Objective-To assess resting and exercise echocardiography for prediction of left ventricular dysfunction in patients with significant asymptomatic aortic regurgitation. Design-Cohort study of patients with aortic regurgitation. Setting-Tertiary referral centre specialising in valvar surgery. Patients-61 patients (38 men, 23 women; mean (SD) age 53 (14) years) with asymptomatic or minimally symptomatic aortic regurgitation and no known coronary artery disease; 35 were treated medically and 26 had aortic valve replacement. Interventions-Exercise echocardiography was used to evaluate ejection fraction, which was measured on the resting and post-stress images using the modified Simpson method. Patients with an increment of ejection fraction after exercise were denoted as having contractile reserve (CR+); those without an increment were labelled CR−. Main outcome measures-Standard univariate and multivariate methods and receiver operating characteristic analyses were used to assess the ability of contractile reserve to predict follow up ejection fraction. Results-In the 35 medically treated patients, 13 of 21 (62%) with CR+ (mean (SD) ejection fraction increment 7 (3)%) had preserved ejection fraction on follow up. In the 14 patients with CR− (ejection fraction decrement 8 (4)%), 13 (93%) had a decrement of ejection fraction on follow up from 60 (5)% at baseline to 54 (3)% on follow up (p = 0.005). Age, resting left ventricular dimensions, medical treatment, aortic regurgitation severity, exercise capacity, and rate-pressure product were similar in both CR+ and CR− groups. Among the 26 surgical patients, 13 showed CR+ (ejection fraction increase 9 (5)%), all of whom had an increase in ejection fraction on follow up (from 49% to 59%). Of 13 surgical patients with CR− (ejection fraction decrease 7 (5)%), 10 (77%) showed the same or worse ejection fraction on postoperative follow up. Conclusions-Contractile reserve on exercise echocardiography is a better predictor of left ventricular decompensation than resting indices in asymptomatic patients with aortic regurgitation. In patients undergoing aortic valve replacement, contractile reserve had a better correlation with resting ejection fraction on postoperative follow up. Measurement of contractile reserve may be useful to monitor the early development of myocardial dysfunction in asymptomatic patients with aortic regurgitation, and may help to optimise the timing of surgery. (Heart 2000;84:606-614)

Background: Diastolic dysfunction (DD) is highly prevalent and associated with increased morbidity and mortality, but its natural history remains poorly defined. Objective: This cohort study sought to characterise the influence of clinical features, medical therapy and echocardiographic parameters on the progression of DD. Methods: We identified 926 consecutive patients (aged 62 (14) years, 221 women) with DD and preserved systolic function. A repeat echocardiogram was performed in 199 patients >1 year after the baseline study (average 3.6 (1.4) years). Follow-up for 4.8 (2.5) years was 97% complete for the major endpoint of all-cause mortality. Cox regression analyses were performed to identify the associations of mortality. Results: Over follow-up, 142 patients died and 22 were admitted with heart failure. The independent predictors of death were age, hyperlipidaemia, co-morbid disease and restrictive filling. The degree of diastolic dysfunction remained stable in 52%, deteriorated in 27% and improved in 21%. There was a greater use of medical therapy in those with stable or worsening diastolic function; when the protective effects of these agents were taken into account in a multivariate model, improvement in diastolic dysfunction was associated with a survival benefit. Conclusion: DD is associated with all-cause mortality, independent of the presence of a major co-morbidity. The degree of DD remains stable in about 50% of patients, the population whose diastolic function improves over time has a more favourable outcome.

the World Health Organization declared coronavirus disease 2019 (COVID-19) a pandemic. The presence of underlying cardiovascular disease (CVD) confers the highest mortality with COVID-19. Thus, patients with CVD must be considered a particularly at-risk population. [1][2][3][4][5] Community transmission, patient-to-patient transmission and health care worker infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are overwhelming health services worldwide. [4][5][6] High quality cardiac care must minimise risk of viral transmission to patients and health care workers. It should adapt resources in the context of reduced access to hospital beds and personal protective equipment (PPE). This consensus statement reviews and summarises data on SARS-CoV-2 infection in pre-existing CVD and acute cardiovascular manifestations of COVID-19, and makes recommendations for cardiac service provision during the pandemic. Development process for the recommendationsA group of CVD experts, drawn from the Cardiac Society of Australia and New Zealand (CSANZ), the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia, convened in March 2020. Key opinion leaders in cardiology, cardiothoracic surgery and public health with broad geographic representation were consulted. We searched major databases (EMBASE, MEDLINE and PubMed) to identify relevant systematic reviews, randomised controlled trials and clinical case series in English from January 2020 to 25 March 2020. As the majority of studies relating to COVID-19 and CVD at the time of writing were observational in nature, results must be interpreted with caution. Given data limitations, consensus documents produced by international cardiology societies from December 2019 to March 2020 were reviewed. [7][8][9] Experts from key areas (electrophysiology and pacing, interventional cardiology, imaging, cardiothoracic surgery, nursing, hypertension, prevention and rural) generated key recommendations from their respective councils and groups. In addition, social networking platforms (eg, WhatsApp) involving CSANZ board members, cardiology heads of department and key opinion leaders were used to identify relevant resources, guidance documents and protocols. An online living document was shared to facilitate wide input. The full draft underwent peer review by the listed authors as well as external experts in each subspecialty field of cardiology before agreement and acceptance of the final document. Pre-existing cardiovascular disease and COVID-19Patients with COVID-19 and pre-existing CVD are at increased risk of severe disease and death. [1][2][3][4][5] A meta-analysis of eight studies and over 46 000 patients in China reported that hypertension, diabetes and CVD were the most common comorbidities. 5 Baseline CVD conferred the highest odds of any comorbidity for developing severe versus mild COVID-19 (odds ratio [OR], 3.42; 95% CI, 1.88-6.22). Hypertension ...

No abstract