Bryan Ristow

Usefulness of Left Atrial Volume Index to Predict Heart Failure Hospitalization and Mortality in Ambulatory Patients With Coronary Heart Disease and Comparison to Left Ventricular Ejection Fraction (from the Heart and Soul Study)

The predictive value of left atrial (LA) dilatation in ambulatory adults with coronary artery disease is not known. It was hypothesized that echocardiographic LA volume index (LAVI) predicts heart failure (HF) hospitalization and mortality with similar statistical power as left ventricular ejection fraction (LVEF) in ambulatory adults with coronary artery disease. We measured LAVI in 935 adults without atrial fibrillation, atrial flutter, or significant mitral valve disease in the Heart and Soul Study. LAVI was calculated using the biplane method of disks. Outcomes included HF hospitalization and mortality. Logistic regression odds ratios (ORs) were calculated and adjusted for age, demographics, medical history, left ventricular mass, diastolic function, and LVEF. Mean LAVI was 32 +/- 11 ml/m2, and mean LVEF was 62 +/- 10%. Sixty-six patients (7%) had LAVI >50 ml/m2. There were 108 HF hospitalizations and 180 deaths at 4.3 years of follow-up. C statistics calculated as the area under the receiver-operator characteristic curve were the same (0.60) for LAVI and LVEF in predicting mortality. The unadjusted OR for HF hospitalization was 4.4 for LAVI >50 ml/m2 and 5.3 for LVEF <45% (p <0.001). In those with normal LVEF, the ORs for LAVI >50 ml/m2 were 5.2 for HF hospitalization (p <0.0001) and 2.5 for mortality (p = 0.006). After multivariate adjustment, LAVI >50 ml/m2 was predictive of HF hospitalization (OR 2.4, p = 0.02), and LAVI >40 ml/m2 was predictive of mortality (OR 1.9, p = 0.005). In conclusion, LAVI had similar predictability as LVEF for HF hospitalization and mortality in ambulatory adults with coronary artery disease.

Overwhelming Parasitemia with Plasmodium falciparum Infection in a Patient Receiving Infliximab Therapy for Rheumatoid Arthritis

We describe a 45-year-old woman receiving infliximab therapy for rheumatoid arthritis who developed an overwhelming Plasmodium falciparum infection with cerebral malaria. Physicians should be aware that patients receiving tumor necrosis factor inhibitors, such as infliximab, may be at increased risk of life-threatening malarial infections.

Predicting Heart Failure Hospitalization and Mortality by Quantitative Echocardiography: Is Body Surface Area the Indexing Method of Choice? The Heart and Soul Study

BACKGROUND Echocardiographic measurements of left ventricular (LV) mass, left atrial (LA) volume, and LV end-systolic volume (ESV) predict heart failure (HF) hospitalization and mortality. Indexing measurements by body size is thought to establish limits of normality among individuals varying in body habitus. The American Society of Echocardiography recommends dividing measurements by body surface area (BSA), but others have advocated alternative indexing methods. METHODS Echocardiographic measurements were collected in 1024 ambulatory adults with coronary artery disease. LV mass, LA volume, and LV ESV were calculated using truncated ellipse method and biplane method of disk formulae. Comparison between raw measurements and measurements divided by indexing parameters was made by hazard ratios per standard deviation increase in variable and c-statistics for BSA, BSA(0.43), BSA(1.5), height, height(0.25), height(2), height(2.7), body weight (BW), BW(0.26), body mass index (BMI), and BMI(0.27). RESULTS Mean LV mass was 192 +/- 57 g, mean LA volume was 65 +/- 24 mL, and mean LV ESV was 41 +/- 26 mL. Average height was 171 +/- 9 cm, average BSA was 1.94 +/- 0.22 m(2), and average BMI was 28.4 +/- 5.3 kg/m(2). At an average follow-up of 5.6 +/- 1.8 years, there were 148 HF hospitalizations, 71 cardiovascular (CV) deaths, and 269 all-cause deaths. There was excellent correlation between raw measurements and those indexed by height (r = 0.98-0.99), and moderate correlation between raw measurements and those indexed by BW (r = 0.73-0.94). C-statistics and hazard ratios per standard deviation increase in indexed variables were similar for HF hospitalization, CV mortality, and all-cause mortality. There were no significant differences among indexing methods in ability to predict outcomes. CONCLUSION The choice of indexing method by parameters of BSA, height, BW, and BMI does not affect the clinical usefulness of LV mass, LA volume, and LV ESV in predicting HF hospitalization, CV mortality, or all-cause mortality among ambulatory adults with coronary artery disease. Continued use of BSA to index measurements of LV mass, LA volume, and LV ESV is acceptable.

Stepping Away From Ritual Right Heart Catheterization Into the Era of Noninvasively Measured Pulmonary Artery Pressure

Knowledge of pulmonary artery (PA) pressure is central to the management of cardiac disease. Noninvasive measurements can be derived by Doppler interrogation of the right ventricular (RV) outflow tract (RVOT), tricuspid regurgitation (TR), and pulmonary regurgitation (PR) signals. In addition, echocardiography provides anatomic information that may indicate elevated PA pressure, such as RV hypertrophy, RV dilation, RV systolic dysfunction, systolic notching of the pulmonary valve, or PA dilation. In this issue of JASE, Aduen et al describe an alternative method of measuring mean PA pressure using the mean gradient from the TR signal. In the absence of obstruction to PA flow, peak TR gradient added to right atrial (RA) pressure accurately measures peak systolic PA pressure. This method has been validated and adopted universally. In contemporary practice, the yield of TR waveform availability is 80%, and the yield is increased with saline contrast enhancement. Limitations on interrogating the TR signal include underestimation of peak velocity because of an inability or failure to position the Doppler interrogation beam parallel to the direction of flow or the generation of a signal with an incomplete envelope. Inaccurate estimation of RA pressure is also a source of error. The first two situations underestimate the catheterization-derived systolic PA pressure and the last either overestimates or underestimates it. Beyond estimating peak PA systolic pressure, echocardiographic techniques also accurately estimate diastolic PA pressure, mean PA pressure, pulmonary vascular resistance (PVR), and pulmonary vascular capacitance (PVC). Doppler flow acceleration time in the distal RVOTor proximal PA estimates mean PA pressure. An acceleration time of #100 ms suggests pulmonary hypertension. This method requires measurement of the time from onset to the peak of forward flow in the pulsedwave Doppler signal across the RVOT and may be useful when TR or PR signals cannot be interrogated. The PA pressure calculated in this manner has been found to be less accurate than estimates derived from TR, especially at low or high heart rates. In our experience, a rounded, slowly rising pulmonary flow signal obviates the need for measuring acceleration because it is connotes normal acceleration and practically excludes elevated pulmonary pressure. The end-diastolic PR gradient correlates with PA diastolic pressure and can be used as a surrogate for pulmonary capillary wedge pressure. Elevations in end-diastolic PR gradients >5 mmHg, and especially >10 mmHg, predict heart failure and cardiovascular mortality in coronary artery disease. The end-diastolic PR gradient added to RA pressure provides a numerical indicator of PA diastolic pressure.

Left Ventricular Outflow Tract and Pulmonary Artery Stroke Distances Independently Predict Heart Failure Hospitalization and Mortality: The Heart and Soul Study

BACKGROUND Stroke distance of the left ventricular outflow tract (LVOT) or pulmonary artery (PA) is readily measurable by Doppler echocardiography. Stroke distance, calculated by the velocity time integral, expresses the average linear distance traveled by red blood cells during systole. We hypothesized that reduced stroke distance predicts heart failure (HF) hospitalization or mortality among ambulatory adults with stable coronary artery disease. METHODS We compared stroke distances by lowest quartile among 990 participants in the Heart and Soul Study. We calculated hazard ratios (HRs) for events adjusted for clinical and echocardiographic parameters. RESULTS At 5.9 ± 1.9-year follow-up, there were 154 HF hospitalizations and 271 all-cause deaths. Among 254 participants with LVOT stroke distance in the lowest quartile (≤ 18 cm), 24% developed HF hospitalization, compared with 10% of those with higher stroke distance (HR 2.7; CI, 2.0-3.8; P < .0001). This association remained after adjustment for multiple variables including medical history, heart rate, blood pressure, and left ventricular ejection fraction (HR 1.8; CI, 1.1-3.0; P = .02). Both LVOT stroke distance ≤ 18 cm and PA stroke distance ≤ 17 cm were independently associated with the combined end point of HF hospitalization and mortality (HR 1.4; CI, 1.1-1.9; P = .02). CONCLUSION Reduced stroke distance predicts HF hospitalization and mortality independent of clinical and other echocardiographic parameters among ambulatory adults with coronary artery disease.

Usefulness of Diastolic Dominant Pulmonary Vein Flow to Predict Hospitalization for Heart Failure and Mortality in Ambulatory Patients With Coronary Heart Disease (from the Heart and Soul Study)

Diastolic dysfunction is usually identified by the combination of characteristic mitral and pulmonary vein flow patterns. However, obtaining a complete set of echocardiographic parameters can be technically difficult and data may conflict. We hypothesized that as a stand-alone variable, (ventricular) diastolic dominant pulmonary vein flow would predict heart failure (HF) hospitalizations and cardiovascular death. Standard transthoracic echocardiograms were obtained in 906 subjects from the Heart and Soul Study, a prospective study of the effects of depression on coronary heart disease. Pulmonary vein flow pattern was determined using the dominant velocity-time integral. Cardiac events were determined by 2 independent adjudicators, and Cox proportional hazards models were used. Systolic dominant pulmonary vein flow was present in 89% of subjects, and diastolic dominant, in the remaining 11%. During an average 4.1 years of follow-up, subjects with diastolic dominant pulmonary vein flow had a 25% rate of HF hospitalization and 9% rate of cardiovascular death. After multivariate adjustment including left ventricular ejection fraction, diastolic pulmonary vein flow was associated with a 3-fold risk of HF hospitalization (p = 0.001) and a 2-fold risk of HF hospitalization or death (p = 0.004). In conclusion, diastolic dominant pulmonary vein flow pattern was a stand-alone predictor of adverse cardiac events, and its presence was associated with significantly higher rates of HF hospitalizations and cardiovascular death.

Doppler under Pressure: It's Time to Cease the Folly of Chasing the Peak Right Ventricular Systolic Pressure

http://dx.doi.o There are three studies in this issue of The Journal that contribute to our understanding of the noninvasive determination of pulmonary hemodynamics. This editorial discusses aspects of each of these studies and places them in context of the contemporary practice of echocardiography. The editorial concludes with a discussion of improving current practice and research, partly based on the model of aortic stenosis (AS).

Pseudoaneurysms of the mitral-aortic intervalvular fibrosa: Survival without reoperation

BACKGROUND the tissue spanning the mitral and aortic valves, the mitral-aortic intervalvular fibrosa (MAIVF), may be the site of pseudoaneurysm formation in the setting of infective endocarditis or congenital heart disease, or after valve surgery. Because of potential complications of MAIVF pseudoaneurysms, patients with such lesions are often referred for surgical repair. METHODS we identified 3 individuals with MAIVF pseudoaneurysms who were followed without surgical intervention after diagnosis of the MAIVF pseudoaneurysm. The courses of these patients are presented below. RESULTS the MAIVF pseudoaneurysms were measured to be stable in size over several years among 3 patients. Dimensions were 5.3 × 2.3, 7.6 × 4.9, and 4.8 × 2.5 cm. Surgical repair was considered too high a risk in 2 of the individuals, and the third individual refused a third surgical intervention. Of the 3 patients, 2 remain asymptomatic. The third patient was 87 years old when her MAIVF pseudoaneurysm was diagnosed, and she died of noncardiac causes at age 92 years. CONCLUSIONS clinical surveillance and serial imaging of MIAVF pseudoaneurysms may be considered an alternative to surgical management in select individuals.

RELATIONSHIP OF BISPHOSPHONATE THERAPY AND ATRIAL FIBRILLATION/ATRIAL FLUTTER: THE OSTEOPOROTIC FRACTURES IN MEN (MROS) STUDY

Methods: MrOS is a prospective cohort study of 5,995 U.S. men ages 65 and older from six clinical sites enrolled in 2000-2002. This analysis used cross-sectional data from a subset of 2,911 men who participated in the sleep visit (2003-2005), had continuous overnight sleep studies with electrocardiogram data that were centrally reviewed for the presence or absence of AF (of any duration), and had medication use data. Logistic regression models were used to estimate the likelihood of AF among bisphosphonate users (compared to nonusers).