Background: Patients with severe mental illness (SMI) including schizophrenia, bipolar disorder, and severe depression have earlier onset of cardiovascular risk factors, predisposing to worse future heart failure (HF) compared with the general population. We investigated associations between the presence/absence of SMI and long-term HF outcomes. Methods: We identified patients with HF with and without SMI in the Duke University Health System from 2002 to 2017. Using multivariable Cox regression, we examined the primary outcome of all-cause mortality. Secondary outcomes included rates of implantable cardioverter defibrillator use, cardiac resynchronization therapy, left ventricular assist device implantation, and heart transplantation. Results: We included 20 906 patients with HF (SMI, n=898; non-SMI, n=20 008). Patients with SMI presented clinically 7 years earlier than those without SMI. We observed an interaction between SMI and sex on all-cause mortality ( P =0.002). Excess mortality was observed among men with SMI compared with men without SMI (hazard ratio, 1.36 [95% CI, 1.17–1.59]). No association was observed among women with and without SMI (hazard ratio, 0.97 [95% CI, 0.84–1.12]). Rates of implantable cardioverter defibrillator use, cardiac resynchronization therapy, left ventricular assist device implantation, and heart transplantation were similar between patients with and without SMI (6.1% versus 7.9%, P =0.095). Patients with SMI receiving these procedures for HF experienced poorer prognosis than those without SMI (hazard ratio, 2.12 [95% CI, 1.08–4.15]). Conclusions: SMI was associated with adverse HF outcome among men and not women. Despite equal access to procedures for HF between patients with and without SMI, those with SMI experienced excess postprocedural mortality. Our data highlight concurrent sex- and mental health-related disparities in HF prognosis, suggesting that patients with SMI, especially men, merit closer follow-up.
Severe Covid-19 may cause a cascade of cardiovascular complications beyond viral pneumonia. The severe inflammation may affect the microcirculation which can be assessed by cardiovascular magnetic resonance (CMR) imaging using quantitative perfusion mapping and calculation of myocardial perfusion reserve (MPR). Furthermore, native T1 and T2 mapping have previously been shown to identify changes in myocardial perfusion by the change in native T1 and T2 during adenosine stress. However, the relationship between native T1, native T2, ΔT1 and ΔT2 with myocardial perfusion and MPR during long-term follow-up in severe Covid-19 is currently unknown. Therefore, patients with severe Covid-19 (n = 37, median age 57 years, 24% females) underwent 1.5 T CMR median 292 days following discharge. Quantitative myocardial perfusion (ml/min/g), and native T1 and T2 maps were acquired during adenosine stress, and rest, respectively. Both native T1 (R2 = 0.35, p < 0.001) and native T2 (R2 = 0.28, p < 0.001) correlated with myocardial perfusion. However, there was no correlation with ΔT1 or ΔT2 with MPR, respectively (p > 0.05 for both). Native T1 and native T2 correlate with myocardial perfusion during adenosine stress, reflecting the coronary circulation in patients during long-term follow-up of severe Covid-19. Neither ΔT1 nor ΔT2 can be used to assess MPR in patients with severe Covid-19.
BACKGROUND: Decreased hydraulic forces during diastole contribute to reduced left ventricular (LV) filling and heart failure with preserved ejection fraction. OBJECTIVES: To determine the association between diastolic hydraulic forces, estimated by atrioventricular area difference (AVAD), and both diastolic function and survival. We hypothesized that decreased diastolic hydraulic forces, estimated as AVAD, would associate with survival independent of conventional diastolic dysfunction measures. METHODS: Patients (n=11,734, median [interquartile range] 3.9 [2.4-5.0] years follow-up, 1,213 events) were selected from the National Echo Database Australia based on the presence of relevant transthoracic echocardiographic measures, LV ejection fraction (LVEF) ≥ 50%, heart rate 50-100 beats/minute, the absence of moderate or severe valvular disease, and no prior cardiac surgery. AVAD was calculated as the cross-sectional area difference between the LV and left atrium. LV diastolic dysfunction was graded according to 2016 guidelines. RESULTS: AVAD was weakly associated with E/e prime, left atrial volume index, and LVEF (multivariable global R2=0.15, p<0.001), and not associated with e prime and peak tricuspid regurgitation velocity. Decreased AVAD was independently associated with poorer survival, and demonstrated improved model discrimination after adjustment for diastolic function grading (C-statistic 0.645 vs 0.607) and E/e prime (C-statistic 0.639 vs 0.621), respectively. CONCLUSIONS: Decreased hydraulic forces, estimated by AVAD, are weakly associated with diastolic dysfunction and provide an incremental prognostic association with survival beyond conventional measures used to grade diastolic dysfunction.
BACKGROUNDBody size indexation is a foundation of the diagnostic interpretation of cardiac size measures used in imaging assessment of cardiovascular health. Body surface area (BSA) is the most commonly used metric for body size indexation of echocardiographic measures, but its use in patients who are underweight or obese is questioned (body mass index (BMI) <18·5 kg/m2 or ≥30 kg/m2, respectively). We hypothesized that mortality can be used to identify an optimal body size indexation metric for echocardiographic measures that would be a better predictor of survival than BSA regardless of BMI.METHODSIn this big data, cohort study, adult patients with no prior valve replacement were selected from the National Echo Database Australia. Survival analysis was performed for echocardiographic measures both unindexed and indexed to different body size metrics, with 5-year cardiovascular mortality as the primary endpoint.FINDINGSIndexation of echocardiographic measures (left ventricular diameter [n=337,481] and mass [n=330,959], left atrial area [n=136,989], aortic sinus diameter [n=125,130], right atrial area [n=81,699], right ventricular diameter [n=3,575], right ventricular outflow tract diameter [n=2,841]) by BSA had better prognostic performance vs unindexed measures (healthy/overweight: C-statistic 0·656 vs 0·618, average change in Akaike Information Criteria (ΔAIC) 800; underweight: C-statistic 0·669 vs 0·654, ΔAIC 15; obese: C-statistic 0·630 vs 0·612, ΔAIC 113). Indexation by other body size metrics (lean body mass or height and/or weight raised to various powers) did not improve prognostic performance versus BSA by a clinically relevant magnitude (average C-statistic increase ≤0·01), with smaller differences in higher BMI subgroups. Similar results were obtained using sex-disaggregated analysis, for indexation of other aortic or cardiac dimension or volume measures, and for all-cause mortality.INTERPRETATIONIndexing measures of cardiac and aortic size by BSA improves prognostic performance regardless of BMI, and no other body size metric has a clinically meaningful better performance.FUNDINGThis research was supported in part by grants (PI Ugander) from New South Wales Health, Heart Research Australia, and the University of Sydney.
Introduction: Decreased hydraulic force has recently been identified as a mechanism contributing to left ventricular (LV) diastolic dysfunction and heart failure with preserved ejection fraction (HFpEF). However, it is unclear if hydraulic forces are independently associated with survival. Hypothesis: Decreased diastolic hydraulic force, estimated as the atrioventricular area difference (AVAD), is associated with survival independent of conventional diastolic dysfunction measures. Methods: Patients (n=37947, median [interquartile range] 4.9 [2.9-8.0] years follow-up, 6103 events) were selected from the National Echo Database Australia based on the presence of relevant transthoracic echocardiographic measures, LV ejection fraction (LVEF) ≥ 50%, heart rate 50-100 beats/minute, the absence of moderate or severe valvular disease, pericardial disease or mitral annular calcification, and no prior cardiac surgery. AVAD was calculated as the cross-sectional area difference between the LV and left atrium (LA) using circular approximation of LV end-diastolic diameter and LA end-systolic diameter. LV diastolic dysfunction grading was performed according to 2016 guidelines. Results: In multivariable linear regression, AVAD was weakly associated with E/e’, e’, peak tricuspid regurgitation velocity, and LVEF (global adjusted R2=0.11, p<0.001), but not associated with left atrial volume index (p=0.83). In multivariable Cox regression, there was an association with survival for both AVAD (chi-square 279, hazard ratio (HR) [95% confidence interval] 1.23 [1.20-1.26], p<0.001) and diastolic dysfunction grading (chi-square 1217, HR 3.21 [3.00-3.42], p<0.001). In a separate multivariable model, there was an association with survival for both AVAD (chi-square 371, HR 1.27 [1.24-1.30], p<0.001) and E/e’ (chi-square 1020, HR 1.39 [1.36-1.42], p<0.001). Conclusions: Decreased hydraulic force, estimated as AVAD, is associated with diastolic dysfunction, and provides prognostic information beyond conventional measures used to grade diastolic dysfunction. This suggests that increased LA size relative to LV size is a potential therapeutic target in HFpEF.
Introduction: Body surface area (BSA) is the most widely accepted metric for body size indexation of cardiac measures to improve diagnosis, but its use in obesity is questioned. Furthermore, big data analyses comparing indexation metrics are limited. Hypothesis: All-cause mortality can be used to identify an optimal indexation metric for transthoracic echocardiographic (TTE) measures that will be a better predictor of survival than BSA regardless of obesity (body mass index [BMI] ≥30kg/m2). Methods: Patients (n=11621) with no prior cardiac surgery, with all TTE measures of interest available, were selected from the National Echo Database Australia. Cox regression survival analysis for all-cause mortality (Wald chi-square) was analyzed for TTE measures both unindexed and indexed to different indexation metrics. Results: For both non-obese (n=7684, median BMI 25 kg/m2, age 65 years, 42% female, 4.2 years follow-up, 1586 deaths) and obese patients (n=3937, BMI 34 kg/m2, age 63 years, 42% female, 4.5 years follow-up, 607 deaths), indexation of cardiac sizes (atrial areas, left ventricular mass and diameter, and aortic sinus diameter) to BSA had better prognostic performance (higher chi-square) vs unindexed measures. Indexing by height^2.7 performed worse than BSA. Cardiac output had the best prognostic performance when indexed by weight^3 vs all other metrics (>3-fold higher chi-square). Stroke volume performed better unindexed than when indexed for body size. Conclusions: When using all-cause mortality as the arbiter of appropriateness among both non-obese and obese patients, indexation by BSA improved prognostic performance, cardiac output performed best when indexed by weight^3, and stroke volume performed best unindexed.
Background: Left anterior fascicular block (LAFB) has been associated with increased mortality, but the underlying causes are unknown. We hypothesized that LAFB is associated with increased left ventricular (LV) scar burden and reduced LV ejection fraction (LVEF). Methods: Patients referred for cardiovascular magnetic resonance imaging (CMR) and electrocardiography (ECG) were retrospectively enrolled. Patients with LAFB (n=51) and matched control patients without LAFB (n=600) were compared regarding size and location of LV scar, LVEF, and a dysfunction index describing the difference between measured LVEF and expected LVEF where the expected LVEF is based on scar size. Results: Compared to matched controls, patients with LAFB had on average a larger LV scar (median [interquartile range] 0.7 [0.0-6.6] vs 0.0 [0.0-1.5] % LV mass, p<0.001). LAFB was associated with a higher prevalence of any scar (59% vs 33%, p<0.001). Patients with LAFB had similar prevalence of ischemic scar (29% vs 23%, p=0.40) but a higher prevalence of non-ischemic scar (29% vs 10%, p=0.001) which was most frequently located in the basal and mid inferoseptal segments and the anterior and lateral apical LV segments. LVEF was lower in patients with LAFB than matched controls (58 [43-60] vs 60 [55-60] %, p=0.02), but there was no difference in dysfunction index (24.0 [17.8-25.5] vs 24.0 [19.0-27.8] %-points of LVEF, p=0.32) Conclusions: In a matched hospital cohort, LAFB was associated with a small decrease in LVEF that was proportionate to the increased LV scar burden. This increased LV scar burden was more commonly due to non-ischemic etiology and not infarction, and not more commonly located near the expected course of the left anterior fascicle.
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