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Objectives: To analyse the implementation, applicability and accuracy of the pretest probability calculation provided by NICE clinical guideline 95 for decision making about imaging in patients with chest pain of recent onset. Methods: The definitions for pretest probability calculation in the original Duke clinical score and the NICE guideline were compared. We also calculated the agreement and disagreement in pretest probability and the resulting imaging and management groups based on individual patient data from the Collaborative Meta-Analysis of Cardiac CT (CoMe-CCT). Results: 4,673 individual patient data from the CoMe-CCT Consortium were analysed. Major differences in definitions in the Duke clinical score and NICE guideline were found for the predictors age and number of risk factors. Pretest probability calculation using guideline criteria was only possible for 30.8 % (1,439/4,673) of patients despite availability of all required data due to ambiguity in guideline definitions for risk factors and age groups. Agreement regarding patient management groups was found in only 70 % (366/523) of patients in whom pretest probability calculation was possible according to both models. Conclusions: Our results suggest that pretest probability calculation for clinical decision making about cardiac imaging as implemented in the NICE clinical guideline for patients has relevant limitations. Key Points: • Duke clinical score is not implemented correctly in NICE guideline 95. • Pretest probability assessment in NICE guideline 95 is impossible for most patients. • Improved clinical decision making requires accurate pretest probability calculation. • These refinements are essential for appropriate use of cardiac CT.

BACKGROUND AND AIMS: The influence of gender and age on risk factor prediction of coronary artery calcification (CAC) in symptomatic patients is unclear.METHODS: From the European Calcific Coronary Artery Disease (EURO-CCAD) cohort, we retrospectively investigated 6309 symptomatic patients, 62% male, from Denmark, France, Germany, Italy, Spain and USA. All of them underwent risk factor assessment and CT scanning for CAC scoring.RESULTS: The prevalence of CAC among females was lower than among males in all age groups. Using multivariate logistic regression, age, dyslipidaemia, hypertension, diabetes and smoking were independently predictive of CAC presence in both genders. In addition to a progressive increase in CAC with age, the most important predictors of CAC presence were dyslipidaemia and diabetes (β = 0.64 and 0.63, respectively) in males and diabetes (β = 1.08) followed by smoking (β = 0.68) in females; these same risk factors were also important in predicting increasing CAC scores. There was no difference in the predictive ability of diabetes, hypertension and dyslipidaemia in either gender for CAC presence in patients aged 70, only dyslipidaemia predicted CAC presence in males and only smoking and diabetes were predictive in females.CONCLUSIONS: In symptomatic patients, there are significant differences in the ability of conventional risk factors to predict CAC presence between genders and between patients aged

BACKGROUND AND AIMS: Although much has been written about the conventional cardiovascular risk factor correlates of the extent of coronary artery calcification (CAC), few studies have been carried out on symptomatic patients. This paper assesses the potential ability of risk factors to associate with an increasing CAC score.METHODS: From the European Calcific Coronary Artery Disease (Euro-CCAD) cohort, we retrospectively investigated 6309 symptomatic patients, 62% male, from Denmark, France, Germany, Italy, Spain and the USA. All had conventional cardiovascular risk factor assessment and CT scanning for CAC scoring.RESULTS: Among all patients, male sex (OR = 4.85, pCONCLUSION: In addition to age and male sex in the total population, diabetes is the most important correlate of CAC extent in both sexes.

Decrease in blood platelet count has been described after percutaneous coronary intervention and surgical valve replacement, although no study has been performed in the setting of transcatheter aortic valve implantation (TAVI). The aim of this study was to address the incidence, mechanism, and impact of blood platelet count decrease after TAVI. One hundred forty-four consecutive patients (mean age 84 ± 7 years, 64 men) with severe symptomatic aortic stenosis who underwent TAVI from December 2007 to July 2011 were enrolled. Blood platelet count was recorded before and after aortic valve implantation. Decrease in blood platelet count was compared with in-hospital major adverse cardiovascular events (death, stroke, and major or life-threatening bleeding). Blood platelet count decreases occurred in all but 1 patient. The percentage of platelet count decrease averaged 34 ± 15% and was 24% greater than blood protein decrease. Decrease in platelet count was associated with a higher rate of prosthesis migration, longer x-ray and procedural times, and larger contrast amounts (230 ± 128 ml for the third tertile vs 170 ± 77 ml for the second and first tertiles, p = 0.0006), but no association was observed with regard to changes in bilirubin. In-hospital major adverse cardiovascular events (n = 50 [35%]) were observed more frequently in patients with severe platelet count decreases (21% for the first tertile, 35% for the second tertile, and 48% for the third tertile, p = 0.02). Finally, the percentage of blood platelet count decrease was the only predictor of in-hospital major adverse cardiovascular events (odds ratio 1.67, 95% confidence interval 1.05 to 2.67, p = 0.03). In conclusion, a decrease in platelet count is a common phenomenon after TAVI, and its severity is associated with poor outcomes.

Diuretics are conventionally prohibited in acute right ventricular myocardial infarction.To assess the benefit of diuretics compared to fluid expansion in patients with inferior myocardial infarction extended to the right ventricule.Of 295 patients admitted for inferior or posterior acute myocardial infarction between November 2008 and November 2010, 77 had a right ventricular extension. Among these 77 patients, 19 presented with oligoanuria (0.5 mL/kg per hour) and no criteria for cardiogenic shock. Overall, 11 patients were treated by low dose of furosemide (40 to 80 mg) and eight received fluid expansion using isotonic saline solution.Baseline right ventricular dilatation and dysfunction, systolic blood pressure and heart rate were similar between the groups. Twenty-four hours after treatment, urine output was similar between the two groups but only the patients in the diuretic group improved their blood pressure (103 ± 16 mmHg versus 127 ± 20 mmHg, P0.001), heart rate (71 ± 15 bpm versus 76 ± 13 bpm, P = 0.03), creatinin level and alanine aminotrasferase plasmatic level. Hospitalization duration and the need of inotropic support were similar in the two groups.Diuretics and fluid expansion provide similar efficiency for triggering diuresis in patients with right ventricular infarction and oligoanuria but only diuretics seem to be associated with improvement in hemodynamic status and venous congestion.

In the setting of low-flow/low-gradient aortic stenosis (LF/LGAS), outcomes of pseudo-severe aortic stenosis (AS) remain poorly described. This study was aimed to assess the outcome of patients with pseudo-severe AS under conservative treatment.Among 305 patients from the European Registry of LF/LGAS, the outcomes of the 107 patients followed under conservative treatment were analysed. Based on the results of dobutamine echocardiography, patients were divided into group IA [left ventricular (LV) contractile reserve present with true-severe AS, n = 43], group IB [pseudo-severe AS (n = 29) defined as LV contractile reserve with a final aortic valve area ≥1.2 cm(2) and a mean transaortic pressure gradient40 mmHg at peak dobutamine infusion], or group II (exhausted LV contractile reserve, n = 35). The rate of death within 5 years was significantly lower in the group IB (43 ± 11%, n = 10), when compared with the group IA (91 ± 6%, n = 33; P = 0.001) and the group II (100%, n = 23; P0.001). The Cox proportional hazard model analysis demonstrated that the hazard ratio for death in the group IB remained significantly lower than in the other groups, even after adjustment for currently established risk factors. Furthermore, the 5-year survival of pseudo-severe AS patients was comparable with that of propensity-matched patients with systolic heart failure and no evidence of valve disease.In patients with pseudo-severe AS, the 5-year survival under conservative treatment is better than in true-severe AS and comparable with that of propensity-matched patients with LV systolic dysfunction and no evidence of valve disease. Further studies are needed to define optimal therapeutic management in these patients.

This study compared strain values from 2-dimensional (2D) and real-time 3-dimensional (3D) speckle tracking with hyperenhancement transmural extent by magnetic resonance imaging (MRI). The study included 18 control subjects (mean age 51 ± 10 years) and 25 patients (20 men, mean age 62 ± 16 years) with ischemic left ventricular (LV) dysfunction (mean LV ejection fraction 41 ± 9%) referred for viability assessment using MRI. Longitudinal, radial, and circumferential strain values were computed using 2D speckle tracking. From analysis of 3D speckle tracking, conventional strain markers (longitudinal, radial, and circumferential) and 2 new 3D strain indexes (area and 3D strains) were obtained from apical view 3D datasets. A hyperenhancement transmural extent segment (16-segment model) was defined as delayed contrast enhancement50%. Overall, 661 of 688 segments (96%) were analyzable by MRI and 3D speckle tracking. All 3D strain components in hyperenhancement transmural extent segments (n = 154) were lower than in nontransmural necrosis (n = 219) and control (n = 288) segments. Longitudinal strain by 3D, but not by 2D, differentiated nontransmural segments with scar25%. All 3D global strain indexes correlated with LV ejection fraction (r(2) = 0.67 to 0.26, p0.05 for all comparisons), whereas only area, longitudinal, and circumferential 3D strains correlated with global scar extent. The best reproducibility was provided by 3D longitudinal (6%) and area (8%) strains. In conclusion, longitudinal and area strains by 3D speckle tracking provide an accurate and reproducible measurement of myocardial deformation that correlate with infarct size in patients with ischemic LV dysfunction.

MRI has become the primary tool for assessment of myocardial inflammation in patients with suspected acute myocarditis. Optimal diagnostic performance is achieved with late gadolinium-enhanced sequences, but cine balanced steady-state free precession (SSFP) MRI sequences are routinely used to evaluate cardiac function. Our aim was to prospectively assess the diagnostic value of unenhanced and contrast-enhanced cine SSFP MRI sequences in comparison with late gadolinium-enhanced sequences for imaging of patients with strong evidence of acute myocarditis.Eighteen patients with strong evidence of acute myocarditis underwent 1.5-T cardiac MRI. Unenhanced and contrast-enhanced cine SSFP images and late gadolinium-enhanced images were obtained. The images were analyzed both qualitatively and quantitatively. Data were analyzed with analysis of variance and the Bonferroni test or paired Student t test.Areas of high signal intensity were detected in 28% (5/18), 94% (17/18), and 89% (16/18) of patients on unenhanced cine, contrast-enhanced cine, and late gadolinium-enhanced images. In one patient, contrast-enhanced cine images revealed subepicardial areas of high signal intensity that were not visible on late gadolinium-enhanced images. The location and transmural nature of involved segments matched on contrast-enhanced cine and late gadolinium-enhanced images (both, r = 0.91, p0.0001). The contrast-to-noise ratio was significantly higher on contrast-enhanced cine images than on late gadolinium-enhanced images (p0.05).Contrast-enhanced cine MRI is a valuable tool for detection of lesions of acute myocarditis and should be recommended for routine clinical MRI.

Strain delay index (SDI) allows quantification of the wasted contraction or gain of myocardial contractility expected after cardiac resynchronization therapy (CRT). The present multicentre prospective study aimed to assess the accuracy of the SDI in predicting responses to CRT in real-life patients with wide and narrow (130 ms) QRS complexes.Implantation of a CRT device was performed in 235 heart failure patients and echocardiography data were analysable in 80% (n= 189) of patients (age 65 ± 12 years, left ventricular ejection fraction = 26 ± 8%, 63 ischaemic, 51 with narrow QRS complexes). Mechanical dyssynchrony before CRT was quantified by the 12-segment standard deviation of peak longitudinal strain by speckle tracking (12SD-ε, 12 standard deviation of time to peak strain by speckle tracking), and SDI, defined as the sum of difference between end-systolic and peak-ε across the 16 segments. Response to CRT was defined as an end-systolic volume reduction (ESVR) at 6 months15%. After CRT, ESVR15% was observed in 60% (n= 114/189) of patients, and was greater in non-ischaemic (68 vs. 44%, P= 0.003) and wide QRS patients (65 vs. 49%, P= 0.04). Correlation between 12SD-ε and ESVR was poor (r = 0.18, P= 0.01). In contrast, SDI correlated with reverse remodelling (r = 0.61, P0.0001 for all) in both wide and narrow QRS patients and ischaemic and non-ischaemic patients. Decrease in SDI after CRT was greater in responders and correlated with ESVR. Finally, SDI25% identified responders to CRT (positive and negative predictive value of 80 and 84%, respectively) with 6% inter-observer variability.The present multicentre study suggests that SDI may identify responders to CRT in ischaemic and non-ischaemic patients.

Objectives In a multicentre series of patients with low-ejection fraction/low-gradient aortic stenosis (LEF/LGAS), we evaluated the prognostic impact of valvuloarterial impedance (Zva). Background Zva in AS, a measure of global afterload taking into account systemic arterial compliance, has been proposed for risk stratification in paradoxical LGAS. We hypothesized that Zva could help risk stratification in LEF/LGAS. Methods and results We retrospectively calculated Zva (5.6 ± 1.7 mmHg/mL/m2) of 184 consecutive patients (mean age: 71 ± 10 years) with severe symptomatic LEF/LGAS (valve area ≤1 cm², EF ≤40%, mean transaortic pressure gradient ≤40 mmHg) included between 1995 and 2005 in a multicentre registry. Zva was higher in patients with LVEF at rest ≤20% (6.6 ± 2.3 vs. 5.5 ± 1.6; P = 0.05) and correlated negatively with LVEF at rest ( R = −0.25; P = 0.001). Zva was lower in patients without contractile reserve (CR) on dobutamine stress echocardiography (DSE) compared with patients with true severe AS (5.3 ± 1.3 vs. 5.8 ± 1.8 mmHg/mL/m2; P = 0.048). Zva and the variation in stroke volume during DSE were positively correlated ( P = 0.0001) but Zva did not allow distinction between true and pseudo-severe AS (5.8 ± 1.8 vs. 5.3 ± 1.8mmHg/mL/m2; P = 0.30). In the total population, Zva was not predictive of long-term mortality. In the 128 patients who underwent aortic valve replacement, Zva was not predictive of operative death and of long-term mortality. Conclusions Increased Zva is related to low LVEF and more frequent CR on DSE in LEF/LGAS. However, Zva did not allow an accurate distinction between true and pseudo-severe AS and failed to predict operative and long-term mortality after aortic valve replacement, in LEF/LGAS.

Background— Real-time 3-dimensional echocardiography (RT3DE) is superior to 2D echocardiography in assessing left ventricular (LV) volumes and ejection fraction (EF), but its feasibility is limited by multibeat acquisition, which requires an optimal breath-hold and a regular heart rhythm. We sought to evaluate the accuracy and feasibility of single- and 2-beat RT3DE for LV volume and EF assessment. Methods and Results— Sixty-six consecutive patients referred for cardiac magnetic resonance (CMR) underwent RT3DE and CMR on the same day. Of the 50 patients (age, 59±18 years; 68%men; 42% coronary artery disease; LVEF=49±14%; limits, 14% to 76%) with an adequate RT3DE image quality, accuracy for LV volumes and EF measurements of single- and 2-beat modalities were compared with the conventional 4-beat acquisition and CMR. Correlations with CMR for LV end-diastolic volume (161±59 mL, r =0.93 to 0.94) and end-systolic volume (86±56 mL, r =0.93 to 0.96) were excellent regardless of the number of cardiac cycles used. However, because of the low temporal resolution (7±2 volumes per second), single-beat underestimated LVEF (bias, −5±8%) with greater bias than 2-beat (bias, 1±6%, P P Conclusions— Compared with conventional multibeat acquisitions, 2-beat modality provides similar accuracy in LV volume and EF measurements and should be preferred due to fewer stitching artifacts. In contrast, the temporal resolution of single-beat modality appears insufficient to provide an accurate estimation of LVEF.

ObjectivesThis study investigated whether aortic valve replacement (AVR) is associated with improved survival in patients with severe low-flow/low-gradient aortic stenosis (LF/LGAS) without contractile reserve (CR) on dobutamine stress echocardiography (DSE).BackgroundPatients with LF/LGAS without CR have a high mortality rate with conservative therapy. The benefit of AVR in this subset of patients remains controversial.MethodsEighty-one consecutive patients with symptomatic calcified LF/LGAS (valve area ≤1 cm2, left ventricular ejection fraction ≤40%, mean pressure gradient [MPG] ≤40 mm Hg) without CR on DSE were enrolled. Absence of CR was defined as the absence of increase in stroke volume of ≥20% compared with the baseline value. Multivariable analysis and propensity scores were used to compare survival according to whether or not AVR was performed (n = 55).ResultsFive-year survival was higher in AVR patients compared with medically managed patients (54 ± 7% vs. 13 ± 7%, p = 0.001) despite a high operative mortality of 22% (n = 12). An AVR was independently associated with lower 5-year mortality (adjusted hazard ratio from 0.16 to 5.21 varying with time [95% confidence interval: 0.12–3.16 to 0.21–8.50], p = 0.00026). In 42 propensity-matched patients, 5-year survival was markedly improved by AVR (65 ± 11% vs. 11 ± 7%, p = 0.019). Associated bypass surgery (p = 0.007) and MPG ≤20 mm Hg (p = 0.035) were independently predictive of operative mortality. Late survival after AVR (excluding operative death) was 69 ± 8% at 5 years.ConclusionsIn patients with LF/LGAS without CR on DSE, AVR is associated with better outcome compared with medical management. Surgery should not be withheld from this subset of patients solely on the basis of lack of CR on DSE.

Context The epidemic of heart failure (HF) in France has not been fully investigated and data on both the systolic and diastolic forms are limited. Objectives To determine the prevalence, aetiology and treatments of both forms in French patients over 65 with HF (NYHA grade II–IV). Participants Cross-sectional study of 446 patients with HF recruited by 273 randomly selected cardiologists in France, with echocardiography and ECG available for central reading. Main measurements Prevalence of diastolic (DHF) and systolic (SHF) HF using the left ventricular ejection fraction (LVEF). Results DHF, with a mean LVEF of 57.6±8.0%, was reported for 245 (54.9%) patients and SHF, with a mean LVEF of 33.33±8.0% was reported for 201 (45.1%) patients. Men were more prone to suffer SHF than DHF whereas for women the reverse was true. As compared to SHF, DHF endsystolic and enddiastolic volumes were smaller, the thickness/radius ratio was greater, with a longer E-wave deceleration time and a shorter peak filling rate. Aetiology and treatments were similar in both types of HF, except for ACE inhibitors and aldosterone antagonists, which were more frequently prescribed in SHF. Conclusion This observational study provides further knowledge of SHF and DHF in outpatients.

Objectives: Peak troponin Ic (cTnI) level could be influenced by renal function. We evaluated the effect of moderate to severe renal failure on peak cTnI level during acute myocardial infarction (AMI). Methods: One hundred and twenty-five consecutive patients admitted to the coronary care unit of a university hospital in France for primary angioplasty during AMI were retrospectively studied. Results: The correlations between peak cTnI level, peak creatine phosphokinase (CK) level, peak cTnI/peak CK ratio and creatinine clearance (CrCl) were assessed. The peak cTnI/peak CK ratio was considered in order to standardize the peak cTnI level with the extent of myocardial necrosis. There was no significant correlation between CrCl and peak CK (r = 0.01, p = 0.95), peak cTnI (r = –0.08, p = 0.38) or the peak cTnI/peak CK ratio (r = –0.14, p = 0.13). There was a trend towards higher peak cTnI in patients with moderate to severe renal failure. The peak cTnI/peak CK ratio did not significantly differ among patients according to CrCl stratification, whereas the ratio of log-transformed values was significantly higher in patients with moderate to severe renal failure. Conclusion: In patients with AMI, the peak cTnI level seemed to be influenced by renal function.

AIMS: In this retrospective study we assessed the predictive value of the coronary calcium score for significant (>50%) stenosis relative to conventional risk factors.METHODS AND RESULTS: We investigated 5515 symptomatic patients from Denmark, France, Germany, Italy, Spain and the USA. All had risk factor assessment, computed tomographic coronary angiogram (CTCA) or conventional angiography and a CT scan for coronary artery calcium (CAC) scoring. 1539 (27.9%) patients had significant stenosis, 5.5% of whom had zero CAC. In 5074 patients, multiple binary regression showed the most important predictor of significant stenosis to be male gender (B=1.07) followed by diabetes mellitus (B=0.70) smoking, hypercholesterolaemia, hypertension, family history of CAD and age but not obesity. When the log transformed CAC score was included, it became the most powerful predictor (B=1.25), followed by male gender (B=0.48), diabetes, smoking, family history and age but hypercholesterolaemia and hypertension lost significance. The CAC score is a more accurate predictor of >50% stenosis than risk factors regardless of the means of assessment of stenosis. The sensitivity of risk factors, CAC score and the combination for prediction of >50% stenosis when measured by conventional angiogram was considerably higher than when assessed by CTCA but the specificity was considerably higher when assessed by CTCA. The accuracy of CTCA for predicting >50% stenosis using the CAC score alone was higher (AUC=0.85) than using a combination of the CAC score and risk factors with conventional angiography (AUC=0.81).CONCLUSION: In symptomatic patients, the CAC score is a more accurate predictor of significant coronary stenosis than conventional risk factors.

To study the impact on outcomes of direct admission versus emergency room (ER) admission in patients with ST-segment elevation myocardial infarction (STEMI) DESIGN: Nationwide observational registry of STEMI patients369 intensive care units in France.Patients were categorised on the basis of the initial management pathway (direct transfer to the coronary care unit or catheterisation laboratory versus transfer via the ER).Delays between symptom onset, admission and reperfusion therapy. Mortality at five days and one year.Of 1204 patients enrolled, 66.9% were admitted direct and 33.1% via the ER. Bypassing the ER was associated with more frequent use of reperfusion (61.7% v 53.1%; p = 0.001) and shorter delays between symptom onset and admission (244 (interquartile range 158) v 292 (172) min; p0.001), thrombolysis (204 (150) v 258 (240) min; p0.01), hospital thrombolysis (228 (156) v 256 (227) min, p = 0.22), and primary percutaneous coronary intervention (294 (246) v 402 (312) min; p0.005). Five day mortality rates were lower in patients who bypassed the ER (4.9% v 8.6%; p = 0.01), regardless of the use and type of reperfusion therapy. After adjusting for the simplified Thrombolysis in Myocardial Infarction (TIMI) risk score, admission via the ER was an independent predictor of five day mortality (odds ratio 1.67, 95% confidence interval 1.01 to 2.75).In this observational analysis, bypassing the ER was associated with more frequent and earlier use of reperfusion therapy, and with an apparent survival benefit compared with admission via the ER.

To analyse the short and long term prognostic significance of admission glycaemia in a large registry of non-diabetic patients with acute myocardial infarction.Assessment of short and long term prognostic significance of admission blood glucose in a consecutive population of 1604 non-diabetic patients admitted to intensive care units in France in November 2000 for a recent (or= 48 hours) myocardial infarction.In-hospital mortality, compared with that of patients with admission glycaemia below the median value of 6.88 mmol/l (3.7%), rose gradually with each of the three upper sextiles of glycaemia: 6.5%, 12.5% and 15.2%. Conversely, one year survival decreased from 92.5% to 88%, 83% and 75% (p0.001). Admission glycaemia remained an independent predictor of in-hospital and one year mortality after multivariate analyses accounting for potential confounders. Increased admission glycaemia also was a predictor of poor outcome in all clinical subsets studied: patients without heart failure on admission, younger and older patients, patients with or without reperfusion therapy, and patients with or without ST segment elevation.In non-diabetic patients, raised admission blood glucose is a strong and independent predictor of both in-hospital and long term mortality.

Background— Dobutamine stress hemodynamics (DSH) has the potential to stratify operative risk in low-gradient aortic stenosis (AS), but little is known about the relation between left ventricle contractile reserve and postoperative left ventricular ejection fraction (LVEF). We sought to assess the value of DSH to predict postoperative improvement in LVEF. Methods and Results— Sixty-six consecutive patients with symptomatic severe AS (aortic valve area ≤1 cm 2 ), LVEF ≤40%, and mean pressure gradient ≤40 mm Hg prospectively enrolled in the French multicenter study on low-gradient AS and who survived to aortic valvular replacement (AVR) were included. Preoperative contractile reserve was present in 46 patients (group I; 70%) and absent in 20 patients (group II; 30%). In the overall sample, 58% of patients improved by 2 New York Heart Association (NYHA) classes after AVR. Mean LVEF improved from 29±6% to 47±11% ( P P =0.54). On multivariable analysis, multivessel coronary artery disease ( P =0.05) and baseline mean transaortic pressure gradient ( P =0.01) were related to LVEF improvement, whereas contractile reserve was not. Conclusions— LVEF increases in the majority of patients with low-gradient AS who survive after AVR. Although the absence of contractile reserve on DSH is related to high operative mortality, it does not predict the absence of LVEF recovery in patients surviving to AVR. These data further support the concept that surgery should not be contraindicated on the basis of absence of contractile reserve alone.

Objective. – To assess the use of mobile coronary care units (MCU) in hypertensive patients previously treated for cardiovascular diseases in comparison with those with no history of cardiovascular disease and to estimate the influence of the use of MCU on cardiovascular outcome in this population. Patients. – We used a nationwide prospective registry of all patients admitted for AMI in French intensive care units in 2000. Patients without history of hypertension or patients admitted with pulmonary oedema or cardiogenic shock were excluded. Men (N = 514) and women (N = 291) were analysed separately . Results. – The proportion of patients with history of myocardial infarction, peripheral artery disease and stroke was not significantly higher in subjects who used physician-staffed MCU as compared with patients with no history of myocardial infarction, peripheral artery disease or stroke. In each sex, revascularization (pre hospital fibrinolysis, in hospital fibrinolysis or coronary angioplasty) were more frequent in patients who used MCU. Also, one year cardiovascular mortality was lower in men who used MCU. Conclusion. – known high risk hypertensive patients did not use physician-staffed MCU more than subjects free of such condition. Education of hypertensive patients at risk during routine visits is required to increase of the use of physician-staffed MCU in case of symptoms suggestive of AMI.

Several classes of medications improve survival in patients with coronary artery disease. Whether these medications, as used in the real world, have additive efficacy remains speculative.To assess whether patients discharged on combined secondary prevention medications after acute myocardial infarction (AMI) have improved 1-year survival, compared with the action of any single class of medications.Nationwide registry of consecutive patients admitted to intensive care units for AMI in November 2000 in France. Multivariate Cox regression analysis, including a propensity score for the prescription of combined therapy, was used.Of the 2119 patients discharged alive, 1095 (52%) were prescribed a combination of antiplatelet agents, beta-blockers, and statins (triple therapy), of whom 567 (27%) also received angiotensin-converting enzyme inhibitors (quadruple therapy) and 528 (25%) did not. One-year survival was 97% in patients receiving triple combination therapy versus 88% in those who received either none, 1, or 2 of these medications (P.0001). After multivariate adjustment including the propensity score, the hazard ratio for 1-year mortality in patients with triple combination therapy was 0.52 (95% CI 0.33-0.81). In patients with ejection fractionor = 35%, beta-blockers and angiotensin-converting enzyme inhibitors were independent predictors of survival, and combination therapy had no additional prognostic value.Compared with the prescription of any single class of secondary prevention medications, combination therapy offers additional protection in patients with AMI.

Objective: To assess actual practices and in-hospital outcome of patients with acute myocardial infarction on a nationwide scale. Methods: Of 443 intensive care units in France, 369 (83%) prospectively collected data on all cases of infarction (within < 48 hours of symptom onset) in November 2000. Results: 2320 patients (median age 68 years, 73% men) were included, of whom 83% had ST segment elevation infarction (STEMI). Patients without STEMI were older and had a more frequent history of cardiovascular disease. Median time to admission was 5.0 hours for patients with and 6.5 hours for those without STEMI. Reperfusion therapy was used for 53% of patients with STEMI (thrombolysis 28%, primary angioplasty 25%). In-hospital mortality was 8.7% (5.5% of patients without and 9.3% of those with STEMI). Multivariate analysis found that age, Killip class, lower blood pressure, higher heart rate on admission, anterior location of infarct, STEMI, diabetes mellitus, previous stroke, and no current smoking independently predicted in-hospital mortality. At hospital discharge, 95% received antiplatelet agents, 75% received β blockers, and over 60% received statins. Angiotensin converting enzyme inhibitors were prescribed for 40% of the patients without and 52% of those with ST elevation. Conclusions: This nationwide registry, including all types of centres irrespective of their size and experience, shows continued improvement in patient care and outcomes. Time from symptom onset to admission, however, has not improved in recent years and reperfusion therapy is used for just over 50% of patients with STEMI, with an increasing use of primary angioplasty.

B-type Natriuretic Peptide (BNP) is activated in patients with severe, symptomatic aortic stenosis (AS), but the prognostic value of BNP in this setting has not been extensively studied. This study aimed to assess the prognostic value of the BNP level in symptomatic and asymptomatic patients with severe AS.Seventy consecutive patients referred to our echocardiography laboratory for severe AS with preserved left ventricular function were prospectively enrolled (40 men, median age 74 years [62-82]; aortic valve area 0.7 cm2 [0.6-0.8]; transaortic gradient 48 mmHg [38-60], and left ventricular fractional shortening 38% [32-43]). C-terminal BNP serum level at enrollment was evaluated against baseline functional and echocardiographic parameters as well as clinical outcome.BNP level was elevated in the presence of symptoms and increased with NYHA functional class. BNP serum level66 pg/ml detected symptomatic patients with a sensitivity, specificity and accuracy of 84%, 82% and 84%, respectively. In symptomatic and asymptomatic patients, BNP level was a strong independent predictor for cardiovascular death by multivariable analysis adjusted to age and NYHA functional class.BNP serum level allows to differentiate symptomatic from asymptomatic patients with severe AS. BNP is an independent predictor of outcome in these patients and may be helpful for risk stratification.

Objective: To assess left ventricular remodelling in patients with reperfused acute myocardial infarction and to study its relation to microvascular damage. Patients: 25 patients successfully treated by primary percutaneous coronary angioplasty for acute myocardial infarction. Setting: University hospital Methods: Indexed end diastolic (EDVi) and end systolic (ESVi) volumes were assessed on admission and repeated at days 1 and 8. Coronary flow reserve (CFR) was assessed in the infarct related artery on day 1. Myocardial blood volume was assessed on admission and at day 8 by myocardial contrast echocardiography. In patients who manifested persistent myocardial dysfunction at hospital discharge (n = 21), local inotropic reserve was assessed by dobutamine echocardiography at day 7. Results: On admission, patients with and without local viability had similar EDVi and ESVi (EDVi 67 (9) and 73 (14) ml/m 2 , respectively; ESVi 34 (8) and 40 (11) ml/m 2 , respectively; NS). EDVi increased to 97 (22) ml/m 2 in patients without local viability (p v admission) but remained unchanged at 70 (11) ml/m 2 in patients with viable myocardium (NS v admission). For pooled patient data, the percentage change in EDVi correlated with CFR ( r = 0.76, p r = 0.80, p Conclusion: Left ventricular dilatation may preferably occur in patients without local viability and is correlated with early CFR and extent of myocardial blood volume in the infarct territory.

Objective: Epicardial adipose tissue (EAT) is suggested to correlate with metabolic risk factors and to promote plaque development in the coronary arteries. We sought to determine whether EAT thickness was associated or not with the presence and extent of angiographic coronary artery disease (CAD). Methods: We measured epicardial fat thickness by computed tomography and assessed the presence and extent of CAD by coronary angiography in participants from the prospective EVASCAN study. The association of EAT thickness with cardiovascular risk factors, coronary artery calcification scoring and angiographic CAD was assessed using multivariate regression analysis. Results: Of 970 patients (age 60.9 years, 71% male), 75% (n=731) had CAD. Patients with angiographic CAD had thicker EAT on the left ventricle lateral wall when compared with patients without CAD (2.7462.4 mm vs. 2.0862.1 mm; p=0.0001). The adjusted odds ratio (OR) for a patient with a LVLW EAT value $2.8 mm to have CAD was OR=1.46 [1.03–2.08], p=0.0326 after adjusting for risk factors. EAT also correlated with the number of diseased vessels (p=0.0001 for trend). By receiver operating characteristic curve analysis, an EAT value $2.8 mm best predicted the presence of.50% diameter coronary artery stenosis, with a sensitivity and specificity of 46.1% and 66.5% respectively (AUC:0.58). Coronary artery calcium scoring had an AUC of 0.76. Conclusion: Although left ventricle lateral wall EAT thickness correlated with the presence and extent of angiographic CAD, it has a low performance for the diagnosis of CAD. Citation: Picard FA, Gueret P, Laissy J-P, Champagne S, Leclercq F, et al. (2014) Epicardial Adipose Tissue Thickness Correlates with the Presence and Severity of

Improved early outcome in non-ST elevation myocardial infarction (NSTEMI) patients has been mainly attributed to a broader use of invasive strategies. Little is known about the impact of other changes in early management.We aimed to assess 15-year trends in one-year mortality and their determinants in NSTEMI patients. We used data from 4 one-month French registries, conducted 5 years apart from 1995 to 2010 including 3903 NSTEMI patients admitted to intensive care units.From 1995 to 2010, no major change was observed in patient characteristics, while therapeutic management evolved considerably. Early use of antiplatelet agents, β-blockers, ACE-inhibitors and statins increased over time (P0.001); use of newer anticoagulants (low-molecular-weight heparin, bivalirudin or fondaparinux) increased from 40.8% in 2000 to 78.9% in 2010 (P0.001); percutaneous coronary intervention (PCI)≤ 3 days of admission rose from 7.6% to 48.1% (P0.001). One-year death decreased from 20% to 9.8% (HR adjusted for baseline parameters, 2010 vs. 1995 = 0.47, 95% CI: 0.35-0.62). Early PCI (HR = 0.67; 95% CI: 0.49-0.90), use of newer anticoagulants (HR = 0.62; 95% CI: 0.48-0.78) and early use of evidence based medical therapy (HR = 0.54; 95% CI: 0.40-0.72) were predictors of improved one year-survival.One-year mortality of NSTEMI patients decreased by 50% in the past 15years. Our data support current guidelines recommending early invasive strategies and use of newer anticoagulants for NSTEMI, and also show a strong positive association between early use of appropriate medical therapies and one-year survival, suggesting that these medications should be used from the start.

OBJECTIVE To test the feasibility and utility of instituting centralized echocardiographic quality control during a multicenter study of regression of left ventricular hypertrophy in hypertension. DESIGN AND METHODS The LIVE (Left Ventricular Hypertrophy: Indapamide Versus Enalapril) study is an ongoing multicenter, double-blind, controlled study of regression of echocardiographic left ventricular mass index in hypertensive patients with left ventricular hypertrophy (left ventricular mass indexes > 100 g/m2 for women and > 120 g/m2 for men) treated for 1 year with 1.5 mg indapamide sustained-release coated tablets versus 20 mg enalapril. A centralized evaluation committee has validated a prestudy sample echocardiogram from each center, and is now reviewing all videotapes recorded during this study for quality control; final results will be based on a further randomized blinded analysis by this centralized evaluation committee. RESULTS Since December 1994, 878 patients have been preselected (videoechocardiographic recordings sent for assessment), 645 selected (videoechocardiographic recordings validated), and 576 randomly allocated to treatment. After preliminary quality control, 27% (233) of baseline echocardiograms were rejected by our centralized evaluation committee, and 22% (142) of postinclusion echocardiographic measurements had to be repeated, mainly because they were of poor echogenic quality. Analysis of approved baseline echocardiograms for the first 274 randomly allocated patients with digitized data showed that there was a significant correlation between centralized evaluation committee and investigator calculations of left ventricular mass index (r = 0.76, P < 0.001), with consistently higher values for investigator calculations, independently of level of left ventricular mass index (correlation between difference and mean of investigator and centralized evaluation committee measurements, r = 0.08, P = 0.28). The mean difference was 8 +/- 20 g/m2 (P < 0.001). CONCLUSION Early results of the LIVE study quality control showed that real-time 'live', centralized echocardiographic reading was not only feasible, but also useful for avoiding unquantifiable echocardiograms and overestimation of left ventricular mass index. Thus, real-time, centralized echocardiographic quality control should be recommended for multicenter studies of regression of left ventricular hypertrophy.

Accurate echocardiographic parameters for predicting the success of cardioversion or maintenance of sinus rhythm are poorly defined. This prospective transthoracic and transesophageal echocardiographic study was conducted to test the hypothesis that the left atrial appendage flow pattern could be a predictive parameter of the success of cardioversion and maintenance of sinus rhythm in patients with nonvalvular atrial fibrillation. Eighty-two consecutive patients with nonvalvular atrial fibrillation of

Objectives. The aim of this study was to assess the effects of ischemia on diastolic function by analyzing flow propagation velocity with color M-mode Doppler echocardiography.Background. Color M-mode Doppler echocardiography has been proposed as a method of assessing left ventricular filling.Methods. Color M-mode Doppler echocardiography and measurement of hemodynamic data were performed simultaneously at baseline and during angioplasty-induced ischemia. Tau was compared with flow propagation velocity. Late diastolic indexes, left ventricular pressure and flow cessation time were also investigated.Results. During ischemia, left ventricular relaxation rate (tau) increased, whereas flow propagation velocity decreased, from (mean ± SD) 46.8 ± 10 ms to 72.6 ± 18.3 ms and from 59.8 ± 15.8 cm/s to 30 ± 8 cm/s, respectively (all p < 0.0001). The maximal slowing of flow propagation velocity was observed 20 to 30 s after the beginning of the inflation, coexisting with a notch on the ascending limb of the negative rate of rise of the left ventricular pressure (dP/dt) curve. Flow propagation velocity was correlated with tau both at baseline (r = 0.53, p < 0.05) and during inflation (r = 0.53, p < 0.03). Left ventricular end-diastolic pressure increased during ischemia from 13.5 ± 8 mm Hg at baseline to 27.5 ± 7 mm Hg, while a premature cessation of the entering flow occurred −13.8 ± 23 ms before the next Q wave onset, compared with 4.5 ± 19.6 ms after the Q wave onset at baseline (all p < 0.0001).Conclusions. The analysis of flow propagation velocity showed that early filling is highly dependent on left ventricular relaxation rate, particularly through the phenomenon of asynchrony. During ischemia, the premature cessation of late filling is associated with increased diastolic pressures.(J Am Coll Cardiol 1997;29:1246–55)

After successful external cardioversion, the rate of recurrence of atrial fibrillation remains high. The hypothesis that plasma B-type natriuretic peptide could predict the recurrence of atrial fibrillation at 1 year was tested. Plasma B-type natriuretic peptide was measured in 66 consecutive asymptomatic patients who underwent external cardioversion for atrial fibrillation. Twelve-lead electrocardiograms were obtained at 1 year. Sinus rhythm was maintained in 55% of patients. The independent predictors of the recurrence of atrial fibrillation at 1 year were a history of atrial fibrillation, plasma B-type natriuretic peptide, and the energy delivered for conversion. In patients without symptoms of heart failure, plasma B-type natriuretic peptide is an independent predictor of the recurrence of atrial fibrillation.

Background The aim of this study was to evaluate changes in three-dimensional (3D) speckle-tracking–derived myocardial strain during ischemia. Methods Twenty patients referred for percutaneous coronary intervention were studied (mean age, 65 ± 11 years; mean left ventricular ejection fraction, 56 ± 7%). Of the 20 study patients, 12 had severe left anterior descending coronary artery stenosis. A full-volume apical view using multibeat 3D modality and two-dimensional (2D) apical views (four chamber, two chamber, and three chamber) were recorded during coronary occlusion before wall motion abnormalities. After percutaneous coronary intervention, ultrasound contrast agent was selectively delivered through the target lesion to delineate ischemic and peri-ischemic segments (ischemia-adjacent segments). Strain values derived from 2D and 3D speckle-tracking echocardiography were compared in ischemic and nonischemic segments. Results Despite no changes in wall motion and 2D left ventricular ejection fraction (56 ± 7% vs 56 ± 7%), global longitudinal strain by 2D imaging was impaired during percutaneous coronary intervention (−16 ± 3% vs −14 ± 3%, P = .01). Similar changes were observed for all 3D strain components: −11 ± 16% for longitudinal (−15 ± 4% vs −13 ± 4%, P = .03), −13 ± 25% for circumferential (−15 ± 4% vs −12 ± 4%, P = .02), −12 ± 16% for area (−25 ± 5% vs −22 ± 6%, P = .009), and −12 ± 25% for radial global strain (39 ± 12% vs 33 ± 12%, P = .04). During coronary occlusion, 2D longitudinal peak strain and all 3D peak strain components decreased in ischemic segments, while no changes was observed in nonischemic segments. In peri-ischemic segments, only 3D longitudinal and area strain were impaired during ischemia. Conclusions Changes in myocardial deformation related to ischemia can be characterized by 3D speckle-tracking echocardiography before the stage of wall motion abnormality.

The ratio of early transmitral blood flow velocity over tissue Doppler early diastolic mitral annulus velocity (E/e') was found unreliable for estimating pulmonary capillary wedge pressure (PCWP) in patients with decompensated systolic heart failure (HF). The objective of this study was to test its reliability in stable HF. Therefore, 130 consecutive patients with a left ventricular (LV) ejection fraction of35% and stable HF underwent right-sided cardiac catheterization and transthoracic echocardiography with measurement of transmitral flow velocities (E, A) and mitral annulus velocities during systole (s') and diastole (e'). Mean age was 56 ± 11 years and mean LV ejection fraction was 28 ± 8%; 48% had PCWP of15 mm Hg. E/e'septal correlated more strongly with PCWP (r = 0.53) compared with E/e'lateral (r = 0.41) and E/e'mean (r = 0.50; all p values0.001). The area under the receiver operating characteristic curve (AUC) of E/e' ratios for PCWP estimation was 0.79 (95% confidence interval [CI] 0.70 to 0.87) for E/e'septal, 0.72 (95% CI 0.63 to 0.82) for E/elateral, and 0.79 (95% CI 0.70 to 0.87) for E/emean (all p values0.0001). AUCs of E/eseptal and E/emean did not vary with s'septal, QRS width, or resynchronization. Using a cutoff of 8, negative predictive value of E/e'septal was 89% and negative likelihood ratio of 0.15. E/e'lateral showed good diagnostic performance only in patients with s'lateral of4.5 cm/s (n = 77, 59%; AUC = 0.82; 95% CI 0.71 to 0.92; s'lateral of ≤4.5 cm/s: AUC = 0.54; 95% CI 0.38 to 0.70; p = 0.005). In conclusion, e' is useful for estimating LV filling pressure in stable severe systolic HF. E/e'septal showed good diagnostic performance for detecting normal filling pressures.

International audience; Computed tomographic coronary angiography (CTCA) has been proposed as a noninvasive test for significant coronary artery disease (CAD), but only limited data are available from prospective multicenter trials. The goal of this study was to establish the diagnostic accuracy of CTCA compared to coronary angiography (CA) in a large population of symptomatic patients with clinical indications for coronary imaging. This national, multicenter study was designed to prospectively evaluate stable patients able to undergo CTCA followed by conventional CA. Data from CTCA and CA were analyzed in a blinded fashion at central core laboratories. The main outcome was the evaluation of patient-, vessel-, and segment-based diagnostic performance of CTCA to detect or rule out significant CAD (≥50% luminal diameter reduction). Of 757 patients enrolled, 746 (mean age 61 ± 12 years, 71% men) were analyzed. They underwent CTCA followed by CA 1.7 ± 0.8 days later using a 64-detector scanner. The prevalence of significant CAD in native coronary vessels by CA was 54%. The rate of nonassessable segments by CTCA was 6%. In a patient-based analysis, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios of CTCA were 91%, 50%, 68%, 83%, 1.82, and 0.18, respectively. The strongest predictors of false-negative results on CTCA were high estimated pretest probability of CAD (odds ratio [OR] 1.97, p

International audience; BACKGROUND: The benefit of load expansion is controversial in acute pulmonary embolism (PE). The aim of this study was to evaluate the benefit of furosemide in cases of normotensive acute PE. METHODS AND RESULTS: We retrospectively included 70 consecutive normotensive patients (systolic blood pressure ≥ 90 mmHg) admitted for acute PE with right ventricular dilation. Overall, 40 patients were treated during the first 24h by repeated bolus of furosemide (78 ± 42 mg, range 40-160 mg) and 30 patients received isotonic saline solution (1.6 ± 0.9L). Severity of hemodynamic status was similar in both groups, but patients in the furosemide group were older and had a greater creatinine level. At 24h, only the furosemide group had a decreased shock index (0.82 ± 0.22 vs. 0.63 ± 0.16, P

Objectives. This study sought to evaluate the relation, if any, between fluid overload in congestive heart failure (CHF) and a newly discovered endogenous natriuretic factor acting like loop diuretic drugs: contransport inhibitory factor (CIF).Background. The humoral mechanisms regulating volume overload in CHF are not fully understood. Therefore, we investigated whether there is a role for CIF in this pathologic condition.Methods. Plasma and urinary CIF levels were investigated in 23 patients with chronic CHF and compared with changes in plasma atrial natriuretic peptide (ANP). Twelve patients without CHF served as control subjects.Results. CHF was associated with a highly significant threefold increase in both plasma CIF levels (mean ± SD 7.10 ± 3.01 vs. 2.28 ± 0.92 U/ml, p < 0.0001) and urinary CIF excretion (7,849 ± 3,600 vs. 2,351 ± 1,297 U/day, p < 0.0001) with respect to patients without CHF. CIF increased as a function of impairment in left ventricular ejection fraction (r = −0.703, p < 0.0001) and the severity of clinical status. Plasma ANP was also increased in patients with CHF, although to a lesser extent (68%, p = 0.0501) than plasma CIF, and was also significantly correlated with left ventricular ejection fraction (r = −0.552, p = 0.0004).Conclusions. Plasma and urinary CIF activities were strongly and very significantly increased in chronic CHF. In addition to ANP, this long-term natriuretic agent may be of potential importance in reducing fluid overload in CHF.

We undertook this study to evaluate the importance of redistribution images in thallium 201 single-photon emission computed tomography (Tl-201 SPECT) assessment of myocardial viability after acute myocardial infarction. Stress-redistribution-reinjection Tl-201 SPECT was performed in 55 consecutive patients with recent (within 1 month) acute myocardial infarction. The myocardium was divided into 16 segments and activity assessed visually with a score from 0 to 3 on stress-redistribution and stress-reinjection images. A defect was considered moderate if the stress score was 2 and severe if the stress score was 0 or 1. All moderate defects were considered viable, regardless of score on redistribution or reinjection images. Severe defects were considered viable if they were reversible (improvement of 1 score) on redistribution or reinjection images. Stress-redistribution and stress-reinjection images were visually analyzed and compared in terms of viability classification. On visual analysis, 461 segments (52%) were abnormal. One hundred eleven stress defects were moderate; of these, 28 were reversible on reinjection images only and 15 on redistribution images only. However, all of these segments were viable, regardless of the analysis chosen. Of 350 severe stress defects, 48 were reversible on reinjection and irreversible on redistribution images, and 4 were reversible on redistribution and irreversible on reinjection images. Therefore, in viability assessment, 48 segments were misclassified with stress-redistribution analysis, whereas only 4 segments were misclassified using stress-reinjection analysis. Although the usefulness of Tl-201 reinjection imaging is confirmed, redistribution images seem to be of little interest in postmyocardial infarction viability assessment.

Summary Background Currently, several anatomical approaches and intervention sites can be used to perform transcatheter aortic valve implantations (TAVIs), often with no clinical indications for choosing one or another. While these choices can have an impact on resource consumption, no costing study is available in the European context to provide information on resource use and assist decision-making. Aims To provide comparative data on the cost of the TAVI procedure, depending on anatomical approach and intervention site used, from a hospital perspective, and to analyze factors associated with cost of hospital stay. Methods Multicentre national registry data were collected in 16 centres between January and October 2009. For 287 patients, a descriptive costing study and a multivariable analysis of hospital stay cost were performed. Results The mean cost of the TAVI procedure was € 22,876 and the mean initial hospital stay cost was € 35,164. The procedure cost, excluding valve cost, did not differ between anatomical approaches and was highest in the hybrid room and lowest in the catheterization laboratory. Factors associated with higher hospital stay cost were transapical approach, Society of Thoracic Surgeons score > 10%, warfarin use at inclusion, complications during procedure and pacemaker implantation following valve implantation. Conclusions If clinical considerations do not interfere, hospital staff may find it economically favorable to opt for the catheterization laboratory and against the hybrid room. The mean hospital stay cost is higher than the tariff paid in 2011, a difference that has grown since the change in tariff in 2012, representing an economic disincentive for the uptake of TAVI in France.

Background Traumatic disruption of the aorta (TDA) is a life-threatening injury that requires rapid diagnosis and treatment. Emergency aortography, which is the current standard diagnostic imaging modality, is invasive, time-consuming, and difficult to perform in hemodynamically unstable patients with multiple trauma. We performed transesophageal echocardiography (TEE) in patients with suspected TDA to determine the diagnostic accuracy and impact on patient management of this alternative, portable imaging modality. Methods and Results Thirty-two consecutive trauma patients (mean age, 40±16 years) with suspected TDA (violent deceleration accident and mediastinum >8 cm on admission chest x-ray) prospectively underwent a TEE examination in the emergency room. Findings during TEE were compared with those encountered during aortography, surgery, or necropsy. Two subsets of traumatic aortic injuries with distinct echocardiographic signs were observed: (1) subadventitial TDA (n=10) and (2) traumatic intimal tears (n=3). Eighteen patients had normal TEE confirmed by aortography. One 2-mm medial tear was missed by TEE (necropsy). The sensitivity and specificity of TEE for the diagnosis of subadventitial TDA were 91% and 100%, respectively. Patients with subadventitial TDA were taken to surgery immediately, whereas patients with intimal aortic tears were treated conservatively. Eighteen patients (mean age, 57±15 years) with confirmed acute aortic dissection involving the aortic isthmus were also included to establish the echocardiographic differential diagnostic criteria between this entity and TDA. Conclusions TEE should be considered the first-line imaging modality for the evaluation of trauma patients with suspected injuries of the thoracic aorta because of its portability, safety, diagnostic accuracy, and potential impact on patient management.

Fetuin-A is a ubiquitous anti-inflammatory glycoprotein that counteracts proinflammatory cytokine production. Previous studies have shown that low fetuin-A concentration is associated with cardiovascular death and may play an important role in the prognosis of patients with acute coronary syndromes (ACS). The purpose of this study was to assess in large cohort of patients admitted for ACS the prognostic value of fetuin-A adjusted for C-reactive protein value (CRP) and Global Registry of Acute Coronary Events (GRACE) risk score. Plasma fetuin-A and CRP concentrations were measured on day 3 in 754 consecutive patients with ACS (mean age 66 ± 14 years, 404 with ST-segment elevation and 350 without ST-segment elevation) included in the French Registry of Acute ST-Elevation or Non-ST-Elevation Myocardial Infarction (FAST-MI), and these data were correlated to 1-year mortality. Plasma fetuin-A and CRP concentrations at admission averaged 95 ± 27 and 12 ± 16 mg/L, respectively. Overall, 1-year cardiovascular mortality was 10% (28 in-hospital deaths and 51 deaths after discharge), 17% in patients with low fetuin-A (less than the first tertile), 18% with high CRP (higher than the third tertile), and 23% in patients with low fetuin associated with high CRP (p0.01). In contrast, patients with neither low fetuin-A nor high CRP had a low mortality rate (5%). Multivariate analysis adjusted for GRACE risk score showed that low fetuin-A and high CRP concentration remained associated with outcomes (odds ratio 2.28, 95% confidence interval 1.20 to 4.33). In conclusion, fetuin-A combined with CRP level is associated with cardiovascular death in patients with ACS.

BACKGROUND: Normal values and the prognostic significance of right ventricle (RV)-2D strain in chronic heart failure (CHF) patients are unknown. METHODS AND RESULTS: Between 2005 and 2010, we prospectively enrolled 43 controls and 118 stable CHF patients. Standard echocardiographic variables, tricuspid annular plane systolic excursion, peak systolic velocity of tricuspid annular motion using tissue Doppler imaging, and RV and left ventricle (LV) 2D-strain were measured. The primary outcome was death or emergency transplantation or emergency ventricular assist device implantation or acute heart failure. RV-2D strain was measurable in 39 controls (58±17 years, 50% men), whose median value was 30% (95% confidence interval [95%CI], 39%; 20%); and in 104 CHF patients (80% men, mean age 57±11 years, and mean LV ejection fraction 29%±8%), whose median value was 19% (95%CI, 34%; 9%). During the mean follow-up of 37±14 months, 44 experienced the primary outcome. By Cox proportional hazards multivariate analysis, only RV-2D strain and log B-type natriuretic peptide independently predicted experiencing the primary outcome within the first year. The best RV-2D strain cut-off by receiver-operating characteristics analysis was 21%, and patients with values >21% were at greatest risk (χ(2)-log-rank test=14.1, P

SummaryBackgroundCentral venous oxygen saturation (ScvO2) provides an estimation of body oxygen consumption/delivery ratio. Its use has been suggested for monitoring treatment of patients admitted for acute decompensated heart failure (ADHF) but the optimal target value has never been clearly reported.AimsWe aimed to address the prognostic value of ScvO2 in ADHF requiring inotrope support.MethodsScvO2 was prospectively assessed in 60 patients with ADHF requiring inotrope support (mean age 62±16 years; 45 men; left ventricular ejection fraction 25±7%) and was compared with major adverse cardiac events (MACE), defined as heart transplantation, cardiac assistance and death.ResultsMACE occurred in 22 (35%) patients (14 deaths; eight referred for heart transplantation or cardiac assistance). Admission ScvO2 (mean 57±13%) did not differ between patients with and without MACE. At 24hours ScvO2 (mean 62±7%) increased only in patients without MACE (65±6% vs. 58±7%; p60% at 24hours.ConclusionIn patients admitted for ADHF requiring inotrope support, ScvO2≤60% despite optimal treatment is a marker of poor outcome and might be an indicator for considering more aggressive therapy.

Aims To evaluate the impact of acoustic window on the feasibility and accuracy of longitudinal global strain (global- ɛ ) by speckle tracking for assessing left ventricular (LV) systolic function. Methods and results The study included 70 patients (57 ± 17 years, 64% men), 28 selected patients with a suboptimal image quality (IQ) defined by three or more segments (4 ± 3 segments/patient) with wall motion score not analysable visually and 42 patients with an optimal two-dimensional (2D) echocardiography IQ. Left ventricular ejection fraction (LVEF) by Simpson's biplane method (2D-EF), global- ɛ by speckle tracking, and peak systolic mitral annulus velocity [systolic tissue Doppler imaging (S-TDI)] were compared with LVEF by cardiac magnetic resonance (EF-CMR; 45 ± 18%, range 9–76%). Speckle-tracking analysis was feasible in all segments with an optimal acoustic window and in 85% (103/121) of segments poorly visualized. Global- ɛ similarly correlated with LVEF by CMR in patients with and without optimal IQ ( r = 0.81 vs. 0.82 for good vs. poor IQ). In contrast, 2D-EF ( r = 0.76) and S-TDI ( r = 0.64) less correlated with LVEF by CMR in patients with a suboptimal IQ. Importantly, IQ only impacted on 2D-EF inter-observer reproducibility (9 ± 5 vs. 24 ± 22% for good vs. poor IQ) but not on global- ɛ reproducibility (9 ± 1 vs. 8 ± 7% for good vs. poor IQ). Conclusion In patients with a limited acoustic window, longitudinal strain by speckle tracking remains accurate and reproducible for assessing global and regional LV systolic function.

Aims To assess the usefulness of miniature transoesophageal echocardiography using a 10 F intracardiac probe (ICE-TEE) for transseptal catheterization during atrial fibrillation (AF) ablation. Methods and results Intracardiac echocardiography probe was used transoesophageally in 79 consecutive patients (56 ± 11 years, 73% male) referred for AF ablation (60% paroxysmal and 38% persistent) to guide transseptal puncture. Transseptal catheterization monitored by ICE-TEE was well tolerated and successfully performed in all patients without any sedation. No mechanical oesophageal complication was noted. Moreover, the mean duration between ICE-TEE probe insertion and successful transseptal puncture was 4.5 min and the mean time of ICE-TEE was 10 min. Finally, no tamponade occurred during the AF ablation procedure. Conclusion Intracardiac echocardiography-TEE is safe and well tolerated for the guidance of transseptal catheterization during AF ablation. Moreover, this technique was performed without requiring any anaesthesia.

Sleep-disordered breathing (SDB) is associated with left ventricle (LV) remodelling in patients with normal LV function. Sleep-disordered breathing is common in chronic heart failure (CHF) with systolic LV dysfunction, and may contribute to LV remodelling and CHF progression. Our aim was to determine the consequence of SDB on LV geometry in patients with CHF. We hypothesised that SDB severity was correlated with the degree of LV hypertrophy (LVH). One-hundred and sixty patients with CHF with a non-ischaemic systolic LV dysfunction were assessed by overnight polygraphy and echocardiography. Patients were classified in four groups according to their apnoea-hypopnoea index (AHI):5 (no-SDB); 5-14 (mild); 15-29 (moderate); ≥30 (severe). Left ventricular mass index (LVM Ind) was calculated using the usual echocardiographic M-Mode parameters. Their mean age, New York Heart Association and left ventricular ejection fraction were, respectively: 56 ± 13 years, 2.4 ± 0.8 and 30 ± 10%, and 77% were men. Body mass index, interventricular septal and posterior LV wall thicknesses, and LVM Ind were significantly increased in severe SDB versus no-SDB. LVM Ind was correlated to the AHI (R = 0.27, P = 0.0006) and, using logistic regression, AHI was the unique independent factor of LVH in this population. In non-ischaemic CHF, SDB severity is associated with LV remodelling.

Background— Longitudinal myocardial deformation indexes appear superior to left ventricular ejection fraction (LVEF) in assessing myocardial contractility. However, few studies have addressed the prognostic value of longitudinal motion markers (velocity, strain, and strain rate) in predicting outcome in heart failure patients. Methods and Results— The study included 125 consecutive symptomatic heart failure patients (63�16 years, 77% male, LVEF=31�10%). All patients underwent a complete echocardiographic and clinical examination, and brain natriuretic peptide level was assessed in 93 patients. Longitudinal myocardial velocity by tissue Doppler imaging, global-ε, and strain rate by speckle tracking were computed from apical views (4-, 3-, and 2-chambers views) and compared with the occurrence of major adverse cardiac events. On the whole, peak longitudinal velocity, global-ε, and strain rate averaged 5�2 cm/s (range, 1 to 9), −8�3% (range, −3 to −18), and −0.33�0.16 s −1 (range, −0.83 to −0.05), respectively. During the follow-up period (266�177 days), major adverse cardiac events occurred in 47 (38%) patients (15 deaths, 29 recurrent heart failure, and 4 heart transplantations). By univariable analysis using Cox model global-ε, strain rate, and LVEF were associated with the occurrence of major adverse cardiac events, whereas only global-ε remained independently predictive of outcome by multivariate analysis. Conclusions— In the heart failure population, longitudinal global strain by speckle tracking is superior to LVEF and other longitudinal markers in identifying patients with poor outcome.

Aims To evaluate the use of intracardiac echocardiography probe through oesophageal route (ICE-TEE) for the monitoring of percutaneous foramen ovale (PFO) closure procedure. Methods and results The study was conducted in 50 patients divided into two groups: in group I ( n = 24), accuracy of ICE-TEE in assessing the inter-atrial septum (IAS) was compared with standard TEE, and in group II, we used ICE-TEE to monitor 26 consecutive patients referred for PFO closure. In group I, IAS was constantly visualized with a close correlation between ICE-TEE and standard TEE for IAS excursion ( r = 0.9, P < 0.0001). In group II, ICE-TEE allowed to rule out four patients (three without PFO and one with septal atrial defect associated) and identified three complications during PFO closure procedure (pericardial effusion, inadequate device deployment, and cardiac thrombus). Finally, device implantation was successfully performed in the 22 patients with no residual shunt and thrombus observed after 3 months. Conclusion ICE-TEE could be used to monitor PFO closure procedure.

International audience; AIMS: Heart failure (HF) has a poor prognosis. Several right ventricular (RV) echocardiographic parameters have been proposed as sensitive markers to detect patients at risk. Our objective was to compare the predictive value of four RV systolic echocardiographic parameters for outcomes in patients with HF. METHODS AND RESULTS: One hundred and thirty-six patients with stable HF and a left ventricular ejection fraction

Background— The management of patients with asymptomatic severe aortic stenosis remains controversial. We sought to develop a continuous risk score for predicting the midterm development of symptoms or adverse events in this setting. Methods and Results— We prospectively followed 107 patients with asymptomatic aortic stenosis (aged 72 years [63 to 77]; 35 women; aortic-jet velocity, 4.1 m/s [3.5 to 4.4]) at a single center in France. Predefined end points for assessing outcome were the occurrence within 24 months of death or aortic valve replacement necessitated by symptoms or by a positive exercise test. Variables independently associated with outcome were used to build a score that was validated in an independent cohort of 107 patients from Belgium. Independent predictors of outcome were female sex, peak aortic-jet velocity, and B-type natriuretic peptide at baseline. Accordingly, the score could be calculated as follows: Score=[peak velocity (m/s)×2]+(natural logarithm of B-type natriuretic peptide×1.5)+1.5 (if female sex). Event-free survival after 20 months was 80% for patients within the first score quartile compared with only 7% for the fourth quartile. Areas under the receiver operating characteristic curve for the score were 0.90 and 0.89 in the development and validation cohorts, respectively. Conclusions— If further validation is achieved, this score may be useful to predict outcome in individual patients with asymptomatic aortic stenosis to select those who might benefit from early surgery.

Background— Intravenous thrombolysis remains a widely used treatment for ST-elevation myocardial infarction; however, it carries a higher risk of reinfarction than primary PCI (PPCI). There are few data comparing PPCI with thrombolysis followed by routine angiography and PCI. The purpose of the present study was to assess contemporary outcomes in ST-elevation myocardial infarction patients, with specific emphasis on comparing a pharmacoinvasive strategy (thrombolysis followed by routine angiography) with PPCI. Methods and Results— This nationwide registry in France included 223 centers and 1714 patients over a 1-month period at the end of 2005, with 1-year follow-up. Sixty percent of the patients underwent reperfusion therapy, 33% with PPCI and 29% with intravenous thrombolysis (18% prehospital). At baseline, the Global Registry of Acute Coronary Events score was similar in thrombolysis and PPCI patients. Time to initiation of reperfusion therapy was significantly shorter in thrombolysis than in PPCI (median 130 versus 300 minutes). After thrombolysis, 96% of patients had coronary angiography, and 84% had subsequent PCI (58% within 24 hours). In-hospital mortality was 4.3% for thrombolysis and 5.0% for PPCI. In patients with thrombolysis, 30-day mortality was 9.2% when PCI was not used and 3.9% when PCI was subsequently performed (4.0% if PCI was performed in the same hospital and 3.3% if performed after transfer to another facility). One-year survival was 94% for thrombolysis and 92% for PPCI ( P =0.31). After propensity score matching, 1-year survival was 94% and 93%, respectively. Conclusions— When used early after the onset of symptoms, a pharmacoinvasive strategy that combines thrombolysis with a liberal use of PCI yields early and 1-year survival rates that are comparable to those of PPCI.

Aims To assess the prognostic impact of prosthesis-patient mismatch (PPM) in a large consecutive series of patients operated for low-gradient aortic stenosis (AS). Methods and results Outcomes after surgery for low-gradient AS were prospectively assessed in 152 consecutive patients from seven institutions. There were 113 men (74%); mean age was 72 years (64–76); valve area, 0.7 cm2 (0.6–0.8); left ventricular (LV) ejection fraction 0.31 (0.25–0.37) and baseline mean transaortic pressure gradient (MPG), 30 mmHg (25–35) Among 139 patients with available prosthetic valve effective orifice area (EOA), PPM (defined by an indexed EOA ≤ 0.85 cm2/m2) was present in 79 patients (57%) and had no significant impact on post-operative mortality. Independent predictors of overall mortality were LV contractile reserve [hazard ratio (HR) 0.52; 95% confidence interval (CI) 0.35–0.78; P = 0.002], associated coronary artery bypass grafting (HR 1.87; 95% CI 1.24–2.82; P =0.003), baseline MPG (per 1 mmHg decrease to 10 mmHg; HR 1.03; 95% CI 1.01–1.06; P = 0.021), previous cancer (HR 2.13; 95% CI 1.05–4.29; P = 0.037), and logistic EuroSCORE (per 1% increase; HR 1.02; 95% CI 1.01–1.04; P = 0.040). Conclusion In this large multicentre series of patients with low-gradient AS, we found that PPM (moderate in most cases) had no influence on post-operative mortality. Therefore, the performance of more complex interventions in order to avoid moderate PPM may not be justified in the setting of low-gradient AS, because their higher risk probably outweighs the expected benefit.

Background: Fetuin-A inhibits inflammation and has a protective effect against myocardial ischemia. Its deficiency has been found to be associated with cardiovascular death in patients with end-stage renal failure disease. We investigated the association between plasma fetuin-A and clinical outcome after ST-elevation acute myocardial infarction (STEMI). Methods: We measured fetuin-A in 284 consecutive patients with STEMI and correlated these data with the occurrence of death at 6 months (n = 25). We also measured fetuin-A in a control group and chose the 95th percentile as the cutoff to define abnormality. Results: Patient mean (SD) age was 60 (14) years, and creatinine clearance was 83 (31) mL/min; 82% were men. Mean (SD) plasma fetuin-A concentrations at admission [188 (69) mg/L, P = 0.01] and at day 3 [163 (57) mg/L, P Conclusions: Fetuin-A is an important predictor of death at 6 months in STEMI patients independent of NT-proBNP, CRP, and CADILLAC risk score.