Peter H Waddingham, Sanjeev Bhattacharyya, Jet Van Zalen and Guy Lloyd
Patients with non-ischaemic systolic heart failure (HF) and idiopathic dilated cardiomyopathy (DCM) are a heterogenous group with varied morbidity and mortality. Prognostication in this group is challenging. We performed a systematic review and meta-analysis to examine the significance of the presence of contractile reserve as assessed via stress imaging on mortality and hospitalisation.
A search for studies that non-invasively assessed contractile reserve in patients with DCM or non-ischaemic HF with reduced ejection fraction, stress imaging with follow-up data comparing outcomes. A range of imaging modalities and stressors were included. We examined primary endpoints of mortality and secondary endpoints of combined cardiovascular events including HF progression or hospitalisation. Our analysis compared endpoints in patients with contractile reserve and those without it.
Nine prospective cohort studies were identified describing a total of 787 patients. These studies are methodologically but not statistically heterogenous (I 2 = 31%). Using a random effect model, the presence of contractile reserve was associated with a significantly lower risk of mortality and cardiovascular events odds ratios of 0.20 (CI 0.11, 0.39) (P < 0.00001) and 0.13 (CI 0.04, 0.40) (P = 0.0004), respectively.
Regardless of stressor and imaging modality and despite the significant methodological heterogeneity within the current data (imaging techniques and parameters), patients with non-ischaemic cardiomyopathy and reduced EF who demonstrate contractile reserve have a lower mortality, and lower events/hospitalisations. The presence of contractile reserve therefore offers a potential positive prognostic indicator when managing these patients.
Daniel A Jeffery, Guy Lloyd and Arjun K Ghosh
Jet van Zalen, Sveeta Badiani, Lesley Hart, Andrew Marshall, Louisa Beale, Gary Brickley, Sanjeev Bhattacharyya, Nikhil Patel and Guy Lloyd
Background: Mortality dramatically rises with the onset of symptoms in patients with severe aortic stenosis (AS). Surgery is indicated when symptoms become apparent or when there is ventricular decompensation. Cardiopulmonary exercise testing (CPET) in combination with exercise echocardiography can unmask symptoms and provides valuable information regarding contractile reserve. The aim of the present study was to determine the prevalence of reduced exercise tolerance and the parameters predicting adverse cardiovascular events.
Methods: Thirty-two patients with asymptomatic severe AS were included in this study. Patients were followed up as part of an enhanced surveillance clinic.
Results: Age was 69±15.7 years, 75% of patients were male. Patients had a raised NT-ProBNP of 301 pg/ml. VO2peak was 19.5±6.2 ml/kg/min. 41% of patients had a reduced %VO2peak and this predicted unplanned cardiac hospitalisation (p=0.005). Exercise systolic longitudinal velocity(S’) and age were the strongest predictors for VO2peak (R2=0.76; p<0.0001). Exercise S’ was the strongest predictor for NT-ProBNP (R2=0.48; p=0.001).
Conclusion: A large proportion of patients had a lower than predicted VO2peak. The major determinant of exercise and NT-proBNP is the ability of the left ventricle(LV) to augment S’ on exercise rather than the severity of aortic valve obstruction or resting structural remodelling of the LV. Reduced exercise tolerance and more adverse remodelling, rather than valve obstruction predicted unplanned hospitalisation. This study demonstrates that for those patients, in whom a watchful waiting is an agreed strategy, a detailed assessment should be undertaken including CPET, exercise echocardiography and biomarkers to ensure those with exercise limitation and risk of decompensation are detected early and treated appropriately.
Sveeta Badiani, Jet van Zalen, Saad Saheecha, Lesley Hart, Ann Topham, Nikhil Patel, Lydia Sturridge, Andrew Marshall, Neil Sulke, Stephen Furniss and Guy Lloyd
The rate of progression of aortic regurgitation (AR) is not well described. Current guidelines state that asymptomatic patients with mild AR should be followed up every 3–5 years and 1–2 yearly for moderate AR. This study describes the lesion and clinical based progression of mild and moderate AR in a population of patients undergoing systematic follow-up.
Methods and results
341 patients with either mild or moderate AR were included. The rates of clinical events (death, aortic valve replacement and cardiac hospitalization) and progression of AR are reported.
341 patients were included; mean age was 71.1 years (IQR 66–80 years) and the median follow-up period was 4.6 (IQR 2–6.7) years. 292 patients did not have any events during follow-up. 3 patients required aortic valve replacement (2 of these due to severe aortic stenosis and 1 due to severe mitral regurgitation and co-existent moderate AR). 44 patients required cardiac hospitalization. 9 patients died during follow-up and 35 patients (10%) showed a progression of AR during follow-up with an average time of 4.0 ± 2.6 years. 8 patients (2.3% of the total) progressed to severe AR.
Patients with mixed valvular pathology showed a greater increase in AR progression (27 (15%) vs 8 (5%); P = 0.004).
Over medium term systematic follow-up progression and clinical events in patients with AR is rare, regardless of etiology. Patients who suffered from AR as an isolated valve pathology were less likely to show AR progression over time.
Jet van Zalen, Nikhil R Patel, Steven J Podd, Prashanth Raju, Rob McIntosh, Gary Brickley, Louisa Beale, Lydia P Sturridge and Guy W L Lloyd
Resting echocardiography measurements are poor predictors of exercise capacity and symptoms in patients with heart failure (HF). Stress echocardiography may provide additional information and can be expressed using left ventricular ejection fraction (LVEF), or diastolic parameters (E/E′), but LVEF has some major limitations. Systolic annular velocity (S′) provides a measure of longitudinal systolic function, which is relatively easy to obtain and shows a good relationship with exercise capacity. The objective of this study was to investigate the relationship among S′, E/E′ and LVEF obtained during stress echocardiography and both mortality and hospitalisation. A secondary objective was to compare S′ measured using a simplified two-wall model. A total of 80 patients with stable HF underwent exercise stress echocardiography and simultaneous cardiopulmonary exercise testing. Volumetric and tissue velocity imaging (TVI) measurements were obtained, as was peak oxygen uptake (VO2 peak). Of the total number of patients, 11 died and 22 required cardiac hospitalisation. S′ at peak exertion was a powerful predictor for death and hospitalisation. Cut-off points of 5.3 cm/s for death and 5.7 cm/s for hospitalisation provided optimum sensitivity and specificity. This study suggests that, in patients with systolic HF, S′ at peak exertion calculated from the averaged spectral TVI systolic velocity of six myocardial segments, or using a simplified measure of two myocardial segments, is a powerful predictor of future events and stronger than LVEF, diastolic velocities at rest or exercise and VO2 peak. Results indicate that measuring S′ during exercise echocardiography might play an important role in understanding the likelihood of adverse clinical outcomes in patients with HF.
Nicola Smith, Richard Steeds, Navroz Masani, Julie Sandoval, Gill Wharton, Jane Allen, John Chambers, Richard Jones, Guy Lloyd, Bushra Rana, Kevin O'Gallagher, Richard Wheeler and Vishal Sharma
Hypertrophic cardiomyopathy (HCM) is a relatively common inherited cardiac condition with a prevalence of approximately one in 500. It results in otherwise unexplained hypertrophy of the myocardium and predisposes the patient to a variety of disease-related complications including sudden cardiac death. Echocardiography is of vital importance in the diagnosis, assessment and follow-up of patients with known or suspected HCM. The British Society of Echocardiography (BSE) has previously published a minimum dataset for transthoracic echocardiography, providing the core parameters necessary when performing a standard echocardiographic study. However, for patients with known or suspected HCM, additional views and measurements are necessary. These additional views allow more subtle abnormalities to be detected or may provide important information in order to identify patients with an adverse prognosis. The aim of this Guideline is to outline the additional images and measurements that should be obtained when performing a study on a patient with known or suspected HCM.
Richard Wheeler, Richard Steeds, Bushra Rana, Gill Wharton, Nicola Smith, Jane Allen, John Chambers, Richard Jones, Guy Lloyd, Kevin O'Gallagher and Vishal Sharma
A systematic approach to transoesophageal echocardiography (TOE) is essential to ensure that no pathology is missed during a study. In addition, a standardised approach facilitates the education and training of operators and is helpful when reviewing studies performed in other departments or by different operators. This document produced by the British Society of Echocardiography aims to provide a framework for a standard TOE study. In addition to a minimum dataset, the layout proposes a recommended sequence in which to perform a comprehensive study. It is recommended that this standardised approach is followed when performing TOE in all clinical settings, including intraoperative TOE to ensure important pathology is not missed. Consequently, this document has been prepared with the direct involvement of the Association of Cardiothoracic Anaesthetists (ACTA).
Richard P Steeds, Craig E Stiles, Vishal Sharma, John B Chambers, Guy Lloyd and William Drake
This is a joint position statement of the British Society of Echocardiography, the British Heart Valve Society and the Society for Endocrinology on the role of echocardiography in monitoring patients receiving dopamine agonist (DA) therapy for hyperprolactinaemia. (1) Evidence that DA pharmacotherapy causes abnormal valve morphology and dysfunction at doses used in the management of hyperprolactinaemia is extremely limited. Evidence of clinically significant valve pathology is absent, except for isolated case reports around which questions remain. (2) Attributing change in degree of valvular regurgitation, especially in mild and moderate tricuspid regurgitation, to adverse effects of DA in hyperprolactinaemia should be avoided if there are no associated pathological changes in leaflet thickness, restriction or retraction. It must be noted that even where morphological change in leaflet structure and function may be suspected, grading is semi-quantitative on echocardiography and may vary between different machines, ultrasound settings and operators. (3) Decisions regarding discontinuation of medication should only be made after review of serial imaging by an echocardiographer experienced in analysing drug-induced valvulopathy or carcinoid heart disease. (4) A standard transthoracic echocardiogram should be performed before a patient starts DA therapy for hyperprolactinaemia. Repeat transthoracic echocardiography should then be performed at 5 years after starting cabergoline in patients taking a total weekly dose less than or equal to 2 mg. If there has been no change on the 5-year scan, repeat echocardiography could continue at 5-yearly intervals. If a patient is taking more than a total weekly dose of 2 mg, then annual echocardiography is recommended.
David Oxborough, Saqib Ghani, Allan Harkness, Guy Lloyd, William Moody, Liam Ring, Julie Sandoval, Roxy Senior, Nabeel Sheikh, Martin Stout, Victor Utomi, James Willis, Abbas Zaidi and Richard Steeds
The aim of the study is to establish the impact of 2D echocardiographic methods on absolute values for aortic root dimensions and to describe any allometric relationship to body size. We adopted a nationwide cross-sectional prospective multicentre design using images obtained from studies utilising control groups or where specific normality was being assessed. A total of 248 participants were enrolled with no history of cardiovascular disease, diabetes, hypertension or abnormal findings on echocardiography. Aortic root dimensions were measured at the annulus, the sinus of Valsalva, the sinotubular junction, the proximal ascending aorta and the aortic arch using the inner edge and leading edge methods in both diastole and systole by 2D echocardiography. All dimensions were scaled allometrically to body surface area (BSA), height and pulmonary artery diameter. For all parameters with the exception of the aortic annulus, dimensions were significantly larger in systole (P<0.05). All aortic root and arch measurements were significantly larger when measured using the leading edge method compared with the inner edge method (P<0.05). Allometric scaling provided a b exponent of BSA0.6 in order to achieve size independence. Similarly, ratio scaling to height in subjects under the age of 40 years also produced size independence. In conclusion, the largest aortic dimensions occur in systole while using the leading edge method. Reproducibility of measurement, however, is better when assessing aortic dimensions in diastole. There is an allometric relationship to BSA and, therefore, allometric scaling in the order of BSA0.6 provides a size-independent index that is not influenced by the age or gender.