Influence of chest wall conformation on reproducibility of main echocardiographic indices of left ventricular systolic function.

BACKGROUND: The possible influence of chest wall conformation, as noninvasively assessed by Modified Haller Index (MHI, the ratio of chest transverse diameter over the distance between sternum and spine), on reproducibility of both left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) has never been previously investigated. METHODS: Two equal groups of healthy individuals, matched by age, sex, and cardiovascular risk factors and categorized according to MHI in those with concave-shaped chest wall (MHI>2.5) and those with normal chest shape (MHI≤2.5), who underwent transthoracic echocardiography implemented with echocardiographic deformation imaging between June 2018 and May 2019, were retrospectively analyzed. LVEF and GLS were measured twice by the two echocardiographers in a double blinded manner. Intra-class correlation coefficients (ICCs), bias and limits of agreement determined with Bland-Altman analysis were calculated for repeated measurements of both LVEF and GLS. RESULTS: Thirty-four healthy individuals with MHI>2.5 (54.9±6.4 years, 58.8% females) and 34 matched controls with MHI≤2.5 (52.5±8.1 years, 50% females) were separately analyzed. In comparison to MHI≤2.5 group, the MHI>2.5 group was found with significantly smaller cardiac chambers and significantly lower GLS magnitude (-15.8±2.5 vs. -22.2±1.3%, P<0.001), despite similar LVEF (61.3±6.4 vs. 61.1±3.6%, P=0.87). In the MHI>2.5 group, intra-rater and inter-rater ICCs were ≤0.5 for both LVEF and LV-GLS, whereas in the MHI≤2.5 group intra-rater and inter-rater ICCs values indicated good reliability for LVEF and excellent reliability for GLS. The greatest bias and largest limits of agreement were detected for LVEF assessment (bias ranging from -1.09 to 2.94%, with the 95% limits of agreement ranging from -13.9 to 21.3%) in individuals with MHI>2.5. On the other hand, the smallest bias and narrowest limits of agreement were obtained for GLS measurement (bias ranging from -0.26 to 0.09%, with the 95% limits of agreement ranging from -1.4 to 1.4%) in participants with normal chest wall conformation (MHI≤2.5). CONCLUSIONS: The test reliability of LVEF and GLS is strongly influenced by the chest wall conformation. MHI might represent an innovative approach for selecting the best echocardiographic method for LV systolic function estimation in the individual case.

Modified Haller Index is inversely associated with asymptomatic status in atrial fibrillation patients undergoing electrical cardioversion: a preliminary observation.

BACKGROUND: No previous study evaluated the possible influence of chest wall conformation on symptoms perception in atrial fibrillation (AF) patients candidates for electrical cardioversion (ECV). We aimed at evaluating the anthropometric and clinical characteristics of patients with persistent AF undergoing ECV, categorized according to the presence or absence of symptoms. METHODS: This study retrospectively analyzed a series of persistent AF patients scheduled for early ECV who underwent pre-procedural clinical evaluation, MHI (the ratio of chest transverse diameter over the distance between sternum and spine) assessment, transthoracic and transesophageal echocardiography implemented with strain analysis of both left atrium and left atrial appendage. Thromboembolic risk and burden of comorbidities were assessed by CHA2DS2-VASc Score and Charlson Comorbidity Index (CCI), respectively. The independent predictors of "asymptomatic AF" were assessed. RESULTS: A total of 25 asymptomatic and 90 symptomatic AF patients were retrospectively examined. Compared to symptomatic AF patients, those asymptomatic were significantly older (78.4±3.8 vs. 71.0±7.7 years, P<0.001), predominantly males (84 vs. 44.4%, P<0.001), with significantly lower MHI (2.0±0.1 vs. 2.4±0.1, P<0.001), higher CHA2DS2-VASc Score (5.8±1.1 vs. 3.6±1.1, P<0.001) and CCI (6.8±1.4 vs. 2.3±0.9, P<0.001), and greater impairment in biventricular systolic function and atrio-auricolar myocardial strain indices. On multivariate logistic regression analysis, CHA2DS2-VASc Score (OR=2.65, 95% CI: 1.53-4.60) and CCI (OR=2.36, 95% CI: 1.16-4.66) were linearly associated with the endpoint "asymptomatic AF," whereas MHI (OR 0.76, 95% CI 0.59-0.97) was inversely associated with the asymptomatic status. A MHI <2.2 was the best cut-off for detecting asymptomatic AF patients. CONCLUSIONS: MHI is inversely associated with asymptomatic status in persistent AF patients undergoing ECV. MHI assessment might represent an innovative practical approach to AF patients.

Incremental prognostic value of global left atrial peak strain in women with new-onset gestational hypertension.

BACKGROUND: Left atrial strain and strain rate parameters, measured by bidimensional-speckle tracking echocardiography, have been proposed as predictors of atrial fibrillation, stroke, congestive heart failure and cardiovascular death. However, they have not yet been tested in hypertensive disorders of pregnancy. The aim of this study was to assess the prognostic role of global left atrial peak strain (GLAPS) in a population of pregnant women with new-onset hypertension in a medium-term follow-up. METHODS: Twenty-seven consecutive women with new-onset hypertension after 20 weeks pregnancy and 23 age-matched, race-matched and gestational week-matched consecutive normotensive pregnant women were enrolled in this prospective study. All participants underwent a complete echocardiographic study with bidimensional-speckle tracking echocardiography and carotid examination. At 1-year follow-up, we evaluated the occurrence of persistent hypertension. RESULTS: In comparison with normotensive women, those hypertensive had a higher burden of cardiovascular risk factors, similar left atrial volume indexed (P = 0.14), but severely impaired left atrial strain (P < 0.0001) and strain rate values (P < 0.0001). At 1-year follow-up, persistent hypertension was documented in 59.3% of patients. At the univariate Cox analysis, the variables associated with the occurrence of the investigated outcome in all hypertensive pregnancies were SBP (hazard ratio 1.04, P = 0.04), DBP (hazard ratio 1.11, P = 0.01), mean arterial pressure (hazard ratio 1.09, P = 0.01) values and the GLAPS value (hazard ratio 0.85, P = 0.0019). The latter was significantly associated with the investigated outcome both in preeclamptic (hazard ratio 0.84, P = 0.02) and nonpreeclamptic pregnant women (hazard ratio 0.83, P = 0.04). The receiver operating characteristics curve analysis highlighted that a GLAPS value of 23.5% or less predicted persistent hypertension with sensitivity of 100% and specificity of 90.90%. CONCLUSION: In hypertensive pregnant women a GLAPS value of 23.5% or less reveals a greater severity of atrial cardiomyopathy and might predict postpregnancy persistent hypertension.

Heterogeneity of clinical presentation in Tako-Tsubo syndromes: the prevalence of normal segmental wall motion and normal ECG pattern.

AIM: The aim of this study is to report the heterogeneity of clinical presentation in Tako-Tsubo syndrome (TTS), including a significant prevalence of normal ECG and echocardiographic patterns in a series of consecutive patients from a single center. METHODS AND RESULTS: From our database we selected a total of 168 cases of TTS. A total of 140 of these (Group A); 14 men (10%), mean age 60.3 years, range 39-87; 126 women (90%), mean age 66.1 years, range 43-93; matched the following reported criteria: typical stenocardic pain immediately following an emotional acute stress, or acute medical or surgical event within the preceding 12 h; acute rise and fall of troponin release; absence of significant coronary disease at coronary angiography. ECG findings at presentation ranged from T wave abnormalities (41 cases, 29.3%) to ST elevation (52 cases, 37.1%) and ST depression (11 cases, 7.9%), whereas in 36 cases (25.7%) the ECG was normal. Echocardiography at presentation showed akinesia of the total apical or medium-apical segments in 74 patients (53%), whereas it showed akinesia of left ventricular wall segments in other locations in 30 patients (21%) and even normal regional wall motion and thickening in 36 patients (26%). We described also a series of 13 female patients (mean age 70.2 years; age range 45-85 years) (Group B) who did not complain of chest pain at presentation, but showed a classical Tako-Tsubo evolution of wall motion abnormalities at echocardiography. Finally we selected 15 female patients (mean age 69.3 years; age range 49-89 years) (Group C) who formally did not report acute stress immediately preceding their presentation to the hospital for chest pain. They showed a classical Tako-Tsubo evolution of wall motion abnormalities at echocardiography and only one case of normal ECG pattern at presentation. CONCLUSION: In this series of acute TTS, a wide variability of ECG and echocardiographic patterns are observed, ranging from ST elevation with coexisting segmental wall motion abnormalities of the typical TTS to a clinical presentation characterized by normal ECG and normal segmental wall motion pattern.

Impact of metabolic syndrome traits on cardiovascular function: should the Adult Treatment Panel III definition be further stratified?

AIMS: The aims of the study were to evaluate whether a further classification of metabolic syndrome according to the number of traits (based on the Adult Treatment Panel III definition) could better explain the impact on cardiovascular remodeling and function, and to assess the role of single metabolic syndrome components in this regard. METHODS: We studied by echocardiography and carotid ultrasound 435 asymptomatic patients with metabolic syndrome. Patients with coronary artery disease or more than mild valvular heart disease were excluded. Carotid stiffness index (ß) was measured using a high-resolution echo-tracking system. Patients with metabolic syndrome were divided into two groups: metabolic syndrome with three traits (Gr.1) and metabolic syndrome with four or five traits (Gr. 2). RESULTS: Patients in Gr. 2 had higher left ventricular mass index (P < 0.001), left ventricular end-diastolic volume index (P = 0.029), left atrial volume index (P = 0.002), E/e' ratio (P = 0.002), intima-media thickness (P = 0.031), and prevalence of plaques (P = 0.01) than patients in Gr. 1. Left ventricular ejection fraction was similar in both groups. The mean carotid ß index tended to be higher in Gr. 2. Considering metabolic syndrome traits separately, in an age-corrected multivariate analysis, abdominal obesity was found to have the strongest association with cardiac structure and carotid artery atherosclerosis and stiffness. CONCLUSION: An increasing number of metabolic syndrome traits had a significantly worse impact on cardiac remodeling and function and carotid artery atherosclerosis. Abdominal obesity showed the strongest association with cardiac structure, carotid artery stiffness, and intima-media thickness. Prospective studies are needed to evaluate whether a new classification of metabolic syndrome using the number of traits could add prognostic information.

Cardiogenic shock with basal transient left ventricular ballooning (Takotsubo-like cardiomyopathy) as first presentation of pheochromocytoma.

Pheochromocytoma is a rare tumor that produces a distant effect by secretion of catecholamines. This tumor usually presents with hypertension and palpitations but it may also cause cardiogenic shock because of catecholamine-induced myocardial dysfunction. We describe a rare case of Takotsubo-like cardiomyopathy as first manifestation of pheochromocytoma with an unusual onset characterized by severe hypotension and transient basal left ventricular ballooning ('inverted' Takotsubo-like cardiomyopathy).

Effect of n-3 polyunsaturated fatty acids and rosuvastatin in patients with heart failure: results of the GISSI-HF trial.

Epidemiological, experimental studies and post hoc analyses of randomized trials suggested that n-3 polyunsaturated fatty acids (PUFA) and statins could be beneficial in chronic heart failure. Two double-blind, placebo-controlled, randomized clinical trials investigated the efficacy and safety of n-3 PUFA 1 g daily (R1) and rosuvastatin 10 mg daily (R2) in patients with heart failure. In total, 6975 and 4574 patients were randomized in R1 and R2, respectively; the main reason for excluding patients from R2 being the open-label administration of statin treatment. Primary end points were death, and death or admission to hospital for cardiovascular reasons. n-3 PUFA, but not rosuvastatin, significantly decreased the two coprimary end points: 56 and 44 patients needed to be treated with n-3 PUFA for a median duration of 3.9 years to avoid one death or one cumulative event. Both drugs were safe and were tolerated. A simple and safe treatment with n-3 PUFA provides a beneficial advantage in patients with heart failure in a context of usual care.

Echo-tracking assessment of carotid artery stiffness in patients with aortic valve stenosis.

BACKGROUND: There is little information about mechanical properties of large arteries in patients (pts) with aortic stenosis (AS). METHODS: Nineteen patients with AS (aortic valve area: 0.88 +/- 0.29 cm(2)) and 24 control subjects without AS but with a similar distribution of risk factors were recruited. beta index, pressure-strain elastic modulus (Ep), arterial compliance (AC), augmentation index (AIx), and local pulse-wave velocity (PWV) were obtained at the level of right common carotid artery (CCA) by a real time echo-tracking system. Time to dominant peak of carotid diameter change waveform, corrected for heart rate (tDPc), and maximum rate of rise of carotid diameter (dD/dt) were measured. Systemic arterial compliance (SAC) was also calculated. Parameters of AS severity (mean gradient, valve area, stroke work loss [SWL]) were determined. RESULTS: tDPc was higher in patients with AS than in controls (7.9 +/- 0.6 vs. 6.6 +/- 0.7, P < 0.0001) while dD/dt was lower (5.3 +/- 3.6 mm/s vs. 7.8 +/- 2.8 mm/s, P = 0.01). AIx was significantly higher in AS group (32.5 +/- 13.6% vs. 20.6 +/- 12.2%, P = 0.005) and had a linear correlation both with tDPc (r = 0.63, P < 0.0001) and with dD/dt (r =-0.38, P = 0.01). There was a significant correlation between carotid AC and SAC (r = 0.49, P = 0.03), but only carotid AC was related to SWL (r = 0.51, P = 0.02), while SAC was not (P = 0.26). CONCLUSIONS: AIx was the only parameter of arterial rigidity found to be higher in patients with AS than in controls. Carotid AC showed a significant correlation with SAC and it seemed to be more closely related to AS severity than to SAC.

High pulse pressure and low mean arterial pressure: two predictors of death after a myocardial infarction.

OBJECTIVES: Although the negative prognostic implication of a clinical history of arterial hypertension in myocardial infarction (MI) survivors is well known, the predictive role of the blood pressure (BP) regimen after MI is not well defined. The aim of this study was to investigate the prognostic significance of different BP indices in post-MI. METHODS AND RESULTS: We evaluated the relationship between baseline systolic, diastolic, pulse and mean arterial pressure (MAP), measured by sphygmomanometry at discharge from hospital or within 3 months of an MI, and total and cardiovascular mortality in 11 116 patients enrolled in the GISSI-Prevenzione trial. Over 3.5 years of follow-up, 999 patients died, 657 of them from cardiovascular causes. Low mean and high pulse pressure were significantly associated with total and cardiovascular mortality after controlling for potential confounders in the multivariate analysis. As compared with patients with less extreme BP values, patients with MAP of 80 mmHg or less (n = 1241; 11.2%) had a 48% higher risk of cardiovascular death [95% confidenceinterval (CI) 1.16-1.87; P = 0.001] and those with pulse pressure greater than 60 mmHg (n = 958; 8.6%) had a 35% higher risk (95% CI 1.09-1.69; P = 0.007); only four subjects (0.04%) had both a high pulse pressure and a low MAP (relative risk of cardiovascular death 3.48; 95% CI 0.48-25.88; P = 0.218). CONCLUSIONS: Our results show for the first time an additional prognostic importance of two easily measurable components of BP, definitely high pulse pressure (> 60 mmHg) and low MAP (< or = 80 mmHg), in a large sample of non-selected patients surviving MI who entered a modern programme of cardiovascular prevention.

[Determinants of late-onset heart failure in myocardial infarction survivors: GISSI Prevenzione trial results]. / Determinantes de insuficiencia cardíaca tardía postinfarto de miocardio: resultados del estudio GISSI Prevenzione.

INTRODUCTION AND OBJECTIVES: Improvement in the early phase of myocardial infarction (MI) is associated with a higher rate of late complications, including late-onset heart failure (LHF). The factors predicting LHF are not well understood. Our aims were to identify the factors predicting LHF and to determine the survival rate in these patients. PATIENTS AND METHOD: The GISSI-Prevenzione trial involved 11,323 low-risk patients (NYHA class < or = II) who had had a recent MI (< 3 months). It was a multicenter, open-label, clinical trial of the efficacy of treatment with polyunsaturated fatty acids, vitamin E, both, or neither. Patients with heart failure at baseline and those whose ejection fraction was unknown (n = 2908) were excluded from the present analysis. Late-onset heart failure was defined prospectively as hospital admission due to heart failure. A Cox regression model adjusted for major covariates was used for risk analysis. RESULTS: The study included 8415 patients. During 3.5 years of follow-up, 192 (2.3%) developed LHF. The risk of LHF could be predicted from readily available parameters: age (per year; RR=1.07; 95% CI, 1.05-1.09), ejection fraction (per 1% increment; RR=0.96; 95% CI, 0.94-0.97), heart rate (> or = 74 beats/min; RR=1.62; 95% CI, 1.21-2.16), white blood cell count (> or = 8900 per ml; RR=1.42; 95% CI, 1.05-1.94), diabetes (RR=1.62; 95% CI, 1.17-2.24), hypertension (RR=1.76; 95% CI, 1.33-2.34), peripheral artery disease (RR=2.11; 95% CI, 1.32-3.37), and reinfarction (RR=2.09; 95% CI, 1.28-3.39). LHF was associated with poor survival: (RR=2.34; 95% CI, 1.63-3.36). CONCLUSIONS: The risk of LHF in post-MI patients can be predicted from readily available parameters. LHF was associated with a poor prognosis.

Determinantes de insuficiencia cardíaca tardía postinfarto de miocardio: resultados del estudio GISSI Prevenzione / Determinants of late-onset heart failure in myocardial infarction survivors: GISSI prevenzione trial results

Introducción y objetivos. La mejoría pronóstica de la etapa inicial del infarto conlleva un mayor número de complicaciones a largo plazo. Entre éstas destaca la insuficiencia cardíaca tardía (ICT). Los factores relacionados con la ICT no son del todo conocidos. El objetivo es determinar qué factores pronósticos se relacionan con la ICT y cuál es la supervivencia de estos pacientes. Pacientes y método. El estudio GISSI Prevenzione fue multicéntrico, abierto, aleatorizado y se estudió a 11.323 pacientes postinfarto reciente (< 3 meses) de bajo riesgo (NYHA ≤ II) para evaluar la eficacia del tratamiento con ácidos grasos poliinsaturados, vitamina E, ambos o ninguno. Para este análisis se excluyó a los pacientes con insuficiencia cardíaca durante el ingreso y a aquellos sin determinación de la fracción de eyección (FE) (n = 2.908). La ICT se definió previamente como la necesidad de hospitalización por insuficiencia cardíaca. La predicción de riesgo se realizó con el modelo de Cox ajustado por diversas covariables. Resultados. Se incluyó a 8.415 pacientes. Durante 3,5 años de seguimiento, 192 pacientes (2,3%) desarrollaron ICT. Variables fácilmente asequibles permiten predecir el riesgo de ICT: edad (por año), riesgo relativo [RR] = 1,07; intervalo de confianza [IC] del 95%, 1,05-1,09), FE (por cada 1% de incremento, RR = 0,96; IC del 95%, 0,94-0,97), frecuencia cardíaca ≥ 74 lat/min (RR = 1,62; IC del 95%, 1,21-2,16), recuento de leucocitos ≥ 8.900/ml (RR = 1,42; IC del 95%, 1,05-1,94), diabetes (RR = 1,62; IC del 95%, 1,17-2,24), hipertensión (RR = 1,76; IC del 95%, 1,33-2,34), vasculopatía periférica (RR = 2,11; IC del 95%, 1,32-3,37) e infarto recurrente (RR = 2,09; IC del 95; 1,28-3,39). La ICT presentó mayor mortalidad alejada (RR = 2,34; IC del 95%, 1,63-3,36). Conclusiones. Elementos fácilmente asequibles en la consulta permiten predecir el riesgo de ICT en pacientes postinfarto. La ICT se asocia con un mal pronóstico

Introduction and objectives. Improvement in the early phase of myocardial infarction (MI) is associated with a higher rate of late complications, including late-onset heart failure (LHF). The factors predicting LHF are not well understood. Our aims were to identify the factors predicting LHF and to determine the survival rate in these patients. Patients and method. The GISSI-Prevenzione trial involved 11 323 low-risk patients (NYHA class ≤ II) who had had a recent MI (< 3 months). It was a multicenter, open-label, clinical trial of the efficacy of treatment with polyunsaturated fatty acids, vitamin E, both, or neither. Patients with heart failure at baseline and those whose ejection fraction was unknown (n = 2908) were excluded from the present analysis. Late-onset heart failure was defined prospectively as hospital admission due to heart failure. A Cox regression model adjusted for major covariates was used for risk analysis. Results. The study included 8415 patients. During 3.5 years of follow-up, 192 (2.3%) developed LHF. The risk of LHF could be predicted from readily available parameters: age (per year; RR=1.07; 95% CI, 1.05-1.09), ejection fraction (per 1% increment; RR=0.96; 95% CI, 0.94-0.97), heart rate (≥74 beats/min; RR=1.62; 95% CI, 1.21-2.16), white blood cell count (≥8900 per ml; RR=1.42; 95% CI, 1.05-1.94), diabetes (RR=1.62; 95% CI, 1.17-2.24), hypertension (RR=1.76; 95% CI, 1.33-2.34), peripheral artery disease (RR=2.11; 95% CI, 1.32-3.37), and reinfarction (RR=2.09; 95% CI, 1.28-3.39). LHF was associated with poor survival: (RR=2.34; 95% CI, 1.63-3.36). Conclusions. The risk of LHF in post-MI patients can be predicted from readily available parameters. LHF was associated with a poor prognosisIntroduction and objectives. Improvement in the early phase of myocardial infarction (MI) is associated with a higher rate of late complications, including late-onset heart failure (LHF). The factors predicting LHF are not well understood. Our aims were to identify the factors predicting LHF and to determine the survival rate in these patients. Patients and method. The GISSI-Prevenzione trial involved 11 323 low-risk patients (NYHA class ≤ II) who had had a recent MI (< 3 months). It was a multicenter, open-label, clinical trial of the efficacy of treatment with polyunsaturated fatty acids, vitamin E, both, or neither. Patients with heart failure at baseline and those whose ejection fraction was unknown (n = 2908) were excluded from the present analysis. Late-onset heart failure was defined prospectively as hospital admission due to heart failure. A Cox regression model adjusted for major covariates was used for risk analysis. Results. The study included 8415 patients. During 3.5 years of follow-up, 192 (2.3%) developed LHF. The risk of LHF could be predicted from readily available parameters: age (per year; RR=1.07; 95% CI, 1.05-1.09), ejection fraction (per 1% increment; RR=0.96; 95% CI, 0.94-0.97), heart rate (≥74 beats/min; RR=1.62; 95% CI, 1.21-2.16), white blood cell count (≥8900 per ml; RR=1.42; 95% CI, 1.05-1.94), diabetes (RR=1.62; 95% CI, 1.17-2.24), hypertension (RR=1.76; 95% CI, 1.33-2.34), peripheral artery disease (RR=2.11; 95% CI, 1.32-3.37), and reinfarction (RR=2.09; 95% CI, 1.28-3.39). LHF was associated with poor survival: (RR=2.34; 95% CI, 1.63-3.36). Conclusions. The risk of LHF in post-MI patients can be predicted from readily available parameters. LHF was associated with a poor prognosis

Metabolic syndrome and risk of cardiovascular events after myocardial infarction.

OBJECTIVES: We aimed to assess the prevalence and prognostic role of metabolic syndrome (METS) and diabetes in post-myocardial infarction (MI) patients. BACKGROUND: Diabetes is a well known risk factor for patients with previous MI, but glycemic dysmetabolism develops over a protracted period of time. Scanty data are available on the role of METS in patients with previous MI. METHODS: Adjusted Cox's regression models, having diabetes, death, major cardiovascular events (CVE), and hospitalization for congestive heart failure (CHF) during follow-up as outcome events, were fitted on 11,323 patients with prior MI enrolled in the GISSI-Prevenzione Trial. RESULTS: At baseline, 21% and 29% of patients had diabetes mellitus and METS, respectively. The METS patients had a significant (93%) increased risk of diabetes during follow-up. As compared with control subjects, the probability of death and CVE were higher in both METS (+29%, p = 0.002; +23%, p = 0.005) and diabetic patients (+68%, p <0.0001; +47%, p <0.0001), although diabetic but not METS patients were more likely to be hospitalized for CHF (+89%, p <0.0003 and +24%, p = 0.241). Moderate (-6% to -10%) and substantial (>-10%) weight reduction were associated with a significant (18% and 41%, respectively) decreased risk of diabetes. Weight gain was significantly associated with increased risk of diabetes. The risk conferred by METS and diabetes tended to be higher among women. CONCLUSIONS: In patients with MI, METS and diabetes were highly prevalent and are associated with increased risk of death and CVE. Diabetes is also associated with increased risk of hospitalization for CHF. Weight reduction significantly decreased the risk of becoming diabetic in patients with METS.

Doppler-derived mitral deceleration time as a strong prognostic marker of left ventricular remodeling and survival after acute myocardial infarction: results of the GISSI-3 echo substudy.

OBJECTIVES: The goal of this study was to assess the impact of left ventricular (LV) diastolic filling on remodeling and survival after acute myocardial infarction (AMI). BACKGROUND: Little is known regarding the link between LV filling, its changes over time, and six-month remodeling and late survival in uncomplicated AMI. METHODS: Doppler mitral profile, end-diastolic volume index (EDVi) and end-systolic volume index (ESVi), ejection fraction (EF), and wall motion abnormalities (%WMA) were evaluated in 571 patients from the GISSI-3 Echo substudy at baseline, pre-discharge, and six months after AMI. Patients with baseline early mitral deceleration time (DT) 130 ms were assigned to the restrictive group (n = 147), and those with DT >130 ms to the nonrestrictive group (n = 424). RESULTS: Restrictive group patients had greater baseline ESVi and %WMA and lower EF than nonrestrictive group, and six-month greater LV dilation (EDVi, ESVi: p < 0.001 for EDVi and ESVi), smaller decrease in %WMA decrease (p < 0.01), and larger EF impairment (p < 0.008). Among the restrictive group, patients (n = 56) with pre-discharge persistent restrictive filling (n = 56) showed six-month greater LV enlargement (p < 0.001) and EF impairment (p < 0.009) than those (n = 91) with reversible restrictive filling. Baseline %WMA and EDVi, together with pre-discharge persistent restrictive filling, predicted severe (>20%) LV dilation. Four-year survival was 93% in nonrestrictive patients versus 88% in the restrictive group (p < 0.06), and 93% in pre-discharge reversible restrictive versus 79% in persistent restrictive (p < 0.0003). The single best predictor of mortality, by Cox analysis, was pre-discharge persistent restrictive filling (chi-square 14.88). CONCLUSIONS: Left ventricular dilation may occur even after uncomplicated AMI and may be paralleled by an improvement in LV filling. However, a baseline restrictive filling that persists at pre-discharge identifies more compromised patients at higher risk for six-month remodeling and four-year mortality.

Left atrium remodeling after acute myocardial infarction (results of the GISSI-3 Echo Substudy).

To evaluate the existence, timing, and determinants of post-infarction left atrial remodeling, we studied a subgroup of 514 patients from the Third Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico Echo Substudy who underwent 4 serial 2-dimensional echocardiograms up to 6 months after acute myocardial infarction. This study is the first to demonstrate, in a large series of patients, the existence of early and late left atrial remodeling after low-risk acute myocardial infarction and the relation of left atrial remodeling to left ventricular remodeling.