Renal artery stenosis: an innocent bystander or an independent predictor of worse outcome in patients with chronic heart failure? A magnetic resonance imaging study.

AIMS: To investigate the prognostic impact of atherosclerotic renovascular disease in patients with chronic heart failure. METHODS AND RESULTS: Patients with heart failure due to left ventricular systolic dysfunction underwent cardiac magnetic resonance imaging and contrast-enhanced magnetic resonance angiography. Renal artery stenosis (RAS) was defined as a luminal narrowing >50%. Of the 366 patients investigated, 112 (31%) had RAS, of whom 41 had bilateral RAS. Patients with RAS were older (P < 0.001), had higher blood pressure (P < 0.001), and worse renal function (P = 0.001). In addition, these patients had more admissions and more prolonged hospital stays because of vascular events (0.09 ± 0.26 vs. 0.02 ± 0.16 admissions/per patient/year; P < 0.001; and 1.26 ± 5.79 vs. 0.31 ± 2.54 days/per patient/year; P < 0.001, respectively) and worse prognosis (hazard ratio 1.60, 95% confidence interval 1.10-2.34, P = 0.015). However, in multivariable analysis, a history of diabetes mellitus, decreasing haemoglobin, and increasing left ventricular end-systolic volume index, but not age and RAS, were independently related to outcome. CONCLUSIONS: RAS is a common finding in patients suffering from heart failure. Although it is associated with an increased vascular morbidity, it is not an independent predictor of mortality.

Atherosclerotic disease of the abdominal aorta and its branches: prognostic implications in patients with heart failure.

Aortic atherosclerosis reduces compliance in the systemic circulation and increases peripheral resistance, afterload and left ventricular wall stress. In patients with heart failure, these changes can impair left ventricular systolic function and energy efficiency, which could reduce exercise capacity. Though the interaction and the impact of aortic atherosclerosis on left ventricular function have been investigated, its prognostic implications in patients with heart failure are unclear. We used cardiac magnetic resonance imaging and gadolinium-enhanced abdominal aortography to investigate the prevalence and prognostic impact of atherosclerotic disease of the abdominal aorta and its side branches in 355 patients with heart failure. Sclerotic abdominal aortic disease was defined as a luminal narrowing >50% of the aorta and its side branches or the presence of abdominal aortic aneurysm. Patients with disease of the aorta and its branches were older (P < 0.0001), had overall longer stay in hospital (P = 0.006) and had more admissions (P = 0.001) and worse prognosis (hazard ratio: 1.97, 95% confidence interval: 1.29-3.00, P = 0.002) than those without. In a multivariable model, increasing age and pulse pressure, diabetes mellitus and increasing left ventricular end-diastolic volume were associated with a worse prognosis, but sclerotic abdominal aortic disease was not independently related to outcome (hazard ratio: 1.06; 95% confidence interval: 0.64-1.74; P = 0.823). These data demonstrate that atherosclerosis of the abdominal aorta and its side branches is common and associated with increased morbidity in patients with chronic heart failure. How such disease should be managed remains uncertain, but its recognition and characterisation are the first steps in finding out.

Prevalence of scarred and dysfunctional myocardium in patients with heart failure of ischaemic origin: a cardiovascular magnetic resonance study.

BACKGROUND: Cardiovascular magnetic resonance (CMR) with late gadolinium enhancement (LGE) can provide unique data on the transmural extent of scar/viability. We assessed the prevalence of dysfunctional myocardium, including partial thickness scar, which could contribute to left ventricular contractile dysfunction in patients with heart failure and ischaemic heart disease who denied angina symptoms. METHODS: We invited patients with ischaemic heart disease and a left ventricular ejection fraction < 50% by echocardiography to have LGE CMR. Myocardial contractility and transmural extent of scar were assessed using a 17-segment model. RESULTS: The median age of the 193 patients enrolled was 70 (interquartile range: 63-76) years and 167 (87%) were men. Of 3281 myocardial segments assessed, 1759 (54%) were dysfunctional, of which 581 (33%) showed no scar, 623 (35%) had scar affecting ≤50% of wall thickness and 555 (32%) had scar affecting > 50% of wall thickness. Of 1522 segments with normal contractile function, only 98 (6%) had evidence of scar on CMR. Overall, 182 (94%) patients had ≥1 and 107 (55%) patients had ≥5 segments with contractile dysfunction that had no scar or ≤50% transmural scar suggesting viability. CONCLUSIONS: In this cohort of patients with left ventricular systolic dysfunction and ischaemic heart disease, about half of all segments had contractile dysfunction but only one third of these had > 50% of the wall thickness affected by scar, suggesting that most dysfunctional segments could improve in response to an appropriate intervention.

Relationship between right ventricular volumes measured by cardiac magnetic resonance imaging and prognosis in patients with chronic heart failure.

AIMS: The aim of this study was to investigate the prognostic impact of right ventricular (RV) size in patients with chronic heart failure. METHODS AND RESULTS: Normal volunteers (n = 80) and patients (n = 380) with left ventricular (LV) ejection fraction <45% on echocardiography and on optimal treatment for heart failure underwent cardiac magnetic resonance imaging with measurement of LV and RV volumes, mass and ejection fraction. The mean and the standard deviation (SD) of the RV end-systolic volume index in normal subjects were used to define the normal range as: mean RV end-systolic volume index +2 SD. Patients with dilated RV (>2 SD beyond the mean) (25%) had more frequent evidence of fluid overload in clinical examination and greater LV dimensions (P < 0.0001). During follow-up (median 45, interquartile range: 28-66 months), 37% of patients with and 24% without RV dilation died (log-rank test = 8.4; P = 0.004). In a multivariable Cox regression model, including 13 other clinical variables, RV (HR: 1.08/10 mL/m(2), 95% CI: 1.00-1.18, P = 0.044), but not LV, end-systolic volume index predicted a worse outcome. CONCLUSION: Twenty-five per cent of patients with heart failure due to LV systolic dysfunction have a dilated right ventricle. Greater RV dimensions predict mortality in patients with chronic heart failure. Treatments aimed at preserving or enhancing RV structure and function, possibly by unloading the RV by reducing pulmonary vascular resistance or left atrial pressure, should be investigated.