Left atrial volume changes during exercise stress echocardiography in heart failure and hypertrophic cardiomyopathy

We assessed feasibility and functional correlates of LAVI (left atrial volume index) changes during exercise stress echocardiography (ESE).ESE on bike or treadmill was performed in 363 patients with heart failure with preserved ejection fraction (HFpEF, n = 173), reduced ejection fraction (HFrEF, n = 59) or hypertrophic cardiomyopathy (HCM, n=131). LAVI stress-rest increase ≥ 6.8 ml/m2 was defined as dilation.LAVI measurements were feasible in 100%. LAVI did not change in HFrEF being at rest 32 (25-45) vs. at stress 36 (24 - 54) ml/m2, P = NS and in HCM at rest 35 (26 - 48) vs. at stress 38 (28 - 48) ml/m2, P = NS whereas it decreased in HFpEF from 30 (24 -40) to 29 (21 - 37) ml/m2 at stress, P = 0.007. LA dilation occurred in 107 (30%) patients (27% with treadmill vs. 33% with bike ESE, P = NS): 26 with HFpEF (15%), 26 with HFrEF (44%) and 55 with HCM (42%) with P 14 at rest with OR 4.4, LVEF < 50% with OR 2.9, and LAVI at rest < 35 ml/m2 with OR 2.7.LAVI assessment during ESE was highly feasible and dilation equally frequent with treadmill or bike. LA dilation was threefold more frequent in HCM and HFrEF and could be predicted by increased resting E/e' and impaired EF as well as smaller baseline LAVI

Natural History of Patients with Ischemia and No Obstructive Coronary Artery Disease: The CIAO-ISCHEMIA Study

Background: Ischemia with no obstructive coronary artery disease (INOCA) is common and has an adverse prognosis. We set out to describe the natural history of symptoms and ischemia in INOCA. Methods: CIAO-ISCHEMIA (Changes in Ischemia and Angina over One year in ISCHEMIA trial screen failures with INOCA) was an international cohort study conducted from 2014-2019 involving angina assessments (Seattle Angina Questionnaire [SAQ]) and stress echocardiograms 1-year apart. This was an ancillary study that included patients with history of angina who were not randomized in the ISCHEMIA trial. Stress-induced wall motion abnormalities were determined by an echocardiographic core laboratory blinded to symptoms, coronary artery disease (CAD) status and test timing. Medical therapy was at the discretion of treating physicians. The primary outcome was the correlation between changes in SAQ Angina Frequency score and change in echocardiographic ischemia. We also analyzed predictors of 1-year changes in both angina and ischemia, and compared CIAO participants with ISCHEMIA participants with obstructive CAD who had stress echocardiography before enrollment, as CIAO participants did. Results: INOCA participants in CIAO were more often female (66% of 208 vs. 26% of 865 ISCHEMIA participants with obstructive CAD, p\u3c0.001), but the magnitude of ischemia was similar (median 4 ischemic segments [IQR 3-5] both groups). Ischemia and angina were not significantly correlated at enrollment in CIAO (p=0.46) or ISCHEMIA stress echocardiography participants (p=0.35). At 1 year, the stress echocardiogram was normal in half of CIAO participants and 23% had moderate or severe ischemia (≥3 ischemic segments). Angina improved in 43% and worsened in 14%. Change in ischemia over one year was not significantly correlated with change in angina (rho=0.029). Conclusions: Improvement in ischemia and improvement in angina were common in INOCA, but not correlated. Our INOCA cohort had a similar degree of inducible wall motion abnormalities to concurrently enrolled ISCHEMIA participants with obstructive CAD. Our results highlight the complex nature of INOCA pathophysiology and the multifactorial nature of angina

Prognostic value of reduced heart rate reserve during exercise in hypertrophic cardiomyopathy

Background: Sympathetic dysfunction can be evaluated by heart rate reserve (HRR) with exercise test. Objectives: To determine the value of HRR in predicting outcome of patients with hypertrophic cardiomyopathy (HCM). Methods: We enrolled 917 HCM patients (age = 49 +/- 15 years, 516 men) assessed with exercise stress echocardiography (ESE) in 11 centres. ESE modality was semi-supine bicycle in 51 patients (6%), upright bicycle in 476 (52%), and treadmill in 390 (42%). During ESE, we assessed left ventricular outflow tract obstruction (LVOTO), stress-induced new regional wall motion abnormalities (RWMA), and HRR (peak/rest heart rate, HR). By selection, all patients completed the follow-up. Mortality was the predetermined outcome measure Results: During ESE, RWMA occurred in 22 patients (2.4%) and LVOTO (>= 50 mmHg) in 281 (30.4%). HRR was 1.90 +/- 0.40 (lowest quartile 2.13). Higher resting heart rate (odds ratio 1.027, 95% CI: 1.018-1.036, p < 0.001), older age (odds ratio 1.021, 95% CI: 1.009-1.033, p < 0.001), lower exercise tolerance (mets, odds ratio 0.761, 95% CI: 0.708-0.817, p < 0.001) and resting LVOTO (odds ratio 1.504, 95% CI: 1.043-2.170, p = 0.029) predicted a reduced HRR. During a median follow-up of 89 months (interquartile range: 36-145 months), 90 all-cause deaths occurred. At multivariable analysis, lowest quartile HRR (Hazard ratio 2.354, 95% CI 1.116-4.968 p = 0.025) and RWMA (Hazard ratio 3.279, 95% CI 1.441-7.461 p = 0.004) independently predicted death, in addition to age (Hazard ratio 1.064, 95% CI 1.043-1.085 p < 0.001) and maximal wall thickness (Hazard ratio 1.081, 95% CI 1.037-1.128, p < 0.001). Conclusions: A blunted HRR during ESE predicts survival independently of RWMA in HCM patients.info:eu-repo/semantics/publishedVersio

Complications of Exercise Echocardiography. Analysis of a Cohort of 19,239 Patients

We analyzed complications of exercise echocardiography in 19,239 studies, performed in a 21-year-period, finding just 19 cases with major complications, without any death

Exercise echocardiography

Exercise echocardiography has been used for 30 years. It is now considered a consolidated technique for the diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). Of the stress echocardiography techniques, it represents the first choice for patients who are able to exercise. Given that the cost-effectiveness and safety of stress echocardiography are higher than those of other imaging techniques, its use is likely to be expanded further. Recent research has also proposed this technique for the evaluation of cardiac pathology beyond CAD. Although the role of new technology is promising, the assessment of cardiac function relies on good quality black and white harmonic images

Is there a role for ischemia detection after an acute myocardial infarction?

Coronary angiography and eventual revascularization have become the most common approaches for patients with acute coronary syndromes. Ischemia detection in this scenario is usually regarded as unnecessary for most of the patients. In fact, current guidelines recommend complete revascularization for patients with multivessel disease in the context of ST-elevation myocardial infarction, although it is in contrast with previous recommendations. However, some recent data suggested that ischemia could have a role for the decision of revascularization in these patients. The CROSS-AMI study randomized patients with ST-elevation myocardial infarction treated with primary angioplasty and who also had multivessel disease to a complete anatomic revascularization of the non-infarct related artery lesions vs subsequent revascularization of the non-infarct related artery lesions only if ischemia was demonstrated by stress echocardiography. The main findings were that only 30% of the patients in the ischemia arm needed a second revascularization and that the outcome was similar in both arms. Regarding non-ST-elevation acute coronary syndrome, coronary angiography is in general warranted for most of the patients. However, recent long-term published studies on patients randomized to an invasive or less aggressive approach based on ischemia detection have found no differences in outcome. The ultimate study in non-ST-elevation acute coronary syndrome comparing ischemia detection with an invasive approach is pending. Therefore, ischemia detection might have a role for stratifying these subjects. This is particularly true in the current era of imaging of high quality and sensitivity, last generation stents, radial access and modern antithrombotic therapy