Clinical Likelihood of Hemodynamically Obstructive Coronary Artery Disease base on clinical risk factors or on coronary artery calcium score
Rasmussen LD, Karim SR, Westra J, et al.
Clinical Likelihood Prediction of Hemodynamically Obstructive Coronary Artery Disease in Patients With Stable Chest Pain.
JACC Cardiovasc Imaging 2024; 20:S1936-878X(24)00185-2; https://doi.org/10.1016/j.jcmg.2024.04.015
This study aimed to validate the risk factor-weighted clinical likelihood (RF-CL) and coronary artery calcium score-weighted clinical likelihood (CACS-CL) models against hemodynamically obstructive coronary artery disease (CAD). The study included 4,371 patients with stable chest pain who underwent coronary computed tomography angiography followed by invasive coronary angiography with fractional flow reserve (FFR) measurements. Hemodynamically obstructive CAD was defined as FFR ≤0.80 or high-grade stenosis (>90%). The study compared these models to a guideline-endorsed basic pretest probability (PTP) model based on age, sex, and symptom typicality. Results indicated that 10.9% of patients had hemodynamically obstructive CAD. Both the RF-CL and CACS-CL models identified more patients with a very low clinical likelihood (≤5%) of obstructive CAD compared to the basic PTP model (33.0% and 53.7% vs 12.0%; P < 0.001) while maintaining a low prevalence of hemodynamically obstructive CAD (<5% for all models). The RF-CL and CACS-CL models showed superior calibration and discrimination compared to the basic PTP model. The study concludes that the RF-CL and CACS-CL models are better calibrated and more effective than the basic PTP model in predicting hemodynamically obstructive CAD.
CT
CCTA
chronic ischaemic heart disease
Stable chest pain, coronary artery disease
Peri-infarct ischemia detected by stress cardiac magnetic imaging is independently associated with adverse cardiovascular events
Bernhard B, Ge Y, Antiochos P, et al.
Association of Adverse Clinical Outcomes With Peri-Infarct Ischemia Detected by Stress Cardiac Magnetic Imaging.
J Am Coll Cardiol 2024; 84:417-429; https://doi.org/10.1016/j.jacc.2024.04.062
This study aimed to determine if peri-infarct ischemia detected by CMR is associated with adverse events, beyond established risk markers. In a cohort from the multicenter SPINS study, 3,915 consecutive patients were included. Peri-infarct ischemia, defined as ischemic segments adjacent to infarcted ones identified through late gadolinium enhancement imaging, was present in 9.8% of patients. Over a median follow-up of 5.3 years, primary events (acute myocardial infarction or cardiovascular death) occurred in 10.4% of patients, while secondary events (including unstable angina, heart failure, and late coronary artery bypass surgery) occurred in 19.0%. Peri-infarct ischemia emerged as the strongest multivariable predictor for both primary and secondary events, with hazard ratios of 1.72 and 1.71, respectively, after adjustment for clinical factors, left ventricular function, ischemia extent, and infarct size. This condition led to a >6-fold increase in the annualized primary event rate compared to those without infarct or ischemia. Peri-infarct ischemia is thus a novel, robust prognostic marker for adverse cardiovascular events.
CMR
LGE, stress perfusion
chronic ischaemic heart disease
Peri-infarct ischemia
A higher coronary calcium burden is associated with lower levels of vascular inflammation and plaque vulnerability
Fujimoto D, Kinoshita D, Suzuki K, et al.
Relationship Between Calcified Plaque Burden, Vascular Inflammation, and Plaque Vulnerability in Patients With Coronary Atherosclerosis.
JACC Cardiovasc Imaging 2024; S1936-878X(24)00303-6; https://doi.org/10.1016/j.jcmg.2024.07.013
Coronary artery calcification is a key feature of atherosclerosis, with early calcification linked to active inflammation, while advanced calcification occurs as inflammation subsides. Inflammation also plays a role in plaque vulnerability, but the connection between coronary calcium, vascular inflammation, and plaque vulnerability is not fully understood. This study aimed to investigate the relationship between calcified plaque burden (CPB), vascular inflammation, and plaque vulnerability in patients with coronary artery disease. Patients who had both computed tomography angiography and optical coherence tomography were divided into four groups: one group without calcification and three groups based on CPB tertiles. CPB was calculated as calcified plaque volume divided by vessel volume at the culprit lesion. The study compared pericoronary adipose tissue (PCAT) attenuation and vulnerable plaque features among the groups. Among 578 patients, those in the highest CPB tertile had significantly lower PCAT attenuation and fewer vulnerable plaque features. Higher age, statin use, and lower PCAT attenuation were linked to increased CPB. The findings suggest that a greater calcium burden is associated with lower levels of vascular inflammation and plaque vulnerability, indicating that higher calcium may represent more stable plaques with less inflammatory activity.
MULTIMODAL
CT, OCT
chronic ischaemic heart disease
Chronic coronary syndrome
A CMR-based machine-learning prognostic model in hypertrophic cardiomyopathy outperformed the conventional HCM SCD risk model.
Zhao K, Zhu Y, Chen X, et al.
Machine Learning in Hypertrophic Cardiomyopathy: Nonlinear Model From Clinical and CMR Features Predicting Cardiovascular Events.
JACC Cardiovasc Imaging 2024; 17:880-893: https://doi.org/10.1016/j.jcmg.2024.04.013
This study sought to develop and evaluate a machine learning (ML) framework that integrates CMR imaging and clinical characteristics to predict MACEs in patients with HCM. A total of 758 patients with HCM were included. The ML model was built on the internal discovery cohort and external test cohort. A total of 14 CMR imaging features (strain and late gadolinium enhancement [LGE]) and 23 clinical variables were evaluated and used to inform the ML model. MACEs included a composite of arrhythmic events, SCD, heart failure, and atrial fibrillation-related stroke. The model outperformed the classic HCM Risk-SCD model, with significant improvement (P < 0.001) of 22.7% in the AUC. the study showed that the extent of LGE and the impairment of global radial strain (GRS) and global circumferential strain (GCS) were nonlinearly correlated with MACEs. ML-empowered risk stratification using CMR and clinical features enabled accurate MACE prediction beyond the classic HCM Risk-SCD model.
CMR
CMR, machine learning
cardiomyopathies
Hypertrophic Cardiomyopathy
Hibernating myocardium conveys a lower risk of major arrhythmic events in patients with ischaemic cardiomyopathy
Kovacs B, Gllareva V, Ruschitzka F, et al.
Prediction of Major Arrhythmic Outcomes in Ischemic Cardiomyopathy: Value of Hibernating Myocardium in PET/CT.
Eur Heart J Cardiovasc Imaging 2024:jeae232; https://doi.org/10.1093/ehjci/jeae232
This study aimed to predict major arrhythmic events (MAE) in patients with ischemic cardiomyopathy (ICM) using combined 13N-ammonia (NH3) and 18F-fluorodeoxyglucose (FDG) PET/CT imaging. Known predictors of MAE in ICM include previous MAE and left ventricular ejection fraction (LVEF) ≤35%, while the prognostic significance of hibernating myocardium (HM) remains unclear. The study included 254 patients with ICM who underwent PET/CT imaging. At baseline, the median LVEF was 35%, and 10% of patients had an implantable cardioverter-defibrillator (ICD). PET/CT identified ischemia in 37%, myocardial scars in 90%, and HM in 77% of patients. Over a median follow-up of 5.4 years, 13% experienced MAE. Large HM (≥7% of the left ventricular myocardium) was associated with a significantly lower incidence of MAE (HR 0.31, p=0.001). After adjusting for MAE history, LVEF ≤35%, and scar size, large HM remained significantly linked to a reduced MAE risk (p=0.016). Additionally, patients with large HM showed improved LVEF over time (p=0.006), while those without or with small HM did not. In conclusion, large HM is associated with a lower risk of MAE in ICM patients, likely due to improved LVEF.
MULTIMODAL
CT/PET
acute ischaemic heart disease
ischemic cardiomyopathy
Circulating proteins present a variable link with left ventricular and left atrial function parameters in patients with chronic heart failure.
Abou Kamar S, Andrzejczyk K, Petersen TB, et al.
The plasma proteome is linked with left ventricular and left atrial function parameters in patients with chronic heart failure.
Eur Heart J Cardiovasc Imaging 2024; 25:1206-1215; https://doi.org/10.1093/ehjci/jeae098
In this study on 173 heart failure patients with reduced ejection fraction (HFrEF), the systemic biological processes, as reflected by circulating proteins, were examined in relation to echocardiographic characteristics. Echocardiography was performed every six months, while blood sampling every three months during a median follow-up of 2.7 (inter-quartile range: 2.5-2.8) years. Circulating proteins in relation to echocardiographic parameters of left ventricular [left ventricular ejection fraction (LVEF), global longitudinal strain (GLS)] and left atrial function [left atrial reservoir strain (LASr)] and elevated LAP (E/eʹ ratio >15) were investigated and gene enrichment analyses were used to identify underlying pathophysiological processes. It was found that circulating proteins show varying associations with different echocardiographic parameters in patients with HFrEF. These findings suggest that pathways involved in atrial and ventricular dysfunction, as reflected by the plasma proteome, are distinct.
ECHO
Echo
heart failure
chronic heart failure, HFrEF
Minimal imaging training is needed to reproducibly assess hypoattenuated thickening and peridevice leak at cardiac CT after left atrial appendage closure
Kramer A, Lo Russo G, Alarouri HS, et al.
Reproducibility of Cardiac Computed Tomography Classifications of Hypoattenuated Thickening and Peridevice Leak Following Left Atrial Appendage Closure.
Eur Heart J Cardiovasc Imaging 2024; jeae236; https://doi.org/10.1093/ehjci/jeae236
One hundred post left atrial appendage closure (LAAC) cardiac computed tomography (CT) scans were comparetively analyzed by an experienced and a novice (having experienced only with 5 preliminary cases) reader for the detection of hypoattenuated thickening (HAT) and peridevice leak (PDL), features associated with increased post-procedure thrombotic risk. The main results of the study were that significant agreement between the readers were found for the definition of both study variables, particulalry for the presence of high-grade HAD and distal pacency of the (LAA). Conversely, the definition of the leak mechanism displayed only fair levels of agreement. Overall high levels of inter- and intra-rater agreement and reliability were found for the detection of HAT and PDL following Watchman FLX LAAC. However, variables that involved a higher degree of clinical interpretation (i.e., definition of PDL mechanism) were more operator dependent.
CT
CT
Other
Atrial fibrillation
Patients with predisposed HFpEF have relatively unique clinical and cardiac MRI features
He J, Yang W, Wu W, et al.
Heart Failure with Normal Natriuretic Peptide Levels and Preserved Ejection Fraction: A Prospective Clinical and Cardiac MRI Study.
Radiol Cardiothorac Imaging 2024; 6:e230281; https://doi.org/10.1148/ryct.230281
This study aimed to describe the clinical presentation, cardiac MRI characteristics, and prognosis of individuals with predisposed heart failure with preserved ejection fraction (HFpEF), defined as HFpEF with normal natriuretic peptide levels based on an HFA-PEFF (Heart Failure Association Pretest Assessment, Echocardiography and Natriuretic Peptide, Functional Testing, and Final Etiology) score of 4 from the latest European Society of Cardiology guidelines, compared with a HFpEF group (HFA-PEFF score of ≥ 5) and with an asymptomatic control group without heart failure. A total of 213 participants with HFpEF, 151 participants with predisposed HFpEF, and 100 control subjects were analyzed. Compared with the control group, participants with predisposed HFpEF had worse left ventricular remodeling and function and higher systemic inflammation. Compared with participants with HFpEF, those with predisposed HFpEF were younger and had higher plasma volume, lower prevalence of atrial fibrillation, lower left atrial volume index, and less impaired left ventricular global longitudinal strain and early-diastolic global longitudinal strain rate, but similar prognosis. Atrial fibrillation occurrence (hazard ratio [HR] = 3.90; P = .009), hemoglobin level (HR = 0.94; P = .001), and eGLSR (per 0.2-per-second increase, HR = 0.28; P = .002) were independently associated with occurrence of primary end points in participants with predisposed HFpEF.
CMR
ventricular function, strain
heart failure
heart failure (HFPEF)
Prognostic Value of Echocardiographic-derived Stroke Volume in Severe Primary Mitral Regurgitation
Granot Y, Gefen S, Karlsberg D, et al.
Prognostic Value of Echocardiographic-derived Stroke Volume in Severe Primary Mitral Regurgitation
Eur Heart J Cardiovasc Imaging 2024; jeae249; https://doi.org/10.1093/ehjci/jeae249
In this retrospective study, the association between either stroke volume (SV) (<55, 55-70 and >70ml) or stroke volume index (SVI) (<30, 30-35 and >35mL/m²) thresholds and all-cause mortality and heart failure (HF) hospitalizations was examined in a retrospective analysis of 283 patients (60% male, median age 70 years, IQR 58-82) with severe primary mitral regurgitation (MR), normal left ventricular size and systolic function and no other significant left-sided valvular abnormalities. Compared with normal values, SV <55ml was found to be associated with worse outcomes, whereas SV between 55-70 ml was not. A non-significant trend for worse outcomes was noted for SVI<35ml/m² compared with normal SVI. In conclusion, a reduced SV (<55 ml) was confirmed as an easily obtainable parameter with prognostic significance in patients with primary mitral regurgitation.
ECHO
Echo, stroke volume, stroke volume index
valvular heart disease
Mitral regurgitation
Pericoronary adipose tissue (PCAT) attenuation does not predict MACE during long-term follow-up
van Rosendael SE, Kamperidis V, Maaniitty T, et al.
Pericoronary adipose tissue for predicting long-term outcomes
Eur Heart J Cardiovasc Imaging 2024; 25:1351-1359; https://doi.org/10.1093/ehjci/jeae197
In the present study pericoronary adipose tissue (PCAT) attenuation values were derived from CCTA images obtained in a retrospective cohort of 483 patients with intermediate likelihood of obstructive CAD and clinically indicated CCTA with a prolonged follow-up (median duration of 9.5 years). PCAT attenuation was not positively associated with MACE on both a per-lesion and a per-patient level and did not predict outcomes at multivariate Cox analyses, including demographic data, cardiovascular risk factors and established CT derived parameters of CAD (total plaque volume, number of lesions and higheste stenosis degree) as covariates. These results do not confirm previous studies documenting indicating PCAT as a prognostic determinant at shorter follow-up periods and stimulate further research in different and prospective cohorts to better understand the association of PCAT with atherosclerosis and cardiovascular events.
CT
CCTA
chronic ischaemic heart disease
Coronary disease, Prognosis
Lung ultrasound predicts prognosis in heart failure patients, regardless of clinical factors
Rastogi T, Gargani L, Pellicori P, et al.
Prognostic implication of lung ultrasound in heart failure: a pooled analysis of international cohorts
Eur Heart J Cardiovasc Imaging 2024; 25:1216-1225; https://doi.org/10.1093/ehjci/jeae099
Lung ultrasound (LUS) is often used to assess congestion in heart failure (HF). The Authors assessed the prognostic role of LUS in patients with HF at admission and hospital discharge, and in an outpatient setting, and explored whether clinical factors [age, sex, left ventricular ejection fraction (LVEF), and atrial fibrillation] impact on the prognostic value of LUS findings. They analysed pooled data from international cohorts and enrolled 1,947 patients at admission (n = 578), discharge (n = 389), and in outpatient clinics (n = 980). The total LUS B-line count was calculated for the eight-zone scanning protocol. The primary outcome was a composite of rehospitalization for HF and all-cause death. Compared with those in the lower tertiles of B lines, patients in the highest tertiles were older, more likely to have signs of HF and had higher N-terminal pro B-type natriuretic peptide levels. A higher number of B lines was associated with increased risk of primary outcome at discharge [Tertile 3 vs. Tertile 1: adjusted hazard ratio (HR): 5.74 (3.26–10.12), P < 0.0001] and in outpatients [Tertile 3 vs. Tertile 1: adjusted HR: 2.66 (1.08–6.54), P = 0.033]. Age and LVEF did not influence the prognostic capacity of LUS in different clinical settings. Adding B-line count to the MAGGIC and AHEAD scores improved net reclassification significantly in all three clinical settings. They concluded that a higher number of B lines in patients with HF was associated with an increased risk of morbidity and mortality, regardless of the clinical setting.
ECHO
Echo; Lung Ultrasound
heart failure
Heart Failure, prognosis
Surgical and transcatheter aortic valve replacement are differently associated with left and right ventricular longitudinal systolic function changes during follow-up
Silva I, Ternacle J, Hahn RT, et al.
Left and right ventricular longitudinal systolic function following aortic valve replacement in the PARTNER 2 trial and registry
Eur Heart J Cardiovasc Imaging 2024; 25:1276-1286; https://doi.org/10.1093/ehjci/jeae114
The study objective was to evaluate the changes in left (LV) and right ventricular (RV) longitudinal systolic function and RV–pulmonary artery (RV–PA) coupling from baseline to 30 days and 1 year after aortic valve replacement (AVR). LV longitudinal strain (LS), tricuspid annulus plane systolic excursion (TAPSE), and RV–PA coupling were evaluated in patients from the PARTNER 2A surgical AVR (SAVR) arm (n = 985) and from the PARTNER 2 SAPIEN 3 registry (n = 719). TAPSE and RV–PA coupling decreased significantly following SAVR, but remained stable following TAVR. Lower LV LS, TAPSE, or RV–PA coupling at baseline was associated with increased risk of the composite of death, hospitalization, and stroke at 5 years. Reduced TAPSE at baseline was the most powerful predictor of the composite endpoint at 5 years. Patients with LV ejection fraction <50% at baseline had increased risk of the primary endpoint with SAVR (HR: 1.34, 95% CI 1.08–1.68, P = 0.009) but not with TAVR (HR: 1.12, 95% CI 0.88–1.42). Lower RV–PA coupling at 30 days showed the strongest association with cardiac mortality. The Authors concluded that SAVR but not TAVR was associated with a marked deterioration in RV longitudinal systolic function and RV–PA coupling. Lower TAPSE and RV–PA coupling at 30 days were associated with inferior clinical outcomes at 5 years. In patients with LVEF < 50%, TAVR was associated with superior 5-year outcomes.
ECHO
systolic function, strain
valvular heart disease
Aortic valve stenosis; aortic valve replacement
Single-center series of 111 patients affected by cancer-associated non-bacterial thrombotic endocarditis
Kurmann RD, Klarich KW, Wysokinska E, et al.
Echocardiographic findings in cancer-associated non-bacterial thrombotic endocarditis: clinical series of 111 patients from a single institution.
Eur Heart J Cardiovasc Imaging 2024; 25:1255-1263; https://doi.org/10.1093/ehjci/jeae112
Echocardiographic assessment of cancer-associated non-bacterial thrombotic endocarditis (Ca-NBTE) is limited to case reports and small clinical series. The study aimed to identify heart valve abnormalities and its relation to embolic complications and cancer types. The authors performed manual review of echocardiographic images and medical records of Mayo Clinic patients (2002–2022). Ca-NBTE in 111 patients (mean age 63.2 ± 9.7 years, 66.7% female) predominantly affected mitral valves (MV) (69), 56 aortic (AV), 8 tricuspid (TV), and rarely pulmonic (PV) (1). In 18 patients, 2 valves were involved, 3 and 4 valve involvement in only a single patient each. Embolic complications were prevalent (n = 102, 91.9%). Ca-NBTE affected MV more frequently on the upstream (atrial) (90% vs. 49.3%) and TV downstream (ventricular) side (75% vs. 37.5%). NBTE size (cm) varied significantly among valves, with TV hosting the largest masses, compared with MV and AV; MV masses were borderline longer in systemic compared with cerebral emboli (P = 0.057). Majority of MV (79.6%) and AV (69.6%) had thickened leaflets. NBTE lesions commonly affected closing margins (73.9% MV, 85.7% AV, and 62.5% of TV) but rarely commissures of MV (8.7%), yet fairly frequently of AV (41.1%). Five patients had severe regurgitation of MV and 5 AV. They concluded that Ca-NBTE manifests mainly as thrombotic mobile masses attached to thickened MV and AV, with distinct variations in size based on valve type. Embolic destination but not cancer type is associated with NBTE mass size and location.
ECHO
Echo
endocarditis
Cancer; Non-bacterial endocarditis
TAPSE/sPAP < 0.40 mm/mmHg assessed by an early echocardiography during an AHF episode is independently associated with in-hospital cardiovascular events
Fauvel C, Dillinger JG, Rossanaly Vasram R, et al; ADDICT-ICCU Investigators.
In-hospital prognostic value of TAPSE/sPAP in patients hospitalized for acute heart failure.
Eur Heart J Cardiovasc Imaging 2024; 25:1099-1108; https://doi.org/10.1093/ehjci/jeae059
The Authors aimed to assess the in-hospital prognostic value of tricuspid annular plane systolic excursion over systolic pulmonary artery pressure (TAPSE/sPAP) in 333 consecutive patients (mean age 68 ± 14 years, 70% of male, mean left ventricular ejection fraction 44 ± 16%) hospitalized for acute heart failure (AHF), with TAPSE/sPAP measured by echocardiography within the first 24 h of hospitalization. The primary outcome was in-hospital major adverse cardiovascular events (MACEs) defined as all-cause death, resuscitated cardiac arrest or cardiogenic shock and occurred in 50 (15%) patients. The best TAPSE/sPAP threshold for in-hospital MACEs was 0.40 mm/mmHg. TAPSE/sPAP < 0.40 mm/mmHg was independently associated with in-hospital MACEs, even after adjustment with comorbidities [odds ratio (OR): 3.75, 95% CI (1.87–7.93), P < 0.001], clinical severity [OR: 2.80, 95% CI (1.36–5.95), P = 0.006]. Using a 1:1 propensity-matched population, TAPSE/sPAP ratio < 0.40 was associated with a higher rate of in-hospital MACEs [OR: 2.98, 95% CI (1.53–6.12), P = 0.002]. After adjustment, TAPSE/sPAP < 0.40 showed the best improvement in model discrimination and reclassification above traditional prognostic factors (C-statistic improvement: 0.05; χ2 improvement: 14.4; likelihood-ratio test P < 0.001). These results were confirmed in an external validation cohort of 133 patients. The study demonstrated that TAPSE/sPAP < 0.40 mm/mmHg assessed by an early echocardiography during an AHF episode is independently associated with in-hospital MACEs suggesting enhanced close monitoring and strengthened heart failure-specific care in these patients.
ECHO
Echo
heart failure
acute heart Failure
Women with moderate or severe primary MR have more impaired LA reservoir mechanics and increased LA stiffness compared with men
Berg-Hansen CE, Sindre RB, Grymyr LMD, et al.
Sex differences in left atrial volumes, mechanics, and stiffness in primary mitral regurgitation-a combined 2D and 3D echocardiographic study.
Eur Heart J Cardiovasc Imaging 2024; 25:1118-1126; https://doi.org/10.1093/ehjci/jeae072
The Authors assessed whether changes in left atrial (LA) size, strain, and stiffness in significant (moderate or greater) primary mitral regurgitation (MR) are sex specific. In the 3D Echocardiography and Cardiovascular Prognosis in Mitral Regurgitation study, 111 patients with primary MR were prospectively investigated with 2D and 3D echocardiography. MR was severe if the 3D regurgitant fraction was ≥50%. LA size was assessed by maximum, minimum, and pre-A 3D volume (LAV), mechanics by peak reservoir (LASr) and contractile strain, and stiffness by the ratio: mitral peak E-wave divided by the annular e′ velocity (E/e′)/LASr. Women were older, had higher heart rate, and lower body mass index and MR regurgitant volumes (P < 0.05). 3D LAV indexed for body surface area and LA contractile strain did not differ by sex, while LASr was lower (22.2 vs. 25.0%) and LA stiffness higher in women (0.56 vs. 0.44) (P < 0.05). In linear regression analysis, female sex was associated with higher LA stiffness independent of age, minimum LAV, left ventricular global longitudinal strain, diabetes, and coronary artery disease (R2 = 0.56, all P < 0.05). In logistic regression analysis, women had a four-fold (95% CI 1.2–13.1, P = 0.02) higher adjusted risk of increased LA stiffness than men. They concluded that women with significant primary MR have more impaired LA reservoir mechanics and increased LA stiffness compared with men despite lower MR regurgitant volumes and similar indexed LA size. The findings reveal sex-specific features of LA remodeling in MR.
ECHO
Echo
valvular heart disease
Mitral regurgitation
Cardiometabolic risk factors and systemic (poly-vascular) subclinical atherosclerosis are associated with impaired coronary microvascular function
Devesa A, Fuster V, García-Lunar I, et al.
Coronary Microvascular Function in Asymptomatic Middle-Aged Individuals With Cardiometabolic Risk Factors.
JACC Cardiovasc Imaging 2024; S1936-878X(24)00342-5; https://doi.or/10.1016/j.jcmg.2024.08.002
This study was performed in a subgroup of the PESA population, a prospective observational cohort of 4,184 apparently healthy asymptomatic subjects enrolled with the goal to characterize atherosclerosis initiation and progression by means of serial multimodality noninvasive imaging and paired biological sampling. The present subgroup included 530 pts with subclinical atherosclerosis detected by arterial US and/or CAC score who performed stress and rest CMR with measurement of myocardal perfusion reserve (MPR). The main finding was that the presence of emerging cardiometabolic risk factors (elevated waist circumference, systolic and diastolic blood pressure, fasting glucose, and triglycerides and low high-density lipoprotein cholesterol) synergistically contributed to cause a depressed MPR (higher resting flow and depressed maximal flow) a marker of coronary microvascular dysfunction. Stress MBF was inversely associated with coronary artery calcium presence and with global plaque burden. Higher stress MBF and MPR were associated with less atherosclerosis progression (increase in plaque volume) at 3 years.
CMR
CMR
normal/healthy people
Coronary Artery Disease and Risk Factors
In patients with cardiac amyloidosis, the presence of mitral and/or tricuspid regurgitation is associated with worse prognosis
Tomasoni D, Aimo A, Porcari A, et al.
Prevalence and clinical outcomes of isolated or combined moderate to severe mitral and tricuspid regurgitation in patients with cardiac amyloidosis.
Eur Heart J Cardiovasc Imaging 2024; 25:1007-1017; https://doi.org/10.1093/ehjci/jeae060
This study aimed to assess the epidemiology and prognostic significance of mitral regurgitation (MR) and tricuspid regurgitation (TR) in patients with cardiac amyloidosis (CA). Overall, 538 patients with either transthyretin (ATTR, n = 359) or immunoglobulin light-chain (AL, n = 179) CA were included at three Italian referral centres. Patients were stratified according to isolated or combined moderate/severe MR and TR. Overall, 240 patients (44.6%) had no significant MR/TR, 112 (20.8%) isolated MR, 66 (12.3%) isolated TR, and 120 (22.3%) combined MR/TR. The most common aetiologies were atrial functional MR, followed by primary infiltrative MR, and secondary TR due to right ventricular (RV) overload followed by atrial functional TR. Patients with isolated or combined MR/TR had a more frequent history of heart failure (HF) hospitalization and atrial fibrillation, worse symptoms, and higher levels of NT-proBNP as compared to those without MR/TR. They also presented more severe atrial enlargement, atrial peak longitudinal strain impairment, left ventricular (LV) and RV systolic dysfunction, and higher pulmonary artery systolic pressures. TR carried the most advanced features. After adjustment for age, sex, CA subtypes, laboratory, and echocardiographic markers of CA severity, isolated TR and combined MR/TR were independently associated with an increased risk of all-cause death or worsening HF events, compared to no significant MR/TR [adjusted HR 2.75 (1.78–4.24) and 2.31 (1.44–3.70), respectively]. Therefore, in patients with CA, isolated TR and combined MR/TR were associated with worse prognosis regardless of CA aetiology, LV, and RV function, with TR carrying the highest risk.
ECHO
Echo
valvular heart disease
Amyloidosis; Mitral regurgitation; Tricuspid regurgitation
Mavacamten improves left ventricular longitudinal strain in obstructive hypertrophic cardiomyopathy
Desai MY, Okushi Y, Gaballa A, et al.
Serial Changes in Ventricular Strain in Symptomatic Obstructive Hypertrophic Cardiomyopathy Treated With Mavacamten: Insights From the VALOR-HCM Trial.
Circ Cardiovasc Imaging 2024; 17:e017185; https://doi.org/10.1161/CIRCIMAGING.124.017185
This study assessed in the VALOR-HCM (A Study to Evaluate Mavacamten in Adults With Symptomatic Obstructive Hypertrophic Cardiomyopathy Who Are Eligible for Septal Reduction Therapy) study serial changes in left ventricular (LV) and right ventricular (RV) strain. It included 112 patients with symptomatic obstructive hypertrophic cardiomyopathy (mean, 60 years; 51% male; LV ejection fraction, 68%). Patients assigned to mavacamten at baseline continued the drug for 56 weeks (n=56) and those assigned to placebo (n=52) transitioned to mavacamten from weeks 16 to 56 (40-week exposure). In the total study sample, LV-GLS significantly improved from baseline to week 56 (P=0.02). Twelve patients had transient reduction in LV ejection fraction (<50%) requiring temporary drug interruption (including 3 permanent discontinuations). The LV-GLS in this subgroup was worse at baseline versus total study population (−11.4%), with no significant worsening from baseline through week 56 (P=0.64). Both free wall and 4-chamber RV-GLS remained unchanged from baseline to week 56 (P=0.62 and P=0.56, respectively). The Authors concluded that mavacamten improved LV-GLS from baseline through week 56 (with no significant worsening of LV-GLS in patients with a reduction in LV ejection fraction ≤50%), suggesting a favorable long-term impact on regional LV systolic function. Additionally, there was no detrimental impact on RV systolic function.
ECHO
Echo, GLS
cardiomyopathies
Hypertrophic Cardiomyopathy
In severe mitral regurgitation, improved left atrial strain during 6-month follow-up is associated with lower rates of all-cause mortality or heart failure hospitalizations, both after transcatheter repair and medical therapy alone
Pio SM, Medvedofsky D, Delgado V, et al.
Left Atrial Improvement in Patients With Secondary Mitral Regurgitation and Heart Failure: The COAPT Trial.
JACC Cardiovasc Imaging 2024; 17:1015-1027; https://doi.org/10.1016/j.jcmg.2024.03.016
The aim of this study was to evaluate the impact of left atrial (LA) strain improvement 6 months after transcatheter edge-to-edge repair (TEER) on the outcomes of patients enrolled in the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) trial. Patients with at least a 15% improvement in LA strain were labeled as “LA strain improvers.” All-cause death and heart failure hospitalization (HFH) were assessed between the 6- and 24-month follow-up. Among 347 patients (mean age 71 ± 12 years, 63% male), 106 (30.5%) showed improvement of LA strain at the 6-month follow-up (64 [60.4%] from the TEER + guideline-directed medical therapy [GDMT] group and 42 [39.6%] from the GDMT alone group). An improvement in LA strain was significantly associated with a reduction in the composite of death or HFH between the 6-month and 24-month follow-up, with a similar risk reduction in both treatment arms. In multivariable analyses, LA strain improvement remained independently associated with a lower risk of the primary composite endpoint both as a continuous variable (adjusted HR: 0.94 [95% CI: 0.89-1.00]; P = 0.03) and as a dichotomous variable (adjusted HR: 0.49 [95% CI: 0.27-0.89]; P = 0.02). The best outcomes were observed in patients treated with TEER in whom LA strain improved.
ECHO
Echo, left atrial strain
valvular heart disease
Secondary mitral regurgitation; Heart failure
Cardiac damage is highly prevalent in patients with mild AS and correlates with comorbidities.
Dahl JS, Julakanti R, Ali M, et al.
Cardiac Damage in Early Aortic Stenosis: Is the Valve to Blame?
JACC Cardiovasc Imaging 2024; 17:1031-1040; https://doi.org/10.1016/j.jcmg.2024.05.003
Aim of this study was to determine the prevalence of and factors associated with cardiac damage (CD) in mild aortic stenosis (AS). This retrospective study included 9,611 patients with mild AS (peak aortic valve velocity [Vmax] 2-3 m/s and description of abnormal aortic valve) from 2010 through 2021. CD was staged using the Genereux classification. All but 20% (n = 1,901; stage 0) of patients with mild AS demonstrated CD: 1,613 (17%) stage 1, 4,843 (50%) stage 2, 891 (9%) stage 3, and 363 (4%) stage 4. Patients with higher stages had more comorbidities (hypertension, heart failure, ischemic heart disease, stroke, peripheral arterial disease, chronic kidney disease, chronic pulmonary disease, and diabetes mellitus) but had valvular hemodynamic status similar to those without CD. CD stage did not worsen with higher Vmax range (stage >1 in 64% with Vmax <2.5 m/s vs 61% with Vmax ≥2.5 m/s) but increased with the number of comorbidities, with stage >1 occurring in 50%, 53%, 60%, 66%, 72%, and 73% in the presence of 0, 1, 2, 3, 4, and 5 or more comorbidities, respectively.
ECHO
Echo
valvular heart disease
Aortic stenosis
Mild mitral annulus calcification has prognostic implications for both valvular function and mortality.
Abbasi M, Al-Abcha A, Lee AT BS, et al.
Progression of Mild Mitral Annulus Calcification to Mitral Valve Dysfunction and Impact on Mortality.
J Am Soc Echocardiogr 2024; 37:752-755; https://doi.org/10.1016/j.echo.2024.03.004
The study aimed to examine the long-term significance of mild mitral annulus calcification (MAC) and its relationship to subsequent mitral valve dysfunction (MVD) and mortality in patients without MVD on the initial echocardiogram. A total of 1,420 patients with mild MAC and no MVD at baseline and 1 or more follow-up echocardiograms at least 1 year after the baseline echocardiogram were included in the analysis. For patients with >1 echocardiogram during follow-up, the last echocardiogram was used. The same criteria were used to identify 6,496 patients without MAC. Mitral valve dysfunction was defined as mitral regurgitation (MR) and/or mitral stenosis (MS) of moderate or greater severity. Mixed disease was defined as the concurrent presence of both moderate or greater MS and MR. The primary end point was development of MVD, and the secondary end point was all-cause mortality. During a median follow-up of 4.7 (interquartile range, 2.7-6.9) years, 215 patients with mild MAC developed MVD, including MR in 170 (79%), MS in 37 (17%), and mixed disease in 8 (4%). In a multivariable regression model compared to patients without MAC, the presence of mild MAC was independently associated with increased mortality (hazard ratio = 1.43; 95% CI 1.24, 1.66; P < .001). Kaplan-Meier 4-year survival rates were 80% and 90% for patients with mild MAC and no MAC, respectively.
ECHO
Echo
valvular heart disease
Degenerative mitral stenosis
Fasting plasma glucose and myocardial flow reserve are independent prognostic predictors of mortality
Filidei E, Caselli C, Menichetti L, et al.
Long-term prognostic impact of fasting plasma glucose and myocardial flow reserve beyond other risk factors and heart disease phenotypes.
Eur Heart J Imaging Methods Pract 2024; 2:qyae070; https://doi.org/10.1093/ehjimp/qyae070
The purpose of this study was to assess whether cardiometabolic risk factors and global myocardial blood flow (MBF) reserve measured by PET, expressing global coronary function, are independent predictors of long-term prognosis. In a retrospective population of 103 patients (mean age 61 ± 10 years, 74 males) with stable chest pain or dyspnoea who underwent cardiac PET/computerized tomography, disease phenotypes included obstructive CAD (35%), LV dysfunction without obstructive CAD (43%), or none (22%). During a median follow-up of 10.9 years (interquartile range 7.8-13.9), 39 patients (37.8%) died (13.6% cardiac death). At multivariable Cox analyses including all risk factors and disease phenotypes, age (HR 1.07, 95% CI 1.02-1.12), hFPG (HR 2.18, 95% CI 1.02-4.63), and depressed MBF reserve (HR 4.47, 95% CI 1.96-10.18) were independent predictors of death (global χ2 37.41, P = 0.0004).
NUCLEAR
PET, myocardial perfusion reserve
chronic ischaemic heart disease
Coronary Artery Disease, HFmrEF
Comparison between positron emission tomography and single-photon emission computed tomography myocardial perfusion imaging for risk prediction
Huck DM, Divakaran S, Weber B, et al.
Comparative effectiveness of positron emission tomography and single-photon emission computed tomography myocardial perfusion imaging for predicting risk in patients with cardiometabolic disease.
J Nucl Cardiol 2024; 10:101908; https://doi.org/10.1016/j.nuclcard.2024.101908
The study aimed to assess in a large retrospective population, referred for myocardial perfusion imaging (MPI), the comparative prognostic value of either qualitative/quantitative PET or SPECT in subjects with cardiometabolic disease (obesity, diabetes, or chronic kidney disease) and without known CAD. Among 21,544 patients referred from 2006 to 2020, cardiometabolic disease was highly prevalent (PET: 2308 [67%], SPECT: 9984 [55%]) and higher among patients referred to PET (P < 0.001). Obstructive CAD findings (total perfusion deficit > 5%) were uncommon (PET: 21% and SPECT: 11%). Conversely, impaired MFR on PET (<2.0) was common (62%). In a propensity-matched analysis over a median 6.4-year follow-up, normal PET identified low-risk (0.9%/year MACE) patients, and abnormal PET identified high-risk (4.2%/year MACE) patients with cardiometabolic disease; conversely, those with normal pharmacologic SPECT remained moderate-risk (1.6%/year, P < 0.001 compared to normal PET). The results demonstrated that cardiometabolic disease is common among patients referred for MPI and is associated with a heterogenous level of risk. Compared with pharmacologic SPECT, PET with measurement of myocardial flow reserve can detect nonobstructive CAD, including coronary microvascular dsease, and can more accurately discriminate low-risk from higher-risk individuals.
NUCLEAR
PET; SPECT
Other
Cardiometabolic risk
Reference values of myocardial work indexes in adult heart transplant recipients free from transplant-related complications
Mandoli GE, Landra F, Tanzi L, et al.
Reference values of strain-derived myocardial work indices in heart transplant patients
European Heart Journal - Imaging Methods and Practice 2024; 2:qyae091; https://doi.org/10.1093/ehjimp/qyae091
Aim of this study was to obtain the reference ranges for 2D echocardiographic indices of myocardial work (MW) for adult heart transplant (HTx) recipients- All consecutive HTx patients admitted at the University Hospital of Siena (Italy) between September 2019 and May 2022 who underwent endomyocardial biopsy (EMB) were considered. Patients with a history of rejection, a history of coronary artery vasculopathy, either acute cellular rejection or acute antibody-mediated rejection at EMB, and donor-specific antibodies were excluded. The study population consisted of 82 HTx patients [68.3% male, median age 53 (46–62) years]. The median duration from HTx was 5 (2–22) months. The main MW indices such as global work efficiency (GWE, 84 ± 8%), global work index (GWI, 1447 ± 409 mmHg%), global constructive work (GCW, 2067 ± 423 mmHg%), and global wasted work [GWW, 310 (217–499) mmHg%] did not differ according to gender. Each of these indices significantly differed from those reported in the EACVI NORRE study (P-value <0.001), with lower GWI, GCW, and GWE and higher GWW values in the HTx population.
ECHO
Echo; Speckle Tracking
heart failure
heart transplantation; myocardial work; reference values
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