Differential Clinical Implications of Current Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography.

BACKGROUND: Classification of left ventricular diastolic function (LVDF) by echocardiography is controversial. The aim of this study was to evaluate the impact of the last 2016 recommendations for LVDF evaluation on brain natriuretic peptide (BNP) levels, proportion of final heart failure (HF) diagnosis, and cardiovascular outcomes. METHODS: Outpatients with first consultation at a one-stop HF clinic (2009-2014) were screened. The initial visit included echocardiography with LVDF evaluation and determination of BNP level. HF diagnosis was confirmed or ruled out at the end of the visit. Cardiovascular events during follow-up were recorded. LVDF classification was originally performed with the 2009 recommendations and reevaluated using the 2016 recommendations. RESULTS: A total of 157 patients (mean age 73.24 ± 10.3 years; 70.1% women) were included. Originally (2009 recommendations), most of the patients were classified with grade I diastolic dysfunction (DD; 67.5%). After the reanalysis using the 2016 recommendations, 49% were reclassified with normal LVDF. These subjects showed lower BNP levels (40.8 pg/mL) and a lower proportion of HF diagnosis (9.6%). Another part of the initial grade I DD group (31.1%) was reclassified with indeterminate LVDF; they had intermediate BNP levels, proportion of HF, and rate of cardiovascular events. Lower reclassification rates were observed in the other groups of DD. Kaplan-Meier survival curves showed significantly better prognostic stratification after the reclassification (P = .539 vs P = .003). CONCLUSIONS: Current recommendations for the evaluation of LVDF by echocardiography resulted in more accurate classification of patients, according to their BNP levels, HF diagnosis, and cardiovascular outcomes, especially for those patients previously classified with grade I DD.

Left atrial deformation predicts success of first and second percutaneous atrial fibrillation ablation.

BACKGROUND: Predictors of second radiofrequency catheter ablation (RFCA) success are not well known. Surgical ablation is accepted for failed first RFCA, but second RFCA has fewer complications. OBJECTIVE: The purpose of this study was to evaluate left atrial (LA) size and function as potential predictors of second RFCA for atrial fibrillation (AF). METHODS: Thirty-three healthy volunteers (group I) and 83 patients with symptomatic drug-refractory AF treated with a first RFCA (group II, n = 48) or a second RFCA (group III, n = 35 patients) were included. Echocardiography was performed in all patients in sinus rhythm before RFCA and in all volunteers. LA size and function were measured using longitudinal strain and strain rate during ventricular systole (LASs, LASRs) and during early diastole (LASRe) or late diastole (LASRa) with speckle tracking echocardiography. The effectiveness of RFCA on arrhythmia recurrence was evaluated at 6-month follow-up. RESULTS: LASs, LASRs, and LASRa were significantly lower in group III patients compared to other groups (P < .001 for all). LA diameter or volumes did not predict success after RFCA. LASs was an independent predictor of arrhythmia suppression after a first RFCA and after a second RFCA, with the best cutoff at LASs >20% (sensitivity 86%, specificity 70%) and LASs >12% (sensitivity 84%, specificity 90%), respectively. CONCLUSION: LA myocardial deformation imaging is a reliable tool for predicting success after a first and a second RFCA. These parameters could improve candidate selection, especially for a second RFCA.

Left atrial size and function by three-dimensional echocardiography to predict arrhythmia recurrence after first and repeated ablation of atrial fibrillation.

AIMS: Left atrial (LA) size has been related to the success of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). However, potential predictors after a repeated procedure are unknown. We evaluate predictive factors related to successful AF ablation after a first and a repeated RFCA. METHODS AND RESULTS: A total of 154 patients with AF were treated with RFCA. LA size and function were assessed with three-dimensional echocardiography (3D Echo) before RFCA. The effectiveness of RFCA was evaluated after 6 months. Recurrence of the arrhythmia was defined as any documented (clinically or by 24-h Holter recording) atrial tachyarrhythmia lasting >30 s after 12 weeks following RFCA. Of 154 patients, 103 (67%) underwent a first ablation (Group 1) and 51 (33%) a repeated RFCA (Group 2). At follow-up, arrhythmias were eliminated in 56 of 103 (54%) patients after a first RFCA and in 20 of 51 (40%) after a repeated ablation. In Group I, hypertension and LA expansion index derived from 3D Echo were independent predictors of arrhythmia elimination. In Group 2, only age predicted persistence of sinus rhythm; and only in younger patients (≤54 year old), though 3D LA maximal volumes were significantly smaller in those without when compared with those with AF recurrences. CONCLUSION: A combination of the analysis of LA function with 3D Echo and clinical data predicts elimination of AF after a first ablation procedure for AF, beyond LA size. Among patients undergoing a repeated procedure, age and 3D echocardiographic LA maximum volume in younger patients predict the success of RFCA.

Myocardial deformation analysis in Chagas heart disease with the use of speckle tracking echocardiography.

BACKGROUND: Assessment of myocardial deformation in Chagas disease may help us to better understand the disease pathophysiology and to detect early myocardial involvement. We aimed to characterize myocardial deformation in patients in different forms of Chagas disease and, specifically, assess differences between patients in the indeterminate form and controls. METHODS AND RESULTS: Speckle tracking echocardiography was performed in 98 subjects (22 with Chagas cardiomyopathy, 32 in the indeterminate form, and 44 control subjects) to quantify global and segmental left ventricular (LV) radial strain (RS), circumferential strain (CS), and longitudinal strain (LS). In a subset of patients from the indeterminate and control groups (n = 25), LV peak systolic twist and untwisting velocities were additionally assessed. Global RS, CS, and LS showed a significant decreasing trend across groups. Patients in the indeterminate form had significantly lower global RS and RS in the midinferior segment (median 39.8% vs 49.3% [P = .046] and 44.0% vs 56.0% [P = .038], respectively) and lower twist and untwisting velocity (P < .05 for both) compared with control subjects. CONCLUSION: Evaluation of myocardial deformation, particularly of RS, appears to be a sensitive technique for detection of myocardial involvement in patients in the indeterminate form and provides insights into the still unrevealed pathophysiology of Chagas heart involvement.

Función endotelial y concentración de proteína C reactiva de alta sensibilidad en pacientes con enfermedad de Chagas que viven en áreas no endémicas / Endothelial function and high-sensitivity C-reactive protein levels in patients with Chagas disease living in a nonendemic area

Introducción y objetivos. El número de pacientes con enfermedad de Chagas ha aumentado de manera significativa en España. La inflamación crónica y la disfunción endotelial han sido consideradas mecanismos fisiopatológicos de la cardiopatía chagásica. Sin embargo, en los estudios clínicos se han obtenido datos contradictorios. Nuestro objetivo fue evaluar la función endotelial y las concentraciones sistémicas de óxido nítrico y proteína C reactiva de alta sensibilidad en pacientes con la forma indeterminada de la enfermedad y con miocardiopatía chagásica crónica que vivían en un área no endémica. Métodos. Se determinó la vasodilatación mediada por flujo, dependiente del endotelio, y la vasodilatación mediada por nitroglicerina mediante ecografía de alta resolución de la arteria humeral en 98 individuos (32 con la forma indeterminada de la enfermedad, 22 con miocardiopatía chagásica crónica y 44 controles). Se efectuaron determinaciones de las concentraciones de óxido nítrico y proteína C reactiva de alta sensibilidad en sangre venosa periférica. Resultados. La media de edad fue 37,6±10,2 años; el 60% eran mujeres. La vasodilatación mediada por nitroglicerina estaba significativamente reducida en la miocardiopatía chagásica crónica en comparación con los controles (mediana, 16,8 frente a 22,5%; p=0,03). No se observaron diferencias significativas en la vasodilatación mediada por flujo ni en los valores de óxido nítrico, aunque se vió una tendencia a una menor vasodilatación mediada por flujo tras la corrección según el diámetro basal de la arteria humeral en la miocardiopatía chagásica crónica. Las cifras de proteína C reactiva fueron significativamente mayores en los pacientes con la forma indeterminada de la enfermedad y con miocardiopatía chagásica que en los controles (p<0,05). Conclusiones. Se observó una reducción de la vasodilatación mediada por nitroglicerina que sugiere una disfunción de las células de músculo liso vascular en pacientes con miocardiopatía chagásica crónica residentes en un área no endémica. Se observaron cifras superiores de proteína C reactiva en la forma indeterminada de la enfermedad y en las fases iniciales de la miocardiopatía chagásica crónica, lo que podría estar relacionado con la respuesta inflamatoria a la infección o la afección cardiovascular temprana (AU)

Introduction and objectives. The number of patients with Chagas disease in Spain has increased significantly. Chronic inflammation and endothelial dysfunction have been considered among the physiopathological mechanisms of Chagas heart disease. However, there have been conflicting data from clinical studies. Our purpose was to assess endothelial function and systemic levels of nitric oxide and high-sensitivity C-reactive protein in patients with the indeterminate form and with chronic Chagas cardiomyopathy living in a nonendemic area. Methods. Flow-mediated endothelium-dependent vasodilatation and nitroglycerin-mediated vasodilatation were assessed with high-resolution ultrasound of the brachial artery in 98 subjects (32 with the indeterminate form, 22 with chronic Chagas cardiomyopathy and 44 controls). Nitric oxide and high-sensitivity C-reactive protein levels were measured in peripheral venous blood. Results. Mean age was 37.6±10.2 years and 60% were female. Nitroglycerin-mediated vasodilatation was significantly reduced in chronic Chagas cardiomyopathy compared to controls (median 16.8% vs 22.5%; P=.03). No significant differences were observed in flow-mediated vasodilatation and nitric oxide levels, although a trend towards lower flow-mediated vasodilatation after correction by baseline brachial artery diameter was observed in chronic Chagas cardiomyopathy. Levels of C-reactive protein were significantly higher in patients with the indeterminate form and with Chagas cardiomyopathy compared with controls (P<.05). Conclusions. Reduced nitroglycerin-mediated vasodilatation suggesting dysfunction of vascular smooth muscle cells was found in patients with chronic Chagas cardiomyopathy living in a nonendemic area. Higher C-reactive protein levels were observed in the indeterminate form and early stages of chronic Chagas cardiomyopathy, which could be related to the inflammatory response to the infection or early cardiovascular involvement (AU)

[Endothelial function and high-sensitivity C-reactive protein levels in patients with Chagas disease living in a nonendemic area]. / Función endotelial y concentración de proteína C reactiva de alta sensibilidad en pacientes con enfermedad de Chagas que viven en áreas no endémicas.

INTRODUCTION AND OBJECTIVES: The number of patients with Chagas disease in Spain has increased significantly. Chronic inflammation and endothelial dysfunction have been considered among the physiopathological mechanisms of Chagas heart disease. However, there have been conflicting data from clinical studies. Our purpose was to assess endothelial function and systemic levels of nitric oxide and high-sensitivity C-reactive protein in patients with the indeterminate form and with chronic Chagas cardiomyopathy living in a nonendemic area. METHODS: Flow-mediated endothelium-dependent vasodilatation and nitroglycerin-mediated vasodilatation were assessed with high-resolution ultrasound of the brachial artery in 98 subjects (32 with the indeterminate form, 22 with chronic Chagas cardiomyopathy and 44 controls). Nitric oxide and high-sensitivity C-reactive protein levels were measured in peripheral venous blood. RESULTS: Mean age was 37.6 ± 10.2 years and 60% were female. Nitroglycerin-mediated vasodilatation was significantly reduced in chronic Chagas cardiomyopathy compared to controls (median 16.8% vs 22.5%; P=.03). No significant differences were observed in flow-mediated vasodilatation and nitric oxide levels, although a trend towards lower flow-mediated vasodilatation after correction by baseline brachial artery diameter was observed in chronic Chagas cardiomyopathy. Levels of C-reactive protein were significantly higher in patients with the indeterminate form and with Chagas cardiomyopathy compared with controls (P<.05). CONCLUSIONS: Reduced nitroglycerin-mediated vasodilatation suggesting dysfunction of vascular smooth muscle cells was found in patients with chronic Chagas cardiomyopathy living in a nonendemic area. Higher C-reactive protein levels were observed in the indeterminate form and early stages of chronic Chagas cardiomyopathy, which could be related to the inflammatory response to the infection or early cardiovascular involvement.

Chagas cardiomyopathy: the potential of diastolic dysfunction and brain natriuretic peptide in the early identification of cardiac damage.

INTRODUCTION: Chagas disease remains a major cause of mortality in several countries of Latin America and has become a potential public health problem in non-endemic countries as a result of migration flows. Cardiac involvement represents the main cause of mortality, but its diagnosis is still based on nonspecific criteria with poor sensitivity. Early identification of patients with cardiac involvement is desirable, since early treatment may improve prognosis. This study aimed to assess the role of diastolic dysfunction, abnormal myocardial strain and elevated brain natriuretic peptide (BNP) in the early identification of cardiac involvement in Chagas disease. METHODOLOGY/PRINCIPAL FINDINGS: Fifty-four patients divided into 3 groups--group 1 (undetermined form: positive serology without ECG or 2D-echocardiographic abnormalities; N = 32), group 2 (typical ECG abnormalities of Chagas disease but normal 2D-echocardiography; N = 14), and group 3 (regional wall motion abnormalities, left ventricular [LV] end-diastolic diameter >55 mm or LV ejection fraction <50% on echocardiography; N = 8)--and 44 control subjects were studied. Patients with significant non-cardiac diseases, other heart diseases and previous treatment with benznidazol were excluded. The median age was 37 (20-58) years; 40% were men. BNP levels, longitudinal and radial myocardial strain and LV diastolic dysfunction increased progressively from group 1 to 3 (p for trend <0.01). Abnormal BNP levels (>37 pg/ml) were noted in 0%, 13%, 29% and 63% in controls and groups 1 to 3, respectively. Half of patients in the undetermined form had impaired relaxation patterns, whereas half of patients with ECG abnormalities suggestive of Chagas cardiomyopathy had normal diastolic function. In group 1, BNP levels were statistically higher in patients with diastolic dysfunction as compared to those with normal diastolic function (27 ± 26 vs. 11 ± 8 pg/ml, p = 0.03). CONCLUSION/SIGNIFICANCE: In conclusion, the combination of diastolic function and BNP measurement adds important information that could help to better stratify patients with Chagas disease.

Decreased likelihood of response to cardiac resynchronization in patients with severe heart failure.

AIMS: We hypothesized that a very advanced stage of dilated cardiomyopathy is associated with lower response to cardiac resynchronization therapy (CRT). METHODS AND RESULTS: A consecutive cohort of 147 patients was studied before device implantation and at 12 months follow-up. All patients were in NYHA functional class III-IV and had left-ventricular (LV) systolic dysfunction (LV ejection fraction 24 +/- 7%) and a wide QRS (171 +/- 29 ms). A patient who was alive without heart transplantation and had improved by at least 10% in the 6 min walking test at 12 months follow-up was considered a clinical responder. Fifty-four patients (36%) did not respond to CRT (15 cardiac deaths, 4 heart transplantations). Quality of life indicators (>41 points), LV end-diastolic volumes (>200 mL) and mitral regurgitant orifice area (>16 mm(2)) at baseline were independent predictors of response to CRT. Patients were assigned 1 point for each predictive parameter. Patients with higher scores showed a significantly higher likelihood of non-response to CRT (chi(2) = 12 891, P = 0.005). CONCLUSION: The results show that non-responder patients have a more advanced stage of the disease, which suggests that CRT should be indicated earlier in the disease process.

Relation of plasma brain natriuretic peptide levels on admission for ST-elevation myocardial infarction to left ventricular end-diastolic volume six months later measured by both echocardiography and cardiac magnetic resonance.

The main objective of this study was to investigate the relation between brain natriuretic peptide (BNP) levels within the first 96 hours after ST-segment elevation acute myocardial infarction (STEMI) and the development of left ventricular (LV) dilatation at 6-month follow-up. Eighty-two patients with first STEMIs, reperfused within 12 hours of symptom onset, were prospectively included. Plasma BNP was determined on admission and at 1- and 6-month follow-up. Clinically significant LV dilatation, defined as a >20% increase in LV end-diastolic volume at 6-month follow-up, was assessed using echocardiography and cardiac magnetic resonance. Thirty-two percent of patients developed clinically significant LV dilatation. BNP values on admission and at follow-up were significantly higher in patients who developed clinically significant LV dilatation at 6 months (182 +/- 117 vs 106 +/- 91 pmol/ml). After adjusting for age, infarct size, E-wave deceleration time, and the LV ejection fraction, BNP on admission was an independent predictor of LV dilatation, whether assessed by echocardiography (B = 0.075, p = 0.04) or cardiac magnetic resonance (B = 0.085, p = 0.04). In conclusion, high BNP levels on admission and at follow-up predict LV dilatation after STEMI. The early determination of plasma BNP upon admission for STEMI could be helpful in identifying patients at higher risk for LV dilatation, in whom aggressive management is warranted.