Multimodality imaging in heart valve disease

In patients with heart valve disease, echocardiography is the mainstay for diagnosis, assessment and serial surveillance. However, other modalities, notably cardiac MRI and CT, are used if echocardiographic imaging is suboptimal but can also give complementary information to improve assessment of the valve lesion and cardiac compensation to aid the timing of surgery and determine risk. This statement discusses the way these imaging techniques are currently integrated to improve care beyond what is possible with echocardiography alone

Exercise physiology and the renin-angiotensin system: Role of the ACE gene insertion/deletion polymorphism in cardiac growth and endurance exercise.

The systemic renin-angiotensin system, an important regulator of cardiovascular homeostasis, is well described, though separate local systems exist in many tissues, the function of which is less well defined. There is evidence for their role in growth responses and cellular metabolism, particularly for the heart, and the understanding of these mechanisms is important, given the detrimental effect of excess cardiac hypertrophy. The examination of these local systems in humans is problematic, though a polymorphism in the human angiotensin converting enzyme (ACE) gene may be utilised to explore the mechanisms involved. This thesis examines the influence of the ACE gene polymorphism in exercise-induced cardiac hypertrophy. Subjects of DD genotype (associated with higher ACE levels) had greater left ventricular (LV) growth than those of II genotype, and the LV growth in DD subjects was disproportionate to the increase in lean body mass. Blockade of the angiotensin receptor with losartan had no effect on LV growth in either genotype, though the dose may have been inadequate. This and other recent studies support the role of the local renin-angiotensin system in human cardiac growth, with higher ACE levels being associated with greater growth. The appropriate indices for scaling LV mass to body size were also examined and lean body mass was found to be the only suitable index for simple ratio scaling. The renin-angiotensin system may also play a role in the efficiency of cellular metabolism. The ACE gene polymorphism was examined in elite endurance athletes, and the I allele (associated with lower ACE levels) was found to be more prevalent, suggesting a genetic advantage for endurance. In Olympic runners, the relative frequency of the I allele rose with the distance run. The data suggests greater efficiency associated with lower ACE levels, and the reduced cardiac growth associated with the II genotype may be related to this improved efficiency. Potential mechanisms are discussed. These results confirm the importance of local renin-angiotensin systems in exercise physiology and may relate closely to disease states. The importance of gene- environment interactions has also been shown

B-Type Natriuretic Peptide at Admission Is a Predictor of All-Cause Mortality at One Year after the First Acute Episode of New-Onset Heart Failure with Preserved Ejection Fraction

Background: Heart failure with preserved ejection fraction (HFpEF) has been assessed extensively, but few studies analysed the predictive value of the NT-proBNP in patients with de novo and acute HFpEF. We sought to identify NT-proBNP at admission as a predictor for all-cause mortality and rehospitalisation at 12 months in patients with new-onset HFpEF. Methods: We analysed 91 patients (73 ± 11 years, 68% females) admitted for de novo and acute HFpEF, using the Cox proportional hazard risk model. Results: An admission NT-proBNP level above the threshold of 2910 pg/mL identified increased all-cause mortality at 12 months (AUC = 0.72, sensitivity = 92%, specificity = 53%, p < 0.001). All-cause mortality adjusted for age, gender, medical history, and medication in the augmented NT-proBNP group was 16-fold higher (p = 0.018), but with no difference in rehospitalisation rates (p = 0.391). The predictors of increased NT-proBNP ≥ 2910 pg/mL were: age (p = 0.016), estimated glomerular filtration rate (p = 0.006), left atrial volume index (p = 0.001), history of atrial fibrillation (p = 0.006), and TAPSE (p = 0.009). Conclusions: NT-proBNP above 2910 pg/mL at admission for de novo and acute HFpEF predicted a 16-fold increased mortality at 12 months, whereas values less than 2910 pg/mL forecast a high likelihood of survival (99.3%) in the next 12 months, and should be considered as a useful prognostic tool, in addition to its utility in diagnosing heart failure

United Kingdom standards for non-invasive cardiac imaging: recommendations from the Imaging Council of the British Cardiovascular Society

Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives