Exercise and heart failure: an update

The present update is dedicated to the evolution of the interaction between heart failure (HF) and exercise and how the scientific community has handled it. Indeed, on the one hand, HF is a leading cause of morbidity and mortality with a stable prevalence from 1998 onward varying between 6.3% and 13.3%. On the other hand, exercise is seen as a diagnostic and prognostic tool as well as a therapeutic intervention in chronic HF. More precisely, the knowledge, the clinical application, and the research interest on the mutual interactions between exercise and HF have different phases in disease progression: Before HF onset (past): exercise provides protective benefit in preventing HF (primary prevention). With HF present: exercise improvement with training provides benefits in HF (secondary prevention). The prediction of future in HF patients: exercise impairment, as a leading characteristic of HF, is used as a prognostic factor

Low-dose CT coronary angiography with a novel intracyclemotion-correction algorithm in patients with high heart rate or heart rate variability

Aims: Motion artefacts due to high or irregular heart rate (HR) are common limitations of coronary computed tomography (CT) angiography (CCTA). The aim of the study was to evaluate the impact of a new motion-correction (MC) algorithm used in conjunction with low-dose prospective ECG-triggering CCTA on motion artefacts, image quality, and coronary assessability. Methods and results: Among 380 patients under going CCTA for suspected CAD, weselected 120 patients with pre-scanning HR.70 bpm or HR variability (HRv) >10 bpm during scanning irrespective of pre-scanning HR or both conditions. In patients with prescanning HR <65 or 6565 bpm, prospective ECG triggering with padding of 80 ms (58 cases) or padding of 200 ms (62 cases) was used, respectively. Mean pre-scanning HR and HRvwere 70\ub17 and 10.9\ub14 bpm, respectively. Overall, the mean effective dose was 3.4\ub11.3 mSv, while a lower dose (2.4\ub10.9 mSv) was measured for padding of 80 ms. In a segment-based analysis, coronary assessability was significantly higher (P < 0.0001) with MC (97%) when compared with standard (STD) reconstruction (81%) due to a significant reduction (P < 0.0001) in severe artefacts (54 vs. 356 cases, respectively). An artefact sub-analysis showed significantly lower number of motion artefacts and artefacts related to chest movement with MC (16 and 4 cases) than with STD reconstruction (286 and 24 cases, P < 0.0001 and P < 0.05, respectively). The number of coronary segments ranked among those of excellent image quality was significantly higher with MC (P < 0.001). Conclusions: The MC algorithm improves CCTA image quality and coronary assessability in patients with high HR and HRv, despite low radiation dose

Diagnostic accuracy of multidetector computed tomography coronary angiography in 325 consecutive patients referred for transcatheter aortic valve replacement

Multidetector computed tomography (MDCT) provides detailed assessment of valve annulus and iliofemoral vessels in transcatheter aortic valve replacement (TAVR) patients. However, data on diagnostic performance of MDCT coronary angiography (MDCT-CA) are scarce. The aim of the study is to assess diagnostic performance of MDCT for coronary artery evaluation before TAVR. Methods: A total of 325 consecutive patients (234 without previous myocardial revascularization, 49 with previous coronary stenting, and 42 with previous coronary artery bypass graft [CABG]) underwent invasive coronary angiography and MDCT before TAVR. MDCT-CA was performed using the same data set dedicated to standard MDCT aortic annulus evaluation. Multidetector computed tomography-CA evaluability and diagnostic accuracy in comparison with invasive coronary angiography as criterion standard were assessed. Results: The MDCT-CA evaluability of native coronaries was 95.6%. The leading cause of unevaluability was beam-hardening artifact due to coronary calcifications. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for detecting 6550% stenosis of 91%, 99.2%, 83.4%, 99.6% and 98.8%, respectively. The MDCT-CA evaluability of coronary stents was 82.1%. In a segment-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy for detecting 6550% in-stent restenosis of 94.1%, 86.7%, 66.7%, 98.1%, and 88.3%, respectively. All CABGs were correctly assessed by MDCT-CA. In a patient-based analysis, MDCT-CA showed sensitivity, specificity, PPV, NPV, and accuracy of 89.7%, 90.8%, 80.6%, 95.4%, and 90.5%, respectively. Conclusions: Multidetector computed tomography-CA allows to correctly rule out the presence of significant native coronary artery stenosis, significant in-stent restenosis, and CABG disease in patients referred for TAVR

Comparison of cardiac computed tomography versus cardiac magnetic resonance for characterization of left atrium anatomy before radiofrequency catheter ablation of atrial fibrillation

Background The outcome of radiofrequency catheter ablation (RFCA) has been improved by the pivotal role of cardiovascular imaging such as cardiac computed tomography (CCT) or cardiac magnetic resonance (CMR) for the characterization of left atrium (LA) anatomy before RFCA. The aim of this study is to compare the procedural characteristics, overall radiation exposure and clinical outcomes between RFCA guided by image integration with CCT versus CMR. Methods Four-hundred patients with drug-refractory paroxysmal or persistent AF referred to RCFA were matched with the propensity score matching analysis to CCT (n: 200) or CMR (n: 200) for evaluation of LA before RFCA procedure. Left atrium diameter, left atrium volume, variant of pulmonary veins' anatomy, pulmonary veins' ostial dimensions, procedural characteristics, overall radiation exposure and rate of AF recurrence after RFCA were measured and compared between the two groups. Results The 2 groups were homogeneous with similar follow-up (557 ± 302 vs. 523 ± 265 days, respectively, p:0.24). The CCT group showed higher LA volume vs. CMR group (117 ± 46 vs. 101 ± 40 mL, p < 0.001). No differences were observed regarding procedural characteristics. AF recurrence at follow-up was similar (29% vs. 26%, p:0.5) despite a higher radiation exposure in the CCT group vs. CMR group (40.4 ± 23.7 mSv vs. 32.8 ± 23.5 mSv, p < 0.005). LA volume detected by CMR was the most robust independent predictor of AF recurrence at multivariate analysis [(HR: 1.08 (1.01-1.15), p: 0.02]. Conclusions CCT and CMR provide similar information before RFCA. However, RFCA CMR-guided is associated with a lower overall cumulative radiation despite similar outcome in comparison with CCT-guided RFCA

The STRATEGY Study (Stress Cardiac Magnetic Resonance Versus Computed Tomography Coronary Angiography for the Management of Symptomatic Revascularized Patients) : Resources and Outcomes Impact

Background - Computed tomography coronary angiography (cTCA) and stress cardiac magnetic resonance (stress-CMR) are suitable tools for diagnosing obstructive coronary artery disease in symptomatic patients with previous history of revascularization. However, performance appraisal of noninvasive tests must take in account the consequent diagnostic testing, invasive procedures, clinical outcomes, radiation exposure, and cumulative costs rather than their diagnostic accuracy only. We aimed to compare an anatomic (cTCA) versus a functional (stress-CMR) strategy in symptomatic patients with previous myocardial revascularization procedures. Methods and Results - Six hundred patients with chest pain and previous revascularization included in a prospective observational registry and evaluated by clinically indicated cTCA (n=300, mean age 68.2\ub19.7 years, male 255) or stress-CMR (n=300, mean age 67.6\ub19.7 years, male 263) were enrolled and followed-up in terms of subsequent noninvasive tests, invasive coronary angiography, revascularization procedures, cumulative effective radiation dose, major adverse cardiac events, defined as a composite end point of nonfatal myocardial infarction and cardiac death, and medical costs. The mean follow-up for cTCA and stress-CMR groups was similar (773.6\ub1345 versus 752.8\ub1291 days; P=0.21). Compared with stress-CMR, cTCA was associated with a higher rate of subsequent noninvasive tests (28% versus 17%; P=0.0009), invasive coronary angiography (31% versus 20%; P=0.0009), and revascularization procedures (24% versus 16%; P=0.007). Stress-CMR strategy was associated with a significant reduction of radiation exposure and cumulative costs (59% and 24%, respectively; P<0.001). Finally, patients undergoing stress-CMR showed a lower rate of major adverse cardiac events (5% versus 10%; P<0.010) and cost-effectiveness ratio (119.98\ub1250.92 versus 218.12\ub1298.45 Euro/y; P<0.001). Conclusions - Compared with cTCA, stress-CMR is more cost-effective in symptomatic revascularized patients

Prognostic value of dipyridamole stress cardiac magnetic resonance in patients with known or suspected coronary artery disease : a mid-term follow-up study

Objectives: Dipyridamole stress cardiac magnetic resonance (CMR) evaluates the key phases (perfusion and wall motion) of the ischemic cascade. We sought to determine the prognostic value of dipyridamole stress-CMR in consecutive\ua0patients symptomatic for chest pain. Methods: Seven hundred and ninety-three consecutive patients symptomatic for chest pain underwent dipyridamole stress-CMR and were followed up for 810 \ub1 665 days. Patients were classified in group 1 (no- reversible ischemia), group 2 (stress perfusion defect alone), and group 3 [stress perfusion defect plus abnormal wall motion (AWM)]. End points were "all cardiac events" (myocardial infarction, cardiac death and revascularization) and "hard cardiac events" (all cardiac events excluding revascularization). Results: One hundred and ninety-five (24 %) all cardiac events and 53 (7 %) hard cardiac events were observed. All and hard cardiac event rates in groups 1, 2, and 3 were 11 %, 49 %, 69\ua0% and 4 %, 8 %, 21 %, respectively, with a higher rate in group 2 vs. group 1 (p<0.01) and group 3 vs. groups 1 and 2 (p<0.01). Multivariate analysis showed the presence of late gadolinium enhancement and stress perfusion defect plus AWM as independent predictors of all and hard cardiac events. Conclusions: Dipyridamole stress-CMR improves prognostic stratification of patients through differentiation between the different components of the ischemic cascade. Key Points: \u2022 Dipyridamole stress cardiac magnetic resonance helps to assess coronary artery disease. \u2022 Novel technique to study the key phases of myocardial ischemia. \u2022 Combined assessment of perfusion and motion defects. \u2022 Dipyridamole stress imaging has additional value for predicting cardiac events

Prognostic value of dipyridamole stress cardiac magnetic resonance in patients with known or suspected coronary artery disease: a mid-term follow-up study

Objectives: Dipyridamole stress cardiac magnetic resonance (CMR) evaluates the key phases (perfusion and wall motion) of the ischemic cascade. We sought to determine the prognostic value of dipyridamole stress-CMR in consecutive&nbsp;patients symptomatic for chest pain. Methods: Seven hundred and ninety-three consecutive patients symptomatic for chest pain underwent dipyridamole stress-CMR and were followed up for 810 ± 665 days. Patients were classified in group 1 (no- reversible ischemia), group 2 (stress perfusion defect alone), and group 3 [stress perfusion defect plus abnormal wall motion (AWM)]. End points were "all cardiac events" (myocardial infarction, cardiac death and revascularization) and "hard cardiac events" (all cardiac events excluding revascularization). Results: One hundred and ninety-five (24 %) all cardiac events and 53 (7 %) hard cardiac events were observed. All and hard cardiac event rates in groups 1, 2, and 3 were 11 %, 49 %, 69&nbsp;% and 4 %, 8 %, 21 %, respectively, with a higher rate in group 2 vs. group 1 (p&lt;0.01) and group 3 vs. groups 1 and 2 (p&lt;0.01). Multivariate analysis showed the presence of late gadolinium enhancement and stress perfusion defect plus AWM as independent predictors of all and hard cardiac events. Conclusions: Dipyridamole stress-CMR improves prognostic stratification of patients through differentiation between the different components of the ischemic cascade. Key Points: • Dipyridamole stress cardiac magnetic resonance helps to assess coronary artery disease. • Novel technique to study the key phases of myocardial ischemia. • Combined assessment of perfusion and motion defects. • Dipyridamole stress imaging has additional value for predicting cardiac events