Abnormal exercise echocardiography plus abnormal E/e' ratio at exercise portends worse outcome in patients with dyspnea.

BACKGROUND: The role of exercise echocardiography (ExE) for the assessment of patients with dyspnea is promising. We aimed to analyze the clinical characteristics and outcome of patients with this condition referred for ExE. METHODS: A total of 505 patients (66 ± 11 years, 57% women) referred for evaluation of dyspnea were considered. Mitral regurgitation, ratio of early left ventricular inflow wave to early diastolic annulus wave (E/e'), and wall motion abnormalities (WMAs) were measured at rest and at exercise. Considered events were overall mortality, non-fatal myocardial infarction, late revascularization, and admission for heart failure. RESULTS: Ischemia was observed in 102 patients (20%), whereas WMAs were already present at rest in 55 patients (11%). A percent achieved of predicted metabolic equivalents >100% was found for most of the patients (70%). During a median follow-up of 3.50 years, 66 patients had events (annualized event rate 3.5%). An E/e' value of 13 at post-exercise was the best cut-off value to predict events. After adjustment by clinical and ExE variables, the combination of an abnormal ExE and E/e' values at post-exercise ≥13 was an independent predictor of events (hazard ratio = 3.67, 95% confidence interval = 2.11-6.38, p < 0.001). The worse outcome corresponded to patients with abnormal ExE and raised E/e' values at post-exercise (annualized event rate 17.2%). Patients with normal E/e' values at post-exercise had better outcome irrespective of the ExE results (annualized event rate 2.2% with normal ExE and 2.9% with abnormal ExE), whereas patients with high E/e' values at post-exercise but normal ExE results were at intermediate risk (annualized event rate 5.0%). CONCLUSIONS: Despite favorable ExE results, event rate remains high among patients with dyspnea referred for ExE, which may have a role to predict outcome in this setting. Patients with both raised E/e' values at post-exercise and abnormal ExE results are at the highest event risk.

Hallazgos diagnósticos y pronósticos en pacientes con prueba de esfuerzo clínica o ECG positivos pero ecocardiografía negativa / Diagnostic and prognostic findings in patients with positive clinical or ECG exercise tests in the absence of echocardiographic abnormalities

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Left ventricular torsion and circumferential strain responses to exercise in patients with ischemic coronary artery disease.

LV torsion during exercise in patients with coronary artery disease (CAD) is not well known. Circumferential strain (CS) and left ventricular (LV) torsion (Tor) have not been evaluated during ischemia in these patients. We aimed to assess the effect of ischemia during exercise echocardiography (ExE) on CS and Tor. We studied a group of 73 patients with true positive ExE results (Ischemic group: ischemia plus an abnormal coronary angiogram) and a matched control group of 66 patients with negative ExE and either normal coronary angiography or low post-test probability of CAD. Basal rotation (Rot) and apical rotation and basal and apical CS were studied by speckle tracking at rest and exercise. Apical CS and apical and basal Rot values were similar between groups at rest, except basal CS which was already worse in the ischemic group. At exercise, all rotational and CS parameters were impaired in the ischemic in comparison with the control group (basal CS: -18 ± 5 vs. -25 ± 7 %, p < 0.001; apical CS: -31 ± 11 vs. - 43 ± 9 %, p < 0.001; time to basal CS: 52 ± 6 vs. 48 ± 7 %, p = 0.001; time to apical CS: 55 ± 7 vs. 49 ± 6 %, p < 0.001; basal rotation: -0.7 ± 6.5° vs. -6.2 ± 8.5°, p < 0.001; LV twist 13.0 ± 10.4° vs.19.7 ± 11.5°, p < 0.001; LV-Tor 1.9 ± 1.6°/cm vs. 2.8 ± 1.7˚/cm, p = 0.001) with the exception of apical rotation which was similar (12.3 ± 7.4° vs. 13.4 ± 7.7°, p = NS). Basal and apical CS and basal rotation impair during exercise-induced ischemia. LV-Tor decreases with ischemia due to worsening of basal rotation, whereas apical rotation does not impair, suggesting the existence of an apical compensatory mechanism.

Outcome by Exercise Echocardiography in Patients with Low Pretest Probability of Coronary Artery Disease.

BACKGROUND: Recommendations for testing in patients with low pretest probability of coronary artery disease differ in guidelines from no testing at all to different tests. The aim of this study was to assess the value of exercise echocardiography (ExE) to define outcome in this population. METHODS: A retrospective analysis was conducted of 1,436 patients with low pretest probability of coronary artery disease (<15%) who underwent initial ExE. Overall mortality, major adverse cardiac events (MACEs), defined as cardiac death or nonfatal myocardial infarction, and revascularization during follow-up, were assessed. Ischemia (development of new wall motion abnormalities with exercise) and fixed wall motion abnormalities were measured. RESULTS: The mean age was 50 ± 12 years. Resting wall motion abnormalities were seen in 13 patients (0.9%) and ischemia in 108 (7.5%). During follow-up, 38 patients died, 10 of cardiac death (annualized death rate, 0.39%); 20 patients had MACEs (annualized MACE rate, 0.21%); and 48 patients (29 with ischemia) underwent revascularization (annualized revascularization rate, 0.51%). The number and percentage of MACEs in the abnormal and normal ExE groups were similar (two [1.7%] vs 18 [1.4%], P = .70), as was the annualized MACE rate (0.31% vs 0.21%, P = .50). Peak left ventricular ejection fraction exhibited a nonsignificant trend for predicting MACEs (P = .11). The number of studies needed to detect an abnormal finding was 12.6 and to detect a patient with extensive ischemia was 26.1. CONCLUSIONS: ExE offers limited prognostic information in patients with low pretest probability of coronary artery disease. The small number of abnormal findings on ExE and low event rates and the large number of studies needed to detect an abnormal finding limit further the value of imaging in this population.

Exercise left ventricular ejection fraction predicts events in right bundle branch block.

OBJECTIVE: Interpretation of the electrocardiogram (ECG) during exercise is not easy in patients with right bundle branch block (RBBB). Also, the value of exercise echocardiography (ExE) for predicting outcome in them has not been addressed. We sought to assess its prognostic value in patients with RBBB and known/suspected coronary disease. DESIGN: Retrospective analysis of data on 703 patients with RBBB who were submitted to a clinically-indicated ExE. The end points were overall mortality and combined myocardial infarction and cardiovascular mortality. RESULTS: During follow-up (4.1 ± 4.5 years) there were 130 deaths and 108 combined events. Independent predictors of combined events were history of coronary artery disease (hazard ratio [HR] = 2.37, 95% Confidence Interval [CI] = 1.24-4.52, p = 0.009) resting wall motion score index (HR = 2.14, 95% CI = 1.12-4.10, p = 0.02), metabolic equivalents (HR = 0.89, 95% CI = 0.93-0.97, p = 0.007), Δ in double product with exercise (HR = 0.96, 95% CI = 0.92-1.00, p = 0.036) and Δ in left ventricular ejection fraction (LVEF) with exercise (HR = 0.97, 95% CI = 0.94-0.99, p = 0.01). Neither positive clinical nor ECG exercise testing was predictive. Combined event rates were 3.3% in patients with ΔLVEF > 5%, 4.7% in those with ΔLVEF between 1-5% and 8.2% in those with no increase (Δ < 1%). CONCLUSIONS: A decrease in LVEF during exercise is predictive of serious events in patients with RBBB.

Predicting mortality in burn patients with bacteraemia.

OBJECTIVE: To determine factors associated with mortality in burn patients with bacteraemia. BACKGROUND: Previous studies have shown the negative impact of bacteraemia on the prognosis of burn patients, but only a few of these have analysed variables intervening in the clinical progress of these patients. METHODS: A retrospective study of adult burn patients (n = 73) with bacteraemia (103 episodes) in a Burns Unit during the 2000-2013 period. The study collected demographic variables, and comorbidity, injury-related and clinical data related to bacteraemia. Variables related to hospital mortality were analysed using a multiple logistic regression model. RESULTS: The cumulative incidence of bacteraemia was 4.4 episodes/100 patients. The mean age was 53.3 ± 19.2 years (65.8 % male). The median total body surface area (TBSA) was 35 %, while 50.7 % of the population had inhalation syndrome. The mean SOFA score at the onset of bacteraemia was 2.7 ± 3.8. The most common pathogen was Pseudomonas aeruginosa (17.5 %). The mortality rate was 24.7 %. The variables that were significantly associated with mortality were age (OR = 1.13), TBSA (OR = 1.05), SOFA score at the onset of bacteraemia (OR = 1.53) and recurrent bacteraemia (OR = 41.6). CONCLUSION: In addition to conventional risk factors, recurrence and organ dysfunction at the onset of bacteraemia are also associated with mortality, while the pathogen involved is not a prognostic factor.

Tracheostomy in the management of patients with thermal injuries.

OBJECTIVE: To assess the use and clinical impact of tracheostomy in burn patients. SUMMARY BACKGROUND DATA: The role of tracheostomy in the management of burn patients is controversial, with only a few recent studies conducted in this population. METHODS: Retrospective study of all adult burn patients who underwent a tracheostomy in a Burns Unit between 1995 and 2013. These were compared with a control group (1:1) who underwent orotracheal intubation. Hospital records were reviewed to obtain demographic and clinical information, including those related to respiratory support and tracheostomy. The McNemar's Chi-square and Signed-Rank Tests were used to study differences in morbimortality between both groups. RESULTS: A total of n = 20 patients underwent tracheostomy (0.9% of admissions, 56.0 ± 19.5 years, 60.0% women). The most common indication was long-term ventilation (75%), 24.6 ± 19.7 days after admission. Thirteen patients were successfully decannulated with a fatal complication observed in one case. Patients in the tracheostomy group were found to require longer-term mechanical ventilation (43.2 vs. 20.4 days; P = 0.004), with no differences in respiratory infection rates (30.0% vs. 31.6%; P = 0.687) or mortality (30.0% vs. 42.1%; P = 0.500). Ventilator weaning times (15.7 vs. 3.3 days; P = 0.001) and hospital stays (99.1 vs. 53.1 days; P = 0.030) were longer in the tracheostomy group, with no differences in duration of sedation. CONCLUSIONS: Tracheostomy may be a safe procedure in burn patients and is not associated with higher rates of mortality or respiratory infection. Tracheostomy patients showed longer mechanical ventilation times and higher morbidity, probably not attributable to tracheostomy.