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Repeated echocardiography after first ever ST segment elevation myocardial

infarction treated with primary percutaneous coronary intervention, is it
necessary

Article  in  European Heart Journal · August 2013

DOI: 10.1093/eurheartj/eht307.P669

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 132 Diagnostic tools in heart failure
P668 | BEDSIDE
Suboptimal accuracy of the ED physician and NT-proBNP levels to
diagnose heart failure in elderly patients with dyspnoea: the
Akershus Cardiac Examination (ACE) 2 Study
J. Brynildsen 1 , A.D. Hoiseth 1 , S. Nygard 2 , T.A. Hagve 3 , G. Christensen 2 ,
T. Omland 1 , H. Rosjo 1 . 1 University of Oslo, Akershus University Hospital,
Department of Medicine, Lorenskog, Norway; 2 University of Oslo, Institute for
Experimental Medical Research, Ulleval University Hospital, Oslo, Norway;
3 University of Oslo, Akershus University Hospital, Division for Diagnostics and
Technology, Lorenskog, Norway
Purpose: To examine accuracy of Emergency Department (ED) physicians and
N-terminal (NT) proBNP levels for diagnosing heart failure (HF) in a contemporary
cohort of patients hospitalised with acute dyspnoea.
Methods: We included 314 consecutive patients with dyspnoea and collected the
probability of HF (0-100%) from the ED physicians prior to NT-proBNP measure-
ments. HF was adjudicated according to guidelines by two independent senior
physicians. Among non-HF related hospitalisations we also assessed whether
there was coexisting myocardial dysfunction, e.g. patient with HF hospitalised
due to pneumonia.
Results: Mean age was 70±1 y and 143 patients (46%) were diagnosed with HF
as the cause of the hospitalisation, of whom 52 patients (36%) had left ventricu-
lar ejection fraction≥50%. Several variables previously reported to be predictive
of HF were independently associated with a diagnosis of HF in our patients, in-
cluding NT-proBNP levels. The area under the curve (AUC) for ED physician to
differentiate HF patients from the other patients was 0.864 (95% CI 0.821-0.900)
compared to AUC=0.859 (0.816-0.896) for NT-proBNP levels, p=0.84. Excluding
the patients with non-HF related hospitalisation but coexisting myocardial dys-
function (n=55) improved the AUC for both ED physicians and NT-proBNP levels:
0.898 (0.854-0.932) vs. 0.926 (0.887-0.955), respectively, p=0.17.
Conclusion: The accuracy of ED physicians and NT-proBNP for diagnosing HF
were sub-optimal in this cohort of elderly subjects hospitalised for acute dyspnoea
compared to previous studies, which primarily was caused by a high proportion
of coexisting myocardial dysfunction also in the group of patients with non-HF
aetiology of the index hospitalisation.
P669 | BEDSIDE
Repeated echocardiography after first ever ST segment elevation
myocardial infarction treated with primary percutaneous coronary
intervention, is it necessary
H. Soeholm, J. Loenborg, M.J. Andersen, N. Vejlstrup, T. Engstroem, J.E. Moller,
C. Hassager. Rigshospitalet - Copenhagen University Hospital, Heart Centre,
Department of Cardiology, Copenhagen, Denmark
Purpose: Current guidelines recommend early echocardiography in patients suf-
fering from ST-segment elevation myocardial infarction (STEMI) and routinely left
ventricular (LV) function is reassessed after 3 months. However, most studies
have been performed in the pre-thrombolysis or thrombolysis era. We sought to
assess changes in LV size/function using echocardiography and cardiac magnetic
resonance imaging (CMRI) in a contemporary STEMI-population treated with pri-
mary percutaneous coronary intervention (pPCI).
Method: In a prospective study, 128 patients (age 61±11 years) with first ever
STEMI were treated with pPCI and examined with 2D echocardiography and
CMRI at baseline (<72hrs) and at follow-up after 3 months.
Results: Using 2D echocardiography 44 patients (34%) were found to have pre-
served LVEF (>50%), 70 patients (55%) to have mild/moderate systolic dysfunc-
tion (35-50%) and 14 patients (11%) to have severe systolic dysfunction (<35%)
at baseline. A significant increase in LVEF of 5% was found from baseline to
follow-up measured by both echocardiography (45% (IQR: 39-53%) to 53% (47-
58%), p<0.001) and CMRI (52% (46-58%) to 57% (51-64%),p<0.001). Improve-
ment was seen in 55 patients (43%) and 79% of patients with severe systolic dys-
function at baseline were re-classified as having preserved or mild/mod. systolic
dysfunction at follow-up. Irrespective of baseline LVEF, deterioration was noted in
12 patients (9%), but no patients went from preserved to severe systolic dysfunc-
tion.
Echocardiography
Conclusion: 79% of patients with severe systolic dysfunction immediately after
STEMI improved systolic function significantly – emphasising the importance of
repeated assessment after 3 months. Echocardiography and CMRI both showed
equal improvement in systolic function with no differences between modalities.
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P670 | BEDSIDE
Echocardiographic indices of right heart function affecting
ventilatory efficiency during exercise in left and right ventricular
failure
M. Jasiewicz, M. Knapp, K. Ptaszynska, A. Szpakowicz, W.J. Musial, K. Kaminski.
Medical University of Bialystok, Department of Cardiology, Bialystok, Poland
The aim of the study was to assess relationship between echocardiographic in-
dices of Right Ventricular (RV) function and gas exchange variables during exer-
cise in patients (pts) with Left Ventricular (LV) failure and preserved systolic RV
function and in pts with Pulmonary Arterial Hypertension (PAH).
We prospectively studied 21 pts with PAH and 24 stable pts with chronic systolic
LV failure (CHF) with no elevation of estimated mean pulmonary artery pressure
(emPAP) and preserved systolic RV function, asessed by echocardiography. Exer-
cise capacity and gas exchange parameters were obtained from cardiopulmonary
exercise test.
Both groups were comparable in respect to key clinical parameters: mean age
51±18 years in PAH pts vs 59±11 in CHF pts, median NYHA class III in
both groups. There was no significant difference in mean BNP concentrations
(421±484 vs 210±14 pg/ml), mean 6MWD (367±124 vs 392±86 m), peak VO2
consumption (15.9±6 vs 17±4.8 ml/kg/min). Mean LVEF was 58±5 vs 24±5%
(p<0.0001), emPAP was 53.6±15.9 vs 19.6±3.9 mmHg (p<0.0001) respectively.
PAH pts were characterised by indices of impaired RV function in echo: smaller
fractional area change (20±9.4 vs 40±8.3%; p<0.0001), increased right atrium
area (26.9±11.9 vs 14±5 cm2 ; p<0.001) and lower TAPSE (18±4 vs 24±6 mm;
p<0.001). RV filling measured by E/E’ was increased but not different between the
groups (7.1 vs 6.3). PAH pts had increased parameters reflecting lower ventila-
tory efficiency during exercise: peak VE/VCO2 (49.1±13.4 vs 32±4.4; p<0.0001)
and VE/VCO2 slope (50.8±14.9 vs 32±4.9; p<0.0001) together with lower rest-
ing and peak PetCO2 (24.6±5.5 vs 30.6±4 mmHg; p<0.001 and 22.1±7.4 vs
33.3±4.1 mmHg; p<0.0001 respectively). There was significant correlation be-
tween exercise ventilatory parameters and echocardiographic indices of RV func-
tion (p<0.05). In PAH pts E/E’ positively correlated with VE/VCO2 and VE/VCO2
slope (r=0.47), negatively with resting and peak PetCO2 (r=-0.48). TAPSE cor-
related inversely with the same parameters. In CHF pts only E/E’ correlated
with abovementioned parameters (p<0.05): VE/VCO2 (r=0.42), VE/VCO2 slope
(r=0.48) and PetCO2 (r=-0.43).
The first quality of RV function affected in LV failure is RV filling, which is as-
sociated with ventilatory inefficiency during exercise. In pts with PAH ventilatory
response is also affected by RV systolic function. Hence RV function is strongly
associated with ventilatory performance of pts with CHF. Despite similar general
clinical presentation pts with LV and RV failure present very different repsonse to
exercise. This should be reflected in diagnostic ang treatment guidelines.
P671 | BEDSIDE
The role of heart failure in hospital management program upon
mortality
C.P. Amorim, R. Bosquetti, E.P.V. Felix, M.B. Carli, R.A. Gomes, V.S.G. Ribeiro,
V.S. Issa, F.J.A. Ramires. Heart Hospital (HCor), São Paulo, Brazil
Introduction: Heart Failure (HF) is a serious public health problem around the
world with a fast growing prevalence. This syndrome curses with high morbidity
and mortality. Patients who need hospitalization are considered to be the higher
risk group. The application of guidelines significantly improves both morbidity and
mortality. Our hypothesis is that an in hospital program for disease management
can improve adherence to guidelines and, therefore, reduce mortality from HF.
Objective: Evaluate the impact of an In Hospital Management Program for HF
upon mortality in this population.
Material and methods: We evaluated 428 patients with a diagnosis of HF with
ventricular dysfunction (VLEF<45%) divided into two groups: Group 1 (G1) 258
hospitalized patients treated in 2010, before the adoption of the program, and
Group 2 (G2) 170 patients hospitalized from August 2011 to October 2012 after
the implementation of the Program. The Program consist in a trained and spe-
cialized multidisciplinary team working directly with the HF patients and their rela-
tives including a telephone follow up interview after discharge. In Hospital mortal-
ity was evaluated. For statistical analysis we used General Estimating Equations
test (GEE).
Results: Table 1.
Table 1
Variable G1 (2010) (n=258) G2 (2011/12) (n=170) P value
Age (years) 74 (63–81) 75 (68–81) 0.088
Male 187 (72%) 112 (70%) 0.66
LVEF 33 (28-39) 32 (27-38) 0.5477
Death 42 (17.6%) 14 (8.4%) 0.0083
Conclusion: The Clinical Care Management Program for patients with HF admit-
ted in a hospital was very efficient, with significant decreased mortality.