Anne Brunet-Bernard

Prognostic value of CHA2DS2-VASc score in patients with ‘non-valvular atrial fibrillation’ and valvular heart disease: the Loire Valley Atrial Fibrillation Project

AIMS The CHA2DS2VASc score is a clinical risk stratification tool which estimates the risk of stroke and thromboembolism in non-valvular atrial fibrillation (AF). We aimed to establish the value of this score for risk evaluation in patients with non-valvular AF and valvular heart disease. METHODS AND RESULTS Among 8053 patients with non-valvular AF (ESC guidelines definition), patients were categorized into Group 1 (no valve disease, n = 6851; 85%) and Group 2 (valve disease with neither rheumatic mitral stenosis nor valve prothesis, n = 1202; 15%). After follow-up of 868 ± 1043 days, 627 stroke/ thromboembolic (TE) events were recorded. Group 2 was significantly older, had a higher CHA2DS2VASc score and had a higher risk of thromboembolic events [hazard ratio (HR) 1.39; 95% CI 1.14-1.69, P = 0.001] compared with Group 1. Severe valve disease was not associated with worse prognosis for stroke/TE events. In the two groups, stroke/TE risk increased with a higher CHA2DS2VASc score. Factors independently associated with increased risk of stroke/TE events were older age (HR 1.25, 95% CI 1.14-1.36 per 10-year increase, P < 0.0001) and higher CHA2DS2VASc score (HR 1.33, 95% CI 1.23-1.45, P < 0.0001). The predictive value (c-statistic) of the CHA2DS2VASc score was similar in the two groups. CONCLUSION In patients with non-valvular AF, left-sided valvular heart disease (excluding mitral stenosis and protheses) was associated with an increased risk of stroke/TE events. A higher CHA2DS2VASc score in these patients is likely to explain these results.

Combined Score Using Clinical, Electrocardiographic, and Echocardiographic Parameters to Predict Left Ventricular Remodeling in Patients Having Had Cardiac Resynchronization Therapy Six Months Earlier

The aim of this study was to evaluate whether a scoring system integrating clinical, electrocardiographic, and echocardiographic measurements can predict left ventricular reverse remodeling after cardiac resynchronization therapy (CRT). The derivation cohort consisted of 162 patients with heart failure implanted with a CRT device. Baseline clinical, electrocardiographic, and echocardiographic characteristics were entered into univariate and multivariate models to predict reverse remodeling as defined by a ≥15% reduction in left ventricular end-systolic volume 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, Nonischemic origin, left ventricular 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. 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 the 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). In conclusion, this L2ANDS2 score provides an easy-to-use tool for the clinician to assess the pretest probability of a patient being a CRT responder.

Predictive factors of contrast-induced nephropathy in patients undergoing primary coronary angioplasty

BACKGROUND Contrast-induced nephropathy (CIN) severely impacts patient morbidity and mortality, especially in patients with ST-segment elevation myocardial infarction treated by primary coronary angioplasty, whose renal function is often unknown at the time of contrast exposure. AIM We sought the incidence and factors predictive of CIN in patients treated by primary coronary angioplasty in our hospital; we also questioned the relevance of Mehrans risk score in this population. METHODS We considered all patients admitted for primary coronary angioplasty between January 2010 and December 2011, and included 322 patients with complete data on renal function. CIN was defined as a relative (≥25%) or absolute (≥44 μmol/L) increase in serum creatinine following contrast medium administration. We compared patients with or without CIN, to identify predictive factors, and investigated the effectiveness of Mehrans score using a receiver operating characteristic (ROC) curve, Youdens index and a likelihood ratio test. RESULTS The incidence of CIN was 9.1%. A multivariable analysis identified two independent risk factors for CIN: impaired glomerular filtration rate and cardiogenic shock at admission (P<0.05). An elevated Mehrans score was associated with increased incidence of CIN, but statistical analysis revealed this score to have poor sensitivity, especially in high-risk patients. Youdens index was very low and the area under the ROC curve was 0.59 in our population. CONCLUSION Renal failure and cardiogenic shock at admission were independent predictors of CIN in our acute myocardial infarction population. Mehrans score added little to the discrimination of patients undergoing primary coronary angioplasty, particularly high-risk individuals.

CHA2DS2-VASc Score for Predicting Stroke and Thromboembolism in Patients With AF and Biological Valve Prosthesis.

Patients with valvular atrial fibrillation (AF), as defined in the 2012 European Society of Cardiology guidelines (those with a valvular prosthesis or rheumatic mitral disease) should receive anticoagulation regardless of the CHA2DS2-VASc score, with vitamin K antagonist being recommended [(1–3)][

Electrocardiographic correlates of mechanical dyssynchrony in recipients of cardiac resynchronization therapy devices.

BACKGROUND The relationship between electrical and mechanical indices of cardiac dyssynchronization in systolic heart failure (HF) remains poorly understood. OBJECTIVES We examined retrospectively this relationship by using the daily practice tools in cardiology in recipients of cardiac resynchronization therapy (CRT) systems. METHODS We studied 119 consecutive patients in sinus rhythm and QRS ≥ 120 ms (mean: 160 ± 17 ms) undergoing CRT device implantation. P wave duration, PR, ePR (end of P wave to QRS onset), QT, RR-QT, JT and QRS axis and morphology were putative predictors of atrioventricular (diastolic filling time [DFT]/RR), interventricular mechanical dyssynchrony (IVMD) and left intraventricular mechanical dyssynchrony (left ventricular pre-ejection interval [PEI] and other measures) assessed by transthoracic echocardiography (TTE). Correlations between TTE and electrocardiographic measurements were examined by linear regression. RESULTS Statistically significant but relatively weak correlations were found between heart rate (r=-0.5), JT (r=0.3), QT (r=0.3), RR-QT intervals (r=0.5) and DFT/RR, though not with PR and QRS intervals. Weak correlations were found between: (a) QRS (r=0.3) and QT interval (r=0.3) and (b) IVMD > 40 ms; and between (a) ePR (r=-0.2), QRS (r=0.4), QT interval (r=0.3) and (b) LVPEI, though not with other indices of intraventricular dyssynchrony. CONCLUSIONS The correlations between electrical and the evaluated mechanical indices of cardiac dyssynchrony were generally weak in heart failure candidates for CRT. These data may help to explain the discordance between electrocardiographic and echocardiographic criteria of ventricular dyssynchrony in predicting the effect of CRT.

Cardiac-resynchronization therapy in heart failure with a narrow QRS complex.

From the Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland (F.R., J.H.); the Division of Cardiovascular Medicine, Ohio State University Medical Center, Davis Heart and Lung Research Institute, Columbus (W.T.A.); Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston (J.P.S.); the Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands (J.J.B.); the Division of Cardiovascular Medicine and Howard Gilman and Ron and Jean Schiavone Institutes, State University of New York Downstate College of Medicine, New York (J.S.B.); Cardiology Department, Thorax Institute, Hospital Clinic, University of Barcelona, Barcelona (J.B.); University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Robertson Centre for Biostatistics, University of Glasgow, Glas gow, United Kingdom (I.F.); University of Pittsburgh, Pittsburgh (J.G.); Nouvelles Cliniques Nantaises, Nantes, France (D.G.); Monash Centre of Cardiovascular Research and Education in Therapeutics, Melbourne, VIC, Australia (H.K.); and Aalborg University, Aalborg, Denmark (P.S.). Address reprint requests to Dr. Holzmeister at the Clinic for Cardiology, University Hospital Zurich, Raemistr. 100, CH-8091 Zurich, Switzerland, or at johannes.holzmeister@usz.ch.

Analysis of longitudinal strain integrals during rest and effort on heart failure patients

Purpose: Left ventricular mechanical dyssynchrony is based classically on the analysis of velocity or strain peak instants, which are detected manually. This method may not reflect the complexity of both contractility and timing of a dilated heart, particularly at exercise. We hypothesized that integral-based indicators of regional longitudinal strain signals, and their variation between rest and exercise, would provide additional information for the characterization of the evolution of heart failure patients. Methods: Forty-nine patients with NYHA II to III, ischemic (28%) or idiopathic DCM (72%), ejection fraction 29,6±7,1%, QRS width 138±35ms, were studied. All patients underwent submaximal supine bicycle exercise stress echocardiography. Thirty of 49 patients had a CRT device implantation following baseline evaluation. Patients were classified as responders (n=18) if they showed a decrease in LV end-systolic volume ≥15% at 6-months follow-up, non-responders (n=12) if not. Apical-4 chamber longitudinal strain was recorded manually on a dedicated software (EchoPAC PC, GE Healthcare) and then strain data was exported for a detailed analysis, based on custom-made methods and algorithms. Integrals of strain signals were calculated for each segment, from the beginning of the cardiac cycle (QRS onset), to the instant of the peak of longitudinal strain. Results: Concerning the global population (n=49), no significant change between rest and exercise was observed for septal and lateral peak of longitudinal strain, or intraventricular mechanical dyssynchrony, when recorded manually on the Echopac interface. Integrals to minimum of longitudinal strain decreased significantly between rest and exercise for mid septal segments (1,96±1,30 vs. 1,54±0,91, p<0,01), but no variation was observed for mid-lateral segments (1,96±1,22 vs. 2,04±1,02, p=NS). CRT responders showed an increase in integral to minimum for the mid-lateral segment (1,64±0,90 at rest vs. 2,26±1,20 at exercise; p<0,01) whereas CRT non-responders did not. The latter showed a decrease in integral to minimum for mid-septal segment during exercise (2,21±1,36 vs. 1,30±0,89; p<0,01) that was not observed on CRT responders. Conclusion: Integral-derived longitudinal strain curves give new insights into LV mechanics for heart failure patients during exercise, revealing different patterns between the septum and the lateral wall. These patterns may be useful to identify potential CRT responders.

Can an exercise evaluation of heart function before deciding cardiac resynchronization therapy help in defining the risk of non-response to the therapy?

34 Can an exercise evaluation of heart function before deciding cardiac resynchronization therapy help in defining the risk of non-response to the therapy? A. Brunet-Bernard a, A. Reynaud b, E. Oger c, F. Gardant d, J.-C. Daubert e, P. Mabo e, E. Donal e a Service de Cardiologie, CHU de Tours, Tours, France b Service de Cardiologie, CHU de Bordeaux, Bordeaux, France c Service de Pharmacologie Clinique, CHU de Rennes, CIC, Rennes, France d Service de Médecine du Sport, CHU de Rennes, Rennes, France e Service de Cardiologie, CHU de Rennes, Rennes, France