AF), heart failure (HF), coronary heart disease (CHD) death, and hard CVD defined by myocardial infarction, resuscitated cardiac arrest, stroke, or CHD death. In multivariable analyses, the associations between LACI and the time-to-event were evaluated, adjusting for demographics, traditional cardiovascular risk factors, menopausal status and sex hormone levels.

RESULTS

Among the 2,087 women (61.2 ± 10.1 years), 485 cardiovascular events were observed during mean follow-up period of 13.2 ± 3.3 years. Greater LACI was independently associated with AF (HR 1.70; 95% CI [1.51-1.90]), HF (HR 1.62; 95% CI [1.33-1.97]), CHD death (HR 1.36; 95% CI [1.10-1.68]), and hard CVD (1.30; 95% CI [1.13-1.51], all p < 0.001). Adjusted models with LACI showed significant improvement in model discrimination and reclassification compared to currently used standard models to predict the incidences of AF (C-statistic: 0.82 vs. 0.79; NRI = 0.325; IDI = 0.036), HF (C-statistic: 0.84 vs. 0.81; NRI = 0.571; IDI = 0.023), CHD death (C-statistic: 0.87 vs. 0.85; NRI = 0.506; IDI = 0.012), and hard CVD (C-statistic: 0.78 vs. 0.76; NRI = 0.229; IDI = 0.012). The prognostic value of LACI was homogeneous in both pre- and post-menopausal women with a better discrimination and reclassification compared to individual LA or LV parameters.

CONCLUSIONS

In a multi-ethnic population of pre- and post-menopausal women, LACI is an independent predictor of HF, AF, CHD death and hard CVD. In both pre- and post-menopausal women, LACI has an incremental prognostic value to predict cardiovascular events over traditional risk factors and sex hormone levels.

ClinicalTrials.gov Identifier: NCT00005487 Abstract Figure. Kaplan-Meier curves by LACI terciles  Abstract Figure. Kaplan-Meier curves by LACI and Menop.

Machine-learning score using stress CMR for death prediction in patients with suspected or known CAD

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

In patients with suspected or known coronary artery disease (CAD), traditional prognostic risk assessment is based upon a limited selection of clinical and imaging findings. Machine learning (ML) methods can take into account a greater number and complexity of variables.

PURPOSE

To investigate the feasibility and accuracy of ML using stress CMR and clinical data to predict 10-year all-cause mortality in patients with suspected or known CAD, and compared its performance to existing clinical or CMR scores.

METHODS

Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (interquartile range: 5.0-8.0) included all consecutive patients referred for stress CMR. Twenty-three clinical and 11 stress CMR parameters were evaluated. Machine learning involved automated feature selection by random survival forest, model building with a multiple fractional polynomial algorithm, and 5 repetitions of 10-fold stratified cross-validation. The primary outcome was all-cause death based on the electronic National Death Registry.

RESULTS

Of 31,752 consecutive patients (mean age 63.7 ± 12.1 years and 65.7% males), 2,679 (8.4%) died with 206,453 patient-years of follow-up. ML score (ranging 0 to 10 points) exhibited a higher area-under-the-curve compared with C-CMR-10-score, ESC-score, QRISK3-score, FRS and stress CMR data alone for prediction of 10-year all-cause mortality (ML: 0.76 vs. C-CMR-10-score: 0.68, ESC-score: 0.66, QRISK3-score: 0.64, FRS: 0.63, extent of inducible ischemia: 0.66, extent of LGE: 0.65, all p < 0.001).

CONCLUSIONS

The ML score including clinical and stress CMR data exhibited a higher prognostic value to predict 10-year death compared with all traditional clinical or CMR scores. Abstract Figure. Random survival Forest: ML score  Abstract Figure. Prognostic Value of ML score

Phenotypic clustering of patients with newly diagnosed coronary artery disease using cardiovascular magnetic resonance and coronary computed tomography angiography

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Epidemiological characteristics and prognostic profiles of patients with newly diagnosed coronary artery disease (CAD) are heterogeneous. Thus, providing individualized cardiovascular (CV) risk stratification and tailored prevention is crucial.

PURPOSE

Phenotypic unsupervised clustering integrating clinical, coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR) data was used to unveil pathophysiological differences between subgroups of patients with newly diagnosed CAD.

METHODS

Between 2008 and 2020, consecutive patients with newly diagnosed obstructive CAD on CCTA and further referred for vasodilator stress CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. A cluster analysis was performed on clinical, CCTA and CMR variables, and associations between phenogroups and outcomes were assessed.

RESULTS

Of 2,210 patients who underwent CMR, 2,015 (46% male, mean 70 ± 12 years) completed follow-up (median 6.8[IQR 5.9-9.2] years); 277 experienced a MACE (13.7%). Three mutually exclusive and clinically distinct phenogroups (PG) were identified based upon unsupervised hierarchical clustering of principal components: [PG1] CAD in elderly patients with few traditional risk factors; [PG2] women with metabolic syndrome, calcified plaques on CCTA and preserved left ventricular ejection fraction (LVEF); and [PG3] younger male smokers with proximal noncalcified plaques on CCTA, myocardial scar and reduced LVEF. Using survival analysis, the occurrence of MACE, cardiovascular mortality and all-cause mortality (all p < 0.001) differed among the three PG, PG3 having the worse prognosis. In each PG, inducible ischemia was associated with MACE (PG1, HR = 3.09, 95%CI, 1.70-5.62; PG2, HR = 3.62, 95%CI, 2.31-5.70; PG3, HR = 3.55, 95%CI, 2.30-5.49; all p < 0.001).

CONCLUSIONS

Cluster analysis of clinical, CCTA and CMR variables identified 3 phenogroups of patients with newly diagnosed CAD that were associated with distinct clinical and prognostic profiles. Inducible ischemia assessed by stress CMR remained associated with the occurrence of MACE within each phenogroup. Abstract Figure. Cluster analysis: Biplot representation  Abstract Figure. Kaplan Meier curves by Phenogroups

Determinants of left atrioventricular coupling index as a prognostic marker of cardiovascular events from the multi-ethnic atherosclerosis study (MESA)

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Recent studies have emphasized the incremental prognostic value of a novel left atrioventricular coupling index (LACI) and its 10-year annual change (ΔLACI) to predict cardiovascular events. However, no study has investigated the potential determinants of this index.

PURPOSE

To identify the determinants of LACI and ΔLACI, measured by cardiovascular magnetic resonance (CMR), and to better understand the parameters governing this left atrioventricular coupling in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

In the MESA, 2,112 study participants, free of cardiovascular disease at baseline, had LACI assessed by CMR imaging at baseline (LACIBaseline, Exam 1, 2000–2002) and 10 years later (Exam 5, 2010–2012). The LACI was defined as the ratio of left atrium to left ventricular (LV) end-diastolic volumes. Multivariable linear regression analyses were performed, adjusting for traditional risk factors and LV structure, to identify independent determinants of LACIBaseline or ΔLACI.

RESULTS

In the 2,112 participants (mean age 58.8 ± 9.1 years and 46.6% male), after adjustment for all covariates, age was independently associated with both LACIBaseline (R2 = 0.10) and ΔLACI (R2 = 0.15, both p < 0.001). Although there was no difference in LACIBaseline between women and men (p = 0.19), ΔLACI was higher in women than in men (1.0 ± 1.1 vs. 0.8 ± 1.0 %/year, p < 0.001). African Americans had the highest LACIBaseline value (18.0 ± 7.7%) while Chinese Americans had the lowest (13.8 ± 6.4%, p < 0.001). Diabetes and a higher body mass index were independently associated with LACIBaseline (coefficients B: 1.75 and 0.24, respectively, both p < 0.001). LACIBaseline was independently associated with LV myocardial fibrosis markers (native T1: R2 = 0.11, p = 0.038; and extra-cellular volume [ECV]: R2 = 0.08, p = 0.035) and NT-proBNP levels (R2 = 0.10, p < 0.001) but was not associated with inflammation biomarkers.

CONCLUSIONS

In a multi-ethnic population, age, sex, ethnicity, diabetes, and a higher body mass index were independent determinants of LACI. LACI was independently associated with LV myocardial fibrosis markers and NT-proBNP levels but not associated with inflammation biomarkers.

ClinicalTrials.gov Identifier: NCT00005487 Abstract Figure. Relationship between LACI and Age  Abstract Figure. Relationship between LACI and Gender

Change in left atrioventricular coupling index to predict incident atrial fibrillation: the multi-ethnic study of atherosclerosis (MESA)

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Left atrial (LA) and left ventricular (LV) structural and functional parameters have independent prognostic values as predictors of atrial fibrillation (AF).

PURPOSE

To investigate the prognostic value of a left atrioventricular coupling index (LACI) and average annualized change in LACI measured by cardiac MRI to predict incident AF in a population-based sample from the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

In a secondary analysis of the prospective Multi-Ethnic Study of Atherosclerosis (MESA) study, 1,911 study participants, free of clinically recognized AF and cardiovascular disease at baseline, had LACI assessed with cardiac MRI at baseline (Exam 1, 2000-2002), and ten years later (Exam 5, 2010-2012). LACI was defined as the ratio of LA to LV end-diastolic volumes. Univariable and multivariable Cox proportional hazard models were used to evaluate the associations of LACI and average annualized change in LACI (ΔLACI) with incident AF.

RESULTS

Among the 1,911 participants (mean age 59 ± 9 years and 907 men), 87 incident AF events occurred over 3.9 ± 0.9 years following the second imaging (Exam 5). After adjustment for traditional risk factors, greater LACI and ΔLACI were independently associated with AF (HR 1.69, 95% CI[1.46-1.96] and HR 1.71, 95% CI[1.50-1.94], respectively; both p<.001). Adjusted models for LACI and ΔLACI showed improvement in model discrimination compared to currently used AF risk score (CHARGE-AF score) model (AUC: 0.78 vs. 0.74, and AUC: 0.80 vs. 0.74, both p<.001); and to the final model including individual LA or LV parameters for predicting AF incidence (AUC: 0.78 vs. 0.76, and AUC: 0.80 vs. 0.78, both p<.001).

CONCLUSIONS

Atrioventricular coupling (LACI) and coupling change (ΔLACI) were strong predictors for AF in a multi-ethnic population. Both had incremental prognostic value for predicting AF over traditional risk factors, and superior discrimination compared to the CHARGE-AF score and to individual LA or LV parameters.

ClinicalTrials.gov Identifier: NCT00005487 Abstract Figure. Kaplan-Meier curves by change in LACI  Abstract Figure. Kaplan-Meier curves by ΔLACI and LACI

Layer-specific regional circumferential strain as prognostic marker of cardiovascular events

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Left ventricular (LV) circumferential strain (Ecc) is an accurate indicator of regional myocardial function. Recent studies have emphasized the potential superiority of regional Ecc, particularly using the layer-specific strain. To date, no studies have assessed the prognostic value of layer-specific regional Ecc in the general population.

PURPOSE

This study aimed to investigate the prognostic value of the layer-specific regional Ecc for predicting the incident of heart failure (HF) and coronary heart disease (CHD) in a population without a history of cardiovascular disease at baseline.

METHODS

Data from participants in the Multi-Ethnic Study of Atherosclerosis (MESA) who underwent tagged magnetic resonance imaging for strain determination were analyzed. Using −17% and −10% as Ecc cut-offs, each segment was rated from 0–2 points according to the Ecc value of each layer. The endo-Ecc, mid-Ecc, and epi-Ecc values from the 16-segment model were used to calculate three indexes: Endo-MyoHealth, Mid-MyoHealth, and Epi-MyoHealth, respectively, which were defined as a percentage of good LV regional function. The Intramyocardial-MyoHealth index was the sum of these three MyoHealth indexes. Cox proportional hazard models were used to evaluate the association between each MyoHealth index and incident HF and hard CHD.

RESULTS

Among the 1,506 participants (63.3 ± 9.4 years, 54.6% men), 122 cases of hard CHD and 91 cases of HF were observed (median [IQR] follow-up 15.9 [12.9-16.6] years). After adjustment, Mid-, Epi-, and Intramyocardial-MyoHealth index values <50% were independently associated with HF (adjusted HR 1.43; 95% CI [1.08-2.87], p = 0.004; HR 1.80; 95% CI [1.12-3.07], p < 0.001; and HR 2.01; 95% CI [1.19-3.20], p < 0.001). After adjustment, Endo-, Mid-, Epi-, and Intramyocardial-MyoHealth <50% were also independently associated with hard CHD (adjusted HR 1.31; 95% CI [1.03-1.51], p = 0.04; HR 1.79; 95% CI [1.26-2.57], p < 0.001; HR 2.03; 95% CI [1.45-3.40], p < 0.001; and HR 2.28; 95% CI [1.51-3.53], p < 0.001).

CONCLUSIONS

Layer-specific regional Ecc, assessed via MyoHealth indexes, provides a robust, independent predictive value for incident HF and hard CHD in asymptomatic participants without any history of previous clinical cardiovascular disease.

Unique identifier Clinical.gov : NCT00005487. Abstract Figure.  Abstract Figure. Kaplan Meier curves

Incremental prognostic value of vasodilator stress cardiovascular magnetic resonance over coronary computed tomography angiography in symptomatic patients

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Current guidelines recommend to perform noninvasive functional imaging in patients with obstructive coronary artery disease (CAD) on coronary computed tomography angiography (CCTA). However, the prognostic value of stress cardiovascular magnetic resonance (CMR) over traditional risk factors and CCTA is not known.

PURPOSE

To assess the incremental prognostic value of stress CMR beyond traditional risk factors and CCTA in patients with obstructive CAD on CCTA.

METHODS

Between 2008 and 2020, consecutive symptomatic patients without known CAD referred for CCTA were screened. Among those, patients with obstructive CAD (at least 1 ≥50% stenosis on CCTA) and referred for functional stress CMR were included and followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Univariable and multivariable Cox regressions were performed to determine the prognostic value of CCTA and CMR findings.

RESULTS

Of 2,210 patients who completed the CMR protocol, 2,038 patients (46.5% male, mean age 69.8 ± 12.2 years) completed the follow-up (median 6.8 [IQR 5.9-9.2] years); 281 experienced a MACE (13.8%). Stress CMR was well tolerated without severe adverse events. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 4.51, [95%CI: 3.55-5.74]; and HR: 3.32, [95%CI: 2.55-4.32], respectively; both p < 0.001). In multivariable Cox regression, the presence of inducible ischemia and LGE were independent predictors of a higher incidence of MACE (HR: 3.97, [95%CI: 3.43-5.13]; HR: 2.30, [95%CI: 1.52-3.33]; respectively, both p < 0.001). After adjustment, stress CMR findings showed the best improvement in model discrimination and reclassification above traditional risk factors and CCTA findings (C statistic improvement: 0.08; NRI = 0.421; IDI = 0.047).

CONCLUSIONS

In symptomatic patients with obstructive CAD of unknown significance on CCTA, stress CMR has an incremental prognostic value to predict MACE over traditional risk factors and CCTA findings. Abstract Figure. Kaplan-Meier curves for MACE  Abstract Figure. Competitive risk analysis

Diagnosis and management of heart failure from hospital admission to discharge: A practical expert guidance

Heart failure (HF) has high event rates, mortality, and is challenging to manage in clinical practice. Clinical management is complicated by complex therapeutic strategies in a population with a high prevalence of comorbidity and general frailty. In the last four years, an abundance of research has become available to support multidisciplinary management of heart failure from within the hospital through to discharge and primary care as well as supporting diagnosis and comorbidity management. Within the hospital setting, recent evidence supports sacubitril-valsartan combination in frail, deteriorating or de novo patients with LVEF≤40%. Furthermore, new strategies such as SGLT2 inhibitors and vericiguat provide further benefit for patients with decompensating HF. Studies with tafamidis report major clinical benefits specifically for patients with ATTR cardiac amyloidosis, a remaining underdiagnosed and undertreated disease. New evidence for medical interventions supports his bundle pacing to reduce QRS width and improve haemodynamics as well as ICD defibrillation for non-ischemic cardiomyopathy. The Mitraclip reduces hospitalisations and mortality in patients with symptomatic, secondary mitral regurgitation and ablation reduces mortality and hospitalisations in patients with paroxysmal and persistent atrial fibrillation. In end-stage HF, the 2018 French Heart Allocation policy should improve access to heart transplants for stable, ambulatory patients and, mechanical circulatory support should be considered to avoid deteriorating on the waiting list. In the community, new evidence supports that improving discharge education, treatment and patient support improves outcomes. The authors believe that this review fills the gap between the guidelines and clinical practice and provides practical recommendations to improve HF management.

Prognostic interest of vasodilator stress perfusion cardiovascular magnetic resonance after a first inconclusive stress testing

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

While current guidelines recommend to perform a noninvasive test to detect coronary artery disease, stress tests are deemed inconclusive in almost a third of cases. The strategy for risk stratification after inconclusive stress testing is not well standardized.

PURPOSE

To assess the prognostic value of stress cardiovascular magnetic resonance (CMR) parameters and CMR-based coronary revascularization in patients after inconclusive stress testing.

METHODS

Between 2008 and 2020, consecutive patients with a first inconclusive stress test referred for vasodilator stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. CMR-related coronary revascularization was defined as any revascularisation occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter.

RESULTS

Of 1,563 patients who completed the CMR protocol, 1,402 patients (66.7% male, mean age 69.5 ± 11.0 years) completed the follow-up (median[interquartile range], 6.5 [5.6-7.5] years); 197 experienced a MACE (14.1%). Stress CMR was well tolerated without severe adverse events. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 2.88 [95%CI, 2.18-3.81]; and HR: 1.46 [95%CI, 1.16-1.89], both p < 0.001; respectively). In multivariable Cox regression, the presence and extent of inducible ischemia were independent predictors of a higher incidence of MACE (HR: 2.53 [95%CI, 1.89-3.40]; and HR: 1.58 [95%CI, 1.47-1.71]; both p < 0.001; respectively). After adjustment, the extent of inducible ischemia showed the best improvement in model discrimination above traditional risk factors (C-statistic 0.75 [95%CI: 0.69-0.81] with C-statistic improvement: 0.12). The study showed no benefit of CMR-related coronary revascularization in reducing MACE.

CONCLUSION

In patients with a first inconclusive stress test, stress CMR has good prognostic value to predict MACE offering an incremental prognostic value over traditional risk factors.

Change in left atrioventricular coupling index to predict incident atrial fibrillation: the multi-ethnic study of atherosclerosis (MESA)

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Left atrial (LA) and left ventricular (LV) structural and functional parameters have independent prognostic values as predictors of atrial fibrillation (AF).

PURPOSE

Due to the intrinsic physiological relationship between LA and LV, we sought to investigate the prognostic value of a left atrioventricular coupling index (LACI) as well as change in LACI to predict incident AF in a multi-ethnic population.

METHODS

In the Multi-Ethnic Study of Atherosclerosis (MESA), 1,911 study participants, free of clinically recognized AF and cardiovascular disease at baseline, had LACI assessed with CMR imaging at baseline (Exam 1, 2000–2002), and ten years later (Exam 5, 2010–2012). LACI was defined as the ratio of LA to LV end-diastolic volumes. Univariable and multivariable Cox proportional hazard models were used to evaluate the associations of LACI and average annualized change in LACI (ΔLACI) with incident AF.

RESULTS

Among the 1,911 participants (mean age 59 ± 9 years and 47.5% male participants), 87 incident AF events occurred over 3.9 ±0.9 years following the second imaging (Exam 5). After adjustment for traditional risk factors, greater LACI and ΔLACI were independently associated with AF (HR 1.69, 95% CI [1.46-1.96] and HR 1.71, 95% CI [1.50-1.94], respectively; both p < 0.0001). Adjusted models for LACI and ΔLACI showed significant improvement in model discrimination compared to currently used AF risk score model for predicting AF incidence (C-statistic: 0.78 vs. 0.74, and C-statistic: 0.80 vs. 0.74, respectively). The LACI and ΔLACI also showed superior discrimination performance for AF compared to the multivariable model including CHARGE-AF score, and individual LA or LV parameters.

CONCLUSIONS

Atrioventricular coupling (LACI) and coupling change (ΔLACI) are strong predictors for AF incidence in a multi-ethnic population. Both have incremental prognostic value for predicting AF over traditional risk factors, and superior discrimination power compared to the CHARGE-AF score and to individual LA or LV parameters.

Long-term prognostic value of stress CMR-related coronary revascularization to predict death: a large registry with > 200,000 patient-years of follow-up

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

While the benefit of coronary revascularization in patients with stable coronary artery disease (CAD) is debated, data assessing the potential interest of stress CMR to guide coronary revascularization are limited.

PURPOSE

To assess the long-term prognostic value of stress CMR-related coronary revascularization in consecutive patients from a large registry.

METHODS

Between 2008 and 2018, a retrospective cohort study with a median follow-up of 6.0 years (interquartile range: 5.0-8.0) included all consecutive patients referred for stress CMR. Stress CMR-related coronary revascularization was defined by any coronary revascularization performed within 90 days after CMR. The primary outcome was all-cause death based on the electronic National Death Registry.

RESULTS

Among the 31,752 consecutive patients (mean age 63.7 ± 12.1 years and 65.7% males), 2,679 (8.4%) died at 206,453 patient-years of follow-up. Inducible ischemia and late gadolinium enhancement (LGE) by CMR were associated with death (both p < 0.001). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of death (HR = 1.61; 99.5%CI 1.41-1.84; HR = 1.62; 99.5%CI 1.41-1.86, respectively; p < 0.001). CMR-related coronary revascularization was an independent predictor of greater survival (HR: 0.66; 99.5%CI: 0.52-0.84; p < 0.001). CMR-related revascularization was associated with a lower incidence of death in patients with severe inducible ischemia (p < 0.001), but showed no benefit in patients with mild or moderate ischemia (p = 0.109).

CONCLUSIONS

In this large observational series of consecutive patients, stress perfusion CMR had important incremental long-term prognostic value to predict death over traditional risk factors. CMR-related revascularization was associated with a lower incidence of death in patients with severe ischemia.

Prognostic value of pre-hospitalization stress perfusion CMR to predict death in patients hospitalized for COVID-19

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Inducible ischemia is a strong marker of vascular vulnerability that may be a key pathogenetic determinant of COVID-19 severity.

PURPOSE

This study investigated the prognostic value of prior inducible ischemia on stress perfusion CMR to predict death in patients hospitalized for COVID-19.

METHODS

In an observational study, we retrospectively analyzed consecutive patients referred for stress perfusion CMR within last two years prior to hospitalization for COVID-19. The primary outcome was all-cause death, including in-hospital and post-hospitalisation deaths, based on the electronic national death registry.

RESULTS

Among the patients referred for stress perfusion CMR, 481 were hospitalized for COVID-19 (mean age =68.4 ± 9.6 years, 61.3% males) and completed the follow-up (median 73[36-101] days). There were 93 (19.3%) all-cause deaths, of which 13.7% were in-hospital and 5.6% post-hospitalisation deaths.

Using Kaplan-Meier analysis, age, male gender, hypertension, diabetes, known CAD, the presence of prior inducible ischemia, the number of ischemic segments, the presence of LGE, and LVEF were significantly associated with all-cause death. In multivariable stepwise Cox regression analysis, age (HR: 1.04; 95%CI:1.01-1.07, p = 0.023), hypertension (HR: 2.77; 95%CI:1.71-4.51, p < 0.001), diabetes (HR: 1.72; 95%CI:1.08-2.74, p = 0.022), known CAD (HR: 1.78; 95%CI:1.07-2.94, p = 0.025) and the presence of prior inducible ischaemia  (HR: 2.05; 95%CI:1.27-3.33, p = 0.004) were independent predictors of all-cause death.

CONCLUSIONS

In COVID-19 patients, prior inducible myocardial ischemia by stress CMR over the last two years preceding the COVID-19 pandemic was independently associated with all-cause in-hospital and post-hospitalisation deaths, suggesting involvement of vasculature and endothelial dysfunction in the severity of COVID-19.

Safety, feasibility and prognostic value of stress perfusion CMR in patients with pacemaker

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Several studies have shown the excellent prognostic value of stress cardiovascular magnetic resonance (CMR). However, its prognostic value in patients with pacemaker (PM) remains unknown because most studies excluded PM patients.

PURPOSE

This study aimed to assess the prognostic value of vasodilator stress perfusion CMR in patients with PM.

METHODS

Consecutive patients with MR-conditional pacemakers referred for stress perfusion CMR at 1.5 T were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Cox regressions analyses were performed to determine the prognostic value of CMR-parameters. The quality of CMR was rated by two observers blinded to clinical details. Data on pacemaker and leads were collected pre- and post-CMR.

RESULTS

Of 224 patients who completed the stress CMR protocol, 2 patients had inconclusive stress CMR due to artefact and 203 patients (72.9% male, mean age 71.4 ± 8.7 years) completed the follow-up (median [interquartile range], 7.0 [5.2-7.3] years). Among those, 23 experienced a MACE (11.3%). Stress CMR was well tolerated with no major adverse events. All scans were completed successfully with no significant change in lead thresholds or pacing parameters. Overall, the image quality was rated good or excellent in 84.1% of segments. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 11.80 [95% CI, 4.63-30.30]; and HR: 6.74 [95% CI, 2.47-18.40], both p &lt; 0.001; respectively). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of a higher incidence of MACE (HR: 5.24 [95% CI, 2.61-14.40]; and HR: 2.98 [95% CI, 2.25-4.02]; both p &lt; 0.001; respectively). In patients with ischemia, CMR-related coronary revascularization showed no benefit in reducing MACE (p = 0.25).

CONCLUSION

Stress CMR is safe, feasible and has a good discriminative prognostic value in consecutive patients with PM.

Long-term prognostic value of stress CMR in patients with history of percutaneous coronary intervention

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Recurrence of cardiovascular (CV) events remains a substantial cause of mortality and morbidity among patients with previous coronary revascularization.

PURPOSE

The aim was to assess the prognostic value of stress cardiovascular magnetic resonance (CMR) parameters and CMR-based revascularization in patients with history of percutaneous coronary intervention (PCI).

METHODS

Between 2011 and 2014, consecutive patients with history of PCI referred for stress perfusion CMR were followed for the occurrence of major adverse cardiovascular events (MACE), defined by cardiovascular death or nonfatal myocardial infarction. Patients with prior coronary artery bypass graft were excluded. CMR-related coronary revascularization was defined as any revascularization occurring within 90 days after CMR. Univariable and multivariable Cox regressions were performed to determine the prognostic value of each parameter.

RESULTS

Of 1,762 patients who completed the CMR protocol, 1,624 patients (81.7% male, mean age 67.9 ± 10.4 years) completed the follow-up (median [interquartile range], 6.7 [5.6–7.3] years); 251 experienced a MACE (15.5%). Stress CMR was well tolerated. Using Kaplan-Meier analysis, inducible ischemia and late gadolinium enhancement (LGE) were significantly associated with the occurrence of MACE (hazard ratio, HR: 2.70 [95%CI, 2.11–3.46], p &lt; 0.001; and HR: 1.52 [95%CI, 1.16–1.99], p = 0.002; respectively). In multivariable Cox regression, inducible ischemia and LGE were independent predictors of a higher incidence of MACE (HR: 2.83 [95%CI, 2.20–3.64]; p &lt; 0.001; and HR: 1.42 [95%CI, 1.06–1.91]; p = 0.012; respectively). CMR-related coronary revascularization was associated with a lower incidence of MACE, even after adjustment.

CONCLUSIONS

Stress CMR and CMR-related revascularization were independently associated with MACE in patients with history of PCI.

Left atrioventricular coupling index to predict incident heart failure: the multi-ethnic study of atherosclerosis (MESA)

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Although left atrial (LA) and left ventricular (LV) structural and functional parameters have independent prognostic value as predictors of HF, the close physiological relationship between LA and LV suggest that the assessment of LA/LV coupling could better reflect left atrioventricular dysfunction and be a better predictor of heart failure (HF).

PURPOSE

We investigated the prognostic value of a left atrioventricular coupling index (LACI), measured by cardiovascular magnetic resonance (CMR), as well as change in LACI to predict incident HF in the Multi-Ethnic Study of Atherosclerosis (MESA).

METHODS

In the MESA, 2,250 study participants, free of clinically recognized HF and cardiovascular disease at baseline, had LACI assessed by CMR imaging at baseline (Exam 1, 2000–2002), and ten years later (Exam 5, 2010–2012). LACI was defined as the ratio of LA to LV end-diastolic volumes. Univariable and multivariable Cox proportional hazard models were used to evaluate the associations of LACI and average annualized change in LACI (ΔLACI) with incident HF after adjustment on traditional HF risk factors. The incremental risk prediction was calculated using C-statistic, categorical net reclassification index (NRI) and integrative discrimination index (IDI).

RESULTS

Among the 2,250 participants (mean age 59.3 ± 9.3 years and 47.6% male participants), 50 incident HF events occurred over 6.8 ± 1.3 years after the second CMR exam. After adjustment, greater LACI and ΔLACI were independently associated with HF (adjusted HR 1.44, 95% CI [1.25-1.66] and adjusted HR 1.55, 95% CI [1.30-1.85], respectively; both p &lt; 0.0001). Adjusted models for LACI showed significant improvement in model discrimination and reclassification compared to currently used HF risk score model for predicting HF incidence (C-statistic: 0.81 vs. 0.77; NRI = 0.411; IDI = 0.043). After adjustment, ΔLACI showed also significant improvement in model discrimination compared to the multivariable model with traditional HF risk factors for predicting incident HF (C-statistic: 0.82 vs. 0.77; NRI = 0.491; IDI = 0.058).

CONCLUSIONS

In a multi-ethnic population, atrioventricular coupling (LACI) and coupling change (ΔLACI) are independently associated with incident HF. Both have incremental prognostic value for predicting HF over traditional HF risk factors.

Feasibility and prognostic value of vasodilator stress perfusion CMR in patients with atrial fibrillation

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND 

Several studies have demonstrated the consistently high diagnostic and prognostic value of stress perfusion imaging with cardiovascular magnetic resonance (CMR). The feasibility and the prognostic value of vasodilator stress perfusion CMR in patients with atrial fibrillation (AF) is unknown, because most studies have excluded arrhythmic patients from analysis. 

PURPOSE 

The aim of our study was to assess the technical feasibility and the prognostic value of vasodilator stress perfusion CMR in patients with AF. 

METHODS 

Between 2008 and 2018, we prospectively included consecutive patients with AF referred for vasodilator stress perfusion CMR with dipyridamole. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or non-fatal myocardial infarction (MI). The secondary outcome was all-cause mortality. The diagnosis of AF was confirmed on 12-lead ECG before and after CMR, and patients with sinus rhythm during CMR were excluded. In the CMR protocol, to limit AF-related artifacts on cine images, an arrhythmia rejection algorithm, or real-time sequences were used. Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR. 

RESULTS 

Of 639 patients with AF and suspected or stable chronic CAD (72 ± 9 years, 77% men), 602 (94%) completed the CMR protocol, and among those 538 (89%) completed the follow-up (median follow-up 5.1 (3.3–7.1) years). Reasons for failure to complete CMR included AF-related ECG-gating problems (n = 17), intolerance to stress agent (n = 7), renal failure (n = 6), declining participation (n = 4) and claustrophobia (n = 3). 

Stress CMR was well tolerated without occurrence of death or severe disabling adverse event. Patients without inducible ischemia or LGE experienced a substantially lower annual event rate of MACE (1.2%) than those with ischemia and without LGE (8.9%), or those with both ischemia and LGE (9.8%; p &lt; 0.001 for all). Using Kaplan-Meier analysis, the presence of myocardial ischemia identified the occurrence of MACE (hazard ratio HR 7.56 ; 95% confidence interval CI: 4.86 – 11.80; p &lt; 0.001) (Figure). 

In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischemia was an independent predictor of a higher incidence of MACE (HR 5.88 ; 95% CI: 3.70 - 10.07; p &lt; 0.001) and all-cause mortality (HR 2.51 ; 95% CI: 1.47 - 4.17; p &lt; 0.001). 

CONCLUSION 

Stress CMR is technically feasible and has a good discriminative prognostic value to predict the occurrence of MACE and all-cause mortality in patients with AF.

Abstract Figure. Kaplan-Meier curves for MACE

Prognostic value of vasodilator stress perfusion CMR in patients with known myocardial infarction

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Several studies have demonstrated the consistently high prognostic value of stress perfusion cardiovascular magnetic resonance (CMR). This prognostic value in patients with known myocardial infarction (MI) is poorly described. There remains some skepticism about the capacity of stress CMR in predicting the clinical outcome due to the technical challenge during image analysis causes by myocardial scar.

PURPOSE

The aim of our study was to assess the prognostic value of vasodilator stress perfusion CMR in patients with known MI.

METHODS

We prospectively included consecutive patients with known MI referred for vasodilator stress perfusion CMR with dipyridamole. They were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiac death or recurrent non-fatal myocardial infarction (MI). Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR.

RESULTS

Of 1602 patients with known MI (68 ± 17 years, 78% men), 1556 (97%) completed the CMR protocol, and among those 1401 (90%) completed the follow-up (median follow-up 5.7 (3.9–7.6) years). Reasons for failure to complete CMR included ECG-gating problems (n = 13), intolerance to stress agent (n = 12), renal failure (n = 12), declining participation (n = 4) and claustrophobia (n = 5). Stress CMR was well tolerated without occurrence of death or severe adverse event. Patients without inducible ischemia experienced a substantially lower annual event rate of MACE (3.1%) than those with 1 or 2 segments of ischemia (4.5%), than those with 3 to 5 segments of ischemia (21.5%), than those with 6 or more segments of ischemia (45.7%, for all p &lt; 0.01). Using Kaplan-Meier analysis, the presence of myocardial ischemia identified the occurrence of MACE (hazard ratio HR 3.52; 95% confidence interval CI: 2.67 – 4.65; p &lt; 0.001). In a multivariable stepwise Cox regression including clinical characteristics and CMR indexes, the presence of inducible ischemia was an independent predictor of a higher incidence of MACE (HR 2.84; 95% CI: 2.14 to 3.78; p &lt; 0.001).

CONCLUSION

Stress CMR is technically feasible and has a good discriminative prognostic value to predict the occurrence of MACE in patients with known MI.

Abstract Figure. Kaplan-Meier curves for MACE

Stress perfusion CMR provides strong long-term prognostic value to cardiac events irrespective of patient sex

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

  

Compelling evidence indicates that women with coronary artery disease (CAD) experience worse outcomes than men due to a lack of early diagnosis and management. Numerous clinical studies have shown that stress cardiovascular magnetic resonance (CMR) detects evidence of myocardial ischemia and infarction at high accuracy. However, long-term prognosis data are limited. 

PURPOSE

The aim of this study was to test the hypothesis that stress perfusion CMR imaging can provide robust prognostic value in women presenting with suspected ischemia, to the same extent as in men. 

METHODS

 

Consecutive patients referred for vasodilator stress perfusion CMR with dipyridamole were followed for the occurrence of major adverse cardiovascular events (MACE) defined as cardiovascular death or non-fatal myocardial infarction (MI). The secondary endpoint was cardiovascular death. The safety of the CMR was assessed by clinical monitoring for 1 hour after the end of the CMR. Univariable and multivariable Cox regressions for MACE were performed to determine the prognostic value of inducible ischemia or late gadolinium enhancement (LGE) by CMR in each sex. 

RESULTS

Of 3436 patients referred for stress CMR in a single French center, 3322 (97%) completed the CMR protocol (59.9 ± 11.8 years, 57% men), and among those 3033 (91%) completed the follow-up (median follow-up 5.4 ± 0.2 years). Reasons for failure to complete CMR included renal failure (n = 29), claustrophobia (n = 26), poor gating (n = 22), intolerance to stress agent (n = 19) and declining participation (n = 18). 

Stress CMR was well tolerated without occurrence of death or severe disabling adverse event. Using Kaplan-Meier analysis, the presence of inducible myocardial ischemia identified the occurrence of MACE for both women (hazard ratio HR 2.36 ; 95% confidence interval CI: 1.54–3.62; p &lt; 0.001) and men (HR 3.57 ; 95% confidence interval CI: 2.75 – 4.64; p &lt; 0.001) (Figure). Moreover, inducible ischemia was associated with cardiovascular death for both women (hazard ratio HR 1.92; 95% confidence interval CI: 1.12 – 2.74; p = 0.04) and men (HR 2.71 ; 95% confidence interval CI: 1.98 – 4.41; p &lt; 0.001). 

In a multivariable stepwise Cox regression including clinical characteristics and CMR, presence of inducible ischemia was an independent predictor of a higher incidence of MACE for both women (hazard ratio HR 1.85 ; 95% confidence interval CI: 1.18 – 2.92; p = 0.008) and men (HR 3.55 ; 95% confidence interval CI: 2.73 – 4.63; p &lt; 0.001). Moreover, inducible ischemia was associated with cardiovascular death for men (HR 1.99; 95% confidence interval CI: 1.65 – 3.01; p &lt; 0.01) but not for women (p = 0.11). 

CONCLUSION

Stress CMR is feasible, safe and has a good discriminative prognostic value to predict the occurrence of MACE in patients of either sex presenting with inducible ischemia. However, inducible ischemia is an independent predictor of a higher incidence of CV mortality only in men.

Abstract Figure.

Cardiac troponin I and BNP for predicting zero Agatston score in patients with diabetes mellitus

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Coronary artery calcifications (CAC) scoring assessed by the Agatston score has shown an excellent prognostic value in large studies, particularly in diabetic patients, with a very low rate of cardiovascular events in patients with a zero Agatston score. Moreover, recent studies have suggested that high-sensitive cardiac troponin I (hs-cTnI) and brain natriuretic peptide (BNP) may be useful for detecting subclinical atherosclerosis, especially in diabetic patients. However, the link between hs-cTnI/BNP and the Agatston score has not been investigated in this population.

PURPOSE

The aim of this study was to investigate if hs-cTnI and BNP can bring additional value to predict zero Agatston score in patients with diabetes mellitus in addition to usual risk factors.

METHODS

Between 2015 and 2019, CAC score was prospectively performed in consecutive patients with diabetes mellitus with high cardiovascular risk. Patients with symptoms or known coronary artery disease were excluded. Within 24h from CT exam, peripheral blood samples were taken to measure hs-cTnI and BNP. The relationship between serum hs-cTnI/BNP concentrations and zero Agatston score was evaluated using univariate and multivariate binomial models. 77 variables have been used to build the model. The implication of hs-cTnI and BNP in this multivariate model was evaluated using nested models associated with Chi-squared test of independence.

RESULTS

A total of 844 patients with diabetes were enrolled (61 ± 7 years, 57% men, mean diabetes duration 18 years). In this population, 294 (35%) had a zero Agatston score, 253 (30%) an Agatston score from 1 to 100, 161 (19%) from 101 to 400, and 136 (16%) higher than 400. In univariate analysis, hs-cTnI and BNP concentrations were associated with a zero Agatston score (respectively OR, 2.63 [95% CI, 1.51-5.01]; p &lt; 0.001 and OR, 1.09 [95% CI, 1.01-1.22]; p = 0.03). In multivariate analysis, hs-cTnI and BNP concentrations were associated with a zero Agatston score (respectively OR, 2.38 [95% CI, 1.51-4.76]; p = 0.009 and OR, 1.18 [95% CI, 1.07-1.32]; p = 0.001). Among the 77 variables, the multivariate model including age, gender, smoking, dyslipidaemia, duration of the diabetes, arterial hypertension, presence of diabetic neuropathy, hs-cTnI and BNP concentrations, significantly discriminated the zero Agatston score (AUC = 0.81; p &lt; 0.001). The most discriminant threshold was ≤ 3ng/l for hs-cTnI and &lt;17ng/l for BNP. In nested models, both hs-cTnI and BNP brought information to this multivariate model to predict a zero Agatston score (respectively p = 0.003 and p &lt; 0.001 to the Chi-squared test). Moreover, removing hs-cTnI and BNP from the model results in a significant reduction in model performance (AUC = 0.79; p = 0.004).

CONCLUSIONS

Cardiac biomarkers hs-cTnI and BNP are associated with a zero Agatston score, which is correlated with a very low risk of cardiovascular events in asymptomatic patients with diabetes mellitus.

Abstract Figure. ROC curve to predict zero Agatston score

Additional prognostic value of vasodilator stress CMR in patients with inconclusive stress test to detect coronary artery disease

Funding Acknowledgements

Type of funding sources: None.

BACKGROUND

Guidelines recommend performing a non-invasive testing for ischemia to diagnose coronary artery disease (CAD). However, these tests are frequently inconclusive (25%). This population has been poorly studied because of its heterogeneity. In such cases, stress cardiac magnetic resonance (CMR) may be useful to improve diagnostic certainty. To date, no study has evaluated the prognostic value of stress CMR in these patients presenting with prior inconclusive test.

PURPOSE

To assess the additional prognostic value of vasodilator stress perfusion CMR in patients with a first inconclusive stress test to detect CAD.

METHODS

Between 2008 and 2018, consecutive patients with inconclusive stress test prospectively referred for vasodilator stress perfusion CMR with dipyridamole were followed for major adverse cardiovascular events (MACE) defined as cardiac death or myocardial infarction. Inconclusive stress test was defined by echocardiography or nuclear stress testing with uncertain conclusion about the diagnosis of CAD. To characterize this population, an unsupervised clustering analysis was performed using 18 variables. Univariable and multivariable Cox regressions were performed to determine the prognostic value of inducible ischemia by stress CMR in each cluster.

RESULTS

Of 1502 patients with inconclusive stress test (62 ± 12 years, 59% men), 1441 (96%) completed the CMR protocol and 1397(93%) completed the follow-up (median 5.5 ± 2.3 years). Stress CMR was well tolerated without occurrence of death or severe adverse event. The clustering analysis identified 3 clusters:

Cluster 1 (n = 524, 35%) had the highest prevalence of previous percutaneous coronary intervention (PCI), the highest presence of myocardial scar on CMR, the lowest LVEF(35 ± 7%) and the highest degree of LV dilatation.

Cluster 2 (n = 406, 27%) had the highest prevalence of previous coronary artery bypass grafting (CABG), preserved LVEF(54 ± 10%), absence of LV dilatation and rate of male(89%).

Cluster 3 (n = 572, 38%) had the lowest rate of previous PCI/CABG and of myocardial scar. This cluster gathered the oldest patients (73 ± 11 years), predominantly female (60%), with the highest rate of atrial fibrillation and body mass index.

Survival analysis found significant differences across clusters for the occurrence of MACE (p = 0.02). Moreover, inducible ischemia was significantly associated with the occurrence of MACE in each cluster (cluster 1, HR 2.28; [95%CI: 1.31-3.99]; p = 0.0028; cluster 2, HR 3.37; [95%CI, 1.97-5.75]; p &lt; 0.0001; cluster 3, HR 2.73; [95%CI, 1.67-4.46]; p &lt; 0.0001). In multivariable Cox regression, inducible ischemia was an independent predictor of a higher incidence of MACE in each cluster (p &lt; 0.001).

CONCLUSIONS

Cluster analysis identified 3 different phenotypes of patients with inconclusive stress test that were associated with distinct clinical and prognostic profiles. Within these clusters, CMR stress has an additional prognostic value to predict the occurrence of MACE.

Abstract Figure. Kaplan-Meier for MACE in each cluster