D. Rakhit

Effect of aggressive risk factor modification on cardiac events and myocardial ischaemia in patients with chronic kidney disease

Objective: To examine whether aggressive risk factor modification in chronic kidney disease (CKD) can limit the development of new ischaemia or reduce cardiac events. Methods: Patients with CKD were randomly assigned to either an aggressive risk factor modification strategy (targeted treatment of hypertension, dyslipidaemia, homocysteine, haemoglobin and phosphate) or standard care. An intention to treat analysis was performed on 152 patients who had baseline dobutamine stress echocardiography (DSE), including 107 who had follow-up DSE. Biochemical parameters, cardiac risk factors and investigations (ECG, two-dimensional echocardiography) were recorded at baseline. New ischaemia was classed as new or worsening stress wall motion abnormality between follow-up and baseline DSE. Patients were followed up for the development of new ischaemia or cardiac death, acute coronary syndrome and non-fatal myocardial infarction over 1.8 years. Results: The development of new ischaemia was common but not different between the standard and aggressively treated groups (15 (21%) v 18 (23%), p  =  0.8). Independent predictors of new ischaemia were older age, abnormal ECG, higher systolic blood pressure and lower serum high density lipoprotein cholesterol, but not treatment arm. The standard and aggressively treated groups did not differ in cardiac event rate (10% v 13%, p  =  0.6) or all-cause mortality (10% v 19%, p  =  0.2). In patients with an abnormal baseline DSE (non-diagnostic, scar or ischaemia), the event rate was similar (22% v 20%, p  =  0.9). Conclusion: Aggressive risk factor modification in CKD does not limit the development of new ischaemia or reduce cardiac events in patients with an abnormal DSE.

Cardiorespiratory Fitness Is Related to Physical Inactivity, Metabolic Risk Factors, and Atherosclerotic Burden in Glucose-Intolerant Renal Transplant Recipients

The mechanisms of reduced cardiorespiratory fitness (CF) in renal transplant recipients (RTR) have not been studied closely. This study evaluated the relationships between CF and specific cardiovascular risk factors (metabolic syndrome [MS], physical inactivity, myocardial ischemia, and atherosclerotic burden) in glucose-intolerant RTR. Data were recorded on 71 glucose-intolerant RTR (mean age 55 yr; 55% male; median transplant duration 5.7 yr). MS was defined using National Cholesterol Education Programme Adult Treatment Panel III criteria. Resting and exercise stress echocardiography were performed, and myocardial ischemia was identified by new or worsening wall motion abnormalities. Cardiorespiratory fitness was determined using peak oxygen uptake (VO(2)) by expired gas analysis. Atherosclerotic burden was assessed by carotid intima-media thickness (IMT). Mean peak VO(2) was 19 +/- 7 ml/kg per min and was significantly lower than predicted peak VO(2) (29 +/- 6 ml/kg per min; P < 0.001). Patients with MS (63%) had reduced CF (17 +/- 6 versus 22 +/- 8 ml/kg per min; P = 0.001) and were more likely to be physically inactive (76 versus 48%; P = 0.02). CF was reduced in 14 patients with myocardial ischemia (15 +/- 3 versus 20 +/- 7 ml/kg per min; P = 0.05). CF was positively correlated with male gender, height, and physical activity and inversely correlated with number of MS risk factors and IMT (adjusted R(2) = 0.66). Carotid IMT added incremental value to clinical variables in determining VO(2) (adjusted R(2) = 0.65 versus 0.63; P = 0.04). Reduced CF is associated with physical inactivity, MS, and atherosclerotic burden in glucose-intolerant RTR. Further studies should address whether increasing exercise and modifying MS risk factors improve CF in RTR.

Takotsubo (apical ballooning) syndrome in the recovery period following dobutamine stress echocardiography: a first report

We report a case of Takotsubo syndrome occurring in the recovery phase after a dobutamine stress echocardiogram. Takotsubo syndrome is a widely acknowledged cause of reversible left ventricular systolic dysfunction. It has garnered much attention from the cardiological community since its presentation frequently mimics that of ST-segment elevation myocardial infarction. The exact aetiology remains incompletely defined, although stress is recognized frequently as a precipitating factor. In recent years it has emerged that stress testing, as part of a patients investigative assessment, can also induce Takotsubos syndrome. All prior reports of dobutamine-induced Takotsubos syndrome have described apical ballooning at peak stress. We describe the case of an 85-year-old lady who developed apical ballooning in the recovery period after a dobutamine stress echocardiogram, despite having normal left ventricular wall motion at rest and at peak stress. We believe this to be the first such case reported in the literature. Dobutamine stress testing can precipitate Takotsubos syndrome not just at peak stress but also during the recovery period. All those performing dobutamine stress tests should be aware of this rare but potentially important complication.

Sports Cardiology – Example Illustrative Cases

The following four cases are typical of the dilemmas faced by sports cardiologists on a regular basis. These are real-life cases and, for each, in addition to a focussed evaluation, the authors openly discuss the clinical predicament and give their personal viewpoints. The cases are designed to be engaging and informative, demonstrating the benefits of expertise in sports cardiology when confronted with athletes with cardiological conundrums.

What May the Future Hold for Sports Cardiology

The field of sports cardiology has advanced significantly over recent times. It has incorporated clinical and research advances in cardiac imaging, electrophysiology and exercise physiology to enable better diagnostic and therapeutic management of our patients. One important endeavour has been to try and better differentiate athletic cardiac remodelling from inherited cardiomyopathies and other pathologies. Whilst our diagnostic tools have improved, there have also been errors resulting from assumptions that the pathological traits observed in the general population would be generalisable to athletic populations. However, we have learnt that athletes with hypertrophic cardiomyopathy, for example, have many unique features when compared with non-athletic patients with hypertrophic cardiomyopathy. We are learning the limitations of cross-sectional observations and a greater number of prospective studies have been initiated which should enable us to more confidently interrogate the associations between exercise, cardiac remodelling and clinical outcomes. This review of the field enables some of the worlds experts in sports cardiology to reflect on where there is a need for research focus to advance knowledge and clinical care in sports cardiology.

37 Transoesophageal Echocardiography Underestimates Transvalvular Gradients following Trans-Catheter Aortic Valve Implantation (TAVI) – Implications for Clinical Practice

Background Trans-catheter aortic valve implantation (TAVI) is an effective treatment for high risk patients with severe aortic stenosis. As with all prosthetic valves, it is important to document accurate post-procedural gradients for future comparison. This study aimed to determine whether there was a difference between gradients measured immediately post-procedure by trans-oesophageal echocardiography (TOE) compared with the pre-discharge trans-thoracic echocardiogram (TTE). We also compared pre-TAVI gradients obtained by TTE vs. TOE. Methods We used local and national databases to gather demographics on TAVI patients from our centre and to identify peak and mean aortic gradients measured by TTE and TOE prior to TAVI and also immediately following TAVI deployment (TOE) and prior to discharge (TTE). Data were compared using the paired t-test. Results We identified 106 TAVI patients with complete echocardiographic data-sets. The mean age was 81+/-8 yrs and 62(54%) were male. All patients received an Edwards Sapien valve. Pre-TAVI, there were no significant differences between TOE and TTE for both peak (72.2+/-24.8 mmHg vs 71.9+/- 24.0 mmHg, p = 0.83) and mean (41.4+/-15.0 mmHg vs 42.4+/-14.9 mmHg,p = 0.22) gradients. However, following TAVI, the peak trans-valvular gradients by TOE vs. TTE were 12+/-6 mmHg vs 22+/-9 mmHg (p < 0.001) and mean trans-valvular gradients were 6+/-3 mmHg vs 11+/-5 mmHg (p < 0.001). There were 36 patients with LV dysfunction: the results were unchanged after excluding these patients (peak gradient 12+/-6 mmHg vs. 23+/-9 mmHg, p < 0.001). Conclusions Although TTE and TOE perform similarly prior to TAVI, the immediate post-procedural assessment of trans-aortic gradients by TOE leads to significant under-estimation compared to TTE. Intra-procedural TOE should not be used to define baseline peak and mean aortic gradients after TAVI.Abstract 37 Figure 1 Pre-TAVI TTE (A) vs TOE (B) and post-TAVI TOE (C) vs TTE (D)

65 The CHA2DS2VASC Risk Score Appropriately Risk Stratifies Patients Prior to Atrial Fibrillation Ablation and Reduces The Requirement for Trans-Oesophageal Echocardiography

Background Prior to atrial fibrillation (AF) ablation, many centres advocate trans-oesophageal echocardiography (TOE) to exclude left atrial appendage (LAA) thrombus. Patients undergoing AF ablation are usually anticoagulated, thus making the presence of thrombus unlikely. This study aimed to determine whether the CHA2DS2VASc scoring system could be used for risk stratification to identify patients that do not require TOE prior to AF ablation. Methods In this single centre retrospective study, primary and secondary care databases and electronic patient records were searched to identify patients that had undergone TOE prior to AF ablation and also correlated with catheter lab records. Patient demographics, CHA2DS2VASc score, TOE findings and anticoagulation status were collected. Results Over a 7 year period (2008–2014), 346 patients underwent TOE prior to AF ablation – 14 patients were excluded due to incomplete data, leaving 332 patients (age 57 ± 10 years; 74% male). There were 227 (68%) patients with paroxysmal AF and the remainder had persistent AF. CHA2DS2VASc scores of 0, 1, 2 and >2 were found in 39%, 34%, 15% and 12% patients respectively. There were 31/113 (27%) patients whose score was 1 due to female gender. The prevalence of LAA thrombus was 0.6% (2 patients). One patient with thrombus (score=4) had hypertrophic cardiomyopathy, mild LV dysfunction and sub-therapeutic INR (1.5) at time of TOE whilst the other patient (score=2) was female with hypertension and mild LV dysfunction. No patients with a score of 0 or 1 had LAA thrombus. Conclusions Patients classed as low riskby theCHA2DS2VASc score (score of 0–1) do not require a pre-ablation TOE to screen for LAA thrombus provided they have been anticoagulated with a therapeutic INR. This would lead to a significant reduction in healthcare expenditures by reducing unnecessary TOE tests and improve patient experience by avoiding TOE.

Left ventricular opacification for the diagnosis of coronary artery disease with stress echocardiography: An angiographic study of incremental benefit and cost-effectiveness

BACKGROUND Left ventricular opacification (LVO) improves image quality at stress echocardiography (SE). We examined whether routine use of LVO adds incremental benefit and is cost-effective for diagnosis of coronary artery disease (CAD). METHODS Contrast pharmacologic and/or exercise SE was performed in 135 patients (81 men; 56 +/- 10 years) undergoing coronary angiography. Observers sequentially interpreted first standard, then LVO images; a positive SE was defined by resting or inducible wall motion abnormality in > or = 2 segments. Coronary artery disease (75 patients, 119 territories) was defined as > 50% stenosis. Three cost-effectiveness models were studied, and a sensitivity analysis was performed. RESULTS Left ventricular opacification increased the sensitivity of SE (80%-91%; P = .03), including single-vessel CAD (65%-87%; P = .04), with no significant change in specificity (72%-77%; P = NS). Left ventricular opacification was of benefit to 14% of patients, unrelated to resting image quality. Use of LVO in all patients added 59% to the cost of the procedure (P < .001), at a cost of

Noninvasive Assessment of high-risk asymptomatic individuals at risk of coronary heart disease - part B

1069 per additional correct diagnosis. In a cost-effectiveness model based on cardiac outcomes after SE, LVO resulted in an increase in total cost of

Left ventricular opacification has a greater impact on left ventricular volume measurement with 2D than 3D echo: comparison with magnetic resonance imaging

1069. A 3.7% improvement in sensitivity resulted in a negative cost to identify CAD, but even 15% to 20% improvements in specificity failed to balance the cost of contrast for exclusion of CAD. CONCLUSIONS Left ventricular opacification adds significant incremental diagnostic benefit to standard SE, especially single-vessel CAD. Despite improved sensitivity, the use of contrast in all patients was not cost-effective when analyzed with a model based on previously published patient outcomes.