Jacob E. Møller

Prediction of all-cause mortality and heart failure admissions from global left ventricular longitudinal strain in patients with acute myocardial infarction and preserved left ventricular ejection fraction.

OBJECTIVESnThis study sought to test the hypothesis that semiautomated calculation of left ventricular global longitudinal strain (GLS) can identify high-risk subjects among patients with myocardial infarctions (MIs) with leftxa0ventricular ejection fractions (LVEFs) >40%.nnnBACKGROUNDnLVEF is a key determinant in decision making after acute MI, yet it is relatively indiscriminant within the normal range. Novel echocardiographic deformation parameters may be of particular clinical relevance in patients with relatively preserved LVEFs.nnnMETHODSnPatients with MIs and LVEFs >40% within 48 h of admission for coronary angiography were prospectively included. All patients underwent echocardiography with semiautomated measurement of GLS. The primary composite endpoint (all-cause mortality and hospitalization for heart failure) was analyzed using Cox regression analyses. The secondary endpoints were cardiac death and heart failure hospitalization.nnnRESULTSnA total of 849 patients (mean age 61.9 ± 12.0 years, 73% men) were included, and 57 (6.7%) reached the primary endpoint (median follow-up 30 months). Significant prognostic value was found for GLS (hazard ratio [HR]: 1.20; 95% confidence interval [CI]: 1.10 to 1.32; pxa0< 0.001). GLS >xa0-14% was associated with a 3-fold increase in risk for the combined endpoint (HR: 3.21; 95% CI: 1.82 to 5.67; pxa0< 0.001). After adjustment for other variables, GLS remained independently related to the combined endpoint (HR: 1.14; 95% CI: 1.04 to 1.26; pxa0= 0.007). For the secondary endpoints, GLS >xa0-14% was significantly associated with cardiovascular death (HR: 12.7; 95% CI: 3.0 to 54.6; pxa0< 0.001) and heart failure hospitalization (HR: 5.31; 95% CI: 1.50 to 18.82; pxa0< 0.001).nnnCONCLUSIONSnAssessment of GLS using a semiautomated algorithm provides important prognostic information in patients with LVEFs >40% above and beyond traditional indexes of high-risk MI.

Fungal–bacterial interaction on beech leaves: influence on decomposition and dissolved organic carbon quality

Fungal–bacterial interaction on decomposing beech leaves was investigated in a microcosm experiment. Sterilised 1 yr old leaves were inoculated with microbial populations isolated from beech forest soil: bacteria (inoculum B), fungi and bacteria (inoculum F+B), a cellulolytic Humicola sp. (inoculum H) and this fungus together with bacteria (inoculum H+B), respectively. The data for mineralization rates and fungal activities, the latter determined by a new enzymatic tool, suggested antagonistic interaction between fungi and bacteria. Carbon transformation in the microcosms, estimated as C mineralized plus net dissolved organic carbon (DOC) formation, was consistently higher when fungi were present in the inoculum as compared to a diverse community of bacteria acting alone. DOC quality was determined as the ability of the carbon to support denitrification with excess nitrate. The DOC quality was dependent on the inoculum type: B and F+B treatments resulted in similar DOC quality, but when the Humicola sp. was present (H and H+B treatment) the quality was low. Thus, in spite of the higher fungal carbon transformation a fungal-mediated flush of DOC made available to heterotrophic bacteria was not observed. Taking all data into account, the antagonistic interaction between fungi and bacteria was most likely explained by competition for C substrate.

Prognostic Importance of Diastolic Function and Filling Pressure in Patients With Acute Myocardial Infarction

Acute myocardial infarction (AMI) is characterized by regional myocardial damage that may lead to systolic and diastolic dysfunction with a subsequent risk of left ventricular (LV) remodeling, local and systemic neurohormonal activation, and vascular dysfunction. The pathophysiology and prognosis of LV systolic dysfunction after AMI have been the focus of research for several decades. Insights from these studies have led to several therapeutic interventions that improve outcome. In addition to depressed systolic function, clinical or radiographic evidence of heart failure is a consistent and powerful predictor of outcome in patients after AMI.1 Pulmonary congestion after infarction reflects raised LV filling pressures but is frequently seen after what appears to be only minor myocardial damage.2 The pathophysiological mechanism for this is incompletely understood but may involve impaired active relaxation of the myocardium and increased LV chamber stiffness and hence abnormalities in diastolic function. If these are to be determined directly, cardiac catheterization with assessment of pressure-volume relationships with the use of high-fidelity micromanometer catheters is required. This highly specialized approach is not suitable for daily clinical practice. Likewise, although direct measurements of right heart or LV end-diastolic pressure are important predictors of adverse outcome after AMI in selected populations,3,4 the risk of complications precludes routine use of indwelling catheters in all patients. There has therefore been considerable interest in using noninvasive estimates of diastolic function, particularly Doppler echocardiographic assessment of LV filling dynamics and, more recently, the volume of the left atrium (LA), to predict outcome in patients with AMI.nnThe objective of this review is to summarize the current understanding of abnormal LV filling in the early phase after AMI with focus on the complementary prognostic information that may be gained by assessment of LV filling dynamics and LA volume with the use of 2-dimensional and Doppler …

Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Præstø Fjord boating accident.

BACKGROUNDnResuscitation guidelines for the treatment of accidental hypothermia are based primarily on isolated cases. Mortality rates are high despite aggressive treatment aimed at restoring spontaneous circulation and normothermia.nnnMETHODSnThe present report is based on a boating accident where 15 healthy subjects (median age 16 (range 15-45) years) were immersed in 2 °C salt water. Seven victims were recovered in circulatory arrest with a median temperature of 18.4 °C (range 15.5-20.2 °C). They were all rewarmed with extracorporeal membrane oxygenation (ECMO) and were subsequently evaluated with advanced neuroradiological and functional testing. The remaining 7 had established spontaneous circulation without the use of ECMO. One victim drowned in the accident.nnnRESULTSnThe victims that survived the accident without circulatory arrest were predominantly females with a higher body mass index. Victims with circulatory arrest pH on arrival was a median of 6.61 (range 6.43-6.94), with ECMO being established a median of 226 (178-241)min after the accident. Magnetic resonance spectroscopy showed neuronal dysfunction in five. In five victims initial normal white matter spectra progressed to show evidence of abnormal axonal membranes. Based on the seven-level Functional Independence Measure test functional outcome was good in six circulatory arrest victims and in all without circulatory arrest. Mild to moderate cognitive dysfunction was seen in six and severe dysfunction in one circulatory arrest victim.nnnCONCLUSIONnSeven patients with profound accidental hypothermic circulatory arrest were successfully resuscitated using a management approach that included extracorporeal rewarming, followed by successive periods of therapeutic hypothermia and sedated normothermia and intensive neurorehabilitation. Seven other hypothermic victims (core temperature as low as 23 °C) that did not suffer circulatory arrest also survived the accident.

Prevalence of infective endocarditis in patients with Staphylococcus aureus bacteraemia: the value of screening with echocardiography

AIMSnStaphylococcus aureus infective endocarditis (IE) is a critical medical condition associated with a high morbidity and mortality. In the present study, we prospectively evaluated the importance of screening with echocardiography in an unselected S. aureus bacteraemia (SAB) population.nnnMETHODS AND RESULTSnFrom 1 January 2009 to 31 August 2010, a total of 244 patients with SAB at six Danish hospitals underwent screening echocardiography. The inclusion rate was 73% of all eligible patients (n= 336), and 53 of the 244 included patients (22%; 95% CI: 17-27%) were diagnosed with definite IE. In patients with native heart valves the prevalence was 19% (95% CI: 14-25%) compared with 38% (95% CI: 20-55%) in patients with prosthetic heart valves and/or cardiac rhythm management devices (P= 0.02). No difference was found between Main Regional Hospitals and Tertiary Cardiac Hospitals, 20 vs. 23%, respectively (NS). The prevalence of IE in high-risk patients with one or more predisposing condition or clinical evidence of IE were significantly higher compared with low-risk patients with no additional risk factors (38 vs. 5%; P < 0.001). IE was associated with a higher 6 months mortality, 14(26%) vs. 28(15%) in SAB patients without IE, respectively (P < 0.05).nnnCONCLUSIONnSAB patients carry a high risk for development of IE, which is associated with a worse prognosis compared with uncomplicated SAB. The presenting symptoms and clinical findings associated with IE are often non-specific and echocardiography should always be considered as part of the initial evaluation of SAB patients.

Post-hypothermia fever is associated with increased mortality after out-of-hospital cardiac arrest

OBJECTIVEnPost-cardiac arrest fever has been associated with adverse outcome before implementation of therapeutic hypothermia (TH), however the prognostic implications of post-hypothermia fever (PHF) in the era of modern post-resuscitation care including TH has not been thoroughly investigated. The aim of the study was to assess the prognostic implication of PHF in a large consecutive cohort of comatose survivors after out-of-hospital cardiac arrest (OHCA) treated with TH.nnnMETHODSnIn the period 2004-2010, a total of 270 patients resuscitated after OHCA and surviving a 24-h protocol of TH with a target temperature of 32-34°C were included. The population was stratified in two groups by median peak temperature (≥38.5°C) within 36h after rewarming: PHF and no-PHF. Primary endpoint was 30-days mortality and secondary endpoint was neurological outcome assessed by Cerebral Performance Category (CPC) at hospital discharge.nnnRESULTSnPHF (≥38.5°C) was associated with a 36% 30-days mortality rate compared to 22% in patients without PHF, plog-rank=0.02, corresponding to an adjusted hazard rate (HR) of 1.8 (95% CI: 1.1-2.7), p=0.02). The maximum temperature (HR=2.0 per °C above 36.5°C (95% CI: 1.4-3.0), p=0.0005) and the duration of PHF (HR=1.6 per 8h (95% CI: 1.3-2.0), p<0.0001) were also independent predictors of 30-days mortality in multivariable models. Good neurological outcome (CPC1-2) versus unfavourable outcome (CPC3-5) at hospital discharge was found in 61% vs. 39% in the PHF group compared to 75% vs. 25% in the No PHF group, p=0.02.nnnCONCLUSIONSnPost-hypothermia fever ≥38.5°C is associated with increased 30-days mortality, even after controlling for potential confounding factors. Avoidance of PHF as a therapeutic target should be evaluated in prospective randomized trials.

Emergency coronary angiography in comatose cardiac arrest patients: do real-life experiences support the guidelines?

Aims: To describe the use of emergency coronary angiography (CAG) and primary percutaneous coronary intervention (PCI) and the association with short- and long-term survival in consecutive comatose survivors after out-of-hospital cardiac arrest (OHCA). Methods: In the period 2004–10, a total of 479 consecutive patients with OHCA of suspected cardiac cause were referred to a tertiary cardiac centre, 360 patients were comatose and admitted to the ICU for post-resuscitative care. The population was stratified in two groups according to the pattern of the first ECG obtained after re-established circulation; ST-segment elevation (STEMI, n=116) and ECG without STEMI pattern (No-STEMI, n=244). Emergency CAG (≤12 hours after OHCA) was performed at the discretion of the attending cardiologist. Primary outcome was 30-day and 1-year survival. Results: Emergency CAG was performed in all patients in the STEMI group compared to 82 (34%) in the group without STEMI pattern (p<0.0001) with significant coronary lesions found in 108 (93%) compared to 43 (52%) patients, respectively (p<0.0001). Survival at 30 day according to emergency CAG vs. no emergency CAG was 65% in the STEMI group compared to 66% and 54% in the group without STEMI pattern (plog-rank=0.11). The use of emergency CAG in the group without STEMI pattern was not associated with reduced mortality (HRadjusted=0.69, 95% CI 0.4–1.2, p=0.18). Conclusions: In comatose survivors of OHCA presenting with STEMI, a high prevalence of coronary disease and culprit lesions suitable for emergency PCI was found, whereas in patients without STEMI pattern, significant coronary stenosis was less frequent. Clinical benefits of emergency CAG/PCI in comatose survivors of OHCA presenting without STEMI could not be identified.

Left Ventricular Filling Pressure Estimation at Rest and During Exercise in Patients With Severe Aortic Valve Stenosis: Comparison of Echocardiographic and Invasive Measurements

BACKGROUNDnThe Doppler index of left ventricular (LV) filling (E/e) is recognized as a noninvasive measure for LV filling pressure at rest but has also been suggested as a reliable measure of exercise-induced changes. The aim of this study was to investigate changes in LV filling pressure, measured invasively as pulmonary capillary wedge pressure (PCWP), at rest and during exercise to describe the relation with E/e in patients with severe aortic stenosis.nnnMETHODSnTwenty-eight patients with an aortic valve areas<1 cm(2) performed a multistage supine bicycle exercise test until exhaustion. PCWP, E/e(septal), and E/e(lateral) were determined simultaneously by echocardiography at rest and at maximal tolerated workload.nnnRESULTSnPCWP increased significantly from 18+/-8 mm Hg at rest to 39+/-10 mm Hg at peak exercise (P < .0001). E, e(septal), and e(lateral) increased with exercise, whereas E/e(septal) remained unchanged (19+/-6 vs 19+/-6; P=NS), and only minimal changes were observed in E/e(lateral) (14+/-4 vs 15+/-4; P=.05). E/e(septal) and E/e(lateral) were significantly correlated with PCWP at rest (r=0.72, P < .0001, and r=0.67, P < .0001, respectively) as well as at peak exercise (r=0.66, P=.0003, and r=0.47, P=.02, respectively), with nearly similar slopes of the linear regression lines. The intercepts, however, increased by 18 mm Hg (P=.01) and by 19 mm Hg (P=.01) at peak exercise, respectively. Changes in E/e(septal) and E/e(lateral) were not related to changes in PCWP with exercise (P=NS). Instead, the ratio of E velocity during exercise to e(septal) at rest (E(exercise)/e(septal, rest)) was correlated with PCWP during exercise (r=0.61, P=.001), and furthermore, E(exercise)-E(rest)/e(septal, rest) was related to changes in PCWP (r=0.45, P=.02). The results for the lateral side were r=0.50 (P=.01) and r=0.44 (P=.03), respectively.nnnCONCLUSIONSnE/e is well correlated with PCWP at rest. However, E/e cannot be used to detect exercise-induced changes in PCWP in patients with severe aortic stenosis. Using the ratio of E during exercise to e at rest may result in a better estimate of the increase in PCWP during exercise.

Global strain in severe aortic valve stenosis: relation to clinical outcome after aortic valve replacement.

Background— Global longitudinal systolic strain (GLS) is often reduced in aortic stenosis despite normal ejection fraction. The importance of reduced preoperative GLS on long-term outcome after aortic valve replacement is unknown.nnMethods and Results— A total of 125 patients with severe aortic stenosis and ejection fraction >40% scheduled for aortic valve replacement were evaluated preoperatively and divided into 4 groups according to GLS quartiles. Patients were followed up for 4 years. The primary end points were major adverse cardiac events (MACEs) defined as cardiovascular mortality and cardiac hospitalization because of worsening of heart failure; the secondary end point was cardiovascular mortality. MACE and cardiac mortality were significantly increased in patients with lower GLS. Estimated 5-year MACE was increased: first quartile 19% (n=6) / second quartile 20% (n=6) / third quartile 35% (n=11) / fourth quartile 49% (n=15); P =0.04. Patients with increased age, left ventricular hypertrophy, and left atrial dilatation were at increased risk. In Cox regression analysis, after correcting for standard risk factors and ejection fraction, GLS was found to be significantly associated with cardiac morbidity and mortality. In a stepwise Cox model with forward selection, GLS was the sole independent predictor: hazard ratio=1.13 (95% confidence interval, 1.02–1.25), P =0.04. Comparing the overall log likelihood χ2 of the predictive power of the multivariable model containing GLS was statistically superior to models based on EuroScore, history with ischemic heart disease, and ejection fraction.nnConclusions— In patients with symptomatic severe aortic stenosis undergoing aortic valve replacement, reduced GLS provides important prognostic information beyond standard risk factors.nnClinical Trial Registration— URL: [http://www.clinicaltrials.gov][1]. Unique identifier: [NCT00294775][2].nn [1]: http://www.clinicaltrial.govn [2]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT00294775&atom=%2Fcirccvim%2F5%2F5%2F613.atomBackground—Global longitudinal systolic strain (GLS) is often reduced in aortic stenosis despite normal ejection fraction. The importance of reduced preoperative GLS on long-term outcome after aortic valve replacement is unknown. Methods and Results—A total of 125 patients with severe aortic stenosis and ejection fraction >40% scheduled for aortic valve replacement were evaluated preoperatively and divided into 4 groups according to GLS quartiles. Patients were followed up for 4 years. The primary end points were major adverse cardiac events (MACEs) defined as cardiovascular mortality and cardiac hospitalization because of worsening of heart failure; the secondary end point was cardiovascular mortality. MACE and cardiac mortality were significantly increased in patients with lower GLS. Estimated 5-year MACE was increased: first quartile 19% (n=6) / second quartile 20% (n=6) / third quartile 35% (n=11) / fourth quartile 49% (n=15); P=0.04. Patients with increased age, left ventricular hypertrophy, and left atrial dilatation were at increased risk. In Cox regression analysis, after correcting for standard risk factors and ejection fraction, GLS was found to be significantly associated with cardiac morbidity and mortality. In a stepwise Cox model with forward selection, GLS was the sole independent predictor: hazard ratio=1.13 (95% confidence interval, 1.02–1.25), P=0.04. Comparing the overall log likelihood &khgr;2 of the predictive power of the multivariable model containing GLS was statistically superior to models based on EuroScore, history with ischemic heart disease, and ejection fraction. Conclusions—In patients with symptomatic severe aortic stenosis undergoing aortic valve replacement, reduced GLS provides important prognostic information beyond standard risk factors. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00294775.

Tertiary centres have improved survival compared to other hospitals in the Copenhagen area after out-of-hospital cardiac arrest ☆

AIMSnOut-of-hospital cardiac arrest (OHCA) has been reported to carry very varying morbidity and mortality. However, it remains unclear whether this is caused by intrinsic factors of the OHCA or due to the level of in-hospital care. The aim of this study is to compare 30-day and long-term mortality after OHCA at tertiary heart centres and non-tertiary university hospitals.nnnMETHODS AND RESULTSnData from the Copenhagen OHCA registry from June 2002 through December 2010 included a total of 1218 consecutive patients treated by the same mobile emergency care unit (MECU) with either return of spontaneous circulation (ROSC) or on-going resuscitation (n=53) at hospital arrival. The MECU transported patients to the nearest hospital unless an ECG on scene suggested ST-segment elevation myocardial infarction, in which case patients were transported to the nearest tertiary centre for acute coronary angiography. Therefore, patients with ST-elevation myocardial infarction (n=198) were excluded from the analysis. 30-day mortality was 56% vs. 76% and long term (up to 8years) mortality was 78% vs. 94% for tertiary and non-tertiary hospitals, respectively, both p<0.001. Multivariate analysis showed that admission to a non-tertiary hospital was independently associated with increased risk of death (HR=1.32, 95% CI: 1.09-1.59, p=0.004). Exclusion of patients with on-going resuscitation at admission resulted in HR=1.34 (1.11-1.62), p=0.003. A matched pair propensity score analysis of 255 patients confirmed the results of the proportional hazard analysis (HR=1.35, 95% CI: 1.11-1.65 p=0.003).nnnCONCLUSIONnAdmission to tertiary centres is associated with lower mortality rates after OHCA compared with non-tertiary hospitals.