Still a Powerful Tool?

Background: New therapies with prognostic benefits have been recently introduced in heart failure with reduced ejection fraction (HFrEF) management. The aim of this study was to evaluate the prognostic power of current listing criteria for heart transplantation (HT) in an HFrEF cohort submitted to cardiopulmonary exercise testing (CPET) between 2009 and 2014 (group A) and between 2015 and 2018 (group B). Methods: Consecutive patients with HFrEF who underwent CPET were followed-up for cardiac death and urgent HT. Results: CPET was performed in 487 patients. The composite endpoint occurred in 19.4% of group A vs. 7.4% of group B in a 36-month follow-up. Peak VO2 (pVO2) and VE/VCO2 slope were the strongest independent predictors of mortality. International Society for Heart and Lung Transplantation (ISHLT) thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers) and VE/VCO2 slope > 35 presented a similar and lower Youden index, respectively, in group B compared to group A, and a lower positive predictive value. pVO2 ≤ 10 mL/kg/min and VE/VCO2 slope > 40 outperformed the traditional cut-offs. An ischemic etiology subanalysis showed similar results. Conclusion: ISHLT thresholds showed a lower overall prognostic effectiveness in a contemporary HFrEF population. Novel parameters may be needed to improve risk stratification.publishersversionpublishe

Morte súbita cardíaca no atleta jovem

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2015Background: A morte súbita é um acontecimento trágico e tema de grande debate nomeadamente no seio da comunidade médica e desportiva. Com efeito, a sua ocorrência no atleta jovem gera particular atenção e leva a que o rastreio pré-desportivo, já implementando em muitos países, seja legitimamente o cerne do debate. A avaliação pré-desportiva é fundamental para a identificação de atletas com patologia cardíaca potencialmente associada a risco acrescido de morte súbita, não sendo no entanto consensual as medidas a adoptar nessa avaliação. Discute-se particularmente a importância da inclusão sistemática do electrocardiograma de 12 derivações no rastreio pré-desportivo. Objectivos: Foi objectivo deste trabalho a realização de uma revisão do conhecimento actual relativamente às principais causas de morte súbita no atleta jovem, bem como o papel do rastreio pré-desportivo na identificação de atletas em risco acrescido de morte súbita. Métodos: Pesquisa na base de dados Pubmed utilizando as palavras-chaves “sudden cardiac death” AND “young” AND “athlete” AND “screening”. Foram seleccionados apenas artigos publicados entre 2007-2015. Conclusões: O rastreio pré-desportivo é essencial na detecção de patologia cardíaca predispondo potencialmente à ocorrência de morte súbita no atleta jovem, destacando-se entre as principais causas, a miocardiopatia hipertrófica e a miocardiopatia arritmogénica do ventrículo direito. No rastreio, são consensuais a realização de história clínica detalhada, da história familiar e da observação. A realização de ECG não é consensual, embora seja recomendada por várias organizações europeias, sendo necessária investigação posterior quanto à sua custo-efectividade a nível global. Com a utilização das recomendações recentes para a sua intepretação, observou-se uma diminuição da taxa de falsos positivos, mantendo a elevada sensibilidade deste exame na identificação de atletas em risco.Background: Sudden death is a tragic event and subject of great debate namely within the medical and sporting community. Indeed, its occurrence in the young athlete deserves particular attention and makes the Pre-Participation Screening (PPS) the crux of the debate. A Pre-Participation Screening is necessary to identify athletes with cardiac conditions potentially associated with increased risk of sudden death. However, there is no consensus regarding the criteria and type of measures to be taken in the screening evaluation. The importance of the 12-lead ECG is particularly under debate. Objectives: The aim of this work was to gather the current knowledge regarding the main causes of sudden death in the young athlete, as well as to point out the importance and role of the Pre-Participation Screening programs aimed the identification of athletes at risk of sudden death. Methods: Research in Pubmed database using the keywords "sudden cardiac death" AND "young" AND "athlete" AND "screening". Only publications between 2007-2015 were selected. Conclusions: Pre-Participation Screening (PPS) programs are essential for the detection of heart conditions that may potentially predispose to the occurrence of sudden death in the young athlete, standing out among its main causes, hypertrophic cardiomyopathy and arrhythmogenic cardiomyopathy of the right ventricle. PPS programs are consensual regarding the need for a detailed medical history, family history and observation. However, performing ECG is not consensual. Although it is recommended by several European organizations, the ECG as a routine procedure seems to require further investigation as to its cost-effectiveness. With the use of recent recommendations for its interpretation, a reduction of the false positive rate was observed, while preserving its high sensitivity concerning the identification of athletes at risk

Capacidade Preditiva dos Parâmetros do Teste de Esforço Cardiopulmonar em Pacientes com Insuficiência Cardíaca em Terapia de Ressincronização Cardíaca

Resumo Fundamento Há evidências sugerindo que um corte do pico de consumo de oxigênio (pVO2) de 10ml/kg/min fornece uma estratificação de risco mais precisa em pacientes com Terapia de Ressincronização Cardíaca (TRC). Objetivo Comparar o poder prognóstico de vários parâmetros do teste cardiopulmonar de exercício (TCPE) nesta população e avaliar a capacidade discriminativa dos valores de corte de pVO2 recomendados pelas diretrizes. Métodos Avaliação prospectiva de uma série consecutiva de pacientes com insuficiência cardíaca (IC) com fração de ejeção do ventrículo esquerdo ≤40%. O desfecho primário foi um composto de morte cardíaca e transplante cardíaco urgente (TC) nos primeiros 24 meses de acompanhamento, e foi analisado por vários parâmetros do TCPE para a maior área sob a curva (AUC) no grupo TRC. Uma análise de sobrevida foi realizada para avaliar a estratificação de risco fornecida por vários pontos de corte diferentes. Valores de p < 0,05 foram considerados significativos. Resultados Um total de 450 pacientes com IC, dos quais 114 possuíam aparelho de TRC. Esses pacientes apresentaram um perfil de risco basal mais alto, mas não houve diferença em relação ao desfecho primário (13,2% vs 11,6%, p = 0,660). A pressão expiratória de dióxido de carbono no limiar anaeróbico (PETCO2AT) teve o maior valor de AUC, que foi significativamente maior do que o de pVO2 no grupo TRC (0,951 vs 0,778, p = 0,046). O valor de corte de pVO2 atualmente recomendado forneceu uma estratificação de risco precisa nesse cenário (p <0,001), e o valor de corte sugerido de 10 ml/min/kg não melhorou a discriminação de risco em pacientes com dispositivos (p = 0,772). Conclusão A PETCO2AT pode superar o poder prognóstico do pVO2 para eventos adversos em pacientes com TRC. O ponto de corte de pVO2 recomendado pelas diretrizes atuais pode estratificar precisamente o risco dessa população

Age Differences in Cardiopulmonary Exercise Testing Parameters in Heart Failure with Reduced Ejection Fraction

Background and Objectives: Cardiopulmonary exercise testing (CPET) is a cornerstone of risk stratification in heart failure with reduced ejection fraction (HFrEF). However, there is a paucity of evidence on its predictive power in older patients. The aim of this study was to evaluate the prognostic power of current heart transplantation (HTx) listing criteria in HFrEF stratified according to age groups. Materials and Methods: Consecutive patients with HFrEF undergoing CPET between 2009 and 2018 were followed-up for cardiac death and urgent HTx. Results: CPET was performed in 458 patients with HFrEF. The composite endpoint occurred in 16.8% of patients ≤50 years vs. 14.1% of patients ≥50 years in a 36-month follow-up. Peak VO2 (pVO2), VE/VCO2 slope and percentage of predicted pVO2 were strong independent predictors of outcomes. The International Society for Heart and Lung Transplantation thresholds of pVO2 ≤ 12 mL/kg/min (≤14 if intolerant to β-blockers), VE/VCO2 slope > 35 and percentage of predicted pVO2 ≤ 50% presented a higher overall diagnostic effectiveness in younger patients (≤50 years). Specific thresholds for each age subgroup outperformed the traditional cut-offs. Conclusions: Personalized age-specific thresholds may contribute to an accurate risk stratification in HFrEF. Further studies are needed to address the gap in evidence between younger and older patients

Sacubitril/Valsartan Improves Left Atrial and Ventricular Strain and Strain Rate in Patients with Heart Failure with Reduced Ejection Fraction

Background: Data on the impact of sacubitril/valsartan (SV) therapy on phasic left atrial (LA) and left ventricular (LV) strain in heart failure with reduced ejection fraction (HFrEF) are limited. The aim of this study was to evaluate changes in two-dimensional speckle tracking (2D-STE) parameters with SV therapy in HFrEF patients. Methods: Prospective evaluation of HFrEF patients receiving optimized medical therapy. Two-dimensional speckle tracking (2D-STE) parameters were assessed at baseline and after 6 months of SV therapy. LA strain and strain rate (SR) in reservoir, conduit, and contraction phases were compared with LV longitudinal, radial, and circumferential strain and SR and stratified according to heart rhythm and HFrEF etiology. Results: A total of 35 patients completed the 6-month follow-up, with a mean age of 59 ± 11 years, 40% in atrial fibrillation, 43% with ischemic etiology, and LVEF of 29 ± 6%. There were significant improvements in LA reservoir, conduit, and contractile strain and SR following SV therapy, particularly among patients in sinus rhythm. There were significant improvements in longitudinal, radial, and circumferential LV function indices. Conclusion: SV therapy in HFrEF was associated with improved longitudinal, radial, and circumferential function, particularly among patients in sinus rhythm. These findings can provide insights into the mechanisms underlying the improvement of cardiac function and help assess subclinical responses to the treatment

Outcomes in Pregnant Women with Valvular Heart Disease from Portuguese-Speaking African Countries Treated in Portugal through an International Agreement of Health Cooperation

Aims: We performed a clinical audit of maternal and fetal outcomes in pregnant women with valvular heart disease (VHD) from Portuguese-speaking African countries who were transferred for their care, during a twenty-year period, through a memorandum of agreement of international cooperation. Methods and results: A retrospective analysis of 81 pregnancies in 45 patients with VHD (median age 24, interquartile range 22–29 years) from 2000 to 2020 was performed. The main outcome measures were maternal cardiovascular and fetal outcomes. History of rheumatic heart disease was present in 60 (74.1%) pregnancies. Most were in New York Heart Association (NYHA) functional class I or II; at the first evaluation, 35 (43.2%) were on cardiac medication and 49 (60.5%) were anticoagulated. Forty-eight pregnancies had at least one valvular prosthesis, including 38 mechanical heart valves. During pregnancy, deterioration in NYHA functional class occurred in 35 (42.0%), and eight (9.9%) patients required initiation or intensified cardiac medication. Mechanical valve thrombosis complicated four (4.9%) pregnancies, all cases on heparin, and resulted in one maternal death. Haemorrhagic complications happened in 7 (8.6%) anticoagulated patients, in the immediate postpartum or puerperal period. The 81 pregnancies resulted in 56 (69.1%) live births, while miscarriage and fetal malformations occurred in 19 (23.5%) and 12 (14.8%) pregnancies, respectively. In multivariate analysis, vitamin K antagonist therapy was the only independent predictor of an unsuccessful pregnancy (p = 0.048). Conclusion: In a high-income country, successful pregnancy was possible with low rate of maternal events in women with VHD transferred from five low-middle income countries in Africa. The use of anticoagulation with a vitamin K antagonist was associated with an unsuccessful pregnancy

Permanent pacemaker implantation after alcoholic septal ablation induced complete heart block: Long-term impact

Introduction and objectives: Patients with hypertrophic obstructive cardiomyopathy (HOCM) that remain symptomatic despite optimized medical therapy often undergo alcohol septal ablation (ASA). One of the most frequent complications is complete heart block (CHB), requiring a permanent pacemaker (PPM) in variable rates of up to 20% of patients. The long-term impact of PPM implantation in these patients remains unclear. This study aimed to evaluate the long-term clinical outcomes in patients who implant PPM after ASA. Methods: Patients who underwent ASA at a tertiary center were consecutively and prospectively enrolled. Patients with previous PPM or implantable cardio-defibrillator were excluded from this analysis. Patients with and without PPM implantation after ASA were compared based on their baseline characteristics, procedure data and three-year primary endpoint of composite of all-cause mortality and hospitalization and secondary endpoint of composite of all-cause mortality and cardiac cause hospitalization. Results: Between 2009 and 2019, 109 patients underwent ASA, 97 of whom were included in this analysis (68% female, mean age 65.2 years old). 16 patients (16.5%) required PPM implantation for CHB. In these patients, no vascular access, pacemaker pocket or pulmonary parenchyma complications were noted. The baseline characteristics of comorbidities, symptoms, echocardiographic and electrocardiographic findings were identical in the two groups, with higher mean age (70.6±10.0 years vs. 64.1±11.9 years) and lower beta-blocker therapy rate (56% vs. 84%) in the PPM group. Procedure-related data showed higher creatine kinase (CK) peaks in the PPM group (1692 U/L vs. 1243 U/L), with no significant difference in the alcohol dose. At three years after ASA procedure, there were no differences in the primary and secondary endpoints between the two groups. Conclusions: Permanent pacemaker after ASA induced CHB do not affect long term prognosis in hypertrophic obstructive cardiomyopathy patients. Resumo: Introdução e objetivos: Doentes com miocardiopatia hipertrófica obstrutiva (MCHO) sintomáticos apesar de terapêutica médica otimizada são frequentemente submetidos a ablação septal alcoólica (ASA). O bloqueio atrioventricular (BAV) completo é uma complicação frequente, requerendo implantação de pacemaker definitivo em taxas variáveis que podem ir até 20% dos doentes. O impacto a longo prazo da implantação de pacemaker nestes doentes permanente mal-esclarecido. Esta análise pretende avaliar os outcomes clínicos a longo prazo nestes doentes. Métodos: Doentes consecutivos submetidos a ASA num centro terciário foram incluídos e seguidos prospetivamente. Pacientes com pacemaker ou cardiodesfibrilhador prévio foram excluídos desta análise. Os doentes com e sem implantação de pacemaker após a ASA foram caracterizados e comparados relativamente aos endpoints primário (composto de mortalidade e hospitalização por todas as causas) e secundário (composto de mortalidade por todas as causas e hospitalização de causa cardíaca) a três anos. Resultados: Entre 2009 e 2019, 109 pacientes foram submetidos a ASA e 97 foram incluídos nesta análise (68% sexo feminino, idade media 65,2 anos). Implantaram pacemaker 16 doentes (16,5%) após a ASA por BAV completo. Não se registaram complicações vasculares, da loca ou parenquimatosas pulmonares. As características basais foram semelhantes entre os grupos, com maior idade média (70,6 ± 10,0 anos versus 64,1 ± 11,9 anos) e menor taxa de terapêutica beta-bloqueante (56% versus 84%) no grupo de pacemaker. Dados do periprocedimento revelaram maior pico de creatina cinase (CK) no grupo de pacemaker, sem diferença na dose de álcool usado. Aos três anos, os endpoints primário e secundário não mostraram diferenças entre os dois grupos. Conclusão: A implantação de pacemaker definitivo por BAV completo induzido por ablação septal alcoólica não afeta o prognóstico de pacientes com MCHO

Myocardial Work Brings New Insights into Left Ventricular Remodelling in Cardio-Oncology Patients

Serial transthoracic echocardiographic (TTE) assessment of 2D left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) are the gold standard screening methods for cancer therapeutics-related cardiac dysfunction (CTRCD). Non-invasive left ventricular (LV) pressure-strain loop (PSL) provides a novel method of quantifying myocardial work (MW) with potential advantages to evaluate the impact of cardiotoxic treatments on heart function. We prospectively assessed breast cancer female patients undergoing cancer therapy through serial monitoring by 2D and 3D TTE. Patients were evaluated at T0, T1 and T2 (before, 4&ndash;6 and 12&ndash;14 months after starting therapy, respectively). Through PSL analysis, MW indices were calculated. A total of 122 patients, with a mean age of 54.7 years, who received treatment with anthracyclines (77.0%) and anti-HER2 (75.4%) were included. During a mean follow-up of 14.9 &plusmn; 9.3 months, LVEF and GLS were significantly diminished, and 29.5% developed CTRCD. All MW indices were significantly reduced at T1 compared with baseline and tended to return to baseline values at T2. Global work index and global work efficiency showed a more pronounced variation in patients with CTRCD. The presence of more than one cardiovascular risk factor, obesity and baseline left atrium volume were predictors of changes in MW parameters. In conclusion, breast cancer treatment was associated with LV systolic dysfunction as assessed by MW, with its peak at 4&ndash;6 months and a partial recovery afterwards. Assessment of myocardial deformation parameters allows a more detailed characterization of cardiac remodelling and could enhance patient screening and selection for cardioprotective therapeutics

Microvascular Dysfunction Is Associated With Impaired Myocardial Work in Obstructive and Nonobstructive Hypertrophic Cardiomyopathy: A Multimodality Study

Background Two‐dimensional speckle tracking echocardiography has been shown to correlate with microvascular dysfunction, a hallmark of hypertrophic cardiomyopathy (HCM). We hypothesized that there is an association between myocardial work and left ventricular ischemia, with incremental value to global longitudinal strain, in patients with HCM. Methods and Results We performed a prospective assessment of patients with HCM, undergoing 2‐dimensional speckle tracking echocardiography and stress perfusion cardiac magnetic resonance. Results were stratified according to obstructive or nonobstructive HCM and the presence of significant replacement fibrosis (late gadolinium enhancement ≥15% of left ventricular mass). Seventy‐five patients with HCM (63% men, age 55±15 years) were evaluated, 28% with obstructive HCM (mean gradient 89±60 mm Hg). Perfusion defects were found in 90.7%, involving 22.5±16.9% of left ventricular mass, and 38.7% had late gadolinium enhancement ≥15%. In a multivariable analysis, a lower global work index (r=−0.519, β‐estimate −10.822; P=0.001), lower global work efficiency (r=−0.379, β‐estimate −0.123; P=0.041), and impaired global constructive work (r=−0.532, β‐estimate −13.788; P−15.5%) had a sensitivity of 64% and a specificity of 57%. The association between myocardial work and perfusion defects was significant independently of late gadolinium enhancement ≥15% and obstructive HCM. Conclusions Impaired myocardial work was significantly correlated with the extent of ischemia in cardiac magnetic resonance, independently of the degree of left ventricular hypertrophy or fibrosis, with a higher predictive power than global longitudinal strain