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Endomyocardial biopsy (EMB) is an invasive diagnostic tool, mainly used during the follow-up of heart transplant patients (HTx). Its others indications have been established and discussed in position statement paper from international cardiac societies. However the use of EMB in real life remains controversial and differs widely from a center to another. We carried out a nationwide survey to describe the current use of EMB in non-heart transplant patients. We used the National Hospital Discharge Database (PMSI) that contains diagnostic codes of all hospitalizations. Medical data is coded from different sources (e.g. laboratory reports, discharge reports) according defined terminologies and coding rules. We included all hospitalizations during which EMB (code CCAM DAHF001 – Endocardium or Myocardium Biopsy, transcutaneous vascular access) was performed from January 1st 2019 to December 31th 2020. We excluded all patients with a main or secondary or associated diagnosis of heart transplant. Main diagnosis as well as secondary and associated diagnoses were collected in order to define the medical indication of EMB. We aggregated EMB indications into 8 groups. Among 9735 EMB, 914 (9%) were carried out for non-transplant patients during the 2 years of analysis. Among the 212 hospitals with interventional cardiology units, only 53 (25%) carried out EMB in non-transplant patients and 86% of these procedures were carried out in transplant centers. Three hospitals carried out 37% of all non-transplant EMB while 23 centers carried out no more than 5 EMB over the 2-year survey. Figure 1 displays main indications of EMB in non-transplant patients. According to the PMSI database, the 3 main indications of EMB were amyloïdosis (29%), non-ischemic dilated cardiomyopathy (28%) and myocarditis (22%). The medical indication could not be specified in 155 (16%) patients. In non-transplant patients, EMB is rarely performed in France, only in a few hospitals and with significant disparity in the annual rate of procedures carried out by each. Most EMB were performed because of amyloidosis or dilated cardiomyopathy and myocarditis. Further data about local constraints as well as clinical impact of EMB for each patient would be useful to understand further the role of EMB in real life. [ABSTRACT FROM AUTHOR]

Several pulmonary arterial hypertension (PAH) risk assessment tools (i.e. risk of all-cause death) exist. Yet their performances within a cohort of heart failure (HF) patients with post-capillary pulmonary hypertension (pcPH) have never been explored. To assess the discrimination performance of usual PAH risk assessment tools in a cohort of pcPH patients. HF patients with stable left heart disease and the need for right heart catheterization at rest were enrolled from 2010 to 2018 and followed-up in this prospective multicenter study. pcPH was defined as a mPAP > 20 mmHg with a PAWP > 15 mmHg according to the 2022 ESC guidelines. The following PAH risk assessment tools were used: REVEAL 2.0 (3-strata and continuous score system), REVEAL Lite (abredged version of REVEAL), COMPERA 2.0 (4-strata) and the French method. Three-years all-cause death was the primary outcome. In total, 519 HF patients were enrolled (59% male, median age 62 yo, mPAP averaged 37 mmHg): 441 (85%) had at least the 7-requested variables for REVEAL2.0 calculation and 319 (61%) the 3-requested variables for COMPERA2.0 or the noninvasive French method calculation. For each of the methods, the higher the score, the better the long-term survival (log-rank P < 0.001, Figures 1 and 2). Each of the method had fair to good discrimination performance. REVEAL2.0 continuous score depicted the highest c-index (0.66, 95%CI [0.62–0.72]) followed by REVEAL2.0 3-strata system (0.63, 95%CI [0.60–0.70]), REVEAL Lite (0.59, 95%CI [0.56–0.62]), COMPERA2.0 (0.59, 95%CI [0.54–0.64]) and the French method (0.54, 95%CI [0.51–0.57]). PAH risk assessment tools may be used for pcPH risk assessment with fair-to-good discrimination power, especially REVEAL2.0. Further research should be focused on risk assessment in this particular population of HF patients. [ABSTRACT FROM AUTHOR]

While few scores are available for risk stratification of patients hospitalized for AHF using traditional statistical methods, the potential benefit of machine learning (ML) is not established. To investigate the feasibility and accuracy of a ML model using clinical, biological, and echocardiographic data to predict in-hospital major adverse events (MAE) in patients hospitalized for AHF and compare its performance to traditional models and existing scores. Three ML models were developed using clinical and echocardiographic parameters to predict in-hospital MAE, including death, resuscitated cardiac arrest or cardiogenic shock requiring medical or mechanical hemodynamic support. The study cohort consists of consecutive patients admitted for AHF from a French nationwide, multicenter, prospective, study involving 39 centers (NCT05063097). Immediately on arrival in ICCU a standardized exhaled carbon monoxide (CO) was systematically measured, and the presence of illicit drugs was determined through an urine drug assay (NarcoCheck®). Least absolute shrinkage and selection operator (LASSO) regression was used to select variables and prevent model over-fitting. The three ML models (LASSO, random forest and XGBoost) were then trained on 70% of patients and evaluated on the other 30% as internal validation. Their performance was compared against standard logistic regression model. Among 459 consecutive patients included (age 68 ± 14 years, 68% male), 47 had in-hospital MAE (9.8%). Out of 28 clinical, biological, ECG, and echocardiographic variables, seven were selected as being the most important in predicting MAE in the training set (n = 322): mean arterial pressure (MAP), ischemic etiology, VTI, E/e', TAPSE (tricuspid annular plane systolic excursion), illicit drugs and Carbon monoxide. The random forest model showed the best performance compared with the other ML models (AUROC = 0.82, PR-AUC = 0.48, F1 score = 0.56) (Figure 1). Our proposed ML model exhibited a higher AUC compared with an existing score for prediction of MAE (AUROC for our ML model: 0.82 vs. acute HF-score: 0.57; P < 0.001). Our ML-model including seven clinical and echocardiographic variables, including carbon monoxide level and illicit drugs use, exhibited a better performance than traditional statistical methods to predict in-hospital outcomes in patients admitted for AHF. [ABSTRACT FROM AUTHOR]

Although the left atrioventricular coupling index (LACI) measured by Cardiac MRI is a strong predictor of CV events, the availability to CMR remains limited in clinical routine. Therefore, it would be useful to validate LACI assessment using other imaging methods such as computed tomography (CT). To investigate the prognostic value of the LACI assessed by cardiac CT, to predict the occurrence of CV death in consecutive patients without known CVD referred for CCTA. Between 2010 and 2020, we conducted a single-center study with all consecutive patients without known CVD referred for CCTA. LACI was defined as the ratio of LA to LV end-diastolic volumes. The primary outcome was cardiovascular death. Cox regressions were used to evaluate the association of LACI with the primary outcome after adjustment for traditional risk factors and CCTA findings. In 1444 patients (70 ± 12 years, 43% men), 92 (6.4%) patients experienced all-cause death, including 67 (4.3%) patients with cardiovascular death after a median (IQR) follow-up of 6.8 (5.9–9.1) years. After adjustment for risk factors and CCTA findings, LACI was positively associated with the occurrence of cardiovascular death (adjusted hazard ratio [HR]: 1.07 [95% CI: 1.05–1.09] per 1% increment, P < 0.001), and all-cause death (adjusted HR, 1.05 [95% CI: 1.03–1.07] per 1% increment, P < 0.001). After adjustment, a LACI ≥ 25% showed the best improvement in model discrimination and reclassification above traditional risk factors and CCTA findings (C-statistic improvement: 0.27; NRI = 0.826; IDI = 0.209, all P < 0.001; LR-test P < 0.001). LACI measured by CCTA is independently associated with cardiovascular death and all-cause death in patients without known CVD referred for CCTA, with an incremental prognostic value over traditional risk factors and CCTA findings. Incremental prognostic value of LACI using CT (Fig. 1). [ABSTRACT FROM AUTHOR]

To assess the risk of clinical worsening in heart failure (HF) is an important goal because HF is a progressive disease with a severe prognosis. The risk is usually estimated by using clinical, biological and clinical variables and by the dosage of natriuretic peptides. Other biomarkers have been tested in this setting and among candidates, the soluble ST2 seems a relevant one. The objective of our study was firstly, to analyze the predictive value of blood levels of sST2 in a cohort of patients with chronic heart failure and secondly, to study the variables associated with sST2 levels and to compare its predictive value to that of BNP levels. Measurement of both BNP and sST2 was performed in patients who were followed in our department. Baseline clinical and biological characteristics were also obtained. The primary endpoint was a composite of unplanned HF-related hospitalizations and all-cause death or cardiac transplantation. Predictive values of sST2 and BNP levels were estimated by using survival curves and Cox models. Our cohort included 298 patients: age 61y (IQR 52-69), 27% female, 46% ischemic heart disease, 22% diabetes, 25% atrial fibrillation, LVEF 0.38 (IQR 0.28-0.48), eGFR 75 (IQR 55-92)ml/min/1.73m2. Median sST2 levels were 31 ng/L (24-46) and BNP levels were 192 pg/mL (IQR 87-420). Increase in sST2 levels was significantly associated with age, BNP and renal function. During a median follow-up of 36 months, there were 76 events (25.5%) including 32 deaths. The increase in sST2 levels was strongly associated with clinical events. The Fig. 1 shows survival curves by using the usual sST2 cut-off of 35 ng/l; after adjustment on BNP levels, the Hazard Ratio was 2.85 [1.77-4.58]. In patients with chronic HF, sST2 levels are significantly predictive of outcome on top of BNP. The clinical usefulness of systematic measurement sST2 in addition to natriuretic peptides deserves dedicated studies. [ABSTRACT FROM AUTHOR]

Background/Objectives: Cardiotoxic drug poisoning can lead to severe cardiac shock (CS) and death. B-type natriuretic peptide (BNP) is a well-established diagnostic and prognostic marker in heart failure but has never been assessed in patients with cardiotoxic drug poisoning. The aim of the study was to determine whether BNP could be useful for early stratification of patients admitted to intensive care unit. Methods: 30 consecutive patients experiencing shock and cardiotoxic drug exposure were enrolled in a prospective monocentric study and underwent at least two BNP measurements within the first 24 h after admission. Results: While BNP values on admission were poorly informative, subsequent BNP measurements (11 ± 6 h after admission) were significantly increased in patients with CS compared to those with non-CS (756; [364-1130] versus 24; [15-65] pg/ml respectively; P == 0.008). This second BNP level was also significantly increased in non-survivor patients compared to survivor patients (784; [654-1028] versus 29; [15-104] pg/ml respectively; P == 0.05): BNP levels above 360 pg/ml predicted in-hospital mortality (sensitivity == 100%, specificity == 92%). In a multivariate analysis, BNP, SAPS II score and lactate blood level were associated with death. Conclusions: Serial BNP measurements after admission for cardiotoxic drug poisoning are useful to identify patients at the highest risk of CS as well as in-hospital death. [ABSTRACT FROM AUTHOR]

Aims: The clinical features, prognosis, and even definition of left ventricular non-compaction (LVNC) are still the subject of much debate. The aim of this registry was to describe the clinical, echocardiographic, and prognostic features of LVNC in France. The main endpoint was to assess clinical and echocardiographic predictors of adverse outcome, defined as death or heart transplantation. Methods and Results: Between 2004 and 2006, 154 suspected cases of LNVC were identified from a nationwide survey in France. The diagnosis of LVNC was confirmed in 105 cases by echocardiographic evaluation in a core laboratory. Clinical and echocardiographic data for the 105 cases of LVNC are presented. Left ventricular non-compaction was first detected from heart failure symptoms in 45 patients, rhythm disorders in 12, and familial screening in 8. Left ventricular ejection fraction (LVEF) was < 30% in 46% of patients, but ≥ 50% in 16%. The latter had less symptoms of severe heart failure (11 vs. 54%, P = 0.001), but similar extension of the NC zone. During 2.33 ± 1.47 years of follow-up, several complications occurred, including severe heart failure in 33 patients, transplantation in 9, ventricular arrhythmia in 7, embolic events in 9, and death in 12. Factors associated with death or heart transplantation were NYHA 3 or 4 (HR = 6.69; P = 0.0007), high LV filling pressures (HR = 7.59; P = 0.001), LVEF (HR = 0.93; P = 0.006), and hospitalization for heart failure (HR = 13.55; P < 0.0001). Conclusion: In this large reported series of LVNC, we observed that: (i) Left ventricular non-compaction was detected by familial screening in asymptomatic patients in 8% of cases. (ii) Left ventricular non-compaction was frequently over-diagnosed by echocardiography. (iii) Patients identified as LVNC presented with a high risk of severe complications, transplantation or death and needed close follow-up. [ABSTRACT FROM AUTHOR]

Diabetes mellitus is a growing epidemic with a prevalence among patients with heart failure (HF) approaching 30%. Diabetes worsens the prognosis of HF, and the pathophysiology is complex and multifactorial. Early detection of subtle alterations in cardiac function by modern tools, such as Doppler echocardiography or brain natriuretic peptide dosage, is thus important in these patients. All drugs known to be effective in HF with systolic dysfunction are also effective in patients with diabetes. Angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists also seem particularly useful. Overall, however, little is known about the treatment of diabetic patients with HF, especially in case of preserved systolic function. Ongoing and future trials should help to determine the best treatment for these patients with or without associated diabetes. This review assesses the relationships between diabetes mellitus and HF and discusses the various medical strategies. [ABSTRACT FROM AUTHOR]

AIMS: Since colour tissue Doppler (CTD) has been shown to underestimate myocardial velocity, we sought to compare CTD with spectral tissue Doppler (STD) and establish agreement and corresponding thresholds for clinical applications. METHODS AND RESULTS: We included 52 consecutive patients with sinus rhythm referred for echocardiographic assessment. Analysis involved a commercially available echosonographer (Vivid 7, GE-Vingmed) and the Echopac system for offline assessment. Myocardial velocities were recorded by STD and CTD in a 4-chamber apical view. CTD values were lower than those measured by STD: 6.0 +/- 2.5 versus 8.2 +/- 2.8 for Ea; 5.5 +/- 2.3 versus 7.9 +/- 2.9 for Aa, and 5.4 +/- 2.0 versus 7.7 +/- 2.4 for Sa (P < 0.001 for all). CTD overestimated the E/Ea: 14.7 +/- 7.6 versus 10.1 +/- 4.1, P < 0.001. Reliability between the two methods was low to moderate: kappa values ranged from 0.33 +/- 0.10 to 0.57 +/- 0.12. CTD thresholds corresponding to usual STD thresholds were calculated, but reliability was not significantly increased, except for the E/Ea ratio. By using continuous values, the ability of the Ea, Sa and E/Ea to predict the presence of heart failure in this sample was similar whatever the method. CONCLUSION: CTD consistently underestimates myocardial velocity values and overestimates E/Ea. A shift of thresholds between the two methods is not sufficient to obtain good agreement, except when measuring the E/Ea ratio. [ABSTRACT FROM AUTHOR]

Coronary artery calcifications (CAC) scoring assessed by the Agatston score has shown an excellent prognostic value in large studies and particularly in diabetic patients, with a very low rate of cardiovascular events in patients with a zero Agatston score. Moreover, recent studies have suggested that high-sensitive cardiac troponin I (hs-cTnI) and brain natriuretic peptide (BNP) may be useful for detecting subclinical atherosclerosis. However, the link between hs-cTnI/BNP and the Agatston score has not been investigated in patients with diabetes. The aim of this study was to investigate if hs-cTnI and BNP can bring additional value to predict zero Agatston score in patients with diabetes mellitus in addition to usual risk factors. Between 2015 and 2019, CAC score was prospectively performed in consecutive patients with diabetes mellitus. Patients with symptoms, known coronary artery disease or history of atrial fibrillation were excluded. Within 24 h from CT examination, peripheral blood samples were taken to measure hs-cTnI and BNP. The relationship between serum hs-cTnI/BNP concentrations and zero Agatston score was assessed using univariate and multivariate binomial models. The implication of hs-cTnI and BNP in this multivariate model was evaluated using nested models associated with Chi2 test of independence. A total of 844 patients with diabetes were enrolled (61 ± 7years, 57% men, mean duration of diabetes 18years). In this population, 294(35%) had a zero Agatston score, 253(30%) an Agatston score from 1 to 100, 161(19%) from 101 to 400, and 136(16%) higher than 400. In univariate analysis, hs-cTnI and BNP concentrations were associated with zero Agatston score (respectively OR, 2.63 [95%CI, 1.51-5.01]; P < 0.001 and OR, 1.09 [95%CI, 1.01-1.22]; P = 0.03). In multivariate analysis, hs-cTnI and BNP concentrations were associated with zero Agatston score (respectively OR, 2.38 [95%CI, 1.51-4.76]; P = 0.009 and OR, 1.18 [95%CI, 1.07-1.32]; P = 0.001). The multivariate model included age, gender, smoking, dyslipidemia, duration of diabetes, hypertension, diabetic neuropathy, hs-cTnI and BNP concentrations, significantly discriminated the zero Agatston score (AUC = 0.81; P < 0.001) (Fig. 1). The most discriminant threshold was ≤ 3 ng/l for hs-cTnI and < 17 ng/l for BNP. In nested models, both hs-cTnI and BNP brought information to this multivariate model to predict a zero Agatston score (respectively P = 0.003 and P < 0.001). Moreover, removing hs-cTnI and BNP from the model results in a significant reduction in model performance (AUC = 0.79; P = 0.004). Cardiac biomarkers hs-cTnI and BNP are associated with zero Agatston score, which is correlated with a very low risk of cardiovascular events, in asymptomatic patients with diabetes mellitus. [ABSTRACT FROM AUTHOR]

Objectives: To assess non-invasively the acute effects of cardiac resynchronisation therapy (CRT) on functional mitral regurgitation (MR) at rest and during dynamic exercise. Methods: 21 patients with left ventricular (LV) systolic dysfunction and functional MR at rest, treated with CRT, were studied. Each patient performed a symptom-limited maximal exercise with continuous two dimensional Doppler echocardiography twice. The first exercise was performed with CRT; the second exercise was performed without CRT. Mitral regurgitant flow volume (RV), effective regurgitant orifice area (ERO) and LV dP/dt were measured at rest and at peak exercise. Results: CRT mildly reduced resting mitral ERO (mean 8 (SEM 2) v 11 (2) mm² without CRT, p = 0.02) and RV (13 (3) v 18 (3) ml without CRT, p = 0.03). CRT attenuated the spontaneous increase in mitral ERO and RV during exercise (1 (1) v 9 (2) mm², p = 0.004 and 1 (1) v 8 (2) ml, p = 0.004, respectively). CRT also significantly increased exercise-induced changes in LV dP/dt (140 (46) v 479 (112) mm Hg/s, p <0.001). Conclusion: Attenuation of functional MR, induced by an increase in LV contractility during dynamic exercise, may contribute to the beneficial clinical outcome of CRT in patients with chronic heart failure and LV asynchrony. [ABSTRACT FROM AUTHOR]

Myocardial dysfunction without coronary involvement may occur in acute cerebral diseases. We report 4 cases where, in the context of acute cerebral disorder, the echocardiograms revealed an extensive left ventricular circumferential akinesis except at the apex. Besides, for three of those cases no coronary disease has been highlighted. Recognition of such a pattern of LV dysfunction should lead to the search for an acute cerebral disease. (ECHOCARDIOGRAPHY, Volume 22, August 2005) [ABSTRACT FROM AUTHOR]

Objectives: We compared the accuracy of B-type natriuretic peptide (BNP) assay with Doppler echocardiography for the diagnosis of decompensated congestive left-heart failure (CHF) in patients with acute dyspnea.Background: Both BNP and Doppler echocardiography have been described as relevant diagnostic tests for heart failure.Methods: One hundred sixty-three consecutive patients with severe dyspnea underwent BNP assay and Doppler echocardiogram on admission. The accuracy of the two methods for etiologic diagnosis was compared on the basis of the final diagnoses established by physicians who were blinded to the BNP and Doppler findings.Results: The final etiologic diagnosis was CHF in 115 patients. Twenty-four patients (15%) were misdiagnosed at admission. The BNP concentration was 1,022 +/- 742 pg/ml in the CHF subgroup and 187 +/- 158 pg/ml in the other patients (p < 0.01). A BNP cutoff of 300 pg/ml correctly classified 88% of the patients (odds ratio [OR] 85 [19 to 376], p < 0.0001), but a high negative predictive value (90%) was only obtained when the cutoff was lowered to 80 pg/ml. The etiologic value of BNP was low in patients with values between 80 and 300 pg/ml (OR 1.85 [0.4 to 7.8], p = 0.4) and also in patients who were studied very soon after onset of acute dyspnea. Among the 138 patients with assessable Doppler findings, a "restrictive" mitral inflow pattern had a diagnostic accuracy for CHF of 91% (OR 482 [77 to 3,011], p < 0.0001), regardless of the BNP level.Conclusions: Bedside BNP measurement and Doppler echocardiography are both useful for establishing the cause of acute dyspnea. However, Doppler analysis of the mitral inflow pattern was more accurate, particularly in patients with intermediate BNP levels or "flash" pulmonary edema. [ABSTRACT FROM AUTHOR]

Objectives This study was designed to assess the prognostic value of a new variable derived from a cardiopulmonary exercise test, the circulatory power, a surrogate of cardiac power, at peak exercise, in patients with chronic heart failure.Background Peak exercise cardiac power and stroke work are invasive parameters with recently proven prognostic value. It is unclear whether these variables have better prognostic value than peak oxygen uptake (VO2).Methods The study population comprised 175 patients with chronic heart failure (ejection fraction <45%) who underwent a cardiopulmonary exercise test. Circulatory power and circulatory stroke work were defined as the product of systolic arterial pressure and VO2 and oxygen pulse, respectively. Prognostic value was assessed by survival curves (Kaplan–Meier method) and uni- and multivariate Cox analyses.Results With a mean follow-up of 25±10 months, ejection fraction, heart rate, systolic arterial pressure, peak VO2, VCO2, the anaerobic threshold, minute ventilation, the ventilatory equivalents of oxygen and carbon dioxide, the half times of VO2 and VCO2 recoveries, and the circulatory stroke work and power predicted outcome. Multivariate analysis demonstrated that the peak circulatory power (chi-square=19·9,P <0·001) (but not peak circulatory stroke work) was the only variable predictive of prognosis.Conclusion The prognostic value of cardiopulmonary exercise tests in heart failure patients can be improved by assessing a new variable, the circulatory power—a surrogate of cardiac power—at peak exercise. [ABSTRACT FROM PUBLISHER]

Aim The aim of this prospective study was to compare the prognostic value of the mitral inflow pattern and peak oxygen uptake in patients with systolic heart failure.Background Peak oxygen uptake is a major prognostic parameter in heart failure. It is not known whether a restrictive mitral inflow pattern has similar prognostic value.Methods One hundred heart failure patients (ejection fraction <45%) underwent exercise testing after Doppler evaluation; prognosis was assessed after a mean follow-up of 17 months.Results The ejection fraction was larger in group 1 (non-restrictive pattern: E/A mitral wave ratio <1 or between 1 and 2 with E wave deceleration time ≥140ms, n=45) than in group 2 (restrictive pattern: E/A ratio >2 or between 1 and 2 with E deceleration time <140ms, n=40) (29±9 vs 22±10%, P<0·05). Peak oxygen uptake was lower in group 2 (17±4 vs 22±5ml.min−1.kg−157±11 vs 75±15% of predicted values;P<0·05 for both comparisons). Univariate analysis showed that the deceleration time (r=0·65), E/A ratio (r=−0·50) and heart rate increment (r=0·47) correlated best with peak oxygen uptake. A third group of patients with persistent fusion of the E and A waves (n=15) had exercise responses similar to those of group 2 patients. A short deceleration time (P=0·006), a restrictive or a fusion pattern (P=0·04) were associated with a poor outcome; the prognostic value of these Doppler variables was greater than that of ejection fraction, but remained less than peak oxygen uptake indexed by predicted values (P=0·0004).Conclusion The left ventricular filling pattern is a strong predictor of exercise capacity, and outcome, in patients with systolic heart failure and is independent of the left ventricular ejection fraction. Peak oxygen uptake remains a more powerful prognostic variable. [ABSTRACT FROM PUBLISHER]

Both left atrial (LA) and left ventricular (LV) functional parameters influence the prognosis of patients with cardiovascular diseases (CVD). This study aimed to investigate the prognostic value of a novel left atrioventricular coupling index (LACI), as well as annual change in LACI (ΔLACI) for predicting hard CVD in a population without history of CVD at baseline. In the Multi-Ethnic Study of Atherosclerosis (MESA), 2221 study participants, free of CVD at baseline, had LACI assessed with CMR imaging at baseline (Exam 1, 2000–2002), and ten years later (Exam 5, 2010–2012). LACI was defined by the ratio of the LA end-diastolic volume divided by the LV end-diastolic volume. Cox proportional hazard models were used to evaluate the associations of LACI and average annualized change in LACI (ΔLACI) with hard CVD defined by myocardial infarction, resuscitated cardiac arrest, fatal and nonfatal stroke, or CHD death. Among the 2221 participants (62.8 ± 10.1 years, 47.9% men), 223 cardiovascular events were observed (mean follow-up 13.0 ± 3.2 years). After adjustment for traditional risk factors, greater LACI and ΔLACI were independently associated with hard CVD (HR: 1.23; 95% CI [1.13–1.34] and HR: 1.71, 95% CI [1.50–1.94]; both P < 0.0001). Adjusted models for LACI and ΔLACI showed significant improvement in model discrimination compared to traditional risk score model (C-statistic: 0.79 vs. 0.77, and C-statistic: 0.80 vs. 0.78, respectively) (Fig. 1). LACI is a strong predictor for the incidence of hard CVD. LACI has incremental prognostic value to predict hard CVD over traditional risk factors, and better discrimination and reclassification power compared to individual LA or LV parameters. [ABSTRACT FROM AUTHOR]

In amyloid patients, cardiac involvement worsens dramatically both functional capacity and prognosis. We sought to study how the cardio-pulmonary exercise test (CPET) could help in functional assessment and risk stratification of patients with cardiac amyloidosis (CA). We carried out a prospective multicenter study including both immunoglobulin light chain (AL) and transthyretin (TTR) cardiac amyloidosis patients. All patients underwent clinical examination, EKG, blood measurement of cardiac biomarkers, echocardiography, CPET and clinical follow-up. The primary prognostic endpoint was the occurrence of death or heart failure (HF) hospitalization. We included 150 patients: 91 AL and 59 TTR cardiac amyloidosis. Median age, systolic blood pressure, NT-proBNP and cardiac troponin T were 70 [64–78] years old, 121 [IQR 109–139] mmHg, 2809 [IQR 1218–4638] ng/L and 64 [IQR 33–120] ng/L respectively. NYHA classes were I–II in 64% and III in 36%. The mean peak VO 2 was low at 13.0 mL/kg/min [10.0–16.9] i.e. 56% of predicted value; mean circulatory power was also impaired (1729 mmHg.mL−1min_1, IQR 1318–2614). The VE/VCO 2 slope i.e. respiratory response was increased to 37 [IQR 33–45]. Seventy-seven patients (51%) had also severe chronotropic insufficiency. After a median follow-up of 20months, there were 37 deaths and 44 HF-related hospitalizations. Multivariate Cox analysis shows that peak VO 2 (HR 2.7; CI 95% 1.6–4.8), circulatory power (HR 2.4; CI 95% 1.2–4.6) and NT-proBNP (HR 2.2, CI 95% 1.1–4.3) were independently associated with the primary outcome. There was no event in patients with both peak VO2 > 13 mL/kg/min and NTproBNP < 1800 ng/L, while the association of peak VO2 < 13 mL/kg/min and NTproBNP > 1800 ng/L identified the subset at highest risk (Fig. 1). In CA, CPET helps to assess functional capacity, circulatory and chronotropic responses and helps to assess the prognosis of patients along with cardiac biomarkers. [ABSTRACT FROM AUTHOR]

Abstract: We report the case of a man admitted for massive pulmonary embolism. Transthoracic echocardiography showed a serpentine thrombus in the right atrium across the foramen oval. Because of an acute worsening of the circulatory insufficiency, an intravenous thrombolysis was prescribed and the patient recovered progressively. An early control echocardiography showed the disappearing of the intracardiac thrombus and no evidence of abnormality of interatrial septum. While there was no evidence of venous thrombosis in legs, a renal cancer was diagnosed by echography. Silent stroke were highlighted at the scanner. This clinical case leads to discuss the origin of thrombus (in situ formation or thrombus migration) as well as the treatment (heparinotherapy, thrombolysis, surgical embolectomy, definitive closure of the foramen oval). [Copyright &y& Elsevier]

Isolated acute right ventricular (RV) infarction is rare, and ECG diagnosis may be difficult. We report two cases of acute myocardial infarction with ST-segment elevation in anterior precordial leads caused by such an RV involvement. Potential mechanisms for the relationship are given. [ABSTRACT FROM AUTHOR]

Cardiac involvement is the most important cause of death in light chain amyloidosis (AL) and its early diagnosis is a major issue for therapeutic strategy. Gold diagnostic standards are either invasive (cardiac biopsy) or not widely available (cardiac MRI). We aim to compare diagnostic value of various diagnostic tools in this setting. Methods Following diagnostic, tests were performed after first diagnosis of AL amyloidogenic disorder: clinical examination, blood testing of BNP and troponin I, EKG, echocardiography, 24-hours EKG Holter, cardiac MRI, cardiopulmonary test. Cutoffs were chosen from literature for parameters with continuous values. Final diagnosis of cardiac amyloidosis (CA) was done either by MRI if diffuse late enhancement was present or by endomyocardial biopsy. Diagnostic values of tests as well as their combination were calculated. Results Among sixty-seven consecutive patients (64 ± 10 years, 21 with multiple myeloma and 46 with MGUS), final diagnosis of CA was done in 45 patients. Renal, digestive and neurologic AL involvements were present in 44%, 15% and 20% respectively of patients with CA. The table shows diagnostic values of EKG, BNP and echography as well as their combinations. Usefulness of troponin, Holter or stress test was less relevant ( Table 1 ). Conclusion Combining EKG, biomarkers and echocardiography result in nearly optimal diagnosis of AL CA. [ABSTRACT FROM AUTHOR]

Acute myocardial infarction (MI) is associated with an inflammatory response that may lead and/or worsen adverse left ventricular (LV) remodeling. Among inflammation markers is Indoleamine 2,3-dioxygenase (IDO), which production is induced upon inflammation. IDO catalyzes the transformation of tryptophane into kynurenine. We tested plasma IDO activity as a predictor of LV remodeling post-MI. The PREGICA cohort recruited prospectively patients with first MI. Blood samples, echocardiography and cardiac MRI were obtained at day 4 and at 6 months. To be included, the number of akinetic LV wall segments had to be ≥ 3 at day 4. IDO activity was the ratio between kynurenine and tryptophane measured by high-pressure liquid chromatography coupled with fluorimetric detection. Remodelers were identified as patients with a variation of end-diastolic left ventricular volume (EDLVV) between day 4 and 6 months post-MI ≥ 20%. Among the 292 patients studied (mean age 57 y, mean necrosis size 26% on MRI), the median increase in EDLVV was 16.7% and 137 (47%) were classified as remodelers. At day 4, IDO activity was significantly higher in remodelers (8.2 ± 4.2% vs. 5.3 ± 2.5% and 8.7 ± 5.7% vs. 5.6 ± 4.4%, p < 0.001) and remained higher at 6 months post-MI. IDO activity at day 4 was highly predictive of LV remodeling (AUC = 87% [95% CI 83–91%]);IDO threshold of 5.8 resulted in specificity = 81%, sensitivity = 89%, negative predictive value = 89%, positive predictive value = 80%. In contrast, plasma levels of NT-proBNP, ST2, Galectin 3 or CRP at day 4 were poorly predictive. In multivariate analysis including other predictive variables at day 4 (primary angioplasty, EDLVV, LVEF, necrosis size), increase in IDO activity was significantly associated with LV remodeling (OR 1.21 [95%CI 1.11–1.33]). IDO activity appears as a promising biomarker for the prediction of LV remodeling after MI. Its specific role in post-MI remodeling pathways requires further investigation. [ABSTRACT FROM AUTHOR]

Left ventricular remodeling (LVR) is one of the complications of myocardial infarction, leading to heart failure. The objective of this study is to clinical, echocardiographic and natriuretic peptides metabolism parameters associated with LVR. This prospective, multicentric study includes patients with first myocardial infarction and at least 3 akinetic segments at the initial echocardiography. LVR is defined as an increase of left ventricular end-diastolic volume (LVEDV) of 20% at 6 months. Neprilysin concentration and activity, NT-proBNP, MR-proANP and galectine 3 were measured the fourth day after the event (D4) and six months later (M6). Three hundred and seven patients are included. One hundred and thirty-three patients (43%) display LVR at 6 months. Factors associated to LVR in multivariate analysis are WMSI score, initial LVEDV and LDL cholestérol. At D4, neprilysin concentration is of 298 pg/mL [239–355], neprilysin activity of 0.28 nM/mL/min [0.14–0.38], galectin 3 concentration of 18.7 ng/mL [15.6–23.4], NT- proBNP of 1770 ng/L [724–5468] and MR-proANP concentration of 501 pmol/L [272–951]. At D4, NT-proBNP is the only biological parameter associated with LVR (2154 ng/L [878–6078] versus 1602 ng/L [610–4815], P = 0.03). Nevertheless, none of natriuretic peptides metabolism parameters is an efficient predictor of LVR (Fig. 1). At M6, neprilysin concentration is of 172 pg/mL [125–219], neprilysin activity of 0.19 nM/mL/min [0.16–0.27], NT-proBNP of 1323 ng/L [542–2721] and MR-proANP concentration of 487 pmol/L [247–855]. Neprilysin concentration, neprilysin activity and NT-proBNP are significantly decreased at M6 (P < 0.001). Nevertheless, none of the parameters measured at M6 are associated with LVR. LVR is still frequent after myocardial infarction, related to infarct size and previous left ventricular morphology. Biological markers of natriuretic peptides metabolism are slightly changed after myocardial infarction without association with LVR. [ABSTRACT FROM AUTHOR]

To evaluate the level of N-terminal pro brain natriuretic peptide and brain natriuretic peptide (NTproBNP and BNP) for acute heart failure (AHF) diagnosis in patients aged 75 or older. In a previous smaller study of very old patients with acute dyspnoea, despite being independently associated with the cardiac aetiology, BNP level was higher in cardiac vs. respiratory origin of dyspnea. In total, 7822 patients aged 75 years or older, hospitalized in geriatrics, cardiologic and pneumologic department for acute dyspnoea in the enlarged Assistance Publique-Hôpitaux de Paris hospitals had a NTproBNP and a BNP measurement in the 48 hours after admission. Mean (SD) age was 85.5 (5.9) years, 55,5% (n = 4190) of patients were women. 72% (n = 5636) were admitted from the emergency department. 4800 (63,5%) patients had AHF diagnosis at discharge. The NTproBNP levels were significantly higher in the AHF group (median = 5598 ng/L, interquartile range = 2604;35000) than in the respiratory group (median = 1290 ng/L, interquartile range = 433;20200; P < 0.001). The BNP levels were significantly higher in the AHF group (median = 574 ng/L, interquartile range = 303;3140) than in the respiratory group (median = 152 ng/L, interquartile range = 66;813; P < 0.001) (Fig. 1). In patients over 75 years of age consulting for acute dyspnea, NTproBNP and levels are higher in patients with AHF than in other cause of dyspnea. In this population, the threshold of natriuretic peptides for AHF diagnostic might be increased. [ABSTRACT FROM AUTHOR]

Introduction Sacubitril/valsartan that combines a neprilysin (NEP) inhibitor and an angiotensin receptor blocker (ARB) was shown superior to enalapril for the treatment of heart failure with reduced ejection fraction (HFrEF) (1). The inhibition of sNEP by Sacubitril on the processing of proBNP remains unclear. Objective The aim was to evaluate the evolution of cardiovascular biomarkers in patients who were switched from angiotensin converting enzyme inhibitor or ARB to sacubitril/valsartan and to evaluate the possible implication of the T71 proBNP glycosylation. Method We included 90 consecutive HFrEF patients who were treated with sacubitril/valsartan according to the current ESC guidelines in two university hospital. Plasma samples were collected before the first intake of sacubitril/valsartan, at day 30 (D30) and at day 90 (D90) for 60 patients who were selected for further paired analysis. Results sNEP activity decreased from D30 onward and being the lowest at D90. In contrast, there was no change in sNEP concentration. BNP and NT-proBNP plasma levels remained unchanged while high-sensitive troponin I decrease and GLP-1 increase from D90. We observed a gradual increase in T71 proBNP glycosylation. To assess the effect of T71 proBNP glycosylation on the processing of proBNP, we plotted the slope of the linear regression between BNP and NT-proBNP versus the median values of T71 proBNP glycosylation at each time points; the direct correlation observed ( R 2 = 0.99) strongly suggest that the independent evolution of BNP and NT-proBNP plasma levels in patients receiving sacubitril/valsartan results directly from the increase in T71 proBNP glycosylation. Conclusion The results showed that while sacubitril/valsartan decreased sNEP activity without no effect on the mNEP release. The increase in T71 proBNP glycosylation being responsible for the discrepancies between BNP and NT-proBNP plasma levels. [ABSTRACT FROM AUTHOR]

Background Heart Failure (HF) is a major public health problem resulting in high rates of hospitalization and mortality. Current HF guidelines recommend sodium-restricted dietary approaches to prevent acute HF, but adherence to salt restriction may be hampered by patients’ perceived burden, as measured by the recently validated Burden scale In Restricted Diets questionnaire (BIRD). Purpose To assess sodium diet prescription patterns by cardiologists and evaluate their relationship with actual understanding, adherence and self-rated burden in HF patients. Methods Enrolment of 3000 patients at the national level is planned for the OFICsel observatory, through a representative panel of 300 cardiologists including out and inpatients. Data collection included clinical, biological, echocardiography and treatment/diet characteristics [physician] and socio-demographics, understanding, adherence and perceived burden (BIRD) related to restricted diets. Results As of May 1st 2017, data from 1438 patients from 79 French departments (mean age 66.8 years ± 13.9 standard deviation; 71% men). Fifty-nine percent patients were hospitalized, 7% in rehabilitation center and 34% outpatients. LVEF, NYHA class II/III and ischemic cardiopathy rates were respectively: 38.8 ± 14.0, 51%/28% and 44%. Eighty-six percent had HF for more than 3 months and 27% were in acute heart failure. Physician salt regimen prescriptions among < 3 g/day, 4–6 g/d, 6 g/d, > 6 g/d, unknown were 10%, 33%, 41%, 11%, 5% while recommendations understood by patients were 21%, 27%, 22%, 22%, 8%, respectively. Overall agreement was only 42% with a low concordance kappa of 0.25. Increasing burden was associated with increasingly stringent salt diets ( Fig. 1 ; P < 0.001). Conclusion Substantial discrepancies were found between salt restricted diets prescribed and those understood by HF patients. Further analyses of the ongoing OFICsel observatory will identify predictors of non-adherence. [ABSTRACT FROM AUTHOR]