Revisiting a classical clinical sign: jugular venous ultrasound.

BACKGROUND: Increased jugular venous pressure, reflecting the increased right atrial pressure, is a classical sign of heart failure (HF) but clinical assessment may be difficult. METHODS: In ambulatory patients with HF and control subjects, jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, during a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as diameter during Valsalva to that at rest. RESULTS: 211 patients (mean age 70 years; mean left ventricular ejection fraction 43%) and 20 controls were included. JVD (median and inter-quartile [IQR] range) at rest was 0.17 (0.15-0.20) cm in controls and 0.23 (0.17-0.33) cm in patients with HF (p=0.012), JVD ratio was 6.3 (4.3-6.8) in controls and 4.4 (2.7-5.8) in patients with HF (p=0.001).With increasing quartiles of plasma NT-proBNP, JVD at rest rose (0.20 (0.15-0.23) cm, 0.21 (0.16-0.29) cm, 0.25 (0.18-0.35) cm and 0.34 (0.20-0.53) cm (P=<0.001), whilst JVD ratio decreased (5.4 (4.2-6.4), 4.4 (3.5-6.3), 3.9 (2.4-5.4) and 2.8 (1.7-4.7); p=<0.001). JVD ratio correlated with log (NT-proBNP) (r=-0.39, p=<0.001), LV filling pressures (E/E', r=-0.33, p=<0.001) and left atrial volume (r=-0.21, p=0.002). In a multivariable regression model, only trans-tricuspid gradient and TAPSE were independently associated with JVD ratio (R(2)=0.27). CONCLUSIONS: Distension of the JV at rest relative to the maximum diameter during a Valsalva manoeuvre (JVD ratio) identifies patients with heart failure who have higher plasma NT-proBNP levels, right ventricular dysfunction and raised pulmonary artery pressure.

Global longitudinal strain in patients with suspected heart failure and a normal ejection fraction: does it improve diagnosis and risk stratification?

Many patients have clinical, structural or bio-marker evidence of heart failure (HF) but a normal left ventricular ejection fraction (LVEF; HeFNEF). Measurement of global longitudinal strain (GLS) may add diagnostic and prognostic information. Patients with symptoms suggesting heart failure and LVEF ≥50% were studied: 76 had no substantial cardiac dysfunction (left atrial diameter (LAD) <40 mm and amino-terminal pro-brain natriuretic peptide (NTproBNP) <400 ng/l); 99 had "possible HeFNEF" (LAD ≥40 mm or NTproBNP ≥400 ng/l); and 138 had "definite HeFNEF" (LAD ≥40 mm and NTproBNP ≥400 ng/L). Mean LVEF was 58% in each subgroup. Patients with definite HeFNEF were older, more likely to have atrial fibrillation, had more symptoms and signs of fluid retention, were more likely to have right ventricular dysfunction and had higher pulmonary pressures than other groups. Mean GLS (SD) was less negative in patients with definite HeFNEF (-13.6 (3.0)% vs. possible HeFNEF: -15.2 (3.1)% vs. no substantial cardiac dysfunction: -15.9 (2.4)%; p < 0.001). GLS was -19.1 (2.1)% in 20 controls. During a median follow up of 647 days, cardiovascular death or an unplanned hospitalisation for heart failure occurred in 62 patients. In univariable analysis, GLS but not LVEF predicted events. However, in a multi-variable analysis, only urea, NTproBNP, left atrial volume, inferior vena cava diameter and atrial fibrillation independently predicted adverse outcome. GLS is abnormal in patients who have other evidence of HeFNEF, is associated with a worse prognosis in this population but is not a powerful independent predictor of outcome.

Prevalence of, associations with, and prognostic value of tricuspid annular plane systolic excursion (TAPSE) among out-patients referred for the evaluation of heart failure.

BACKGROUND: Prevalence, predictors, and prognostic value of right ventricular (RV) function measured by the tricuspid annular plane systolic excursion (TAPSE) in patients with chronic heart failure (CHF) symptoms with a broad range of left ventricular ejection fraction (LVEF) are unknown. METHODS AND RESULTS: Of 1,547 patients, mean (±SD) age was 71 ± 11 years, 48% were women, median (interquartile range [IQR]) TAPSE was 18.5 (14.0-22.7) mm, mean LVEF was 47 ± 16%, 47% had LVEF ≤45% and 67% were diagnosed with CHF, defined as systolic (S-HF) if LVEF was ≤45% and as heart failure with preserved ejection fraction (HFPEF) if LVEF was >45% and treated with a loop diuretic. During a median (IQR) follow-up of 63 (41-75) months, mortality was 34%. In multivariable analysis, increasing age, N-terminal pro-B-type natriuretic peptide (NT-proBNP), New York Heart Association functional class, right atrial volume index, and transtricuspid pressure gradient; lower TAPSE, diastolic blood pressure, and hemoglobin; and atrial fibrillation (AF) or COPD were associated with an adverse prognosis. Receiver operating characteristic curve analysis identified a TAPSE of 15.9 mm as the best prognostic threshold (P = .0001); 47% of S-HF and 20% of HFPEF had a TAPSE of <15.9 mm. The main associations with a TAPSE <15.9 mm were higher NT-proBNP, presence of atrial fibrillation and presence of LV systolic dysfunction. CONCLUSIONS: In patients with CHF, low values for TAPSE are common, especially in those with reduced LVEF. TAPSE, unlike LVEF, was an independent predictor of outcome.

An atrial mass: the value of echocardiographic three-dimensional reconstruction.

An 88-year-old lady was referred to our Heart Failure Clinic with a history of 'occasional' breathlessness. Electrocardiography showed sinus rhythm and no other major abnormalities and N-terminal pro-B-type natriuretic peptide (NT-proBNP) was normal. Transthoracic echocardiography showed a non-dilated left ventricle with good systolic function. A bright and well-circumscribed, echogenic mass appeared inside a mildly dilated left atrium, visible in both parasternal and apical views. A three-dimensional echocardiographic reconstruction showed no mass within the left atrium; however, an extracardiac mass impinging its posterior wall was seen. Suspicion of an intrathoracic tumour was raised and cardiac magnetic resonance showed a hiatus hernia immediately adjacent to the left atrium. Care must be taken when evaluating masses in or close to the heart.

Cardiac resynchronization therapy: dyssynchrony imaging from a heart failure perspective.

PURPOSE OF REVIEW: To review the evidence for and against imaging as a means of selecting patients for cardiac resynchronization therapy (CRT). RECENT FINDINGS: There is no evidence that either the QRS interval on the surface ECG or dyssynchrony measured by imaging is of any practical value in predicting the clinical response to CRT in patients with a dilated and dysfunctional left ventricle. Careful assessment of the patient, so that therapy can be logically aligned with treatment goals, such as improving symptoms or prognosis, is the only useful method for selecting patients. Simple clinical evaluation may be as effective as, or more effective than, more complex assessments in predicting treatment benefits. Patients with a low blood pressure and moderate functional mitral regurgitation might benefit more, in absolute terms, from CRT. The benefits of adding a defibrillator to CRT are modest and, for many patients, uncertain. SUMMARY: Echocardiography, which was supposed to facilitate the introduction of CRT, may have become the greatest barrier to its appropriate implementation. Cardiac dyssynchrony, measured by echocardiography prior to implantation, may not be the substrate for the effects of CRT.

Clinical trials update from the European Society of Cardiology Congress 2007: 3CPO, ALOFT, PROSPECT and statins for heart failure.

This article provides information and a commentary on trials relevant to the pathophysiology, prevention and treatment of heart failure, presented at the European Society of Cardiology Congress 2007. Unpublished reports should be considered as preliminary data, as analyses may change in the final publication. In the 3CPO study, non-invasive ventilation produced a more rapid resolution of symptoms in patients hospitalised with acute cardiogenic pulmonary oedema; but had no effect on survival, compared to standard oxygen therapy. The ALOFT study showed that the selective oral renin inhibitor aliskiren reduces plasma BNP levels and is well tolerated in patients with heart failure receiving ACE inhibitors or ARBs, although the study was not powered to show clinical benefit. In the PROSPECT study, no echocardiographic measure of mechanical dyssynchrony was identified that was useful for identifying patients more or less likely to respond to CRT. Low dose atorvastatin reduced the incidence of sudden cardiac death in a small placebo controlled study of patients with advanced chronic heart failure.

Should patients who have persistent severe symptoms receive a left ventricular assist device or cardiac resynchronization therapy as the next step?

Currently, cardiac resynchronization therapy (CRT) should be considered before a left ventricular assist device for most patients who have moderate or severe left ventricular systolic dysfunction and have not responded symptomatically to conventional pharmacologic measures. There is little evidence that the severity of cardiac dyssynchrony as measured using current techniques is useful in predicting the benefits of CRT. QRS duration on the surface ECG is a surrogate marker of the severity of the left ventricular ejection fraction as well as of several types of dyssynchrony. More clinical trials are required to determine whether excluding patients who have QRS duration less than 120 msec or those who have no evidence of dyssynchrony from implantation of CRT is appropriate. Perhaps all patients who have moderate or severe left ventricular systolic dysfunction should be considered for CRT, either to improve symptoms if they are persistent or relapsing, or to improve outcome. In the longer-term future, it is possible that the development of less expensive, small, and safe left ventricular assist devices will supplant the role of both CRT and CRT-defibrillator devices.