Simon Woldman

Expansion of the red cell distribution width and evolving iron deficiency as predictors of poor outcome in chronic heart failure.

BACKGROUND An elevated red cell distribution width (RDW) and iron deficiency (ID) at baseline predict enhanced mortality in chronic heart failure (CHF), but little is known about the prognostic implications of their temporal trends. We sought to determine the survival implications of temporal changes in RDW and evolving ID in patients with CHF. METHODS The relation between red cell indices on first consultation and over time with mortality in 274 stable patients with systolic CHF was analysed. The combination of a rising RDW with a falling mean cell volume (MCV) over time defined evolving ID. RESULTS Over a median 12 month period, 51% and 23% of patients had a rise in RDW and evolving ID, respectively. After a median follow-up of 27 months, 60 (22%) patients died. A rising RDW predicted enhanced all-cause mortality (unadjusted HR for 1% per week rise 9.27, 95% CI 3.58 to 24.00, P<0.0001) independently and incrementally to baseline RDW, with an absolute increase >0.02% per week optimally predictive. Evolving ID also related to higher rates of mortality (HR 2.78, 95% CI 1.64 to 4.73, P<0.001) and was prognostically worse than a rising RDW alone (P<0.005). Patients with evolving ID who maintained their Hb levels over time had a 2-fold greater risk of death than those whose Hb levels declined without evolving ID. CONCLUSIONS An expanding RDW and evolving iron deficiency over time predict an amplified risk of death in CHF and should be utilised for risk stratification and/or therapeutically targeted to potentially improve outcomes.

Cardiac magnetic resonance imaging in patients with systemic lupus erythematosus

Objectives: To delineate the cardiac magnetic resonance (MR) appearances of cardiovascular disease (CVD) in patients with systemic lupus erythematosus (SLE), in comparison with transthoracic echocardiographs. Methods: Cardiac MR was performed on 22 patients with SLE—11 with previous CVD and 11 matched controls—using late gadolinium contrast enhancement (LGE) to identify areas of myocardial scarring; Transthoracic echocardiography (TTE) was performed on the same day. Results: Twenty female and two male patients participated. LGE was seen in 5/11 subjects in the CVD group (4/5 with previous myocardial infarction) and 1/11 in the control group. TTE detected myocardial abnormalities in 2/6 patients with LGE. Conclusion: The cardiac MR appearance of CVD in these patients with SLE was suggestive of coronary disease, rather than cumulative inflammatory muscle damage. Cardiac MR detected more abnormalities than TTE. Further studies of cardiac MR in patients with SLE are warranted to investigate these preliminary findings.

Calculated plasma volume status and prognosis in chronic heart failure

Plasma volume (PV) expansion hallmarks worsening chronic heart failure (CHF) but no non‐invasive means of quantifying volume status exists. Because weight and haematocrit are related to PV, they can be used to calculate relative PV status (PVS). We tested the validity and prognostic utility of calculated PVS in CHF patients.

Setting up a myocardial perfusion scintigraphy service: clinical and business aspects.

Writing groupAndrew Kelion, Consultant Cardiologist, Harefield HospitalConstantinos Anagnostopoulos, Consultant Nuclear Physician, Royal Brompton HospitalGlyn Davies, Head of Medical Physics, Hull and East Yorkshire HospitalsJane Flint, Consultant Cardiologist, Dudley Group of HospitalsMark Harbinson, Consultant Cardiologist, Queens University BelfastAndrew Hilson, Consultant Nuclear Physician, Royal Free HospitalAvijit Lahiri, Consultant Cardiologist, Wellington HospitalEric Lim, Research Fellow, Wellington HospitalLiz Prvulovich, Consultant Nuclear Physician, Middlesex HospitalNikant Sabharwal, Specialist Registrar in Cardiology, Oxford DeaneryAnn Tweddel, Consultant Cardiologist, Hull Royal InfirmaryRichard Underwood, Professor of Cardiac Imaging, Imperial CollegeSimon Woldman, Consultant Cardiologist, Ayr HospitalAdvisory groupRoger Boyle, National Director for Heart Disease, Department of HealthIan Jones, Nuclear Medicine Technologist, South Derbyshire Acute HospitalsKate Latus, Nurse Practitioner, Royal Brompton HospitalCharlie McKenna, Consultant Cardiologist, Royal Berkshire and Battle HospitalsVicky Parkin, Nuclear Medicine Technologist, Bristol Royal InfirmarySarah Powell, Southampton City Primary Care Trust

Microwave Ablation of Pulmonary Metastases Associated with Perioperative Takotsubo Cardiomyopathy

From: Lawrence Best, BSc Beatrice Seddon, PhD, MRCP, FRCR Simon Woldman, MD, FRCP (Glas), FRCP, FESC Alexander Lyon, PhD, MRCP Rowland Illing, DM, MRCS, FRCR University College London Medical School (L.B.) Department of Specialist Imaging (R.I.) Podium Level 2 University College Hospital London NW1 2BU, UK University College London Hospitals NHS Foundation Trust (B.S., S.W.) NIHR Cardiovascular Biomedical Research Unit (A.L.) Royal Brompton Hospital London, United Kingdom

Exercise 201Tl/rest 99Tcm-tetrofosmin myocardial perfusion imaging : A convenient protocol for the assessment of coronary disease

Standard exercise thallium-201 (201Tl)-redistribution protocols for the detection of coronary artery disease take about 4 h to complete. This is inconvenient for both patients and staff. The higher energy technetium-99m (99Tcm) emissions permit immediate imaging after 201Tl with minimal crosstalk. This study assessed exercise gated planar 201Tl scintigraphy (55 MBq) followed by rest gated planar 99Tcm-tetrofosmin scintigraphy (250 MBq) in 32 patients. The results showed a high sensitivity for the detection of coronary disease (100%) in this highly selective group of patients. In order to diagnose myocardial infarction accurately, it was necessary to view the gated 201Tl images and assess regional wall motion in a defect zone. This gave a specificity of 88% and a sensitivity of 71% for the prediction of myocardial infarction on the angiographic ventriculogram. Stress 201Tl/rest 99Tcm-tetrofosmin is a useful short protocol for patients unable to complete the full 4-h exercise 201Tl-redistribution study.

Rest or redistribution thallium myocardial imaging for resting myocardial perfusion : A detailed comparison with regional wall motion

Redistribution thallium-201 (201T1) imaging is the most common method of assessing resting myocardial perfusion. However, the equivalence of a redistribution image and a separate rest injection is unclear. Although the presence of a defect on rest imaging has normally been equated with the presence of a myocardial infarction, it has recently been shown that a significant proportion of fixed defects on exercise-redistribution 201T1 actually represent areas of viable myocardium. This study was a detailed comparison of rest and redistribution imaging in 30 patients undergoing routine exercise 201T1 scanning for the assessment of coronary artery disease. A small dose (15 MBq) of 201T1 was administered at rest following the imaging in three standard planar views. Similar stress images were acquired using a further 50-55 MBq of 201T1 administered at peak effort. Redistribution images were acquired 3-4 h later and equilibrium blood pool ventriculography performed using in vivo labelling with 600 MBq 99Tcm-pertechnetate. Of 150 abnormal segments on the exercise scans, 74 (49%) were identified as being reversible on the redistribution scans and 58 (39%) on the rest images. Only 39 (53%) of these reversible defects were identified on both the redistribution and rest scans. Only 41% of the fixed defects on the redistribution images (32% of fixed defects on the rest images) had abnormal wall motion. Therefore, rest and redistribution images are not equivalent. Both rest and redistribution images significantly overestimate myocardial infarction. This may have significant effects on patient selection for revascularization procedures and therefore all patients having perfusion scintigraphy should also have additional assessment of regional wall motion to allow accurate classification of the functional status of myocardial segments.

Lung uptake of thallium-201: a marker of defect reversibility?

High lung uptake of thallium-201 at stress is reported to be associated with a large number of perfusion defects and poor prognosis. This study was performed to assess whether the reversibility of stress perfusion defects was related to lung uptake. Gated planar thallium scans at stress and at redistribution from 102 consecutive patients with essentially normal left ventricular ejection fraction (using 99mTc gated blood pool ventriculography) were graded in terms of defect size. Lung and myocardial uptake of thallium were quantitated by region of interest methods relative to the given activity in a previously validated method. There was no significant correlation (non-parametric) between lung uptake and degree of redistribution (p = ns, rs = 0.140). There was a weak but positive correlation between lung uptake and defect size (p < 0.05, rs = 0.188). Both exercise time and double product showed a negative correlation with lung uptake (e.g. for double product, p < 0.0005, rs = -0.541). In conclusion, contrary to our expectation, lung uptake is not related to the degree of redistribution. High lung uptake seems to reflect poor cardiovascular reserve.

18 One Page User Friendly Proforma Delivers Dramatic Improvements in Heart Failure Management in a Busy District General Hospital

Background Heart failure affects almost one million people in the UK with survival rates comparable to or worse than many cancers. Recent publications of the NICOR National Heart Failure Audit have focused attention on the need for improvement. This challenge is particularly acute in busy district general hospitals in London such as Whipps Cross University Hospital. Objective We aimed to investigate if the implementation of a simple one-page user friendly Whipps Cross Heart Failure Improvement Proforma- the ‘WHIP form’ in all medical wards could help improve the management of patients admitted with heart failure against standard quality measures. Methods The ‘WHIP form’ was introduced and implemented in all medical wards supported with a one-day educational seminar and a new dedicated heart failure email service. Results Between June to September 2015, 106 patients with a primary admission diagnosis of heart failure were enrolled and managed using the ‘WHIP form’. Inpatient mortality remained stable at 11.3% with an average hospital stay of 13.5 days. The 30-day readmission rate halved from 14% to 7%. Patients with documented left ventricular systolic dysfunction on Echocardiogram had significant improvements in the prescription of prognostic medication on discharge: ACEi/ARBs prescription increased from 78% from 88% [10% improvement]. B-Blockers prescription increased from 68% to 95% [27% improvement]. Conclusion The initiation of an “easy to use” one page heart failure management proforma led to a dramatic reduction in 30-day readmission rates and significant increase in the prescription of prognostically important ACE inhibitors and B-blockers. If the reductions in 30-day readmissions are sustained, we estimate that our cost neutral intervention could translate to yearly savings of nearly £80K for Whipps Cross University Hospital alone.

104 Prognostic utility of calculated plasma volume status in chronic heart failure

Background Plasma volume (PV) expansion is a hallmark feature of worsening heart failure that is notoriously underestimated by clinical examination. While radioisotope assays optimally quantify PV status, numerous haemodialysis-based equations also exist for its estimation. The prognostic utility of such formulas in chronic heart failure (CHF) is unknown. Methods We analysed the relation between estimated PV status and mortality in 246 outpatients with CHF (mean (±SD) age 67±13 years, NYHA class 2±1, LVEF 28±8%). PV status was calculated (Hakim RM, et al) by subtracting the patients actual PV ((1-haematocrit) × (a + (b × weight)); a and b are gender-specific constants) from their ideal PV ((c × weight); c=gender-specific constant). Results Median (±IQR) PV status was—261±550 ml with 78% and 21% of patients having PV contraction and expansion, respectively. Patients with PV excess had significantly higher creatinine and lower albumin levels. Over a median follow-up of 13±16 months, 36 (15%) patients died. PV status predicted mortality (HR 1.001, 95% CI 1.001 to 1.002, p=0.001) in a graded fashion (Abstract 104 figure 1A) and did so independently of NYHA class, LVEF, weight, haematocrit and creatinine. A PV status ≤−178 ml optimally predicted survival (ROC AUC 0.68, p=0.0007) and conferred a 75% reduced hazard for death (HR 0.16, 95% CI 0.07 to 0.37, p<0.0001, Abstract 104 figure 1B).Abstract 104 Figure 1 Conclusions Calculating plasma volume status in CHF patients appears prognostically useful and suggests that dehydration is better tolerated than volume excess in these individuals and that targeting therapy to achieve a plasma volume status ≤178 ml might increment survival.