Robert Dragu

Relationship Between Reactive Pulmonary Hypertension and Mortality in Patients With Acute Decompensated Heart Failure

Background— In patients with heart failure, pulmonary hypertension (PH) predicts higher risk for morbidity and mortality. However, few data are available on the prognostic implications of reactive (precapillary) PH superimposed on passive (postcapillary) PH. Methods and Results— We performed a subgroup analysis of 242 patients with acute decompensated heart failure assigned to pulmonary artery catheter placement in the Vasodilation in the Management of Acute Congestive Heart Failure trial. Patients were classified into 3 groups, using the final (posttreatment) hemodynamic measurements: (1) no PH (mean pulmonary artery pressure ⩽25 mm Hg; (2) passive PH (mean pulmonary artery pressure >25, pulmonary capillary wedge pressure >15 mm Hg, and pulmonary vascular resistance⩽3 Wood units); and (3) reactive PH (mean pulmonary artery pressure >25, pulmonary capillary wedge pressure >15 mm Hg, and pulmonary vascular resistance >3 Wood units). Fifty-eight patients were classified as normal mean pulmonary artery pressure, 124 with passive PH and 60 with reactive PH. During follow-up of 6 months, 5 (8.6%), 27 (21.8%), and 29 (48.3%) deaths occurred in patients without PH, patients with passive PH, and with reactive PH, respectively (P<0.0001). After multivariable adjustments, reactive PH remained an independent predictor of death, with an adjusted hazard ratio of 4.8 compared with patients without PH, and 2.8 compared with patients with passive PH (95% confidence interval, 1.7 to 4.7, P=0.0001). Similar results were obtained when reactive PH was defined on the basis of transpulmonary gradient. Conclusions— Reactive PH is common among patients with acute decompensated heart failure after initial diuretic and vasodilator therapy. The adverse outcome associated with PH is predominantly due to increased mortality rates in the subgroup of patients with reactive PH.

16-MDCT coronary angiography versus invasive coronary angiography in acute chest pain syndrome: a blinded prospective study.

OBJECTIVE The purpose of our study was to prospectively evaluate the usefulness of CT coronary angiography versus invasive coronary angiography for the detection of clinically significant coronary artery disease in patients hospitalized for acute chest pain syndrome. SUBJECTS AND METHODS Sixty-six consecutive patients (52 men and 14 women; average age, 57 +/- 11 [SD] years) who were hospitalized for acute chest pain syndrome underwent CT coronary angiography and invasive coronary angiography within an average time interval of 4 days. ECG-gated CT coronary angiography was performed with a 16-MDCT scanner (0.42-sec rotation time, 16 x 0.75 mm detector collimation). Beta-blockers were not administered routinely, and thus the average heart rate was 71 +/- 11 beats per minute. CT coronary angiographic images were evaluated concurrently by two radiologists, who were blinded to invasive coronary angiography results, for stenoses having a diameter of 50% or more, using a 15-segment classification, including all segments 2 mm or more in diameter. The consensus interpretation was compared with results of invasive coronary angiography. RESULTS CT coronary angiography was technically successful in 59 patients (89%). After exclusion of 20 (3.1%) of 649 coronary segments, which were classified as nonevaluable by CT coronary angiography, the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of CT coronary angiography for identifying significant coronary artery disease in the remaining 629 coronary segments were 80% (68/85), 89% (482/544), 52% (68/130), 97% (482/499), and 87% (550/629), respectively. The overall accuracy for the main vessels (left main, left anterior descending, left circumflex, and right coronary arteries) was 93%, 88%, 86%, and 86%, respectively. CONCLUSION CT coronary angiography using a 16-MDCT scanner enables accurate noninvasive detection of significant coronary artery disease in patients hospitalized for acute chest pain syndrome. Furthermore, relative high sensitivity and specificity of CT coronary angiography can be achieved without pharmacologic manipulation of patient heart rates.

Pulmonary arterial capacitance in patients with heart failure and reactive pulmonary hypertension

Reactive pulmonary hypertension (PH) is a severe form of PH secondary to left‐sided heart failure (HF). Given the structural and functional abnormalities in the pulmonary vasculature that occur in reactive PH, we hypothesized that pulmonary artery capacitance (PAC) may be profoundly affected, with implications for clinical outcome.

Pulmonary Hypertension, Right Ventricular Function, and Clinical Outcome in Acute Decompensated Heart Failure

BACKGROUND Pulmonary hypertension (PH) and right ventricular (RV) dysfunction have been associated with adverse outcome in patients with chronic heart failure. However, data are lacking in the setting of acute decompensated heart failure (ADHF). We sought to determine prognostic significance of PH in patients with ADHF and its interaction with RV function. METHODS We studied 326 patients with ADHF. Pulmonary artery systolic pressure (PASP) and RV function were determined with the use of Doppler echocardiography, with PH defined as PASP >50 mm Hg. The primary end point was all-cause mortality during 1-year follow-up. RESULTS PH was present in 139 patients (42.6%) and RV dysfunction in 83 (25.5%). The majority of patients (70%) with RV dysfunction had PH. Compared with patients with normal RV function and without PH, the adjusted hazard ratio (HR) for mortality was 2.41 (95% confidence interval [CI] 1.44-4.03; P = .001) in patients with both RV dysfunction and PH. Patients with normal RV function and PH had an intermediate risk (adjusted HR 1.78, 95% CI 1.11-2.86; P = .016). Notably, patients with RV dysfunction without PH were not at increased risk for 1-year mortality (HR 1.04, 95% CI 0.43-2.41; P = .94). PH and RV function data resulted in a net reclassification improvement of 22.25% (95% CI 7.2%-37.8%; P = .004). CONCLUSIONS PH and RV function provide incremental prognostic information in ADHF. The combination of PH and RV dysfunction is particularly ominous. Thus, the estimation of PASP may be warranted in the standard assessment of ADHF.

Diagnostic accuracy of myocardial hypoenhancement on multidetector computed tomography in identifying myocardial infarction in patients admitted with acute chest pain syndrome.

Objective: To evaluate prevalence and diagnostic accuracy of myocardial hypoenhancement (MH) using multidetector computed tomography (MDCT) in patients admitted for acute chest pain syndromes. Methods: Sixty-nine patients underwent first-pass MDCT, coronary angiography, and echocardiography. Using a standardized analysis protocol, left ventricular short-axis reformations were evaluated for presence, size, and density of MH in 16 myocardial segments. These were correlated with the presence and location of myocardial infarction (MI), regional myocardial dysfunction, and coronary artery disease. Results: Myocardial hypoenhancement was found in acute MI (27/35), healed MI (6/14), unstable angina (3/9), and atypical chest pain (0/11). Sensitivity, specificity, and positive and negative predictive values of MH for diagnosing any MI were 67%, 85%, 92% and 52%, respectively. Conclusions: The presence of MH on MDCT in acute chest pain patients has high positive predictive value and specificity but only moderate sensitivity for presence of acute or healed MI using the strict criteria proposed in this study.

Anomalous origin of right coronary artery: Diagnosis and dynamic evaluation with multidetector computed tomography

16 slice multidetector CT findings of an anomalous right coronary artery originating from the left sinus of Valsalva are presented. Multidetector CT depicted the malignant coronary anomaly in great anatomic detail as well as enabled dynamic evaluation through the cardiac cycle, documenting a substantial reduction in arterial diameter during peak systole. This case illustrates the full capabilities of multidetector cardiac CT in the evaluation of coronary artery pathology.

The Relation between Serum Phosphorus Levels and Clinical Outcomes after Acute Myocardial Infarction

Background Elevated serum phosphorus levels have been linked with cardiovascular disease and mortality with conflicting results, especially in the presence of normal renal function. Methods We studied the association between serum phosphorus levels and clinical outcomes in 1663 patients with acute myocardial infarction (AMI). Patients were categorized into 4 groups based on serum phosphorus levels (<2.50, 2.51–3.5, 3.51–4.50 and >4.50 mg/dL). Cox proportional-hazards models were used to examine the association between serum phosphorus and clinical outcomes after adjustment for potential confounders. Results The mean follow up was 45 months. The lowest mortality occurred in patients with serum phosphorus between 2.5–3.5 mg/dL, with a multivariable-adjusted hazard ratio of 1.24 (95% CI 0.85–1.80), 1.35 (95% CI 1.05–1.74), and 1.75 (95% CI 1.27–2.40) in patients with serum phosphorus of <2.50, 3.51–4.50 and >4.50 mg/dL, respectively. Higher phosphorus levels were also associated with increased risk of heart failure, but not the risk of myocardial infarction or stroke. The effect of elevated phosphorus was more pronounced in patients with chronic kidney disease (CKD). The hazard ratio for mortality in patients with serum phosphorus >4.5 mg/dL compared to patients with serum phosphorus 2.50–3.50 mg/dL was 2.34 (95% CI 1.55–3.54) with CKD and 1.53 (95% CI 0.87–2.69) without CKD. Conclusion We found a graded, independent association between serum phosphorus and all-cause mortality and heart failure in patients after AMI. The risk for mortality appears to increase with serum phosphorus levels within the normal range and is more prominent in the presence of CKD.

Contrast enhanced multi‐detector computed tomography coronary angiography versus conventional invasive quantitative coronary angiography in acute coronary syndrome patients–correlation and bias

Background: Previous studies that compared multi‐detector computed tomography (MDCT) non‐invasive coronary angiography with conventional coronary angiography, did not assessed the ability of MDCT to detect stenotic lesions correctly in acute coronary syndromes (ACS) patients. The aim of the present study was to assess prospectively the correlation and bias between 16‐slice MDCT coronary angiography and quantitative coronary angiography analysis (QCA) in these patients. Methods: Patients underwent electrocardiogram‐gated, 16‐slice MDCT coronary angiography and routine invasive percutaneous coronary angiography with quantitative coronary angiography (QCA) analysis blinded to MDCT results. The correlation and the bias between the results of MDCT and QCA were assessed in segments observed by both modalities in vessels⩾2 mm in diameter. Results: 59 patients (81% male, age 56±11 years), admitted due to ACS, underwent MDCT and invasive coronary angiography. 544 segments were analyzed. The correlations between MDCT and QCA observed for the left anterior descending coronary artery (LAD), the left circumflex coronary artery (Cx), the right coronary artery (RCA) and for all analyzed segments were 0.74 (P<0.0001), 0.54 (P<0.009), 0.72 (P<0.0001) and 0.70 (P<0.0001), respectively. By Bland‐Altman analysis, a small overestimation of the lesion severity with MDCT of 4.8% for the LAD, 5.9% for the Cx, and 3.3% for the RCA was observed. Conclusions: In ACS patients, MDCT contrast‐enhanced coronary angiography provides good quantification of the luminal diameter as compared to coronary angiography, and it is characterized by a small overestimation bias.

Time Dependence of the Effect of Right Ventricular Dysfunction on Clinical Outcomes After Myocardial Infarction: Role of Pulmonary Hypertension.

Background The clinical importance of right ventricular (RV) function in acute myocardial infarction is well recognized, but the impact of concomitant pulmonary hypertension (PH) has not been studied. Methods and Results We studied 1044 patients with acute myocardial infarction. Patients were classified into 4 groups according to the presence or absence of RV dysfunction and PH, defined as pulmonary artery systolic pressure >35 mm Hg: normal right ventricle without PH (n=509), normal right ventricle and PH (n=373), RV dysfunction without PH (n=64), and RV dysfunction and PH (n=98). A landmark analysis of early (admission to 30 days) and late (31 days to 8 years) mortality and readmission for heart failure was performed. In the first 30 days, RV dysfunction without PH was associated with a high mortality risk (adjusted hazard ratio 5.56, 95% CI 2.05–15.09, P<0.0001 compared with normal RV and no PH). In contrast, after 30 days, mortality rates among patients with RV dysfunction were increased only when PH was also present. Compared with patients having neither RV dysfunction nor PH, the adjusted hazard ratio for mortality was 1.44 (95% CI 0.68–3.04, P=0.34) in RV dysfunction without PH and 2.52 (95% CI 1.64–3.87, P<0.0001) in RV dysfunction with PH. PH with or without RV dysfunction was associated with increased risk for heart failure. Conclusion In the absence of elevated pulmonary pressures, the risk associated with RV dysfunction after acute myocardial infarction is entirely confined to the first 30 days. Beyond 30 days, PH is the stronger risk factor for long‐term mortality and readmission for heart failure.

Heart failure in patients with diabetes undergoing primary percutaneous coronary intervention

Introduction: Diabetes mellitus is associated with increased risk after acute coronary syndromes. Primary percutaneous coronary intervention is the most effective method of reperfusion for acute ST-elevation myocardial infarction and can limit the ischaemic damage to the left ventricle. However, there are few data on the impact of diabetes mellitus on the risk of heart failure following primary percutaneous coronary intervention. Methods: We studied 958 ST-elevation myocardial infarction patients treated with primary percutaneous coronary intervention, of whom 263 (27.5%) had diabetes mellitus, with 67 (7.0%) treated with insulin. The primary end points of the study were re-admission for heart failure. Secondary end points were all-cause mortality and recurrent infarctions. The follow-up period was 5 years after hospital discharge. Results: The cumulative incidence of re-admission for heart failure was 8.4%, 15.2% and 26.7% in patients without diabetes mellitus, non-insulin-treated and insulin-treated diabetes mellitus, respectively. Compared with patients without diabetes mellitus, the adjusted hazard ratio for heart failure was 1.95 (95% confidence intervals 1.30–2.93) and 3.09 (95% confidence intervals 1.71–5.60) in non-insulin-treated and insulin-treated diabetes mellitus, respectively. The corresponding hazard ratios for mortality were 1.03 (95% confidence intervals 0.68–1.55) and 2.04 (95% confidence intervals 1.22–3.42), respectively. There was a J-shaped association between fasting glucose levels in the acute phase and risk of mortality (P=0.0001) and a direct association with heart failure (P=0.03). Conclusion: Despite modern treatment of ST-elevation myocardial infarction and high levels of guideline-based medical care, diabetes mellitus had an independent adverse effect on the risk of re-admissions for heart failure, which was particularly high among insulin-treated patients.