Electrocardiographic characteristics associated with late gadolinium enhancement and prognostic value in patients with dilated cardiomyopathy.

Background: Late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) imaging has emerged as an important tool for assessment of patients with dilated cardiomyopathy (DCM). Electrocardiography (ECG) is an accessible, reproducible, low-cost diagnostic and prognostic tool. This study aimed to investigate the ECG characteristics associated with LGE, as well as to assess the prognostic significance of ECG in patients with DCM. Methods: Consecutive patients diagnosed with DCM by CMR [left ventricular ejection fraction (LVEF) < 50%] between 2011 and 2020 were included. Multivariable analysis was conducted to evaluate ECG predictors associated with LGE. Receiver operating characteristic (ROC) analysis was performed to assess the diagnostic performance of ECG in combination of clinical data and LVEF for LGE. Two composite outcomes were also assessed among patients with and without ECG predictors: (1) sudden cardiac death (SCD), sustained ventricular arrhythmia, or appropriate implantable cardioverter-defibrillator (ICD) therapy, and (2) all-cause death or hospitalization for heart failure. Results: A total of 422 patients, with a mean age of 59.5 ± 16.3 years (58.3% male), were included. LGE was present in 169 (40%) of the patients. Multivariable analysis identified lateral inverted T-waves, intraventricular conduction delay, low voltage, and fragmented QRS as independent predictors of LGE. ROC analysis showed a significant increase in the area under the curve (AUC) when ECG predictors of the four aforementioned characteristics were added to the clinical-LVEF model (AUC 0.66, 95% CI 0.59-0.71 vs. 0.72, 95% CI 0.67-0.78, p = 0.003). During a median follow-up of 2.7 years (IQR 0.8, 5.2), 16 events of SCD, sustained ventricular arrhythmia, or appropriate ICD therapy, and 70 events of all-cause death or hospitalization for heart failure occurred. ECG predictors were independently associated with SCD, sustained ventricular arrhythmia, or appropriate ICD therapy (HR 4.84, 95% CI 1.34-17.40, p = 0.01). However, ECG predictors were not associated with all-cause death or hospitalization for heart failure (HR 1.22, 95% CI 0.76-1.96, p = 0.39). Conclusion: In patients with DCM, lateral inverted T-waves, intraventricular conduction delay, low voltage, and fragmented QRS were independently associated with LGE. Additionally, these ECG predictors had prognostic value for predicting SCD, sustained ventricular arrhythmia, or appropriate ICD therapy, assisting clinicians in stratifying SCD risk and identifying primary prevention ICD implantation candidates.

Correction: Mahasing et al. Myocarditis and Pericarditis following COVID-19 Vaccination in Thailand. Vaccines 2023, 11, 749.

The authors wish to make the following corrections to this published paper [...].

Aortic stiffness effectively risk stratifies diabetic patients with suspected myocardial ischemia undergoing vasodilatory stress perfusion cardiac magnetic resonance.

BACKGROUND AND AIMS: Cardiovascular magnetic resonance (CMR) comprehensively assesses aortic stiffness and myocardial ischemia in a single examination. Aortic stiffness represents a subclinical marker of cardiovascular risk in the general population, including patients with diabetes mellitus. However, there is no prognostic data regarding aortic stiffness in patients with diabetes mellitus undergoing stress perfusion CMR. METHODS: Consecutive patients with diabetes mellitus with suspected myocardial ischemia referred for adenosine stress perfusion CMR with aortic pulse wave velocity (PWV) during 2010-2013 were studied. The primary outcome was major adverse cardiovascular events (MACE), defined as the composite of cardiac mortality, nonfatal myocardial infarction (MI), hospitalization for heart failure, coronary revascularization (> 90 days post-CMR), and ischemic stroke. The secondary outcome was hard cardiac events, defined as the composite of cardiac mortality and nonfatal MI. RESULTS: A total of 424 patients (median follow-up 7.2 years) were included. The mean PWV was 12.16 ± 6.28 m/s. MACE and hard cardiac events occurred in 26.8% and 9.4% of patients, respectively. Patients with elevated PWV (> 12.16 m/s) had a significantly higher incidence of MACE (HR 2.14 [95%CI 1.48, 3.09], p < 0.001) and hard cardiac events (HR 2.69 [95%CI 1.42, 5.10], p = 0.002) compared to those with non-elevated PWV. Multivariable analysis demonstrated that PWV independently predicts MACE (p = 0.003) and hard cardiac events (p = 0.01). Addition of PWV provided incremental prognostic value beyond clinical data, left ventricular mass index, myocardial ischemia, and late gadolinium enhancement in predicting MACE (incremental χ² 7.54, p = 0.006) and hard cardiac events (incremental χ² 5.99, p = 0.01). CONCLUSIONS: Aortic stiffness measured by CMR independently predicts MACE and hard cardiac events and confers significant incremental prognostic value in patients with diabetes mellitus with suspected myocardial ischemia. Aortic stiffness measurement could potentially be considered as part of a stress perfusion CMR protocol to enhance risk prediction in patients with diabetes mellitus.

The novel H2VK-65 clinical risk assessment tool predicts high coronary artery calcium score in symptomatic patients referred for coronary computed tomography angiography.

Background: Coronary computed tomographic angiography (CCTA) has emerged as a powerful imaging modality for the detection and prognostication of individuals with suspected coronary artery disease (CAD). High amounts of coronary artery calcium (CAC) significantly obscure the interpretation of CCTA. Clinical risk assessment tools and data specific to predictors of high CAC in symptomatic patients are limited. Methods: Consecutive patients who underwent CAC scan and CCTA to diagnose CAD during 2016-2020 were included. A high CAC score was defined as >400 by Agatston method. Univariate and multivariate analyses were performed to determine the predictors of high CAC. The clinical risk score was derived from factors independently associated with high CAC. The derivation cohort was composed of 465 patients; this score was validated in 98 patients. Results: The mean age was 63 ± 11 years, 53% were female, and 15.9% had high CAC scores. The independent predictors of high CAC scores were age >65 years (odds ratio [OR] 3.02, 95% confidence interval (95%CI) 1.56-5.85, p = 0.001), chronic kidney disease (CKD) (OR 11.09, 95%CI 3.38-36.38, p < 0.001), heart failure (OR 6.52, 95%CI 2.23-19.09, p = 0.001), hypertension (OR 26.44, 95%CI 9.02-77.44, p < 0.001), and vascular diseases, including ischemic stroke/transient ischemic attack and peripheral arterial disease (OR 20.96, 95%CI 4.19-104.86, p < 0.001). The H2VK-65 (Hypertension, Heart failure, Vascular diseases, CKD, and Age > 65) score allocates 1 point for age >65, 2 points for CKD or heart failure, and 3 points for hypertension or vascular diseases. Using a threshold of ≥4 points, the sensitivity and specificity to detect high CAC was 81% and 80%, respectively. The area under the curve was 0.88 and 0.85 in the derivation and validation cohorts, respectively. Conclusion: The novel H2VK-65 score demonstrated good performance for predicting high CAC scores in symptomatic patients referred for CCTA.

Myocarditis and Pericarditis following COVID-19 Vaccination in Thailand.

BACKGROUND: Myocarditis and pericarditis cases following Coronavirus 2019 (COVID-19) vaccination were reported worldwide. In Thailand, COVID-19 vaccines were approved for emergency use. Adverse event following immunization (AEFI) surveillance has been strengthened to ensure the safety of the vaccines. This study aimed to describe the characteristics of myocarditis and pericarditis, and identify the factors associated with myocarditis and pericarditis following COVID-19 vaccination in Thailand. METHOD: We carried out a descriptive study of reports of myocarditis and pericarditis to Thailand's National AEFI Program (AEFI-DDC) between 1 March and 31 December 2021. An unpaired case-control study was conducted to determine the factors associated with myocarditis and pericarditis after the CoronaVac, ChAdOx1-nCoV, BBIBP-CorV, BNT162b2, and mRNA-1273 vaccines. The cases consisted of COVID-19 vaccine recipients who met the definition of confirmed, probable, or suspected cases of myocarditis or pericarditis within 30 days of vaccination. The controls were people who underwent COVID-19 vaccination between 1 March and 31 December 2021, with no adverse reactions documented after vaccination. RESULTS: Among the 31,125 events recorded in the AEFI-DDC after 104.63 million vaccinations, 204 cases of myocarditis and pericarditis were identified. The majority of them were male (69%). The median age was 15 years (interquartile range (IQR): 13-17). The incidence was highest following the BNT162b2 vaccination (0.97 cases per 100,000 doses administered). Ten deaths were reported in this study; no deaths were reported among children who received the mRNA vaccine. Compared with the age-specific incidence of myocarditis and pericarditis in Thailand before the introduction of the COVID-19 vaccination, the incidence of myocarditis and pericarditis after the BNT162b2 vaccine was greater in the 12-17 and 18-20 age groups in both males and females. It was higher after the second dose in 12- to 17-year-olds (2.68 cases per 100,000 doses administered) and highest after the second dose in male 12- to 17-year-olds (4.43 cases per 100,000 doses administered). Young age and a mRNA-based vaccination were associated with myocarditis and pericarditis following administration of the COVID-19 vaccine after multivariate analysis. CONCLUSIONS: Myocarditis and pericarditis following vaccination against COVID-19 were uncommon and mild, and were most likely to affect male adolescents. The COVID-19 vaccine offers the recipients enormous benefits. The balance between the risks and advantages of the vaccine and consistent monitoring of AEFI are essential for management of the disease and identification of AEFI.

Prognostic Value of Adenosine Stress Perfusion Cardiac Magnetic Resonance Imaging in Older Adults with Known or Suspected Coronary Artery Disease. / Valor Prognóstico da Imagem de Ressonância Magnética Cardíaca de Perfusão em Estresse com Adenosina em Idosos com Doença Arterial Coronariana Conhecida ou Suspeita.

BACKGROUND: There is limited data on the prognostic value of stress cardiac magnetic resonance (CMR) in older adults. OBJECTIVE: To determine the prognostic value of adenosine stress CMR in older individuals with known or suspected coronary artery disease (CAD). METHODS: Between 2010 and 2015, consecutive patients aged 65 years or older referred for adenosine stress CMR were followed for the occurrence of severe cardiac events (cardiac death and nonfatal myocardial infarction) and major adverse cardiovascular events (MACE) that also included hospitalization for heart failure and ischemic stroke. Univariate and multivariate analyses were performed to determine the prognostic value of myocardial ischemia, with p-value <0.05 considered statistically significant. RESULTS: After a mean follow-up period of 50.4 months in 324 patients (48% male, 73±7 years), 21 severe cardiac events and 52 MACE occurred. Patients with myocardial ischemia (n=99) had significantly higher rates of severe cardiac events (HR 5.25 [95% CI 2.11-13.04], p<0.001) and MACE (HR 3.01 [95% CI 1.75-5.20], p<0.001) than those without ischemia. Multivariable analysis determined ischemia as an independent predictor of severe cardiac events (HR 3.14 [95% CI 1.22-8.07], p=0.02) and MACE (HR 1.91 [95%CI 1.02-3.59], p=0.04). Ischemia provided an incremental prognostic value over clinical factors and left ventricular ejection fraction for predicting severe cardiac events and MACE (p<0.01 for both). No severe adverse events occurred during or immediately after CMR examinations. CONCLUSION: Adenosine stress CMR is safe and has prognostic value in older adults with known or suspected CAD.

FUNDAMENTO: Há dados limitados sobre o valor prognóstico da ressonância magnética cardíaca (RMC) em estresse em pacientes idosos. OBJETIVO: Determinar o valor prognóstico da RMC em estresse com adenosina em idosos com doença arterial coronariana (DAC) conhecida ou suspeita. MÉTODOS: Entre 2010 e 2015, pacientes consecutivos com 65 anos ou mais encaminhados para RMC em estresse com adenosina foram acompanhados para a ocorrência de eventos cardíacos graves (morte cardíaca e infarto do miocárdio não-fatal) e eventos cardiovasculares adversos maiores (ECAM) que também incluíram hospitalização por insuficiência cardíaca e acidente vascular cerebral isquêmico. As análises univariadas e multivariadas foram realizadas para determinar o valor prognóstico da isquemia miocárdica, com valor de p <0,05 considerado estatisticamente significante. RESULTADOS: Após um período médio de seguimento de 50,4 meses em 324 pacientes (48% do sexo masculino, 73±7 anos), ocorreram 21 eventos cardíacos graves e 52 ECAM. Pacientes com isquemia miocárdica (n=99) apresentaram taxas significantemente maiores de eventos cardíacos graves (HR 5,25 [IC 95% 2,11-13,04], p<0,001) e ECAM (HR 3,01 [IC 95% 1,75-5,20], p<0,001) do que aqueles sem isquemia. A análise multivariada determinou a isquemia como preditor independente de eventos cardíacos graves (HR 3,14 [IC 95% 1,22-8,07], p=0,02) e ECAM (HR 1,91 [IC 95% 1,02-3,59], p=0,04). A isquemia forneceu um valor prognóstico incremental sobre fatores clínicos e fração de ejeção do ventrículo esquerdo para predizer eventos cardíacos graves e ECAM (p<0,01 para ambos). Nenhum evento adverso grave ocorreu durante ou imediatamente após os exames de RMC. CONCLUSÃO: A RMC em estresse com adenosina é segura e demonstra valor prognóstico em idosos com DAC conhecida ou suspeita.

Prognostic Value of Aortic Stiffness using Cardiovascular Magnetic Resonance in The Elderly with Known or Suspected Coronary Artery Disease. / Valor Prognóstico de Rigidez Aórtica usando Ressonância Magnética Cardiovascular em Idosos com Suspeita ou Confirmação de Doença Arterial Coronariana.

BACKGROUND: Aortic stiffness is established as a marker of cardiovascular disease. Cardiovascular magnetic resonance (CMR) provides a comprehensive assessment of aortic stiffness and myocardial ischemia in a single examination. However, prognostic data concerning aortic stiffness in elderly patients remain limited. OBJECTIVE: To determine the prognostic value of aortic stiffness using CMR-based pulse wave velocity (PWV) in elderly patients with known or suspected coronary artery disease (CAD). METHODS: This study enrolled consecutive patients aged >70 referred for adenosine stress perfusion CMR including PWV between 2010 and 2014. Patients were followed up for occurrence of major adverse cardiovascular events (MACE), including cardiac mortality, nonfatal myocardial infarction, hospitalization for heart failure, late revascularization (>180 days after CMR), and ischemic stroke. Univariable and multivariable analyses were performed to determine the predictors of MACE. A p-value of <0.05 is considered statistically significant. RESULTS: Mean PWV was 13.98±9.00 m/s. After a median follow-up period of 59.6 months in 263 patients (55% female, 77±5 years), 61 MACE occurred. Patients with elevated PWV (>13.98 m/s) had significantly higher rates of MACE (HR 1.75; 95% CI 1.05-2.94; p=0.03) than those with non-elevated PWV (<13.98 m/s). Multivariate analysis demonstrated diastolic blood pressure, left ventricular ejection fraction (LVEF), myocardial ischemia, and elevated PWV as independent predictors for MACE (p<0.05 for all). PWV provided an incremental prognostic value over clinical data, LVEF, and ischemia (increased global chi-square=7.25, p=0.01). CONCLUSION: Aortic stiffness using CMR is a strong and independent predictor of cardiovascular events in elderly patients with known or suspected CAD.

FUNDAMENTO: A rigidez aórtica é considerada um marcador de doença cardiovascular. A ressonância magnética cardiovascular (RMC) permite realizar uma avaliação abrangente da rigidez aórtica e da isquemia miocárdica em um único exame. Entretanto, dados prognósticos relacionados à rigidez aórtica em pacientes idosos permanecem limitados. OBJETIVO: Determinar o valor prognóstico da rigidez aórtica usando a velocidade da onda de pulso (VOP) baseada em RMC em pacientes idosos com doença arterial coronariana (DAC). MÉTODOS: Foram cadastrados pacientes consecutivos com idade >70 com indicação para RMC com perfusão de estresse com adenosina incluindo VOP, entre 2010 e 2014. Os pacientes foram acompanhados para verificar a ocorrência de eventos cardíacos adversos maiores (MACE), incluindo mortalidade cardíaca, infarto do miocárdio não fatal, hospitalização por insuficiência cardíaca, revascularização tardia (>180 dias após a RMC), e acidente vascular isquêmico. Foram realizadas análises univariadas e multivariadas para determinar os preditores de MACE. Um p-valor <0,05 foi considerado estatisticamente significativo. RESULTADOS: A VOP média foi 13,98±9,00 m/s. Depois de um período mediano de acompanhamento de 59,6 meses em 263 pacientes (55% do sexo feminino, 77±5 anos), ocorreram 61 MACE. Pacientes com VOP elevada (>13,98 m/s) tiveram índices de MACE significativamente mais altos (FC 1,75; IC 95% 1,05-2,94; p=0,03) que os dos pacientes com VOP não elevada (<13,98 m/s). A análise multivariada demonstrou que pressão arterial diastólica, fração de ejeção ventricular esquerda (FEVE), isquemia miocárdica, e VOP elevada são preditores independentes de MACE (p<0,05 para todos). A VOP apresentou um valor prognóstico incremental em relação a dados clínicos, FEVE e isquemia (qui-quadrado global aumentado = 7,25, p=0,01). CONCLUSÃO: A rigidez aórtica, usando-se a RMC, é um preditor independente forte de eventos cardiovasculares em pacientes idosos com suspeita de DAC ou DAC confirmada.

Valor Prognóstico de Rigidez Aórtica usando Ressonância Magnética Cardiovascular em Idosos com Suspeita ou Confirmação de Doença Arterial Coronariana / Prognostic Value of Aortic Stiffness using Cardiovascular Magnetic Resonance in The Elderly with Known or Suspected Coronary Artery Disease

Resumo Fundamento A rigidez aórtica é considerada um marcador de doença cardiovascular. A ressonância magnética cardiovascular (RMC) permite realizar uma avaliação abrangente da rigidez aórtica e da isquemia miocárdica em um único exame. Entretanto, dados prognósticos relacionados à rigidez aórtica em pacientes idosos permanecem limitados. Objetivo Determinar o valor prognóstico da rigidez aórtica usando a velocidade da onda de pulso (VOP) baseada em RMC em pacientes idosos com doença arterial coronariana (DAC). Métodos Foram cadastrados pacientes consecutivos com idade >70 com indicação para RMC com perfusão de estresse com adenosina incluindo VOP, entre 2010 e 2014. Os pacientes foram acompanhados para verificar a ocorrência de eventos cardíacos adversos maiores (MACE), incluindo mortalidade cardíaca, infarto do miocárdio não fatal, hospitalização por insuficiência cardíaca, revascularização tardia (>180 dias após a RMC), e acidente vascular isquêmico. Foram realizadas análises univariadas e multivariadas para determinar os preditores de MACE. Um p-valor <0,05 foi considerado estatisticamente significativo. Resultados A VOP média foi 13,98±9,00 m/s. Depois de um período mediano de acompanhamento de 59,6 meses em 263 pacientes (55% do sexo feminino, 77±5 anos), ocorreram 61 MACE. Pacientes com VOP elevada (>13,98 m/s) tiveram índices de MACE significativamente mais altos (FC 1,75; IC 95% 1,05-2,94; p=0,03) que os dos pacientes com VOP não elevada (<13,98 m/s). A análise multivariada demonstrou que pressão arterial diastólica, fração de ejeção ventricular esquerda (FEVE), isquemia miocárdica, e VOP elevada são preditores independentes de MACE (p<0,05 para todos). A VOP apresentou um valor prognóstico incremental em relação a dados clínicos, FEVE e isquemia (qui-quadrado global aumentado = 7,25, p=0,01). Conclusão A rigidez aórtica, usando-se a RMC, é um preditor independente forte de eventos cardiovasculares em pacientes idosos com suspeita de DAC ou DAC confirmada.

Abstract Background Aortic stiffness is established as a marker of cardiovascular disease. Cardiovascular magnetic resonance (CMR) provides a comprehensive assessment of aortic stiffness and myocardial ischemia in a single examination. However, prognostic data concerning aortic stiffness in elderly patients remain limited. Objective To determine the prognostic value of aortic stiffness using CMR-based pulse wave velocity (PWV) in elderly patients with known or suspected coronary artery disease (CAD). Methods This study enrolled consecutive patients aged >70 referred for adenosine stress perfusion CMR including PWV between 2010 and 2014. Patients were followed up for occurrence of major adverse cardiovascular events (MACE), including cardiac mortality, nonfatal myocardial infarction, hospitalization for heart failure, late revascularization (>180 days after CMR), and ischemic stroke. Univariable and multivariable analyses were performed to determine the predictors of MACE. A p-value of <0.05 is considered statistically significant. Results Mean PWV was 13.98±9.00 m/s. After a median follow-up period of 59.6 months in 263 patients (55% female, 77±5 years), 61 MACE occurred. Patients with elevated PWV (>13.98 m/s) had significantly higher rates of MACE (HR 1.75; 95% CI 1.05-2.94; p=0.03) than those with non-elevated PWV (<13.98 m/s). Multivariate analysis demonstrated diastolic blood pressure, left ventricular ejection fraction (LVEF), myocardial ischemia, and elevated PWV as independent predictors for MACE (p<0.05 for all). PWV provided an incremental prognostic value over clinical data, LVEF, and ischemia (increased global chi-square=7.25, p=0.01). Conclusion Aortic stiffness using CMR is a strong and independent predictor of cardiovascular events in elderly patients with known or suspected CAD.

Valor Prognóstico da Imagem de Ressonância Magnética Cardíaca de Perfusão em Estresse com Adenosina em Idosos com Doença Arterial Coronariana Conhecida ou Suspeita / Prognostic Value of Adenosine Stress Perfusion Cardiac Magnetic Resonance Imaging in Older Adults with Known or Suspected Coronary Artery Disease

Resumo Fundamento: Há dados limitados sobre o valor prognóstico da ressonância magnética cardíaca (RMC) em estresse em pacientes idosos. Objetivo: Determinar o valor prognóstico da RMC em estresse com adenosina em idosos com doença arterial coronariana (DAC) conhecida ou suspeita. Métodos: Entre 2010 e 2015, pacientes consecutivos com 65 anos ou mais encaminhados para RMC em estresse com adenosina foram acompanhados para a ocorrência de eventos cardíacos graves (morte cardíaca e infarto do miocárdio não-fatal) e eventos cardiovasculares adversos maiores (ECAM) que também incluíram hospitalização por insuficiência cardíaca e acidente vascular cerebral isquêmico. As análises univariadas e multivariadas foram realizadas para determinar o valor prognóstico da isquemia miocárdica, com valor de p <0,05 considerado estatisticamente significante. Resultados: Após um período médio de seguimento de 50,4 meses em 324 pacientes (48% do sexo masculino, 73±7 anos), ocorreram 21 eventos cardíacos graves e 52 ECAM. Pacientes com isquemia miocárdica (n=99) apresentaram taxas significantemente maiores de eventos cardíacos graves (HR 5,25 [IC 95% 2,11-13,04], p<0,001) e ECAM (HR 3,01 [IC 95% 1,75-5,20], p<0,001) do que aqueles sem isquemia. A análise multivariada determinou a isquemia como preditor independente de eventos cardíacos graves (HR 3,14 [IC 95% 1,22-8,07], p=0,02) e ECAM (HR 1,91 [IC 95% 1,02-3,59], p=0,04). A isquemia forneceu um valor prognóstico incremental sobre fatores clínicos e fração de ejeção do ventrículo esquerdo para predizer eventos cardíacos graves e ECAM (p<0,01 para ambos). Nenhum evento adverso grave ocorreu durante ou imediatamente após os exames de RMC. Conclusão: A RMC em estresse com adenosina é segura e demonstra valor prognóstico em idosos com DAC conhecida ou suspeita.

Abstract Background: There is limited data on the prognostic value of stress cardiac magnetic resonance (CMR) in older adults. Objective: To determine the prognostic value of adenosine stress CMR in older individuals with known or suspected coronary artery disease (CAD). Methods: Between 2010 and 2015, consecutive patients aged 65 years or older referred for adenosine stress CMR were followed for the occurrence of severe cardiac events (cardiac death and nonfatal myocardial infarction) and major adverse cardiovascular events (MACE) that also included hospitalization for heart failure and ischemic stroke. Univariate and multivariate analyses were performed to determine the prognostic value of myocardial ischemia, with p-value <0.05 considered statistically significant. Results: After a mean follow-up period of 50.4 months in 324 patients (48% male, 73±7 years), 21 severe cardiac events and 52 MACE occurred. Patients with myocardial ischemia (n=99) had significantly higher rates of severe cardiac events (HR 5.25 [95% CI 2.11-13.04], p<0.001) and MACE (HR 3.01 [95% CI 1.75-5.20], p<0.001) than those without ischemia. Multivariable analysis determined ischemia as an independent predictor of severe cardiac events (HR 3.14 [95% CI 1.22-8.07], p=0.02) and MACE (HR 1.91 [95%CI 1.02-3.59], p=0.04). Ischemia provided an incremental prognostic value over clinical factors and left ventricular ejection fraction for predicting severe cardiac events and MACE (p<0.01 for both). No severe adverse events occurred during or immediately after CMR examinations. Conclusion: Adenosine stress CMR is safe and has prognostic value in older adults with known or suspected CAD.

Clinical values of resting electrocardiography in patients with known or suspected chronic coronary artery disease: a stress perfusion cardiac MRI study.

BACKGROUND: Electrocardiography (ECG) is an essential investigation in patients with chronic coronary artery disease (CAD). However, evidence regarding the diagnostic and prognostic value of ECG in this population is limited. Therefore, we sought to determine whether baseline ECG abnormalities were associated with myocardial ischemia and cardiac events in patients with known or suspected chronic CAD. METHODS: Consecutive patients with known (n = 146) or suspected chronic CAD (n = 349) referred for adenosine stress cardiac magnetic resonance (CMR) between 2011 and 2014 were enrolled. Resting ECGs were classified as major, minor, and no abnormalities. Predictors of myocardial ischemia on CMR and major adverse cardiac events (MACE) including cardiac death, nonfatal myocardial infarction, hospitalization for heart failure and late revascularization (> 180 days after CMR) were evaluated. RESULTS: Average age was 69 ± 11 years (51% men). One hundred and eighty-five patients (37.4%) had major and 154 (31.1%) had minor ECG abnormalities. In patients with suspected CAD, myocardial ischemia was presented in 83 patients (23.8%). Multivariable analysis demonstrated major ECG abnormality as the strongest predictor of myocardial ischemia (HR 2.51; 95% CI 1.44-4.36; p = 0.001). Adding ECG to clinical pretest probability models improved the prediction of myocardial ischemia in ROC analyses (p = 0.04). In the whole cohort (n = 495), 91 MACE occurred during the median follow-up period of 4.8 years. Multivariable analysis showed that diabetes mellites, history of heart failure, prior revascularization, left ventricular ejection fraction, ischemia, and major ECG abnormality were independent predictors of MACE. CONCLUSION: Abnormal resting ECG is common in patients with known or suspected chronic CAD. ECG had important diagnostic and prognostic values in this population.

Impact of aortic stiffness by velocity-encoded magnetic resonance imaging on late gadolinium enhancement to predict cardiovascular events.

BACKGROUND: Increased aortic stiffness has been established as a marker in various cardiovascular diseases. Previous reports revealed a significant correlation between aortic stiffness and myocardial scarring using the late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR). However, prognostic data concerning aortic stiffness combining myocardial scarring remains limited. METHOD: A total of 402 patients who had undergone clinical CMR for the evaluation of cardiac function, LGE, and aortic pulse wave velocity (PWV) using velocity encoded-CMR (VE-CMR) were included. Patients were classified into 4 groups using mean PWV and the presence of LGE as elevated or non-elevated PWV and positive or negative LGE. Patients received follow-up for major adverse cardiovascular events (MACE) comprising cardiovascular death, non-fatal myocardial infarction, hospitalization for heart failure, coronary revascularization, and ischemic stroke. Predictors of MACE and hard cardiac events (cardiovascular death or non-fatal myocardial infarction) were evaluated. RESULTS: During the average follow-up period of 47.7 months, 58 MACE occurred. Patients who had elevated PWV and positive LGE experienced the highest rate of MACE compared to the group with non-elevated PWV and negative LGE (HR 11.90, p < 0.001). Among patients who had LGE, those who had elevated PWV experienced a 2.4-times higher rate of MACE compared to those who had non-elevated PWV. Multivariate analysis showed that PWV and LGE were independent predictors of MACE and hard cardiac events. PWV had excellent intra- and inter-observer reproducibility (intra-: ICC = 0.98, p < 0.001, inter-: ICC = 0.97, p < 0.001). CONCLUSION: Aortic stiffness using VE-CMR had prognostic value to predict cardiovascular events, with the added benefits of LGE.

Incremental prognostic value of aortic stiffness in addition to myocardial ischemia by cardiac magnetic resonance imaging.

BACKGROUND: Aortic stiffness is an independent predictor of cardiovascular (CV) events and mortality. However, no data exists for the prognosis of combined aortic stiffness and myocardial ischemia. Using cardiac magnetic resonance (CMR) imaging, we assessed the association of aortic stiffness by pulse wave velocity (PWV), myocardial ischemia, and CV events in patients with known or suspected coronary artery disease (CAD). METHODS: Velocity-encoded CMR was performed in 520 patients who had undergone adenosine stress CMR. The PWV was determined between the mid-ascending and mid-descending thoracic aorta. Patients were divided into 4 groups by PWV (higher or lower PWV) and myocardial ischemia (positive or negative ischemia). Combined CV events including mortality, acute coronary syndrome, heart failure, coronary revascularization, and stroke were analyzed among the 4 groups. RESULTS: The median follow-up period was 46.5 months, and the median PWV was 10.54 m/sec. Myocardial ischemia was positive in 199 patients (38.3%). The group with a higher PWV and positive ischemia had the most CV events (hazard ratio 8.94, p <  0.001). The group with a higher PWV and negative ischemia also was significantly associated with CV events (HR 2.19, p = 0.02). Groups with a lower PWV-positive ischemia and a higher PWV-negative ischemia showed no difference in terms of CV events (HR 0.60, p = 0.08). Patients with myocardial ischemia who had higher PWV demonstrated significantly higher event rates than those who had lower PWV (HR 2.41, p <  0.001). Multivariate analysis demonstrated that myocardial ischemia and PWV were independent predictors for combined CV events (HR 2.71, p <  0.001 and HR 2.42, p <  0.001, respectively). CONCLUSIONS: Stress perfusion CMR provided prognostic utility in patients with known or suspected CAD. Adding aortic stiffness to stress perfusion CMR could improve risk assessment and prediction for future CV events.

Usefulness of apical area index to predict left ventricular thrombus in patients with systolic dysfunction: a novel index from cardiac magnetic resonance.

BACKGROUND: LV systolic dysfunction presents an elevated risk of thromboembolism. Previous studies demonstrated low left ventricular ejection fraction (LVEF), ischemic cardiomyopathy and increased myocardial scarring as independent risk factors for LV thrombus formation. Structural changes that alter the size and shape of LV apex may have a significant role in predicting LV thrombus, but there is no definite evidence exists in this entity. METHODS: A case-control cardiac magnetic resonance (CMR) study of 150 patients with LV systolic dysfunction (LVEF < 40%; 30 patients with LV thrombus and 120 patients without thrombus) was performed. Factors associated with thrombus including sphericity index and 'new' apical area index (ratio of apical area to entire LV area from a cine four-chamber view) were evaluated. RESULTS: Average age was 63.48 ± 12.82 years and mean LVEF was 29.22 ± 8.53%. Patients with LV thrombus had significantly higher apical area index than those without thrombus (46.5 ± 3.27 vs. 42.71 ± 3.02, p <  0.001) while sphericity index in both groups was not different (1.63 ± 0.27 vs. 1.67 ± 0.19, p = 0.57). Univariate analysis revealed that male gender, prior myocardial infarction, presence of apical aneurysm, ischemic-typed scar, apical scar and apical area index were associated with thrombus. Further, multivariate analysis showed only apical area index and apical scar as independent predictors for thrombus formation. CONCLUSION: Apical area index from CMR is a new index to predict LV thrombus in patients with LV systolic dysfunction and may have a future role in early anticoagulant therapy.

Abnormal aortic stiffness in patients with bicuspid aortic valve: phenotypic variation determined by magnetic resonance imaging.

The aim of this study was to assess aortic stiffness in patients with bicuspid aortic valve (BAV), and to determine if differences exist among the BAV phenotypes. Stiffness was measured by pulse wave velocity (PWV) determined using velocity-encoded magnetic resonance imaging (VENC-MRI). VENC-MRI was performed in 100 BAV patients and 45 normal controls. PWV was determined between the mid ascending and mid descending aorta. The BAV phenotypes were characterized using steady-state free precession (SSFP) images acquired across the face of the aortic valve, and classified as follows: right-left cusp (R-L) fusion, right and non-coronary cusp (R-NC) fusion, and left and non-coronary cusp (L-NC) fusion. The following BAV phenotypes were identified: 76 R-L, 23 R-NC, and 1 L-NC fusion. BAV patients demonstrated significantly greater PWV compared to normal controls, after adjusting for age (9.16 vs. 3.83 m/s; p < 0.0001). Furthermore, PWV was significantly greater in patients with R-NC fusion than those with R-L fusion phenotype (12.27 vs. 7.97 m/s; p < 0.001). There was significantly increased PWV from VENC-MRI in BAV patients compared to normal controls. Thisis the first to demonstrate the association of different BAV phenotypes and aortic stiffness. VENC-MRI PWV assessment potentially represents a novel parameter for enhanced surveillance and may alter surgical triage of aorta in this high risk group.

Positive Pulmonary Computed Tomography Angiography in Patients with Suspected Acute Pulmonary Embolism: Clinical Prediction Rules, Thromboembolic Risk Factors, and Implications for Appropriate Use.

BACKGROUND: Acute pulmonary embolism (PE) is associated with a variety of non-specific clinical manifestations. Using diagnostic algorithms that are based on internationally recognized guidelines, pulmonary computed tomography angiography (CTA) serves as the gold standard diagnostic imaging tool in PE. However; inappropriate use of pulmonary CTA may lead to unnecessary radiation exposure, contrast exposure, and cost. Based on our review of the literature, there is no existing data regarding prevalence and appropriate use of pulmonary CTA in suspected acute PE in Thailand. OBJECTIVE: To assess the prevalence of positive pulmonary CTA and evaluate appropriateness of use of pulmonary CTA, according to clinical prediction rules and recent guidelines. MATERIAL AND METHOD: Three hundred consecutive patients admitted to the general medical ward at a large university-based tertiary referral center who were sent for pulmonary CTA due to suspected acute PE were included. Prevalence of positive pulmonary CTA for PE and other abnormalities were analyzed. Baseline clinical characteristics (including thromboembolic risk factors) and basic investigations (including chest X-ray, ECG, pulse oximetry, and D-dimer) were compared between patients with and without acute PE. RESULTS: Acute PE was diagnosed by pulmonary CTA in 110 (36.7%) patients. According to Wells score and revised Geneva score, patients were categorized into low, moderate, and high probability, as follows: 63, 178, and 59 patients, respectively, and 44, 246, and 10 patients, respectively. Patients with high probability according to Wells score and revised Geneva score had higher rate of positive pulmonary CTA results, as compared to low and moderate probability (59.3%, 7.9%, and 39.3%, respectively, and 60%, 19.5%, and 38.2%, respectively). Predictors of positive CTA were sign of deep vein thrombosis (DVT) (OR: 2.6, 95% CI: 1.497-4.514; p<0.001), S1Q3T3 (OR: 4.211, 95% CI: 2.242-7.908; p<0.001), and enlarged right pulmonary artery (OR: 2.439, 95% CI: 1.475-4.035; p<0.001). Using multivariate analysis, all three parameters remained independent factors. In the Wells score low probability group, 31 of 63 patients were not tested for D-dimer prior to pulmonary CTA, with only one patient in that group being diagnosed with acute PE. CONCLUSION: This was the first study to investigate prevalence of positive pulmonary CTA for acute PE in a large university-based tertiary referral hospital in Thailand Prevalence of positive test for PE by pulmonary CTA in patients with suspected acute PE was approximately 33%. Sign of DVT S1Q3T3 pattern, and enlarged right pulmonary artery were significant clinical predictors of positive pulmonary CTA. Positive pulmonary CTA result was much less likely in patients with low probability, especially in the absence of thromboembolic risk factors and positive D-dimer This study emphasized the importance and value of accurate and effective triage in reducing both patient care costs and patient radiation exposure.

Absence of coronary sinus tributaries in ischemic cardiomyopathy: An insight from multidetector computed tomography cardiac venographic study.

OBJECTIVE: Cardiac resynchronization therapy (CRT) is an important therapeutic strategy in heart failure. However, there is a high incidence of lead implantation failure and suboptimal response, particularly in ischemic cardiomyopathy. This failure rate may partly be secondary to lack of suitable coronary sinus branches for lead implantation. We sought to assess the presence of coronary sinus (CS) tributaries in patients with ischemic and non-ischemic cardiomyopathy. MATERIALS AND METHODS: Multidetector computed tomography (MDCT) was performed in 100 patients: 25 coronary artery bypass graft (CABG) patients with impaired left ventricular ejection fraction (LVEF), 25 CABG patients with preserved LVEF, 25 patients with non-ischemic cardiomyopathy, and 25 controls. The presence of the CS and its tributaries, including the posterior interventricular vein (PIV), posterolateral vein (PLV), left marginal vein (LMV), and the anterior interventricular vein (AIV) was assessed. RESULTS: The CS, PIV, and AIV were demonstrated in all patients, whereas presence of a PLV and LMV was identified in 68% and 48% of CABG patients with impaired LVEF, 96% and 68% of CABG patients with preserved LVEF, 92% and 80% of patients with non-ischemic cardiomyopathy, and 100% and 80% of controls (p = 0.001 and 0.046 for PLV and LMV, respectively). CONCLUSIONS: This is the first report to demonstrate that the posterolateral vein and left middle vein, branches of the coronary sinus, are detectable in a significantly smaller number of CABG patients with impaired LVEF compared to controls, CABG with preserved LVEF, and non-ischemic cardiomyopathy. The absence of CS tributary veins in ischemic cardiomyopathy potentially hinders proper lead implantation and results in suboptimal CRT response.

Correlation between aortic stiffness and left atrial volume index in hypertensive patients.

BACKGROUND: Both arterial stiffness and left atrial volume index are crucial predictors of cardiovascular outcomes in hypertensive patients. The correlation between these two factors has not been previously well established in hypertensive population. OBJECTIVES: To determine the correlation between arterial stiffness and left atrial volume index in hypertensive patients. METHODS AND RESULTS: The study was performed in 111 consecutive hypertensive patients (49.5% male, mean age 70.8 ± 10.3 years) undergoing cardiac magnetic resonance imaging (CMR). Arterial stiffness was determined by pulse wave velocity in the thoracic aorta by velocity-encoded imaging. Left atrial volume was assessed by biplane area-length method. Pulse wave velocity was significantly correlated with left atrial volume index in univariate analysis (r = 0.20, p = 0.032). In multivariate analysis, pulse wave velocity, coronary artery disease and left ventricular mass remain independent predictors (ß = 1.01, p = 0.02). CONCLUSION: Increased arterial stiffness correlates with left atrial enlargement in hypertensive patients. The prevention of left atrial enlargement and subsequent complications by specific antihypertensive drugs with positive effect on aortic stiffness warrants further studies.

Relationship between Cardio-Ankle Vascular Index (CAVI) and Obstructive Sleep Apnea (OSA).

BACKGROUND AND OBJECTIVE: A non-invasive test called Cardio-Ankle Vascular Index (CA VI) measures aortic stiffness, which is an early sign of atherosclerosis. Obstructive sleep apnea (OSA) has a close association with cardiovascular mortality and morbidity. We sought to assess the relationship between OSA and arterial stiffness. MATERIAL AND METHOD: Seventy-one patients with OSA (apnea-hypopnea index AHI ≥ 5, mean age 51.5 ± 14.1 years, 27 females) and 11 controls (AHI < 5, mean age 56.8 ± 11.8 years, 5 females) were enrolled in the study. In all subjects, arterial stiffness (CAVI) was performed and recorded along with blood pressure, pulse pressure of brachial arteries, and ankle arteries. RESULTS: The demographic data of the patients with OSA and controls were not significantly different. Subjects with OSA demonstrated higher values ofmean ankle artery pulse pressure than the controls (73.1 ± 14.6 vs. 59.6 ± 6.1 mmHg, respectively), but arterial stiffness and CAVI had no statistically significant difference (7.47 ± 1.68 vs. 7.25 ± 1.61, respectively). CONCLUSION: There was no relationship between arterial stiffness CAVI, and the presence of OSA. However; there was a significant association between ankle artery pulse pressure and the presence of OSA.

Accuracy of left atrial enlargement diagnosed by electrocardiography as compared to cardiac magnetic resonance in hypertensive patients.

BACKGROUND: Anatomical left atrial enlargement is associated with significant cardiovascular morbidity and mortality, heart failure, stroke, atrial fibrillation and diastolic dysfunction. This concept is more pronounced in hypertensive population, who have an especially increased risk of LA enlargement from diastolic dysfunction when compared to the general population. However left atrial enlargement may not be correlated with basic investigation such as electrocardiographic (ECG) criteria. In the past, studies usually correlating ECG criteria with anatomic measures mainly used an inferior M-mode or two-dimensional echocardiography; moreover, these were applied in the general population, not hypertensive patients. In the present study it was sought to determine the accuracy of the ECG criteria to diagnose anatomical left atrial enlargement in a hypertensive population, as determined by volumetric cardiovascular magnetic resonance imaging (CMR). MATERIAL AND METHOD: A total of 230 consecutive hypertensive patients referring for CMR (46.2% males, mean age 71.5 +/- 10.44 years) were enrolled. The ECG criteria for left atrial enlargement (LAE) was analyzed as well as left atrial volume index using the biplane area-length method from CMR. ECG criteria for LAE were assessed by investigator blinded to CMR data. RESULTS: Mean SBP/DBP at the time of CMR was 140/67 +/- 18.5/9.7 mmHg. Mean BMI was 26.8 +/- 4.7 kg/m2, co-morbid diseases were as follows; DM, 68 patients (57.1%) and dyslipidemia 67 patients (56.3%). Mean LA volume index was 59.77 +/- 17.93 ml/m2 and mean LVEF was 63.18 +/- 7.16%. The prevalence of CMR (with the cut-off point of 28 ml/m2) LAE was 98% and by any ECG criteria, was 47%. Sensitivity of individual ECG criteria for LAE, p > 120 ms was 49.6%, biphasic P wave in V1 was 30.8%, and P notch > 40 ms was 9.7%. If combined, ECG criteria p > 120 ms and biphasic P wave in V1, sensitivity increased to 58.1%, that was higher than individual criteria. Specificity of individual ECG criteria for LAE was 100%. CONCLUSION: In the LAE from ECG criteria, at least one criteria is not sensitive for anatomical LAE but for specificity in hypertensive population. For individual criteria, p > 120 ms had the highest sensitivity. These findings from our study emphasized the lack of sensitivity of LAE by ECG criteria in hypertensive patients. Therefore, LAE by ECG criteria might be discovered too late to be the prognosticator in hypertensive patients.

PINOT NOIR: pulmonic insufficiency improvement with nitric oxide inhalational response.

BACKGROUND: Tetralogy of Fallot (TOF) repair and pulmonary valvotomy for pulmonary stenosis (PS) lead to progressive pulmonary insufficiency (PI), right ventricular enlargement and dysfunction. This study assessed whether pulmonary regurgitant fraction measured by cardiovascular magnetic resonance (CMR) could be reduced with inhaled nitric oxide (iNO). METHODS: Patients with at least moderate PI by echocardiography undergoing clinically indicated CMR were prospectively enrolled. Patients with residual hemodynamic lesions were excluded. Ventricular volume and blood flow sequences were obtained at baseline and during administration of 40 ppm iNO. RESULTS: Sixteen patients (11 with repaired TOF and 5 with repaired PS) completed the protocol with adequate data for analysis. The median age [range] was 35 [19-46] years, BMI was 26 ± 5 kg/m(2) (mean ± SD), 50% were women and 75% were in NYHA class I. Right ventricular end diastolic volume index for the cohort was 157 ± 33 mL/m(2), end systolic volume index was 93 ± 20 mL/m(2) and right ventricular ejection fraction was 40 ± 6%. Baseline pulmonary regurgitant volume was 45 ± 25 mL/beat and regurgitant fraction was 35 ± 16%. During administration of iNO, regurgitant volume was reduced by an average of 6 ± 9% (p=0.01) and regurgitant fraction was reduced by an average of 5 ± 8% (p=0.02). No significant changes were observed in ventricular indices for either the left or right ventricle. CONCLUSION: iNO was successfully administered during CMR acquisition and appears to reduce regurgitant fraction in patients with at least moderate PI suggesting a potential role for selective pulmonary vasodilator therapy in these patients. TRIALS REGISTRATION: ClinicalTrials.gov, NCT00543933.