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Resting heart rate is an important predictor of outcome in patients with stable chronic HF without AF, regardless of LVEF or beta-blocker use.

AimsQuantification of linear lung ultrasound (LUS) artefacts (B-lines) represents a novel, non-invasive approach to assess pulmonary congestion. We investigated the relationship between the number of B-lines (vertical artefacts arising from the pleural line) and intracardiac pressures. Methods and resultsPrior to scheduled right heart catheterization (RHC), 100 subjects underwent LUS of eight zones. A reviewer blinded to the haemodynamic data quantified the number of sonographic B-lines. Of 92 subjects who completed RHC, 79 had adequate LUS data of all zones [median age 61 years, 26 women, median left ventricular ejection fraction (LVEF) 58%, 35 with history of heart failure; 22 postcardiac transplantation]. The number of B-lines correlated with measured right atrial (r ¼ 0.32), pulmonary artery diastolic (PADP) (r ¼ 0.34), mean pulmonary artery (mPAP) (r ¼ 0.43), pulmonary artery systolic (PASP) (r ¼ 0.48) pressures, and pulmonary vascular resistance (PVR) (r ¼ 0.51) (P , 0.005 for all), but not with pulmonary capillary wedge pressure. There was a graded association between tertiles of B-line number and increasing PADP, mPAP, PASP, and PVR (P for trend ≤0.001 for all). Each additional B-line was associated with an increase in PASP of 1 mmHg and an increase in PVR of 0.1 Wood units. These associations remained robust after multivariable adjustment (P ¼ 0.002). Assessment of two inferior lateral zones resulted in similar correlations to the eight-zone method. ConclusionsEasily obtainable, LUS may be useful in the estimation of right-sided cardiac pressures and PVR. Further evaluation of lung ultrasound as an adjunct to heart failure diagnosis, monitoring, and prognosis is warranted.--

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BackgroundPatients with stable coronary heart disease (CHD) have widely varying prognoses and treatment options. Validated models for risk stratification of patients with CHD are needed. We sought to evaluate traditional and novel risk factors as predictors of secondary cardiovascular (CV) events, and to develop a prediction model that could be used to risk stratify patients with stable CHD.Methods and ResultsWe used independent derivation (912 participants in the Heart and Soul Study) and validation (2876 participants in the PEACE trial) cohorts of patients with stable CHD to develop a risk prediction model using Cox proportional hazards models. The outcome was CV events, defined as myocardial infarction, stroke, or CV death. The annual rate of CV events was 3.4% in the derivation cohort and 2.2% in the validation cohort. With the exception of smoking, traditional risk factors (including age, sex, body mass index, hypertension, dyslipidemia, and diabetes) did not emerge as the top predictors of secondary CV events. The top 4 predictors of secondary events were the following: N-terminal pro-type brain natriuretic peptide, high-sensitivity cardiac troponin T, urinary albumin:creatinine ratio, and current smoking. The 5-year C-index for this 4-predictor model was 0.73 in the derivation cohort and 0.65 in the validation cohort. As compared with variables in the Framingham secondary events model, the Heart and Soul risk model resulted in net reclassification improvement of 0.47 (95% CI 0.25 to 0.73) in the derivation cohort and 0.18 (95% CI 0.01 to 0.40) in the validation cohort.ConclusionsNovel risk factors are superior to traditional risk factors for predicting 5-year risk of secondary events in patients with stable CHD.

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AimsWe assessed the relationship between diabetes and cardiac structure and function following myocardial infarction (MI) and whether diabetes influences the effect of direct renin inhibition on change in left ventricular (LV) size. Methods and resultsThe ASPIRE trial enrolled 820 patients 2-8 weeks after MI with ejection fraction ≤45% and randomized them to the direct renin inhibitor aliskiren (n ¼ 423) or placebo (n ¼ 397) added to standard medical therapy. Echocardiography was performed at baseline and after 36 weeks in 672 patients with evaluable paired studies. Compared with non-diabetic patients, diabetic patients (n ¼ 214) were at higher risk for a composite of cardiovascular (CV) death, heart failure hospitalization, recurrent MI, stroke, or aborted sudden death (14 vs. 7%; adjusted hazard ratio 1.63, 95% confidence interval 1.01-2.64, P ¼ 0.045), despite similar left ventricular ejection fraction (37.9 + 5.3 vs. 37.6 + 5.2%, P ¼ 0.48) and end-systolic volume (ESV) (84 + 25 vs. 82 + 28 mL, P ¼ 0.46). Diabetic patients demonstrated greater concentric remodelling (relative wall thickness 0.38 + 0.07 vs. 0.36 + 0.07, P ¼ 0.0002) and evidence of higher LV filling pressure (E/E ′ 11.1 + 5.3 vs. 9.1 + 4.3, P ¼ 0.0011). At 36 weeks, diabetic patients experienced similar per cent reduction in ESV overall (24.9 + 17.9 vs. 25.5 + 16.9, P ¼ 0.67) but tended to experience greater reduction in ESV than non-diabetic patients when treated with aliskiren (interaction P ¼ 0.08). ConclusionsCompared with non-diabetic patients, diabetic patients are at increased risk of CV events post-MI despite no greater LV enlargement or reduction in systolic function. Diabetic patients demonstrate greater concentric remodelling and evidence of higher LV filling pressure, suggesting diastolic dysfunction as a potential mechanism for the higher risk observed among these patients.--

Objectives In an entirely African-American cohort, we compared clinical characteristics, cardiac structure and function, and all cause mortality in heart failure (HF) with preserved ejection fraction (HFpEF) in relation to HF with reduced ejection fraction (HFrEF) and those without HF. Background African-Americans are at increased risk for HF. Nevertheless, there are limited phenotypic and prognostic data in African-Americans with HFpEF compared to those with HFrEF and those without HF. Methods Middle-aged African-Americans from the Jackson cohort of the Atherosclerosis Risk in Communities study (n=2,445) underwent echocardiography between 1993 and 1995. HF prevalence was available in 1,962 for whom left ventricular ejection fraction (LVEF) could be quantified. Participants with HF were categorized as having HFpEF (LVEF ≥ 50%) or HFrEF (LVEF < 50%), or no HF, with comparisons made between groups. Results HF was identified in 116 (5.9%) participants (n=85 [73%] HFpEF; n=31 [27%] HFrEF). Compared to those without HF, those with HFpEF were older, more likely to be female, had more frequent comorbidities, and concentric hypertrophy. In relation to HFrEF, those with HFpEF were more likely female, but less likely to have coronary heart disease, diabetes mellitus, chronic kidney disease, left atrial enlargement, and eccentric hypertrophy. Over a median 13.7 years of follow up, risk of death differed between groups, with age and sex adjusted hazard ratios of 1.51 (95%CI 1.01–2.25) for HFpEF vs. those without HF, and 2.50 (95%CI 1.37–4.58) for HFrEF vs. HFpEF. Conclusions In this cohort of middle-aged African-Americans, HFpEF was the most common form of HF, and was associated with a substantially better prognosis than HFrEF, but worse than those without HF.