1 Saturday 30 August 2014
2 2 Heart failure: prognostic pointers HEART FAILURE: PROGNOSTIC POINTERS 12 BEDSIDE Combined score using clinical, ECG, and echocardiographic parameters to predict left ventricular remodeling in CRT patients A. Brunet Bernard 1, S. Marechaux 2, L. Fauchier 1, A. Guiot 2, M. Fournet 3, A. Reynaud 3, F. Schnell 3, C. Leclercq 3, P. Mabo 3, E. Donal 3. 1 Tours Regional University Hospital, Hospital Trousseau, Tours, France; 2 Université Lille Nord de France, GCS-Groupement des Hôpitaux de l Institut Catholique de Lille, Facu, Lille, France; 3 University Hospital of Rennes, Department of Cardiology and Vascular Disease / CIC-IT 804, Rennes, France Background: Up to 30% of patients selected on guideline criteria fail to respond to CRT. Methods: The derivation cohort consisted of 162 heart failure patients implanted with a CRT device. Baseline clinical, ECG and echocardiographic characteristics were entered into a univariable and multivariable model to predict reverse remodeling as defined by a 15% reduction in LVESV at 6 months (60%). Combinations of predictors were then tested under different scoring systems. A new 7-point CRT response score termed L2ANDS2: Left bundle branch block (2 points), Age >70 years, Non-ischemic etiology, LV end-diastolic Diameter <40 mm/m 2, and Septal Flash (2 points) was calculated for these patients. This score was then validated against a validation cohort of 45 patients from another academic center. Results: A highly significant incremental predictive value was noted when Septal Flash was added to an initial 4-factor model including left bundle branch block (difference between area-under-curve C statistics = 0.125; p<0.001). The predictive accuracy using the L2ANDS2 score was then 0.79 for the C statistic. Application of the new score to the validation cohort (71% of responders) gave a similar C statistic (0.75). A score >5 had a high positive likelihood ratio (+LR=5.64), whereas a score <2 had a high negative likelihood ratio ( LR=0.19). Conclusions: This L2ANDS2 score provides an easy-to-use tool for the clinician to assess the pre-test probability of a patient being a CRT responder. 13 BEDSIDE ACTN3 R577X polymorphism and long-term survival in patients with chronic heart failure S. Bernardez, P.C.J.L. Santos, J.E. Krieger, A.J. Mansur, A.C. Pereira. Heart Institute of the University of Sao Paulo (InCor), Laboratory of Genetics and Molecular Cardiology, Sao Paulo, Brazil Background: Previous studies have shown the occurrence of actinin 3 deficiency in the presence of the R577X polymorphism in the ACTN3 gene. A recent systematic review and meta-analysis brought a stronger evidence of the influence of the genetic profile with physical performance in athletes with positive association between ACTN3 R allele and power events. However, the impact of alpha actinin-3 deficiency caused by this polymorphism is still unknown in heart failure. In this scenario, the main aim of our study was to assess whether ACTN3 R577X polymorphism is associated with mortality in a heart failure patients. Methods: A prospective cohort study was conducted from 2002 to The eligibility criteria included diagnosis of chronic heart failure stage C from different etiologies. We excluded all patients with concomitant disease that could be related to poor prognosis. ACTN3 rs (R577X) polymorphism was detected by polymerase chain reaction. Survival curves were calculated with the Kaplan- Meier method and evaluated with the log-rank statistic. The relationship between baseline variables and the composite endpoint of all-cause death was assessed using a Cox proportional hazards survival model. Results: A total of 463 patients were included in this study. The frequency of the ACTN3 R577X variant allele was 39.0%. The LVEF mean was 45.6±18.7% and the most common etiology of this study was hypertensive. After mean follow-up of five years, 239 (51.6%) patients met the pre-defined study endpoint. Survival curves showed higher mortality in patients carrying RX or XX genotypes compared with patients carrying RR genotype (p=0.01). Furthermore, in a Cox proportional hazards survival model, the presence of the RX or XX genotypes in patients with heart failure was independently associated with higher hazard ratio compared with carriers of RR genotype (HR 1.72, 95% CI , p=0.01), after adjusted for covariates. Conclusion: R577R polymorphism in the ACTN3 gene was independently associated with worse survival in patients with chronic heart failure. Further studies are necessary to ensure its use as a marker of risk for this syndrome. 14 BEDSIDE Which formula for estimating glomerular filtration rate is the better predictor of outcomes in heart failure with preserved ejection fraction? An analysis from the I-Preserve trial A. Pozzi 1, P.S. Jhund 1, K. Damman 2, B.M. Massie 3, P. Carson 4, M.R. Komajda 5, R. Mckelvie 6, M.R. Zile 7, I.S. Anand 8, J.J.V. Mcmurray 1. 1 University of Glasgow, Glasgow, United Kingdom; 2 University Medical Center Groningen, Groningen, Netherlands; 3 University of California, San Francisco, ; 4 Veterans Affairs Medical Center, Washington, United States of America; 5 University Pierre & Marie Curie Paris VI, Paris, France; 6 McMaster University, Hamilton, Canada; 7 Medical University of South Carolina, Charleston, ; 8 University of Minnesota, Minneapolis, United States of America Purpose: Low GFR is associated with poor prognosis in heart failure (HF). We compared the predictive value of Cockroft-Gault (CG), Modification of Diet in Renal Disease Study Group (smdrd) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) in the Irbesartan in Patients with Heart Failure and Preserved systolic function (I-Preserve) trial Methods: In 4023 patients, aged 60 years with LVEF 45% and NYHA II-IV, we compared the predictive value of each equation for all-cause mortality, CV death (CVD) and a composite of HF death or HF hospitalization using C statistics. We added egfr to published predictors of outcome (see footnote) Results: There were 861 deaths (21.4%), 604 CVD (15.0%) and 849 composite HF endpoints (21.1%). All formulae improved the model for each endpoint except for CV death. CKD-EPI was better than CG only for the composite HF outcome (p=0.018), but better than smdrd for all the endpoints (all cause mortality p=0.03; CVD p=0.007 and HF composite p=0.005). There was no difference between CG and smdrd HR 95% (CI) P-value C-statistic All cause mortality (Model without egfr ) Model + CKD-EPI (per log decrease) 1.34 ( ) Model + smdrd (per log decrease) 1.29 ( ) * Model + Cockroft-Gault (per log decresase) 1.26 (1 1.59) CV Death (Model without egfr ) Model + CKD-EPI (per log decrease) 1.16 ( ) Model + smdrd (per log decrease) 1.12 ( ) # Model + Cockroft-Gault (per log decresase) 1.11 ( ) HF hospitalization/hf death (Model without egfr ) Model + CKD-EPI (per log decrease) 1.35 ( ) Model + smdrd (per log decrease) 1.32 ( ) Model + Cockroft-Gault (per log decresase) 1.11 ( ) Baseline model includes: history of HF hospitalization, diabetes mellitus, COPD, history of ischaemic heart disease, history of myocardial infarction, log neutrophil count, age, ejection fraction, heart rate, and log NT-proBNP. *CKD-EPI vs smdrd=0.03, # CKD-EPI vs smdrd=0.007, CKD-EPI vs smdrd=0.005, CKD-EPI vs CG = Conclusions: CKD-EPI was a better predictor of events in HFpEF compared with smdrd or CG. 15 BEDSIDE Left ventricular global strain is a superior predictor of all-cause mortality compared to left ventricular ejection fraction in patients with severe heart failure M. Sengelov, T. Biering-Sorensen, P.G. Jorgensen, N.E. Bruun, T. Fritz-Hansen, J. Bech, F.J. Olsen, J. Sivertsen, J.S. Jensen. Gentofte University Hospital, Department of Cardiology, Gentofte, Denmark Objective: Myocardial strain deformation analysis (global strain) obtained by 2D speckle tracking may be superior to left ventricular ejection fraction (LVEF) in predicting all-cause mortality in patients with severe systolic heart failure. Methods: In this study transthoracic echocardiographic examinations were retrieved from heart failure clinic s database of our hospital in 1061 patients. The echocardiographic images were subsequently analyzed and conventional echocardiographic parameters and strain data were obtained. Results: During a median follow-up of 40 months 177 (16.7%) patients died. Patients who died during follow-up had significantly lower LVEF (23.7% vs. 28.2%, P<0.001) and mean global strain (8.12% vs. 9.86%, p<0.001). The risk of dying increased with decreasing tertile of global strain being approximately three times higher for the patients in the lowest tertile compared to patients in the highest tertile (1. tertile vs 3. tertile HR: % CI: ,P<0.001) (figure). Many of the conventional echocardiographic parameters proved to be predictors of mortality. However, global strain remained an independent predictor of mortality after adjusting for age, gender, BMI, total cholesterol, heart rate, atrial fibrillation, diabetes mellitus and conventional echocardiographic parameters (HR: % CI: , per 1% decrease, P=0.014) while ejection fraction proved to be insignificant adjusted for aforementioned characteristics (P=0.81). In addition, global strain had a higher Harrell s C statistics than LVEF (0.67 vs. 0.65). Conclusion: In patients with severe systolic heart failure global strain is an independent predictor of all-cause mortality. Furthermore, global strain proved to be a superior prognosticator when compared to left ventricular ejection fraction.
3 Heart failure: prognostic pointers 3 16 BEDSIDE Left ventricular ejection fraction as a prognostic marker for all-cause mortality in HIV-infected patients N. Reinsch 1, L. Eisele 2, B. Schwarz 3, T. Neumann 1, F. Lunschken 1, V. Holzendorf 4, N. Brockmeyer 5, D. Schadendorf 3, R. Erbel 1, S. Esser 3. 1 West German Heart Center Essen Clinic for Cardiology, Essen, Germany; 2 University Hospital of Essen (Ruhr), Institute for Medical Informatics, Biometry and Epidemiology, Essen, Germany; 3 Department of Dermatology and Venerology, University of Essen, Essen, Germany; 4 Center for Clinical Trials (KKS), University of Leipzig, Leipzig, Germany; 5 Ruhr-University Bochum, St. Josef Hospital, Department of Dermatology and Allergology, Bochum, Germany Background: Since the advent of highly active antiretroviral treatment, cardiovascular disease has become an area of increasing concern among patients infected with HIV. Heart failure may result as the final path of many cardiovascular diseases in this population. The aim of this study was to assess the prevalence and prognostic importance of a reduced left-ventricular ejection fraction (LVEF) in HIV-infected individuals. Methods: This prospective multicentre observational Cohort study elucidates cardiovascular disease prevalence by standardised non-invasive cardiovascular screening program and echocardiographic investigation in 843 HIV-infected patients from four specialised outpatient clinics in Germany between 2004 and The follow-up was 60 month. The LVEF grouped into 35%, 35-50% and >50% on the incidence of all-cause mortality was assessed using multivariate Cox regression analysis. Results: At baseline, 84% of the 843 patients were male, 89% Caucasians, 60% MSM, 31% were CDC-categorised C and 47% immunological stage 3. In mean, HIV-infection was diagnosed for 7.8±5.6 years at baseline (IQR years). The mean age was 44±10 (IQR 37-50, Range 20-75) years and the mean measured CD4 cell counts were 505±296 (IQR , range ) cells/μl. 729 (87%) patients underwent antiretroviral treatment, of whom 74% had an HIV-RNA <50 copies/ml. 7/843 patients (1%) had LVEF 35% and 53/843 (6%) patients had LVEF values ranged in 35 to 50%. Subjects with low LVEF had increased frequency of death (mortality: 57% for LVEF 35%, 14% LVEF values ranged in 35 to 50% and 6% LVEF >50%). In unadjusted univariate cox model, LVEF 35% and LVEF ranged 35-50% were associated with a 7.3 [ ]-fold and a 1.7 [ ]-fold risk, respectively, for all-cause mortality. After further adjustment for traditional cardiovascular risk factors (age, smoking, total cholesterol, antihypertensive drugs) and HIV related variables (HIV Stadium C = AIDS) and CD4 cell count, LVEF 35% was still predictive in the model (4.8 [ ]). Conclusions: According to our data, reduced LVEF is an independent predictor for an increased risk for all-cause mortality in a HIV-infected population. Screening for low LVEF is of main importance in this group of patients and should be carried out in patients with suspected heart failure. 17 BEDSIDE Features and outcomes of acute myocarditis in children C. Walton, M. Veyrier, M. Bakloul, C. Ducreux, L. Boussel, R. Henaine, O. Metton, J. Ninet, S. Di Filippo. University Hospital of Lyon - Hospital Louis Pradel, Lyon, France This study was to assess features and outcomes of children with acute myocarditis. Methods: Patients <18y with acute myocarditis (proved by virology and/or MRI and/ or complete recovery of myocardial function) were included. Clinical data, echocardiographic parameters and outcomes were collected and cases divided in groups I (<2y), II (2 to 10y) and III (>10y). Results: 72 patients were included (1983 to 2012), 30 males, aged 4.1±5.1y (med 1.5y): 43 in group I, 17 in II and 12 in III. Heart failure was present at onset in 57 cases (78%): 8 cardiogenic shock (12%), 30 severe HF (44%) were more frequent in groups I (56%) and II (46%) than in III (17%, p<0.0001), while chest pain (15.5% of all) was more frequent in III (83%). LVSF at diagnosis was 18.4±9% (med 16%): 16% and 15% in groups I and II vs 30.5% in III (p=0.0001). Aortic VTI was 11.4±5.8 cm (med 10): 8cm and 11 in groups I and II vs 17 in group III (p<0.05). Mitral regurgitation was present in 76.5%, pericarditis in 16.4%, thromboembolic in 5 cases (7%), arrhythmias in 7 (10%). Virus was positive in 27 cases = 37.5% (1 virus in 24, >1 viruse in 3). Nine patients died (13%) within 2months post-diagnosis (2 days to 8.6 months), 1 was transplanted (3rd month), 19 have sequellae (27.5%), 40 completely recovered (58%), at FU=5.5±5.6y (med 4y). Inotrope support was needed in 34 cases (47%): 51%, 59% and 16% of groups I, II and III respectively (p<0.0001). Six patients (8.3%, 1 in groupiii) needed mechanical circulatory support (3ECMO, 3VAD), within day-14 from onset: 1 died on support, 5 were weaned-off (duration of support: 4 days to 3 months). Survival was 96%, 90%, 87.5% and 86% at 1 month, 3 months, 6 months, 2y and 10y of FU. All patients in group III survived. Ten-year survival was 81.4% in group I and 88.2% in II (p=ns). LVSF improved from 18.4±8.9% (med 16%) at onset, to 24.6±10.3% (med 23.5%) at 1st month, 26.5±8.6% (med 26.5%) at 3rd month, 30.7±8.6% (med 29.6%) at 6th month and 38±7% (med 37%) at last FU. Conclusion: Acute myocarditis in children has favourable outcomes despite early mortality. Myocardial dysfunction and heart failure are less frequent in patients >10 years of age. Mechanical circulatory support successfully lessens mortality. Myocardial contractility can progressively improve within the first 6months after onset of disease. 18 BEDSIDE Left ventricular contractile function assessed by 2D strain is a simple surrogate of recruitable function and predicts the outcome after cardiac resynchronization therapy L.E. Sade, I. Atar, B. Ozin, H. Muderrrisoglu. Baskent University, Faculty of Medicine, Ankara, Turkey Purpose: Recruitable contractile function is important for a favorable response to cardiac resynchronization therapy (CRT). Ejection fraction (EF) is inferior to newer parameters that quantify myocardial deformation to study LV contractile function. We tested the hypothesis that average peak radial strain (RS) by 2D speckle tracking can be a simple surrogate of recruitable function to predict the outcome after CRT. Methods: We prospectively studied patients undergoing CRT and followed-up over 5 years. RS was measured by speckle tracking echocardiography in 18 segments from the short axis basal, mid and apical levels. Regional RS 10% indicated scar. Lead position by fluoroscopy and its relation to scar was also assessed. Pre-specified outcome events were death, heart transplantation or LV assist device implantation. Volume response was considered as reduction in end systolic volume (ESV) >15%. Results: Out of 107 patients (20% female, 60% ischemic) 60% were volume responders. 33 end-point events occured over 5 years: 30 deaths, 2 heart transplants, and 1 LV assist device. Baseline average peak RS but not baseline ESV or EF, correlated with the extent of volume reduction and mechanical resynchronization after CRT (r=0.32, P=0.001 and r=0.55, P<0.001, respectively). On multivariate regression analysis including average peak RS, ESV, RS dyssynchrony, EF, and lead position in relation to scar, only the average peak RS independently predicted (P=0.003, 95% CI ) reverse remodeling at 6 mo. Furthermore, average peak RS was predictive and additive with mechanical dyssynchrony for event-free survival after CRT over 5 years (Figure). Conclusion: LV contractile function assessed by 2D average peak radial strain is a simple surrogate of recruitable function and predicts the outcome after CRT. 19 BEDSIDE Non-sustained ventricular tachycardia lasting 8 or more beats is associated with sudden cardiac death in patients with chronic heart failure: A serial holter monitoring study M. Ishimi, T. Yamada, T. Morita, Y. Furukawa, S. Tamaki, Y. Iwasaki, M. Kawasaki, A. Kikuchi, M. Fukunami. Osaka General Medical center, Cardiology, Osaka, Japan Background: Non-sustained ventricular tachycardia (NSVT) is often observed in patients (pts) with chronic heart failure (CHF). In the sub-analysis of MERLIN TIMI-36 trial, high-grade NSVT lasting 8 or more beats was reported to be associated with the highest risk of sudden cardiac death (SCD) in pts with acute coronary disease. However, there is no information available on the relation between SCD and the number of consecutive beats of NSVT in pts with CHF. Methods and results: We studied consecutive 162 CHF pts with LVEF <40%, who were enrolled in our prospective cohort study. All pts underwent 24-hour Holter ECG monitorings at the entry, every 2 to 6 months after the entry for three years. NSVT was categorized as low-grade (lasting 3 to 7 beats) and high-grade NSVT (lasting 8 or more beats). During a mean follow-up period of 7.4±4.3 years, 29 of 162 pts had SCD. In the serial Holter monitoring, 28 and 77 pts had highand low-grade NSVT, respectively. Compared to pts with no NSVT (n=57), there NSVT 2014
4 4 Heart failure: prognostic pointers / Deciphering ischaemic myocardial mechanics with strain imaging was no increased risk of SCD in pts with low-grade NSVT (19% vs 9%, adjusted hazard ratio (HR): 1.3 ( ), p=0.63); however, the risk of SCD was significantly greater in pts with high-grade NSVT (36%, adjusted HR, 3.9 ( ), p=0.04). Furthermore, pts with high-grade NSVT had the significantly increased risk of SCD, compared to those with low-grade NSVT (36% vs 19%,adjusted HR 2.5 ( ), p=0.03). Conclusion: NSVT lasting 8 or more beats detected by serial Holter ECG monitorings would be more strongly associated with an increased risk of SCD in patients with CHF. 20 BEDSIDE Prediction of rehospitalisation or death within 30 days after discharge among heart failure patients: roles of administrative, socio-economic, geomapping and clinical data Q. Huynh, C.L. Blizzard, M. Saito, M. Eskandari, B. Johnson, G. Adabi, J. Hawson, K. Negishi, T.H. Marwick. Menzies Research Institute, Hobart, Australia Purpose: Better targeting of heart failure (HF) intensive management programs may reduce readmission. However, available prediction scores are modestly effective. We hypothesised that these scores could be improved by including other factors, and aimed to develop a prediction score of 30-day rehospitalisation or death in HF, using clinical, demographic and socio-economic data. Methods: This Statewide study included all 1499 HF patients (male 49.6%, median age 80 years) who were admitted and survived the first admission to a public hospital with HF during General administrative, socio-economic and geomapping data were available for the whole cohort. Full clinical data collected before the first discharge were available from 675 patients. Prediction models were developed using logistic regression, and were validated using bootstrap validation method. Results: 388 patients (25.9%) were rehospitalised or dead within 30 days after discharge. The prediction model that was derived using general administrative, socio-economic and geomapping data had fair discrimination (C-statistic 0.65 [95% CI: 0.62, 0.68]). Using clinical data provided better discrimination (C-statistic 0.69 [95% CI: 0.64, 0.73]). Combining both sources of data best predicted risk of 30-day rehospitalisation or death (C-statistic 0.72 [95% CI: 0.67, 0.76]). The C-statistics for internal validation of the three models were 0.65, 0.69 and 0.71 respectively. Conclusions: Clinical data are stronger predictors than administrative data, but combining both sources of data may provide the best prediction of 30-day rehospitalisation or death among HF patients. 21 BEDSIDE Prognostic implication of worsening renal function in acute heart failure syndrome patients with and without baseline renal failure R. Ninomiya 1, Y. Matsue 1, N. Kagiyama 2,T.Kume 2, H. Okura 2, M. Suzuki 1, A. Matsumura 1, K. Yoshida 2, Y. Hashimoto 1. 1 Kameda Medical Center, Department of Cardiology, Kamogawa, Japan; 2 Kawasaki Medical School, Division of Cardiology, Kurashiki, Japan Background: Dynamics changes of renal function is frequently observed in treatment course of acute heart failure syndrome (AHFS) patients, and called worsening renal function (WRF). However, prognostic implication of WRF in AHFS is remained to be elucidated. Baseline chronic kidney disease (CKD: estimated GFR<60ml/min/1.73m 2 ) is the strongest predictor of WRF and one of the powerful prognostic predictors in AHFS, whether prognostic implication of WRF is different when occurred in patients with CKD and without CKD is not known. Methods: We retrospectively included 383 consecutive AHFS patients (75.7±12.7 years, 52.0% male) from two hospitals who admitted during January 2011 to December 2012 and can discharge. They had postdischarge death or AHFS readmission rate of 27.4% during median follow-up of 1 year ( days). Patients were divided into 4 groups according to had WRF or not during hospitalization and the baseline CKD at admission. Kaplan-Meier analysis and Cox regression model which was adjusted by other risk factors including egfr at discharge were used. Results: Patients with CKD and no WRF (HR 3.11, 95% CI ) and with CKD and WRF (HR 2.30, 95% CI ) had significantly worse prognosis in Kaplan-Meier analysis and Cox regression model. However, patients without CKD and WRF had similar prognosis compared with those without CKD and without WRF (HR 1.60, 95% CI ). Figure 1. Kaplan-Meier curves. Conclusion: Prognostic implication of WRF is influenced by whether the baseline CKD is present or not in AHFS patients. DECIPHERING ISCHAEMIC MYOCARDIAL MECHANICS WITH STRAIN IMAGING 34 BENCH Diagnostic ability of early systolic lengthening in evaluating myocardial ischemic memory K. Masuda, T. Asanuma, H. Koriyama, D. Sakurai, M. Oka, K. Kotani, S. Nakatani. Osaka University Graduate School of Medicine Division of Functional Diagnostics, Suita, Osaka, Japan Background: Myocardial ischemic memory can be evaluated by post-systolic shortening (PSS) because it persists for a while after brief ischemia. Recently, early systolic lengthening (ESL) assessed by speckle tracking echocardiography has been reported to be a novel useful parameter for detecting myocardial ischemia. However, it is still unclear whether ESL persists after brief ischemia and can be used for evaluating ischemic memory. Methods: The left circumflex coronary artery was occluded for 2 minutes followed by reperfusion in 16 dogs. Short-axis images were acquired at baseline, during occlusion, 10 and 30 minutes after reperfusion. Circumferential strain was analyzed in the ischemic and nonischemic areas. Peak systolic strain, post-systolic index (PSI) as a parameter of PSS, strain amplitude of ESL (ɛesl) and time from the onset of QRS to the beginning of regional contraction over the initial length (ESL time) were measured. Diagnostic accuracy for evaluating ischemic memory after reperfusion was calculated by the receiver operating characteristics (ROC) curve analysis. Results: In the risk area, peak systolic strain decreased and ɛesl increased during occlusion compared to the baseline, but these parameters recovered to the baseline after reperfusion. In contrast, PSI and ESL time significantly increased during occlusion and the significant increase still persisted at 10 minutes after reperfusion (PSI: 0.02±0.04 vs. 0.19±0.10, p<0.05; ESL time: 88±30 vs. 118±38 ms, p<0.05). However, in diagnostic accuracy of ischemic memory at 10 minutes after reperfusion, PSI was better than ESL time (Fig. 1). Figure 1 Conclusion: ESL time can evaluate ischemic memory after brief ischemia but its diagnostic accuracy of ischemic memory may be inferior to PSI. Abstract 20 Table 1. The three prediction models Administrative model (C-statistic 0.65) Clinical model (C-statistic 0.69) Combined model (C-statistic 0.72) Remoteness index 1.15 (1.00, 1.35) Remoteness index 1.39 (1.00, 2.12) Living alone 1.73 (1.24, 2.42) Living alone 2.60 (1.77, 3.83) Age at admission (per year) 1.03 (1.02, 1.05) HF stage 1.28 (1.00, 1.66) HF stage 1.20 (1.00, 1.59) Hospital stay (per 3 days) 0.90 (0.85, 0.95) Diuretics use 0.41 (0.22, 0.76) Diuretics use (Y/N) 0.49 (0.26, 0.96) Number of comorbidities 1.10 (1.05, 1.15) C-reactive protein (mg/l) 1.01 (1.00, 1.02) C-reactive protein (mg/l) 1.01 (1.01, 1.02) BUN (mmol/l) 1.05 (1.03, 1.08) BUN (mmol/l) 1.06 (1.03, 1.09) Heart rate (per 5 beats/min) 1.10 (1.03, 1.17) Heart rate (per 5 beats/min) 1.12 (1.05, 1.21) Deep vein thrombosis 2.27 (1.01, 5.32) Deep vein thrombosis (Y/N) 3.25 (1.35, 7.67) Arrythmia 2.15 (1.11, 4.17) Arrythmia (Y/N) 2.63 (1.31, 5.30) Data are shown as odds ratio (95% confidence interval).
5 Deciphering ischaemic myocardial mechanics with strain imaging 5 35 BEDSIDE Longitudinal 2D strain predicts severe coronary artery disease in patients with NSTEMI, normal left ventricular ejection fraction and no wall motion abnormality G. Malcles, G. Clerfond, S. Monzy, G. Souteyrand, P. Gautier, N. Combaret, R. Eschalier, B. Citron, J.R. Lusson, P. Motreff. University Hospital Gabriel Montpied, Cardiology, Clermont-Ferrand, France Purpose: In the era of high-sensitivity troponin, many patients are diagnosed with NSTEMI. Noninvasive, accessible bedside tools are needed for early risk stratification. Longitudinal strain provided by speckle tracking echocardiography has been proven to be very sensitive for diagnosing subclinical myocardial injuries. Our aim was to compare global and territorial longitudinal strains to the findings of coronary angiography in subjects with NSTEMI and no sign of myocardial dysfunction, to determine if the decline of the systolic longitudinal function was related to the severity of the coronary artery disease (CAD). Methods and results: 40 patients were prospectively examined by echocardiography immediately prior to coronary angiography after a first hospitalisation for NSTEMI. Global longitudinal strain (GLS) was provided semi automatically and we calculated territorial longitudinal strains (TLS) on the basis of the perfusion areas of the 3 major coronary arteries, by averaging all segmental peaks systolic strain values within each territory. The subjects were classified into three groups depending on the extent of CAD: no significant CAD, one-vessel and two-vessel CAD (excluding left main [LM] or proximal left anterior descending [LAD] arteries), three-vessel CAD or LM and proximal LAD arteries involvement (qualified as severe CAD). The mean GLS value for the entire cohort was -19.3±2.3%. A significant worsening of GLS depending on the extent of CAD was found (-21±1.6% [no significant CAD] vs ±1.8% [1 or 2- vessel disease] vs ±2.2% [severe CAD] p=0.002). Univariate then multivariate analyses have confirmed that only GLS (OR: 5.62; 95%CI: 1.40 to p=0.015) prognosticates severe CAD. Receiver operating characteristic (ROC) curves analyses of GLS showed a cut-off value of -18%, to identify patients with severe CAD with excellent sensibility and specificity, 82% and 86%, respectively. The AUC for GLS was significantly greater than the AUC for peak troponin T (TnT) (0.86; 95% CI: 0.71 to 1.00 vs. 0.63; 95% CI: 0.44 to 0.82; p<0.001) A predominant deterioration of longitudinal strain was found in the territory supplied by the infarct-related artery, except in the right coronary artery territory. The cut-off value of GLS in the LAD territory was -18.7% (sensibility 56% and specificity 88%). Conclusion: This study confirms that global myocardial longitudinal function is impaired in patients with NSTEMI depending on the extent of CAD, even if left ventricle visual assessment is normal. GLS enables rapid risk stratification and predicts severe CAD with excellent accuracy. 36 BEDSIDE Postsystolic shortening measured early in PCI-treated STEMI patients is a strong predictor of myocardial salvage and left ventricular recovery: a cross-modality imaging study S. Limalanathan, J. Eritsland, P. Hoffmann, G.Ø. Andersen. University of Oslo, Ulleval University Hospital, Department of Cardiology, Oslo, Norway Purpose: Assessment of potential recovery of myocardium at risk after reperfusion is difficult in patients with ST elevation myocardial infarction (STEMI). Previous studies have indicated that postsystolic shortening (PSS) is associated with myocardial recovery in patients with non-stemi. However, little is known about a possible association between PSS and myocardial salvage in patients with STEMI. The aim of the study was to evaluate the association between myocardial strain measured by echocardiography in the acute stage and myocardial salvage measured by repeated cardiac magnetic resonance (CMR) imaging. Methods: The study population consisted of 100 patients with first-time STEMI treated by primary PCI. Global longitudinal peak systolic strain (ε SYS ), and peak strain (ε PEAK ) were measured by two-dimensional speckle tracking echocardiography at a median of 2.4 (range 1-5) days after PCI. Postsystolic index (PSI) was calculated manually, PSI = [(ε PEAK ε SYS ):ε PEAK ] x 100. ε SYS and PSI were dichotomized into two groups and defined as, those with low negative strain values (minimum to median) and those with high negative strain values (median to maximum). Myocardial salvage index (MSI), infarct size (IS) and ejection fraction (EF) were assessed by CMR performed both in the acute stage and after 4 months. MSI was defined as [(myocardium at risk infarct size):myocardium at risk] x 100. Results: Median values of ε SYS and PSI were 13.1 and 9.6, respectively. Low negative ε SYS range was from 3.2 to 13.1 and high negative ε SYS range was from 13.2 to Low PSI range was from 0.0 to 9.6 and high PSI range was 9.7 to Global longitudinal Post-systolic index peak systolic strain (εsys) (PSI) Low εsys High εsys p-value Low PSI High PSI p-value Ejection fraction (%) Infarct size (% of left ventricular mass Myocardial salvage index Conclusion: Reduced negative systolic strain and a high degree of postsystolic shortening measured in the acute stage were associated with large infarct size, low ejection fraction and impaired myocardial salvage in STEMI patients treated by primary PCI. 37 BEDSIDE Assessment of right ventricular functional recovery after acute myocardial infarction by 2D speckle analysis O. Huttin, M. Di Meglio, J. Lemarie, F. Moulin, D. Voilliot, N. Girerd, D. Mandry, P.Y. Marie, Y. Juilliere, C. Selton-Suty. University Hospital of Nancy - Hospital Brabois, Vandoeuvre les Nancy, France Objective: To evaluate the pattern of right ventricular (RV) functional recovery in low risk patients after acute myocardial infarction (AMI) with the help of 2D speckle imaging (2DSI). Design and setting: Prospective analysis clinical trial Patients: 129 consecutive patients (112 men, mean age 55.2±10.9 yrs, gr1: 63 inferior MI, gr2: 66 anterior MI) treated with primary percutaneous coronary intervention underwent both cardiac MRI and echocardiograms hours (V1) and 6 months (V2) after acute MI. To assess echocardiographic RV function, we measured TAPSE and analyzed the 3 walls of the RV by 2DSI, septal and lateral from 4C view and inferior from RV2C view. We measured maximal systolic ε (%) in the basal, median and apical segments of these 3 walls. We calculated lateral, inferior and septal ε as the means of 3 segments of respectively lateral, inferior and septal walls and global RV ε as the mean of these 9 values. All strain values were averaged on 3 consecutives cycles. Results: At acute phase, MRI-RVEF (%) was lower in gr1 than in gr2 pts (53.2±6.7 vs 56.0±4.9, p=0.01) and TAPSE was similar in both groups. RV global ε was more severely impaired in patients with inferior than with anterior AMI (- 18.9±4.3 vs -23.0±3.0, p<0.001) mainly due to a significant difference in inferior ε ( vs , p<0.001) and lateral ε (- 22.8±6.8 vs 28.3±5.6, p<0.001) but not in septal ε (-14.9±3.6 vs -15.4±3.7, ns). At 6 months, MRI- RVEF (56.7±6.9 vs 58.6±6.1, ns) and TAPSE were similar in both groups and inferior ε was the only RV function parameter that remained significantly different among both groups (-24.5±6.5 vs -27.5±5.4, p=0.03). Among the whole population, MRI-RVEF significantly increased between V1 and V2 (54.1±6.1 vs 57.8±6.6, p<0.001) as did all strain values (global ε: -20.9±4.1 vs -24.5±4.0%, p<0.001) and TAPSE (21.9±5.0 vs 24.6±4.6 mm, p<0.001). The magnitude of increase between V1 and V2 was significantly higher in gr 1 than in gr 2 for all strain values but nor for RVEF or TAPSE. Conclusions: In low risk patients after AMI, RV function recovered throughout six months of follow up. The degree of RV impairment and the magnitude of RV functional recovery were higher in patients with inferior MI than with anterior MI. Although RV function was relatively preserved in those patients, 2DSI analysis of RV strain allows the assessment of subtle changes in RV deformation not shown by the measurement of RVEF by MRI or by conventional echocardiographic parameter such as TAPSE and is therefore an interesting parameter to measure following MI. 38 BEDSIDE Restrictive filling pattern is not related to ischemic times but is associated with worse outcome in STEMI patients who underwent primary PCI I. Ilic, V. Jovanovic, R. Vidakovic, A. Vlahovic Stipac, I. Stankovic, D. Milicevic, G. Obradovic, B. Putnikovic, A.N. Neskovic. Clinical Hospital Center Zemun, Cardiology, Belgrade, Serbia Purpose: Altered diastolic function has been identified as an early prognostic marker after myocardial infarction. We sought to investigate the relationship of ischemic times on echocardiographic parameters of diastolic function and its longterm impact on clinical outcomes in STEMI patients treated with primary PCI during 2-year period, in a single, academic, high-volume PCI centre. Methods: 639 consecutive patients who underwent primary PCI in were enrolled in the study. Patients were excluded from the analysis if they suffered previous MI, have been previously treated with PCI or CABG, received thrombolytics, presented in cardiogenic shock, had significant valvular disease, were in atrial fibrillation or had previously implanted pacemaker. Comprehensive echocardiogram was performed after patients stabilization, within 48 hours after primary PCI. During follow-up patients status was assessed by telephone interview. Results: After accounting for the exclusion criteria, the study group consisted of 433 patients. Comprehensive echocardiogram was performed 1.39±1.54 days after admission. The restrictive filling pattern (RFP), defined as mitral inflow E/A ratio >2.0 or E wave deceleration time <140 ms, occurred in 21.5% of patients. The RFP+ and RFP- patients had similar baseline characteristics, except that RFP+ group had more smokers (RFP % vs. RFP %; p=0.036). The groups had similar door-to-balloon time (RFP+ 51±23 vs 57±40 min; p=ns) and total ischemic time (314±264 vs 334±369 min; p=ns). However, RFP+ pts had higher maximum values of troponin I (45.54±33.26 vs 29.93±26.80; p<0.001), higher LV end-systolic volume (53.75±22.20 vs ±18.03 ml; p=0.003), enddiastolic volume (94.20±28.51 vs ±27.19ml; p=0.032), maximal left atrial volume index (25.26±8.44 vs ±6.14ml/m 2 ;p<0.001), and lower LV EF (43.93±8.86 vs 46.83±10.00%; p=0.027).