Ehokardiografija u ranoj detekciji poremećaja funkcije desne komore pri promjeni volumena krvi kod bolesnika na hemodijalizi

Uvod. Poremećaji funkcije desnog srca su prediktori loše prognoze kodpacijenata na programu hronične hemodijalize (HD). U ovoj studiji ispitivanaje validnost ehokardiografije u procjeni sistolne i dijastolne funkcije desnekomore kod pacijenata na HD.Metode. Istraživanjem je obuhvaćeno 30 pacijenata (55±11 godina) na hroničnojHD kojima su rađene standardna 2D ehokardiografija i tkivni Doppler, prijei nakon HD.Rezultati. Ispitivanje sistolne funkcije desne komore prije i poslije HD jepokazalo da su frakciona promjena površine – FAC (36%±11 vs. 34%±11,p=0,464) i amplituda sistolne pokretljivosti anulusa trikuspidne valuvle–TAPSE (25,2mm±4,8 vs. 24,2mm±5, p=0,207) bile u granicama normalnihvrijednosti, nezavisno od smanjenja ukupnog volumena krvi nakon HD, dokje frakciono skraćenje – Fs (43,8%±11,6 vs. 39,3%±13,2, p=0,014) bilo značajnomanje nakon HD, što pokazuje zavisnost ovog parametra od smanjenja cirkulatornogvolumena. Tei indeks desne komore pokazao je normalne vrijednosti,nezavisno od smanjenja punjenja desne komore nakon HD (0,59±0,44 vs.0,69±0,27, p=0,18). Evaluacija dijastolne funkcije desne komore preko brzinatranstrikuspidnog protoka (E talas, E/A) pokazala je značajno smanjenje brzinanakon smanjenja volumena poslije HD, dok je odnos brzina E/E’ (6,02±3,19vs. 5,66±1,83, p=0,599) ostao u granicama normalnih vrijednosti i nakon HD.Zaključak. Ehokardiografska procjena sistolne funkcije desne komore pomoćuFAC i TAPSE, kao i procjena globalne funkcije miokarda pomoću Tei indeksa,su pouzdane metode kod pacijenata na HD, pošto se njihove vrijednosti nisumijenjale u uslovima smanjenja cirkulatornog volumena nakon HD. Kaopouzdan parametar za procjenu dijastolne funkcije kod pacijenata na HD semože koristiti odnos brzina E/E’, koji se u ovom istraživanju nije značajnomijenjao usljed smanjenja volumena krvi nakon HD

Left ventricular contractile reserve in stress echocardiography: the bright side of the force

Stress echocardiography (SE) is based on the detection of regional wall motion abnormalities (RWMA) mirroring a physiologi­cally critical epicardial artery stenosis which determines subendocardial underperfusion. Recently, the core protocol of SE has been enriched by the addition of left ventricular contractile reserve (LVCR) based on force. Changes in force can be caused by microvascular and/or epicardial coronary artery disease, but also by myocardial scar, necrosis, and/or sub-epicardial layer disease. Left ventricular contractile reserve is calculated as the stress-to-rest ratio of force (systolic arterial pressure measured by cuff sphygmomanometer to end-systolic volume determined by two-dimensional echocardiography). In contrast to the ejection fraction, force is not dependent on changes in preload and afterload. Cut-off values for a preserved LVCR are > 2.0 for dobu­tamine or exercise stress and > 1.1 for vasodilators, which are weaker inotropic stimuli. Patients with a “strong” heart (normal LVCR values) have a better outcome than patients with a “weak” heart (reduced LVCR values), and this is the prognostic “bright side of the force,” meaning that the prognostic value of force-based contractile reserve is higher than that of ejection fraction-based contractile reserve or RWMA. The addition of force to standard SE based on RWMA detection increases the spectrum of risk stratification without any signifi­cant increase in imaging time and only a slight increase in analysis time. In both ischaemic (with RWMA) and non-ischaemic (without RWMA) hearts, the preserved force is associated with a more benign prognosis. The prospective multicentre interna­tional Stress Echo 2020 trial which started in September 2016 has already recruited > 5000 patients with dual RWMA-force imaging and will systematically test the impact of force on the prognosis within and beyond coronary artery disease, including heart failure and hypertrophic cardiomyopathy

European Society of Cardiology Working Group on Adult Congenital Heart Disease and Study Group for Adult Congenital Heart Care in Central and South Eastern European Countries consensus paper : current status, provision gaps and investment required

Aims: To examine the current status of care and needs of adult congenital heart disease (ACHD) services in the Central and South Eastern European (CESEE) region. Methods and results: We obtained data regarding the national ACHD status for 19 CESEE countries from their ACHD representative based on an extensive survey for 2017 and/or 2018. Thirteen countries reported at least one tertiary ACHD centre with a median year of centre establishment in 2007 (interquartile range 2002–2013). ACHD centres reported a median of 2114 patients under active follow-up with an annual cardiac catheter and surgical intervention volume of 49 and 40, respectively. The majority (90%) of catheter or surgical interventions were funded by government reimbursement schemes. However, all 19 countries had financial caps on a hospital level, leading to patient waiting lists and restrictions in the number of procedures that can be performed. The median number of ACHD specialists per country was 3. The majority of centres (75%) did not have ACHD specialist nurses. The six countries with no dedicated ACHD centres had lower Gross Domestic Product per capita compared to the remainder (P = 0.005). Conclusion: The majority of countries in CESEE now have established ACHD services with adequate infrastructure and a patient workload comparable to the rest of Europe, but important gaps still exist. ACHD care is challenged or compromised by limited financial resources, insufficient staffing levels, and reimbursement caps on essential procedures compared to Western Europe. Active advocacy and increased resources are required to address the inequalities of care across the continent

The 'peptide for life' initiative in the emergency department study

Aims: Natriuretic peptide (NP) uptake varies in Emergency Departments (EDs) across Europe. The 'Peptide for Life' (P4L) initiative, led by Heart Failure Association, aims to enhance NP utilization for early diagnosis of heart failure (HF). We tested the hypothesis that implementing an educational campaign in Western Balkan countries would significantly increase NP adoption rates in the ED. Methods and results: This registry examined NP adoption before and after implementing the P4L-ED study across 10 centres in five countries: Bosnia and Herzegovina, Croatia, Montenegro, North Macedonia, and Serbia. A train-the-trainer programme was implemented to enhance awareness of NP testing in the ED, and centres without access received point-of-care instruments. Differences in NP testing between the pre-P4L-ED and post-P4L-ED phases were evaluated. A total of 2519 patients were enrolled in the study: 1224 (48.6%) in the pre-P4L-ED phase and 1295 (51.4%) in the post-P4L-ED phase. NP testing was performed in the ED on 684 patients (55.9%) during the pre-P4L-ED phase and on 1039 patients (80.3%) during the post-P4L-ED phase, indicating a significant absolute difference of 24.4% (95% CI: 20.8% to 27.9%, P < 0.001). The use of both NPs and echocardiography significantly increased from 37.7% in the pre-P4L-ED phase to 61.3% in the post-P4L-ED phase. There was an increased prescription of diuretics and SGLT2 inhibitors during the post-P4L-ED phase. Conclusions: By increasing awareness and providing resources, the utilization of NPs increased in the ED, leading to improved diagnostic accuracy and enhanced patient care

Hemodynamic Heterogeneity of Reduced Cardiac Reserve Unmasked by Volumetric Exercise Echocardiography

Background: Two-dimensional volumetric exercise stress echocardiography (ESE) provides an integrated view of left ventricular (LV) preload reserve through end-diastolic volume (EDV) and LV contractile reserve (LVCR) through end-systolic volume (ESV) changes. Purpose: To assess the dependence of cardiac reserve upon LVCR, EDV, and heart rate (HR) during ESE. Methods: We prospectively performed semi-supine bicycle or treadmill ESE in 1344 patients (age 59.8 ± 11.4 years; ejection fraction = 63 ± 8%) referred for known or suspected coronary artery disease. All patients had negative ESE by wall motion criteria. EDV and ESV were measured by biplane Simpson rule with 2-dimensional echocardiography. Cardiac index reserve was identified by peak-rest value. LVCR was the stress-rest ratio of force (systolic blood pressure by cuff sphygmomanometer/ESV, abnormal values ≤2.0). Preload reserve was defined by an increase in EDV. Cardiac index was calculated as stroke volume index * HR (by EKG). HR reserve (stress/rest ratio) <1.85 identified chronotropic incompetence. Results: Of the 1344 patients, 448 were in the lowest tertile of cardiac index reserve with stress. Of them, 303 (67.6%) achieved HR reserve <1.85; 252 (56.3%) had an abnormal LVCR and 341 (76.1%) a reduction of preload reserve, with 446 patients (99.6%) showing ≥1 abnormality. At binary logistic regression analysis, reduced preload reserve (odds ratio [OR]: 5.610; 95% confidence intervals [CI]: 4.025 to 7.821), chronotropic incompetence (OR: 3.923, 95% CI: 2.915 to 5.279), and abnormal LVCR (OR: 1.579; 95% CI: 1.105 to 2.259) were independently associated with lowest tertile of cardiac index reserve at peak stress. Conclusions: Heart rate assessment and volumetric echocardiography during ESE identify the heterogeneity of hemodynamic phenotypes of impaired chronotropic, preload or LVCR underlying a reduced cardiac reserve