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ABSTRACT: BACKGROUND: Myocardial stunning is an important sequela of acute coronary syndromes and its determination might affect decisions on defibrillator implantation and assist devices after myocardial infarction (AMI). The aim of the study was to evaluate and compare the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of cardiac magnetic resonance imaging (CMR) assessing myocardial stunning after acute myocardial infarction using low-dose dobutamine (LDD), end-diastolic wall thickness, and contrast delayed enhancement (DE). METHODS AND RESULTS: A systematic review of Medline, Embase, and Cochrane for all prospective trials assessing myocardial stunning by CMR following AMI was performed using a standard approach for meta-analysis for diagnostic test and a bivariate analysis. Search results revealed 9384 studies, out of which 17 met criteria. A total of 634 patients (mean age 59 years, 85% male, mean left ventricular ejection fraction: 52%) were included. DE-CMR had a weighted sensitivity of 87% and specificity of 68% to detect myocardial stunning using 50% transmurality as a cut-off, with a PPV and NPV of 83 and 72%, respectively. With an overall diagnostic accuracy of 82%, LDD-CMR had a sensitivity of 67% and a specificity of 81%, with a PPV and NPV of 82 and 63%, respectively. LDD showed an overall accuracy of 74%. CONCLUSION: DE-CMR has a higher sensitivity, whereas LDD-CMR has a higher specificity for the detection of viable stunned myocardium following myocardial infarction. Whether the combination of DE and LDD may improve the prediction of myocardial recovery remains to be determined.
European heart journal cardiovascular Imaging. 04/2013;
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ABSTRACT: Angioedema is a rare, potentially life-threatening adverse event of renin-angiotensin system inhibitors. The objective of the present study was to determine the risk of angioedema from randomized clinical trials. A PubMed/CENTRAL/EMBASE search was made for randomized clinical trials from 1980 to October 2011 in patients on angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), or direct renin inhibitor (DRI). Trials with a total number of patients ≥100 and a duration of ≥8 weeks were included for analysis. Incidence of angioedema was pooled by weighing the incident rate of each trial by the inverse of the variance. Twenty-six trials with 74,857 patients in the ACE inhibitor arm with 232,523 person-years of follow-up, 19 trials with 35,479 patients on ARB with 122,293 person-years of follow-up, and 2 trials with 5,141 patients on DRI with 1,735 person-years of follow-up met the inclusion criteria and were included in the analysis. In head-to-head comparison in 7 trials, risk of angioedema with ACE inhibitors was 2.2 times higher than with ARBs (95% confidence interval [CI] 1.5 to 3.3). With ACE inhibitors and ARBs, incidence of angioedema was higher in heart failure trials compared to hypertension or coronary artery disease trials without heart failure (p <0.0001). Weighted incidence of angioedema with ACE inhibitors was 0.30% (95% CI 0.28 to 0.32) compared to 0.11% (95% CI 0.09 to 0.13) with ARBs, 0.13% (95% CI 0.08 to 0.19) with DRIs, and 0.07% with placebo (95% CI 0.05 to 0.09). In conclusion, incidence of angioedema with ARBs and DRI was <1/2 than that with ACE inhibitors and not significantly different from placebo. Incidence of angioedema was higher in patients with heart failure compared to those without heart failure with ACE inhibitors and ARBs.
The American journal of cardiology 04/2012; 110(3):383-91. · 3.58 Impact Factor
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Omar Wever-Pinzon,
Valentin Suma,
Ameeta Ahuja,
Jorge Romero,
Nishtha Sareen,
Sonia A Henry,
Maria De Benedetti Zunino,
Farhan F Chaudhry,
Ramya S Suryadevara,
Mark V Sherrid,
Farooq A Chaudhry
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ABSTRACT: Echocardiographic contrast (EC) improves the diagnostic accuracy of suboptimal echocardiograms. In October 2007, the Food and Drug Administration (FDA) placed a black box warning on the label of the perflutren-based agents Definity and Optison, contraindicating their use in patients with pulmonary hypertension (PHT) and unstable cardiopulmonary status, after serious cardiopulmonary reactions occurred in temporal relation to EC administration. In 2008 and 2011, the FDA revised the black box warning allowing their use in this same population. However, limited data exist regarding the safety profile of these agents in patients with PHT.
Consecutive hospitalized patients with PHT who were referred for echocardiographic evaluation, but required the use of EC, were included. All our patients received the EC agent Definity. We evaluated these patients for serious adverse events (respiratory decompensation, hypotension, syncope, convulsions, arrhythmias, anaphylactic reactions, or death) occurring within 24 h of EC administration. The study group included 1513 patients (age 69 ± 14 years, 55% males, BMI 33 ± 9 kg/m(2)), of which 911 (60%) had mild PHT, 515 (34%) had moderate PHT, and 87 (6%) had severe PHT. The mean pulmonary artery systolic pressures (PASP) in the groups with mild, moderate, and severe PHT were 41 ± 4 (range 35-49) mmHg, 55 ± 5 (range 50-69) mmHg, and 78 ± 9 (range 70-122) mmHg, respectively. The incidence of adverse events in all subgroups was rare (0.002%) and they were not attributed to EC because of temporal and clinical considerations.
The use of the EC agent Definity is safe in hospitalized patients with PHT.
European heart journal cardiovascular Imaging. 03/2012; 13(10):857-62.
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ABSTRACT: The purpose of this study was to evaluate the prognostic value of stress echocardiography in patients with angiographically significant coronary artery disease (CAD). Two hundred sixty patients (mean age 63 ± 10 years, 58% men) who underwent stress echocardiography (41% treadmill, 59% dobutamine) and coronary angiography within 3 months and without intervening coronary revascularization were evaluated. All patients had significant CAD as defined by coronary stenosis ≥70% in major epicardial vessels or branches (45% had single-vessel disease, and 55% had multivessel disease). The left ventricle was divided into 16 segments and scored on a 5-point scale of wall motion. Patients with abnormal results on stress echocardiography were defined as those with stress-induced ischemia (increase in wall motion score of ≥1 grade). Follow-up (3.1 ± 1.2 years) for nonfatal myocardial infarction (n = 23) and cardiac death (n = 6) was obtained. In patients with angiographically significant CAD, stress echocardiography effectively risk stratified normal (no ischemia, n = 91) in contrast to abnormal (ischemia, n = 169) groups for cardiac events (event rate 1.0%/year vs 4.9%/year, p = 0.01). Multivariate logistic regression analysis identified multivessel CAD (hazard ratio 2.53, 95% confidence interval 1.16 to 5.51, p = 0.02) and number of segments in which ischemia was present (hazard ratio 4.31, 95% confidence interval 1.29 to 14.38, p = 0.01) as predictors of cardiac events. A Cox proportional-hazards model for cardiac events showed small, significant incremental value of stress echocardiography over coronary angiography (p = 0.02) and the highest global chi-square value for both (p = 0.004). In conclusion, in patients with angiographically significant CAD, (1) normal results on stress echocardiography conferred a benign prognosis (event rate 1.0%/year), and (2) stress echocardiographic results (no ischemia vs ischemia) added incremental prognostic value to coronary angiographic results, and (3) stress echocardiography and coronary angiography together provided additive prognostic value, with the highest global chi-square value.
The American journal of cardiology 01/2012; 109(2):153-8. · 3.58 Impact Factor
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ABSTRACT: Japanese-variant or apical hypertrophic cardiomyopathy (HCM) is a specific type of HCM, first described in Japan and initially thought to carry a benign prognosis. However, current evidence suggests that these patients experience severe symptoms and are at increased risk of ventricular arrhythmias and death, especially in the presence of an apical akinetic chamber. The management of patients who do not respond to medical therapy is challenging. We describe a patient with Japanese-variant HCM, with an apical akinetic chamber and severe symptoms who failed medical therapy. The use of dual chamber pacing relieved obstruction and significantly improved the patient's symptoms.
American journal of therapeutics 01/2012;
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Echocardiography 12/2011; 29(3):369-72. · 1.24 Impact Factor
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ABSTRACT: The purpose of this study was to assess whether inotropic contractile reserve (ICR) during dobutamine stress echocardiography (DSE) could risk-stratify patients with human immunodeficiency virus (HIV) cardiomyopathy and predict improvement of left ventricular ejection fraction (LVEF).
HIV cardiomyopathy is an important cause of heart failure and death. ICR is associated with better survival and improvement of LVEF in patients with ischemic and nonischemic cardiomyopathies. However, the prognostic value of ICR in patients with HIV cardiomyopathy is unknown.
Patients with HIV cardiomyopathy and a LVEF <45% who were referred for DSE were enrolled. ICR was evaluated by the delta wall motion score index (ΔWMSI), calculated as the difference between rest and peak WMSI. Patients were followed for cardiac death and change in LVEF on follow-up.
Sixty patients (75% men; age, 54 ± 9 years) with HIV cardiomyopathy (mean LVEF, 28 ± 11%) formed the study group. After 2.4 ± 2.1 years, 11 cardiac deaths occurred (event rate of 7.6%/year). A receiver-operating characteristic curve identified a ΔWMSI of 0.38 as an optimal cut point for the presence of ICR, with a specificity of 88% and a sensitivity of 73% for the prediction of cardiac death. On univariable analysis, the absence of ICR (hazard ratio: 6.6; 95% confidence interval: 1.93 to 22.62; p = 0.003) and New York Heart Association functional class IV (hazard ratio: 7.2; 95% confidence interval: 2.20 to 23.65; p = 0.001) were the only predictors of cardiac death. After 2.1 ± 1.8 years, 41 patients had a follow-up echocardiogram. LVEF improvement from baseline occurred in 23 patients (56%), more so in patients with ICR than without ICR. A ΔWMSI of 0.59 predicted improvement in the LVEF with a specificity of 78% and a sensitivity of 74%.
The presence of ICR during DSE can risk-stratify and predict subsequent improvement in LVEF in patients with HIV cardiomyopathy.
JACC. Cardiovascular imaging 12/2011; 4(12):1231-8. · 14.29 Impact Factor
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ABSTRACT: In dilated cardiomyopathy, a condition characterized by chamber enlargement and reduced myocardial contractility, decreases in β-adrenergic receptor density and increases in Gαi and β-adrenergic receptor kinase activities attenuate the stimulation of adenylyl cyclase in response to catecholamines. PDE3 inhibitors have been used to 'overcome' the reduction in cAMP generation by blocking cAMP hydrolysis. These drugs increase contractility in the short-term, but long-term administration leads to an increase in mortality that correlates with an increase in sudden cardiac death. Whether separate mechanisms account for these beneficial and harmful effects, and, if so, whether PDE3 can be targeted so as to increase contractility without increasing mortality are questions that remain unanswered.
Current Opinion in Pharmacology 09/2011; 11(6):707-13. · 6.86 Impact Factor
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ABSTRACT: Patients with human immunodeficiency virus (HIV) infection are at increased risk of accelerated coronary artery disease (CAD) and cardiovascular events. Stress echocardiography (SE) is routinely used for risk stratification and prognosis of patients with known or suspected CAD. The prognostic value of SE in this high-risk group is unknown. The purpose of this study was to evaluate the prognostic value of SE in HIV-infected patients with known or suspected CAD.
We evaluated 311 patients (age, 52 ± 9 years; 74% men; left ventricular ejection fraction, 54 ± 12%) with history of HIV, undergoing SE (56% dobutamine). Left ventricular wall motion was evaluated on a 16-segment model, 5-point scale. An abnormal SE was defined by a fixed (infarction), biphasic, or new (ischemia) wall motion abnormality on stress. Follow-up for cardiac death and myocardial infarction was obtained. Seventy-nine (26%) patients had an abnormal SE. After 2.9 ± 1.9 years, 17 confirmed myocardial infarction and 14 cardiac deaths occurred. SE risk-stratified patients into normal versus abnormal subgroups (event rate, 0.6% per year versus 11.8% per year; P < 0.0001). Both abnormal SE (hazard ratio, 28.2; 95% confidence interval, 6.2 to 128.0; P < 0.0001) and the presence of any ischemia on SE (hazard ratio, 3.4; 95% confidence interval, 1.3 to 8.6; P = 0.009) were independent predictors of cardiac events. On a forward conditional Cox proportional hazards regression model, SE provided incremental prognostic value over clinical, stress ECG, and resting echocardiographic variables (global χ(2) increased from 17.8 to 24.5 to 65 to 109, P < 0.05 across all groups).
SE can effectively risk-stratify and prognosticate patients with HIV. The presence of ischemia and scar during SE provides independent and incremental prognostic value over traditional variables. A normal SE response portends a benign prognosis even in this high-risk subset.
Circulation Cardiovascular Imaging 07/2011; 4(4):363-70. · 5.94 Impact Factor
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ABSTRACT: Peripheral edema is a common adverse effect of calcium channel blockers. The addition of a renin-angiotensin system blocker, either an angiotensin-converting enzyme inhibitor or an ARB, has been shown to reduce peripheral edema in a dose-dependent way.
We performed a MEDLINE/COCHRANE search for all prospective randomized controlled trials in patients with hypertension, comparing calcium channel blocker monotherapy with calcium channel blocker/renin-angiotensin system blocker combination from 1980 to the present. Trials reporting the incidence of peripheral edema or withdrawal of patients because of edema and total sample size more than 100 were included in this analysis.
We analyzed 25 randomized controlled trials with 17,206 patients (mean age 56 years, 55% were men) and a mean duration of 9.2 weeks. The incidence of peripheral edema with calcium channel blocker/renin-angiotensin system blocker combination was 38% lower than that with calcium channel blocker monotherapy (P<.00001) (relative risk [RR] 0.62; 95% confidence interval [CI], 0.53-0.74). Similarly, the risk of withdrawal due to peripheral edema was 62% lower with calcium channel blocker/renin-angiotensin system blocker combination compared with calcium channel blocker monotherapy (P=.002) (RR 0.38; 95% CI, 0.22-0.66). ACE inhibitors were significantly more efficacious than ARBs in reducing the incidence of peripheral edema (P<.0001) (ratio of RR 0.74; 95% CI, 0.64-0.84) (indirect comparison).
In patients with hypertension, the calcium channel blocker/renin-angiotensin system blocker combination reduces the risk of calcium channel blocker-associated peripheral edema when compared with calcium channel blocker monotherapy. ACE inhibitor seems to be more efficacious than ARB in reducing calcium channel blocker-associated peripheral edema, but head-to-head comparison studies are needed to prove this.
The American journal of medicine 02/2011; 124(2):128-35. · 4.47 Impact Factor
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ABSTRACT: Normal exercise single-photon emission computed tomography (SPECT) studies are associated with a low event rate (<1.0%/year) during short-term follow-up. The influence of cardiac risk factors on long-term outcomes in such patients has not been well studied.
2,597 patients (55 ± 12 years, male 41%) without a history of heart disease and a normal exercise SPECT between the years 1995 and 2006 were followed for a mean 6.8 ± 3.1 years for all-cause mortality assessed for using the Social Security Death Index. Baseline clinical risk factors and other clinical information were recorded for each patient and compared to outcomes.
The mortality rate was 0.9%/year for our overall study population but varied according to individual baseline risk factors. Three coronary artery disease (CAD) risk factors were significant predictors of all-cause mortality: hypertension, diabetes, and smoking. When all three were absent, long-term all-cause mortality rate averaged 0.2%/year and when all three were present, all-cause mortality averaged 1.8%/year, constituting a 5.7-fold adjusted increase in risk (95% CI 2.7-12.8, P < .0001).
During follow-up, annualized mortality rate varies markedly according to the number of CAD risk factors in patients without known heart disease and a normal exercise SPECT stress. Despite overall excellent long-term prognosis of a normal exercise SPECT, the burden of traditional CAD risk factors exert a strong synergistic influence on long-term survival and warrant aggressive treatment in this patient population.
Journal of Nuclear Cardiology 12/2010; 18(2):207-14; quiz 217. · 2.67 Impact Factor
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International journal of cardiology 11/2010; 148(3):379-81. · 7.08 Impact Factor
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ABSTRACT: The shape of Doppler velocity tracings in obstructive hypertrophic cardiomyopathy offers insights into its pathophysiology. Inflection points are the points on a curve where its shape changes from concave to convex, or vice versa. These dynamic systolic abnormalities are caused: 1) by the amplifying nature of the obstruction; and 2) by the adverse effect of the sudden imposition of afterload in midsystole. The midsystolic drop in left ventricular ejection velocities and the premature termination of longitudinal shortening are compelling evidence of the deleterious mechanical effect of obstruction on the ventricle. This dynamic systolic dysfunction, demonstrated on the Doppler curves, may contribute to heart failure symptoms and adverse outcome. In outflow obstruction, these abnormalities normalize after abolition of gradient. Therefore, their detection in an individual patient confirms obstruction as a therapeutic target.
Journal of the American College of Cardiology 08/2009; 54(3):212-9. · 14.16 Impact Factor
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Congestive Heart Failure 16(3):129-31.
