In-Chang Hwang

Myocardial scarring on cardiovascular magnetic resonance in asymptomatic or minimally symptomatic patients with "pure" apical hypertrophic cardiomyopathy

BackgroundLate gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) enables state-of-the-art in vivo evaluations of myocardial fibrosis. Although LGE patterns have been well described in asymmetrical septal hypertrophy, conflicting results have been reported regarding the characteristics of LGE in apical hypertrophic cardiomyopathy (ApHCM). This study was undertaken to determine 1) the frequency and distribution of LGE and 2) its prognostic implication in ApHCM.MethodsForty patients with asymptomatic or minimally symptomatic pure ApHCM (age, 60.2u2009±u200910.4 years, 31 men) were prospectively enrolled. LGE images were acquired using the inversion recovery segmented spoiled-gradient echo and phase-sensitive inversion recovery sequence, and analyzed using a 17-segment model. Summing the planimetered LGE areas in all short axis slices yielded the total volume of late enhancement, which was subsequently presented as a proportion of total LV myocardium (% LGE).ResultsMean maximal apical wall thickness was 17.9±2.3mm, and mean left ventricular (LV) ejection fraction was 67.7u2009±u20098.0%. All but one patient presented with electrocardiographic negative T wave inversion in anterolateral leads, with a mean maximum negative T wave of 7.2u2009±u20094.7mm. Nine patients (22.5%) had giant negative T waves, defined as the amplitude of ≥10mm, in electrocardiogram. LGE was detected in 130 segments of 30 patients (75.0%), occupying 4.9u2009±u20095.5% of LV myocardium. LGE was mainly detected at the junction between left and right ventricles in 12 (30%) and at the apex in 28 (70%), although LGE-positive areas were widely distributed, and not limited to the apex. Focal LGE at the non-hypertrophic LV segments was found in some ApHCM patients, even without LGE of hypertrophied apical segments. Over the 2-year follow-up, there was no one achieving the study end-point, defined as all-cause death, sudden cardiac death and hospitalization for heart failure.ConclusionsLGE was frequently observed not only in the thickened apex of the heart but also in other LV segments, irrespective of the presence or absence of hypertrophy. The simple presence of LGE on CMR was not representative of adverse prognosis in this population.

Epicardial Adipose Tissue Contributes to the Development of Non-Calcified Coronary Plaque: A 5-Year Computed Tomography Follow-up Study.

Aim: Epicardial adipose tissue (EAT) has been suggested as a contributing factor for coronary atherosclerosis based on the previous cross-sectional studies and pathophysiologic background. However, a causal relationship between EAT and the development of non-calcified coronary plaque (NCP) has not been investigated. Methods: A total of 122 asymptomatic individuals (age, 56.0 ± 7.6 years; male, 80.3%) without prior history of coronary artery disease (CAD) or metabolic syndrome and without NCP or obstructive CAD at baseline cardiac computed tomography (CT) were enrolled. Repeat cardiac CT was performed with an interval of more than 5 years. Epicardial fat volume index (EFVi; cm3/m2) was assessed in relation to the development of NCP on the follow-up CT where the results were classified into “calcified plaque (CP),” “no plaque,” and “NCP” groups. Results: On the follow-up CT performed with a median interval of 65.4 months, we observed newly developed NCP in 24 (19.7%) participants. Baseline EFVi was significantly higher in the NCP group (79.9 ± 30.3 cm3/m2) than in the CP group (63.7 ± 22.7 cm3/m2; P = 0.019) and in the no plaque group (62.5 ± 24.7 cm3/m2; P = 0.021). Multivariable logistic regression analysis demonstrated that the presence of diabetes (OR, 9.081; 95% CI, 1.682–49.034; P = 0.010) and the 3rd tertile of EFVi (OR, 4.297; 95% CI, 1.040–17.757; P = 0.044 compared to the 1st tertile) were the significant predictors for the development of NCP on follow-up CT. Conclusions: Greater amount of EAT at baseline CT independently predicts the development of NCP in asymptomatic individuals.

PDE 5 inhibition with udenafil improves left ventricular systolic/diastolic functions and exercise capacity in patients with chronic heart failure with reduced ejection fraction; A 12-week, randomized, double-blind, placebo-controlled trial

BACKGROUNDnImpaired nitric oxide-mediated pulmonary vascular tone is commonly found in heart failure with reduced ejection fraction (HFrEF), and is associated with derangement of left ventricular (LV) hemodynamics and decreased exercise capacity, which may be reversed by PDE5 inhibitor. This study investigated the effects of a new, long-acting PDE5 inhibitor on LV hemodynamics and exercise capacity in HFrEF.nnnMETHODSnPatients with chronic HFrEF on optimal medical therapy for >30 days before enrollment were randomly assigned to placebo or udenafil at a dose of 50mg 2x/day for the first 4 weeks followed by 100mg 2x/day for the next 8 weeks. All patients underwent cardiopulmonary exercise echocardiography before and after the 12-week treatment.nnnRESULTSnImprovement of subjective functional capacity was more frequently reported in the udenafil group (P = 0.002). Also, a higher increase in peak VO2 (Δpeak VO2, 21.6% (6.9 ~ 106.4%) vs 1.9% (-15.7 ~ 21.0%) in the placebo group, P = 0.04) and a larger decrease in ventilatory efficiency were observed in the udenafil group (Δ-6.4 ± 9.7 vs Δ1.9 ± 12.1 in the placebo group, P = 0.03). Regarding LV systolic function, the extent of increment in LV ejection fraction was significantly greater in the udenafil group (6.6 ± 6.4% vs 2.3 ± 4.8% in the placebo group, P = 0.02). In the udenafil group, an echocardiographic surrogate of LV filling pressure was more prominently decreased (P = 0.006) along with a significant reverse remodeling of left atrial volume index (57 ± 25mL at baseline to 44 ± 23 at 12th week, P = 0.04) and a progressive fall in B-type natriuretic peptide level (589 ± 679pg/mL at baseline to 220 ± 225pg/mL at 12th week, P < 0.001), indicating LV diastolic function improvement. Udenafil was well tolerated without excess of adverse events compared to placebo.nnnCONCLUSIONSnUdenafil improves LV systolic/diastolic functions and exercise capacity in conjunction with established conventional pharmacotherapy, without significant adverse events in HFrEF.

Pulmonary hemodynamics and effects of phosphodiesterase type 5 inhibition in heart failure: a meta-analysis of randomized trials

BackgroundPrevious studies suggested that phosphodiesterase 5 inhibitors (PDE5i) have a beneficial effect in patients with heart failure (HF), although the results were inconsistent. We performed a meta-analysis to evaluate the effect of PDE5i in HF patients, and investigated the relationship between PDE5i effects and pulmonary hemodynamics.MethodWe searched PubMed, EMBASE and the Cochrane Library for randomized controlled trials (RCTs) that compared PDE5i with placebo in HF with reduced ejection fraction (HFrEF) or HF with preserved EF (HFpEF). PDE5i effects were interpolated according to baseline pulmonary arterial pressure (PAP) or according to changes in PAP after PDE5i treatment.ResultsThirteen RCTs enrolling 898 HF patients, and two sub-analysis studies with different study outcomes, were included in the meta-analysis. Among patients with HFrEF, PDE5i improved peak VO2 (mean difference [MD], 3.76xa0mL/min/kg; 95% confidence interval [CI], 3.27 to 4.25; Pxa0<xa00.00001), VE/VCO2 slope (MD, −6.04; 95% CI, −7.45 to −4.64; Pxa0<xa00.00001), LVEF (MD, 4.30%; 95% CI, 2.18 to 6.42; Pxa0<xa00.0001), and pulmonary vascular resistance (MD, −80.74xa0dyn·sec/cm5; 95% CI, −110.69 to −50.79; Pxa0<xa00.00001). The effects of PDE5i in patients with HFpEF were heterogeneous. Meta-regression analyses indicated that the beneficial effect of PDE5i was related to the baseline PAP as well as the extent of PDE5i-mediated PAP decrease.ConclusionPDE5i improved pulmonary hemodynamics and exercise capacity in patients with HFrEF, but not in HFpEF. The relationship between the benefits by PDE5i with the baseline PAP and the changes in PAP indicates the therapeutic potential of PDE5i in HF according to pulmonary hemodynamics.

Quantified degree of eccentricity of aortic valve calcification predicts risk of paravalvular regurgitation and response to balloon post-dilation after self-expandable transcatheter aortic valve replacement

BACKGROUNDnLimited data exist regarding the impact of aortic valve calcification (AVC) eccentricity on the risk of paravalvular regurgitation (PVR) and response to balloon post-dilation (BPD) after transcatheter aortic valve replacement (TAVR). We investigated the prognostic value of AVC eccentricity in predicting the risk of PVR and response to BPD in patients undergoing TAVR.nnnMETHODSnWe analyzed 85 patients with severe aortic stenosis who underwent self-expandable TAVR (43 women; 77.2±7.1years). AVC was quantified as the total amount of calcification (total AVC load) and as the eccentricity of calcium (EoC) using calcium volume scoring with contrast computed tomography angiography (CTA). The EoC was defined as the maximum absolute difference in calcium volume scores between 2 adjacent sectors (bi-partition method) or between sectors based on leaflets (leaflet-based method).nnnRESULTSnTotal AVC load and bi-partition EoC, but not leaflet-based EoC, were significant predictors for the occurrence of ≥moderate PVR, and bi-partition EoC had a better predictive value than total AVC load (area under the curve [AUC]=0.863 versus 0.760, p for difference=0.006). In multivariate analysis, bi-partition EoC was an independent predictor for the risk of ≥moderate PVR regardless of perimeter oversizing index. The greater bi-partition EoC was the only significant parameter to predict poor response to BPD (AUC=0.775, p=0.004).nnnCONCLUSIONnPre-procedural assessment of AVC eccentricity using CTA as bi-partition EoC provides useful predictive information on the risk of significant PVR and response to BPD in patients undergoing TAVR with self-expandable valves.

Effect of Dipeptidyl Peptidase-4 Inhibitor on All-Cause Mortality and Coronary Revascularization in Diabetic Patients.

Background Anti-atherosclerotic effect of dipeptidyl peptidase-4 (DPP-4) inhibitors has been suggested from previous studies, and yet, its association with cardiovascular outcome has not been demonstrated. We aimed to evaluate the effect of DPP-4 inhibitors in reducing mortality and coronary revascularization, in association with baseline coronary computed tomography (CT). Methods The current study was performed as a multi-center, retrospective observational cohort study. All subjects with diabetes mellitus who had diagnostic CT during 2007-2011 were included, and 1866 DPP-4 inhibitor users and 5179 non-users were compared for outcome. The primary outcome was all-cause mortality and secondary outcome included any coronary revascularization therapy after 90 days of CT in addition to all-cause mortality. Results DPP-4 inhibitors users had significantly less adverse events [0.8% vs. 4.4% in users vs. non-users, adjusted hazard ratios (HR) 0.220, 95% confidence interval (CI) 0.102-0.474, p = 0.0001 for primary outcome, 4.1% vs. 7.6% in users vs. non-users, HR 0.517, 95% CI 0.363-0.735, p = 0.0002 for secondary outcome, adjusted variables were age, sex, presence of hypertension, high sensitivity C-reactive protein, glycated hemoglobin, statin use, coronary artery calcium score and degree of stenosis]. Interestingly, DPP-4 inhibitor seemed to be beneficial only in subjects without significant stenosis (adjusted HR 0.148, p = 0.0013 and adjusted HR 0.525, p = 0.0081 for primary and secondary outcome). Conclusion DPP-4 inhibitor is associated with reduced all-cause mortality and coronary revascularization in diabetic patients. Such beneficial effect was significant only in those without significant coronary stenosis, which implies that DPP-4 inhibitor may have beneficial effect in earlier stage of atherosclerosis.

Association Between Global Longitudinal Strain and Cardiovascular Events in Patients With Left Bundle Branch Block Assessed Using Two-Dimensional Speckle-Tracking Echocardiography

Background: The prognostic value of left ventricular (LV) global strain and twist in patients with left bundle branch block (LBBB) is not fully investigated. The aim of this study was to investigate the association between myocardial strain and twist and cardiovascular events in patients with LBBB, as assessed using two‐dimensional speckle‐tracking echocardiography. Methods: A total of 269 patients with LBBB (mean age, 69.5 ± 10.9 years; 46.8% men) were retrospectively identified. Using speckle‐tracking, LV global longitudinal strain (GLS), global circumferential strain, and twist were measured. Association between LV global function and a composite of cardiovascular mortality and hospitalization for heart failure was compared with clinical risk factors, LV ejection fraction (LVEF), and other echocardiographic parameters. Results: During a median of 27.5 months (interquartile range, 12.8–43.9 months), the composite end point occurred in 55 patients (20.4%). In univariate analyses, diabetes mellitus, chronic kidney disease, ischemic etiology of LBBB, dilated left atrium, reduced LVEF, dilated left ventricle, and impaired LV global strain (GLS > −12.2%, global circumferential strain > −11.8%, and twist < 6.5°) showed associations with the composite end point. In multivariate analyses, GLS was significantly associated with the composite end point (adjusted hazard ratio, 4.697; 95% CI, 1.344–16.413; P = .015), whereas global circumferential strain, twist, and LVEF were not. GLS showed an additive association with poor prognosis over clinical risk factors and other echocardiographic parameters, including LVEF. Patients with preserved LVEFs (≥40%) but impaired GLS (>−12.2%) had a larger number of clinical events than those with impaired LVEFs but preserved GLS. Conclusions: Among patients with LBBB, GLS can provide better risk stratification than LVEF or other echocardiographic parameters. HighlightsLV GLS is a powerful prognostic factor and detects subtle LV dysfunction.The authors assessed the association between LV GLS and cardiovascular events in patients with LBBB.Impaired GLS had a significant association with cardiovascular events in patients with LBBB.The association between LV GLS and cardiovascular events was significant regardless of LVEF values.LV GLS may provide better risk stratification than LVEF in patients with LBBB.

Coronary computed tomography angiography vs. myocardial single photon emission computed tomography in patients with intermediate risk chest pain: a randomized clinical trial for cost-effectiveness comparison based on real-world cost

AIMSnTo compare the cost-effectiveness of coronary computed tomography angiography (CCTA) vs. myocardial single photon emission computed tomography (SPECT) in patients with stable intermediate risk chest pain.nnnMETHODS AND RESULTSnNon-acute patients with 10-90% pre-test probability of coronary artery disease from three high-volume centres in Korea (nu2009=u2009965) were randomized 1:1 to CCTA or myocardial SPECT as the initial non-invasive imaging test. Medical costs after randomization, the downstream outcome, including all-cause death, acute coronary syndrome, cerebrovascular accident, repeat revascularization, stent thrombosis, and significant bleeding following the initial test and the quality-adjusted life-years (QALYs) gained by the EuroQoL-5D questionnaire was compared between the two groups. In all, 903 patients underwent the initially randomized study (nu2009=u2009460 for CCTA, 443 for SPECT). In all, 65 patients underwent invasive coronary angiography (ICA) in the CCTA and 85 in the SPECT group, of which 4 in the CCTA and 30 in the SPECT group demonstrated no stenosis on ICA [6.2% (4/65) vs. 35.3% (30/85), P-valueu2009<u20090.001]. There was no difference in the downstream clinical events. QALYs gained was higher in the SPECT group (0.938 vs. 0.955, P-valueu2009=u20090.039) but below the threshold of minimal clinically important difference of 0.08. Overall cost per patient was lower in the CCTA group (USD 4514 vs. 5208, P-valueu2009=u20090.043), the tendency of which was non-significantly opposite in patients with 60-90% pre-test probability (USD 5807 vs. 5659, P-valueu2009=u20090.845).nnnCONCLUSIONnCCTA is associated with fewer subsequent ICA with no difference in downstream outcome. CCTA may be more cost-effective than SPECT in Korean patients with stable, intermediate risk chest pain.