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Several studies have demonstrated an association between elevated cardiac biomarkers and adverse outcomes in patients with COVID-19. However, the prognostic and predictive capability of a multimarker panel in a prospectively collected, diverse "all-comers" COVID-19 population has not been fully elucidated.We prospectively assessed high sensitivity cardiac troponin I (hsTnI), NT-pro B-type Natriuretic Peptide (NT-proBNP), Galectin-3 (Gal-3), and procalcitonin (PCT) in 4,282 serial samples from 358 patients admitted with symptomatic, RT-PCR confirmed SARS-CoV-2 infection. Outcomes examined were 30-day in-hospital mortality and requirement for intubation within 10 days.Baseline hsTnI had the highest AUC for predicting 30-day mortality (0.81; 95% CI, 0.73-0.88), followed by NT-proBNP (0.80; 0.74-0.86), PCT (0.77; 0.70-0.84), and Gal-3 (0.68; 0.60-0.76). HsTnI 3.5 ng/L at baseline identified patients at low risk for in-hospital mortality (NPV 95.9%, sensitivity 97.3%) and 10-day intubation (NPV 90.4%, sensitivity 88.5%). Continuous, log-2 increases in troponin concentration were associated with reduced survival (p 0.001) on Kaplan-Meier curves and increased risk of 30-day mortality: HR 1.26 (1.16-1.37) in univariate and 1.19 (1.03-1.4) in multivariate models. Time-varying doubling of concentrations of hsTnI and Gal-3 were associated with increased risk of 30-day mortality (adjusted HR 1.21, 1.06-1.4, and 1.92, 1.40-2.6).HsTnI, NT-proBNP, Gal-3, and PCT are elevated at baseline in patients that have worse outcomes from COVID-19. HsTnI was the only independent predictor of 30-day mortality and intubation. Time-varying, doubling in hsTnI and Gal-3 further aided in prognostication of adverse outcomes. These results support the use of hsTnI for triaging patients with COVID-19.

The relation of high-sensitivity cardiac troponin I (hs-cTnI) concentration and presence of obstructive coronary artery disease (CAD) in patients without myocardial infarction (MI) is unclear. Study participants selected from patients free of MI who underwent coronary angiography with or without intervention were enrolled, and hs-cTnI measured. A gradient boosting model was implemented to build a model for detection of CAD. Cox proportional hazard regression was used to assess the association of hs-cTnI and adverse cardiovascular (CV) outcome. Among 978 study participants, 607 patients (62%) had CAD. Higher concentrations of hs-cTnI were associated with chronic kidney disease, heart failure, CAD, male gender, current tobacco use, anemia, age, and low-density lipoprotein cholesterol. History of CAD, male gender, type 2 diabetes mellitus, hs-cTnI, anemia, age, and high-density lipoprotein cholesterol were the most influential factors for detection of CAD. The gradient boosting model had an area under the curve of 0.82, accuracy of 75%, sensitivity of 88%, specificity of 52%, positive predictive value of 76%, and negative predictive value of 72% for detection of CAD. Increase in 1 log unit of hs-cTnI was significantly associated with increased risk of incident MI (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.22 to 1.47, p0.001), CV mortality (HR 1. 24, 95% CI 1.11 to 1.39, p0.001), and composite of incident MI or CV mortality (HR 1.29, 95% CI 1.20 to 1.40, p0.001). In conclusion, among patients without acute MI and CAD, higher concentrations of hs-cTnI were associated with the presence of CAD and linked to increased risk of future CV events. ClinicalTrials.gov Identifier: NCT00842868.

Variations in high-sensitivity cardiac troponin I by age and sex along with various sampling times can make the evaluation for acute myocardial infarction (AMI) challenging. Machine learning integrates these variables to allow a more accurate evaluation for possible AMI. The goal was to test the diagnostic and prognostic utility of a machine learning algorithm in the evaluation of possible AMI. We applied a machine learning algorithm (myocardial-ischemic-injury-index [MI3]) that incorporates age, sex, and high-sensitivity cardiac troponin I levels at time 0 and 30 minutes in 529 patients evaluated for possible AMI in a single urban emergency department. MI3 generates an index value from 0 to 100 reflecting the likelihood of AMI. Patients were followed at 30-45 days for major adverse cardiac events (MACEs). There were 42 (7.9%) patients that had an AMI. Patients were divided into 3 groups by the MI3 score: low-risk (≤ 3.13), intermediate-risk (3.13-51.0), and high-risk (51.0). The sensitivity for AMI was 100% with a MI3 value ≤ 3.13 and 353 (67%) ruled-out for AMI at 30 minutes. At 30-45 days, there were 2 (0.6%) MACEs (2 noncardiac deaths) in the low-risk group, in the intermediate-risk group 4 (3.0%) MACEs (3 AMIs, 1 cardiac death), and in the high-risk group 4 (9.1%) MACEs (4 AMIs, 2 cardiac deaths). The MI3 algorithm had 100% sensitivity for AMI at 30 minutes and identified a low-risk cohort who may be considered for early discharge.

High sensitive cardiac troponin I (hs-cTnI) increases with inducible myocardial ischemia in patients with coronary artery disease (CAD). We aimed to assess if the change in hs-cTnI levels with exercise stress testing is associated with major adverse cardiac events (MACE). A cohort of 365 (age 62 ± 9 years, 77% men) patients with stable CAD underwent 99mTc sestamibi myocardial perfusion imaging with treadmill testing. Plasma hs-cTnI level was measured at rest and at 45 min after stress. Multivariable Fine & Gray’s subdistribution hazards models were used to determine the association between the change in hs-cTnI and MACE, a composite end point of cardiovascular death, myocardial infarction, and unstable angina requiring revascularization. During a median follow-up of 3 years, 39 (11%) patients experienced MACE. After adjustment, for each two-fold increment in hs-cTnI with stress, there was a 2.2 (95% confidence interval 1.3–3.6)-fold increase in the hazard for MACE. Presence of both a high resting hs-cTnI level (>median) and ≥ 20% stress-induced hs-cTnI elevation was associated with the highest incidence of MACE (subdistribution hazards models 4.6, 95% confidence interval 1.6 to 13.0) compared with low levels of both. Risk discrimination statistics significantly improved after addition of resting and change in hs-cTnI levels to a model including traditional risk factors and inducible ischemia (0.67 to 0.71). Conversely, adding inducible ischemia by SPECT did not significantly improve the C-statistic from a model including traditional risk factors, baseline and change in hs-cTnI (0.70 to 0.71). In stable CAD patients, higher resting levels and elevation of hs-cTnI with exercise are predictors of adverse cardiovascular outcomes beyond traditional cardiovascular risk factors and presence of inducible ischemia.

Improvements in cancer survival have led to the emergence of cardiovascular disease as an important determinant of adverse outcome in survivors. Cancer therapeutics-related cardiac dysfunction is the most well-known form of cardiotoxicity. However, newer cancer therapies bring a broader range of cardiotoxicities. The optimal method to identify patients at risk of these complications is unclear, but circulating biomarkers comprise one possible approach. Troponins and natriuretic peptides have garnered the broadest evidence base for cardiotoxicity risk prediction, but other markers are being investigated. In this review, we explore evidence for circulating biomarkers in cardiotoxicity prediction associated with cancer therapies.

Hypertrophic cardiomyopathy (HC) represents a major cause of sudden cardiac death in young adults. Late gadolinium enhancement (LGE) and extracellular volume (ECV) by T1 mapping are cardiac magnetic resonance (CMR) techniques to quantify fibrosis in HC. The relationships of LGE and ECV with ventricular arrhythmia, left ventricular (LV) diastolic function, and risk factors for sudden cardiac death (SCD) in HC are unclear. We studied 103 HC patients (mean age 51 ± 14, 42% women) who underwent CMR from 2012 to 2014. Global LGE and mean ECV were evaluated in relation to history of nonsustained ventricular tachycardia (NSVT), diastolic function by echocardiography, and SCD risk factors. LGE was present in 71 (69%) subjects. Wide variation was demonstrated in LGE (0.5% to 45.9%) and mean ECV (17.6% to 47.4%). Prevalence of NSVT increased continuously with LGE and was greater in subjects with ECV above the study population mean (27%). Increased LGE was associated with LV diastolic dysfunction and LV wall thickness. In conclusion, while ECV appears to have a threshold (27%) above which it is associated with NSVT, LGE demonstrates a more robust relationship with NSVT and measures of diastolic dysfunction.

Background Multiple biomarkers have been independently and additively associated with major adverse cardiovascular events in patients with coronary artery disease. We investigated the prognostic value of suPAR (soluble urokinase‐type plasminogen activator receptor) and hsTnI (high‐sensitivity troponin I) levels in symptomatic patients with no obstructive coronary artery disease. We hypothesized that high levels of these biomarkers will be associated with the risk of future adverse outcomes. Methods and Results Plasma levels of suPAR and hsTnI were measured in 556 symptomatic patients with no obstructive coronary artery disease. A biomarker risk score was calculated by counting the number of biomarkers above the median in this cohort (suPAR>2523 pg/mL and hsTnI>2.7 pg/mL). Survival analyses were performed with models adjusted for traditional risk factors. All‐cause death and major adverse cardiovascular events (cardiovascular death, myocardial infarction, stroke, and heart failure) served as clinical outcomes over a median follow‐up of 6.2 years. Mean age was 57±10 years, 49% of the cohort patients were female, and 68% had a positive stress test. High suPAR and hsTnI levels were independent predictors of all‐cause death (hazard ratio=3.2 [95% CI, 1.8–5.7] and 1.3 [95% CI, 1.0–1.7], respectively; both P P Conclusions Among symptomatic patients with no obstructive coronary artery disease, higher levels of suPAR and hsTnI were independently and additively associated with an increased risk of adverse events. Whether modification of these biomarkers will improve risk in these patients needs further investigation.

Natriuretic peptides (NPs) are recommended by international guidelines to exclude non-heart failure causes of acute dyspnea and to assess prognosis. NPs are commonly used as an entry criterion for clinical trials, to minimize enrollment of misdiagnosed patients, or to ensure enrollment of a sufficiently at-risk population. NP values used to select trial populations to date have been inconsistent across studies. Future trials should consider using standardized thresholds for NP levels, with protocol-specified adaptations appropriate for the specific study and patient population to account for factors that can influence the NP level. NPs have been used as an endpoint for proof-of-concept or phase 2 clinical trials, although it is important to remember that positive results in early phase studies may be unstable due to small numbers and the play of chance, and they are not always reproducible in phase 3 trials. Likewise, failure to reduce NP in phase 2 may not necessarily indicate that a drug will be ineffective on clinical outcomes in phase 3. NP guided therapy has been intensively studied, but the clinical outcome benefits of this approach remain uncertain. Neprilysin inhibitors have stimulated further exploration of the NP system and how it influences, and is potentially influenced by, heart failure therapies. This paper discusses the utility of NPs in the current clinical research and practice environment and addresses areas in need of further research from the perspectives of academic clinical trialists, clinicians, biostatisticians, regulators, and pharmaceutical industry scientists who participated in the 13th Global Cardiovascular Clinical Trialists Forum.

Serial assessments of left ventricular ejection fraction (LVEF) are customary in patients with breast cancer receiving trastuzumab. Radionuclide angiography (RNA) is often used; however, a typical monitoring schedule could include 5 scans in a year. We evaluated the proportion of imaging-related ionizing radiation attributable to RNA in 115 patients with breast cancer, from 3 medical centers in the United States, Ireland, and Japan, who completed 12 months of trastuzumab treatment. Estimated radiation dose (ERD) was used to calculate exposure associated with imaging procedures spanning the 18 months before and after trastuzumab therapy. In addition, 20 cardiologists and oncologists from participating centers were surveyed for their opinions regarding the contribution of RNA to overall radiation exposure during trastuzumab treatment. When RNA was used to monitor LVEF, the mean ERD from imaging was substantial (34 ± 24.3 mSv), with the majority attributable solely to RNA (24.7 ± 14.8 mSv, 72.6%). Actual ERD associated with RNA in this population differed significantly from the perception in surveyed cardiologists and oncologists; 70% of respondents believed that RNA typically accounted for 0% to 20% of overall radiation exposure from imaging; RNA actually accounted for more than 70% of ERD. In conclusion, RNA was used to monitor LVEF in most patients in this cohort during and after trastuzumab therapy. This significantly increased ERD and accounted for a greater proportion of radiation than that perceived by surveyed physicians. ERD should be taken into account when choosing a method of LVEF surveillance. Alternative techniques that do not use radiation should be strongly considered.

Doxorubicin (Dox), a mainstay of adjuvant breast cancer treatment, is associated with cardiac toxicity in the form of left ventricular dysfunction (LVD), LV diastolic dysfunction, or LV systolic dysfunction. Study objectives were to evaluate the prevalence of LVD in long-term breast cancer survivors treated with Dox and determine if brain-type natriuretic peptide (BNP) may help identify patients at risk for LVD. Patients who participated in prospective clinical trials of adjuvant Dox-based chemotherapy for breast cancer with a baseline left ventricular (LV) ejection fraction evaluation from 1999 to 2006 were retrospectively identified from the St Vincent's University Hospital database. Patients were invited to undergo transthoracic echocardiography, BNP analysis, and cardiovascular (CV) risk factor assessment. LVDD was defined as left atrial volume index34 mL/m(2) and/or lateral wall E prime10 m/s, and LVSD as LVEF50 %. Of 212 patients identified, 154 participated, 19 patients had died (no cardiac deaths), and 39 declined. Mean age was 60.7 [55:67] years. A majority of the patients (128, 83 %) had low CV risk (0/1 risk factors), 21 (13.6 %) had 2 RFs, and 5 (3.2 %) ≥3 RFs. BMI was 27.2 ± 4.9 kg/m(2). Median Dox dose was 240 mg/m(2) [225-298]; 92 patients (59.7 %) received ≤240 mg/m(2) and 62 (40.3 %)240 mg/m(2). Baseline LVEF was 68.2 ± 8 %. At follow-up of 10.8 ± 2.2 years, LVEF was 64.4 ± 6 %. Three (1.9 %) subjects had LVEF50 % and one (0.7 %) had LVDD. Dox240 mg/m2 was associated with any LVEF drop. BNP levels at follow-up were 20.3 pg/ml [9.9-36.5] and 21.1 pg/ml [9.8-37.7] in those without LVD and 61.5 pg/ml [50-68.4] in those with LVD (p = 0.04). Long-term prospective data describing the impact of Dox on cardiotoxicity are sparse. At over 10 years of follow-up, decreases in LVEF are common, and dose related, but LVD as defined is infrequent (2.6 %). Monitoring with BNP for subclinical LVD needs further evaluation.

Background The associations between high‐sensitivity troponin I (hsTnI) levels and coronary artery disease (CAD) severity and progression remain unclear. We investigated whether there is an association between hsTnI and angiographic severity and progression of CAD and whether the predictive value of hsTnI level for incident cardiovascular outcomes is independent of CAD severity. Methods and Results In 3087 patients (aged 63±12 years, 64% men) undergoing cardiac catheterization without evidence of acute myocardial infarction, the severity of CAD was calculated by the number of major coronary arteries with ≥50% stenosis and the Gensini score. CAD progression was assessed in a subset of 717 patients who had undergone ≥2 coronary angiograms >3 months before enrollment. Patients were followed up for incident all‐cause mortality and incident cardiovascular events. Of the total population, 11% had normal angiograms, 23% had nonobstructive CAD , 20% had 1‐vessel CAD, 20% had 2‐vessel CAD, and 26% had 3‐vessel CAD . After adjusting for age, sex, race, body mass index, smoking, hypertension, diabetes mellitus history, and renal function, hsTnI levels were independently associated with the severity of CAD measured by the Gensini score (log 2 ß=0.31; 95% confidence interval, 0.18–0.44; P CAD progression (log 2 ß=0.36; 95% confidence interval, 0.14–0.58; P =0.001). hsTnI level was also a significant predictor of incident death, cardiovascular death, myocardial infarction, revascularization, and cardiac hospitalizations, independent of the aforementioned covariates and CAD severity. Conclusions Higher hsTnI levels are associated with the underlying burden of coronary atherosclerosis, more rapid progression of CAD , and higher risk of all‐cause mortality and incident cardiovascular events. Whether more aggressive treatment aimed at reducing hsTnI levels can modulate disease progression requires further investigation.

It is unknown whether the association of high-sensitivity troponin I (hs-TnI) with adverse cardiovascular outcomes varies by the presence of chronic kidney disease (CKD). We examined the association of hs-TnI with adverse cardiovascular outcomes in those with and without CKD in 4,107 (mean age, 64 years; 63% men; 20% black) patients from the Emory Cardiovascular Biobank who underwent coronary angiography. CKD (n = 1,073) was defined as estimated glomerular filtration rate 30 mg/g at baseline. Cox regression was used to compute hazard ratios (HR) for the association between hs-TnI levels (per doubling of hs-TnI: log2[hs-TnI] + 1) and death, cardiovascular death, and major adverse cardiac events (MACE), separately. Hs-TnI was a stronger predictor of death (CKD: HR 1.23, 95% confidence interval [CI] 1.15 to 1.31; no CKD: HR 1.11, 95% CI 1.05 to 1.17, p-interaction = 0.023), cardiovascular death (CKD: HR 1.24, 95% CI 1.14 to 1.34; no CKD: HR 1.15, 95% CI 1.07 to 1.22, p-interaction = 0.12), and MACE (CKD: HR 1.18, 95% CI 1.11 to 1.25; no CKD: HR 1.11, 95% CI 1.06 to 1.16, p-interaction = 0.095) in CKD compared with non-CKD. The association between hs-TnI and death in patients with CKD was stronger for patients without obstructive coronary artery disease (no obstructive coronary artery disease: HR 1.60, 95% CI 1.27 to 2.01; obstructive coronary artery disease: HR 1.19, 95% CI 1.11 to 1.27, p-interaction = 0.041). In conclusion, hs-TnI is a stronger predictor of adverse cardiovascular events in patients who have CKD than those without, even in the absence of obstructive coronary artery disease. Hs-TnI may identify CKD patients who are high risk for adverse cardiovascular outcomes in whom aggressive risk factor modification strategies are warranted.

Background— Recent data suggest that circulating biomarkers may predict outcome in patients undergoing transcatheter aortic valve replacement (TAVR). We examined the association between inflammatory, myocardial, and renal biomarkers and their role in ventricular recovery and outcome after TAVR. Methods and Results— A total of 112 subjects undergoing TAVR were included in the prospective registry. Plasma levels of B-type natriuretic peptide, hs-TnI (high-sensitivity troponin I), CRP (C-reactive protein), GDF-15 (growth differentiation factor 15), GAL-3 (galectin-3), and Cys-C (cystatin-C) were assessed before TAVR and in 100 sex-matched healthy controls. Among echocardiographic parameters, we measured global longitudinal strain, indexed left ventricular mass, and indexed left atrial volume. The TAVR group included 59% male, with an average age of 84 years, and 1-year mortality of 18%. Among biomarkers, we found GDF-15 and CRP to be strongly associated with all-cause mortality ( P P P =0.01). Among survivors, functional recovery in global longitudinal strain (>15% improvement) and indexed left ventricular mass (>20% decrease) at 1 year occurred in 48% and 22%, respectively. On multivariate logistic regression, lower baseline GDF-15 was associated with improved global longitudinal strain at 1 year (hazard ratio=0.29; P P =0.03). Conclusions— Elevated GDF-15 correlates with lack of reverse remodeling and increased mortality after TAVR and improves risk prediction of mortality when added to the Society of Thoracic Surgeons score.

Many existing and emerging cancer therapies have a significant effect on the cardiovascular health of patients with cancer and cancer survivors. This paper examines current aspects of interdisciplinary cardio-oncology clinical care delivery and education in the United States and outlines how these data provide a platform for future development of the field. We present the results of the nationwide survey on cardio-oncology services, practices, and opinions, conducted among chiefs of cardiology and program directors, which demonstrate ranges of clinical activities and identify significant interest for increased educational opportunities and expert training of cardiovascular physicians in this field. The survey respondents recognized clinical relevance but emphasized lack of national guidelines, lack of funds, and limited awareness and infrastructure as the main challenges for development and growth of cardio-oncology. We discuss potential solutions to unmet needs through interdisciplinary collaboration and the active roles of professional societies and other stakeholders.

We evaluated the extent to which left ventricular diastolic dysfunction (LVDD) contributes to the high false-positive rates observed when natriuretic peptides (NPs) are used to screen for left ventricular systolic dysfunction (LVSD), and the use of NPs in combination with electrocardiogram (ECG) to screen for pre-clinical ventricular dysfunction (PCVD).Eight hundred and fourteen patients over 40 years of age and with at least one cardiovascular risk factor were recruited. Screening strategies for LVSD included brain natriuretic peptide (BNP) alone at cut-offs of 20, 50, and 100 pg/mL, and BNP and abnormal ECG combined. Systolic and diastolic function was assessed by Doppler echocardiography. A left ventricular ejection fraction (LVEF) of50% was present in 33 (4.1%) of subjects, while 11 (1.4%) had LVEF40%. At a cut-off of 20, 50, and 100 pg/mL, sensitivity for BNP alone when screening for LVSD was 88, 70, and 45%, and specificity 46, 77, and 90%, respectively. Of those labelled 'false positive' in the 20, 50, and 100 pg/mL cut-off groups, 26, 46, and 65%, respectively, were found to have significant LVDD (left atrial volume index34 mL/m(2)). Optimal sensitivity (80%) and specificity (72%) for PCVD was obtained when BNP at a cut-off of 50 pg/mL or an abnormal ECG were defined as a positive screen so that only this group would be sent for Doppler echocardiography.A significant number of patients at risk for LVSD and labelled false positive with screening were found to have LVDD. Identifying this at-risk cohort may improve outcomes, but the clinical and economic benefit of this screening strategy requires formal assessment.

High levels of high sensitivity troponin I (hs-cTnI) are associated with higher risk of inducible myocardial ischemia (ISC) and adverse outcomes in patients with stable coronary artery disease (CAD). ISC is also associated with worse prognosis. We examined whether hs-cTnI levels and ISC are additive

Background Cardiac infiltration is an important cause of death in sarcoidosis. Transthoracic echocardiography (TTE) has limited sensitivity for the detection of cardiac sarcoidosis (CS). Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) is used to diagnose CS but has limitations of cost and availability. We sought to determine whether TTE-derived global longitudinal strain (GLS) may be used to identify individuals with CS, despite preserved left ventricular ejection fraction (LVEF), and whether abnormal GLS is associated with major cardiovascular events (MCE). Methods We studied 31 patients with biopsy-proven extra-cardiac sarcoidosis, LVEF>50% and LGE on CMR (CS+ group), and 31 patients without LGE (CS− group), matched by age, sex, and severity of lung disease. GLS was measured using vendor-independent speckle tracking software. Parameters of left and right ventricular systolic and diastolic function were also studied. Receiver-operating characteristic curves were used to identify GLS cutoff for CS detection, and Kaplan–Meier plots to determine the ability of GLS to predict MCE. Results LGE was associated with reduced GLS (−19.6±1.9% in CS− vs −14.7±2.4% in CS+, P

Background— Cardiac sarcoidosis is associated with an increased risk of heart failure and sudden death, but its risk in patients with preserved left ventricular ejection fraction is unknown. Using cardiovascular magnetic resonance in patients with extracardiac sarcoidosis and preserved left ventricular ejection fraction, we sought to (1) determine the prevalence of cardiac sarcoidosis or associated myocardial damage, defined by the presence of late gadolinium enhancement (LGE), (2) quantify their risk of death/ventricular tachycardia (VT), and (3) identify imaging-based covariates that predict who is at greatest risk of death/VT. Methods and Results— Parameters of left and right ventricular function and LGE burden were measured in 205 patients with left ventricular ejection fraction >50% and extracardiac sarcoidosis who underwent cardiovascular magnetic resonance for LGE evaluation. The association between covariates and death/VT in the entire group and within the LGE+ group was determined using Cox proportional hazard models and time-dependent receiver–operator curves analysis. Forty-one of 205 patients (20%) had LGE; 12 of 205 (6%) died or had VT during follow-up; of these, 10 (83%) were in the LGE+ group. In the LGE+ group (1) the rate of death/VT per year was >20× higher than LGE− (4.9 versus 0.2%, P P P =0.04). LGE burden was the best predictor of death/VT (area under the receiver-operating characteristics curve, 0.80); for every 1% increase of LGE burden, the hazard of death/VT increased by 8%. Conclusions— Sarcoidosis patients with LGE are at significant risk for death/VT, even with preserved left ventricular ejection fraction. Increased LGE burden and right ventricular dysfunction can identify LGE+ patients at highest risk of death/VT.

The differential diagnosis of dyspnoea is difficult due to the low predictive value of clinical and laboratory parameters. The elevated levels of NT-proBNP in congestive heart failure may improve diagnostic accuracy. We have evaluated the effect of the introduction of an NT-proBNP assay on hospital length of stay (LOS) and mortality.There were 11,853 AMAU patient episodes in the 22 months study period (March 2005-Dec 2006). An NT-proBNP assay was requested in 657 (5.5%) of these. Comparison between categorical variables such as diagnosis, NT-proBNP testing, LOS, and in-hospital mortality was made using Chi-square tests. Literature review suggested that an NT-proBNP cut-offor=5000 ng/L should predict acute in-patient mortality. Logistic regression analysis was used to examine the association between such an elevated NT-proBNP level and outcomes.Of the 396 patients with NT-proBNP5000 ng/L, 8.1% died compared with 22.5% of the 178 patients dying with valuesor=5000 ng/L (p0.0001). An NT-proBNPor=5000 ng/L was predictive of both LOSor=9 days (odds ratios (OR) 1.54 (95% CI 1.06, 2.24: p=0.02) and LOSor=14 days (OR=1.87 (95% CI 1.29, 2.71: p=0.0009). NT-proBNP requests increased over time, from 2.6% to 8.2% of all patients; the result fell in the diagnostic range for CHF in 60% of requests.The introduction of an NT-proBNP was reflected in an appropriate but rapidly increasing pattern of requests from clinicians. High NT-proBNP levels predicted in-hospital mortality and longer LOS in an acute medical population.

There is an increasing awareness and clinical interest in cardiac safety during cancer therapy as well as in optimally addressing cardiac issues in cancer survivors. Although there is an emerging expertise in this area, known as cardio-oncology, there is a lack of organization in the essential components of contemporary training. This proposal, an international consensus statement organized by the International Cardioncology Society and the Canadian Cardiac Oncology Network, attempts to marshal the important ongoing efforts for training the next generation of cardio-oncologists. The necessary elements are outlined, including the expectations for exposure necessary to develop adequate training. There should also be a commitment to local, regional, and international education and research in cardio-oncology as a requirement for advancement in the field.

Significant advances have been made in detecting cancer therapeutics-related cardiac dysfunction with serum biomarkers, cardiovascular MRI, echocardiography and multi-modality approaches. Serum biomarkers, notably cardiac troponins and natriuretic peptides, have been evaluated for their prognostic ability in predicting left ventricular dysfunction. Imaging modalities, such as cardiovascular MRI and echocardiography, have been used for cardiac surveillance of patients with cancer undergoing chemotherapy. Developments in imaging, specifically myocardial deformation imaging, also known as strain, have been shown to be sensitive tools in detecting early changes in cardiac function. This review aims to synthesize the evidence that supports emerging serum biomarkers and complementary imaging modalities that continue to enhance the detection of cancer therapeutics-related cardiac dysfunction.

In the management of aortic coarctation, endovascular techniques and surgical repair have been shown to have similar short-term morbidity.1 However, further studies have shown that, in patients with coarctation that are complex or have previously undergone surgical repair, an ascending-descending aortic bypass surgery is effective in decreasing future interventions.2 We present postoperative findings in a 67-year-old female patient after ascending-descending aortic bypass surgery for recurrent aortic coarctation. The patient has a history of aortic coarctation for which she underwent 2 separate surgical corrections via thoracotomies as a child (at 5 and 16 years of age). Her preoperative computed tomography scan (Figure 1A) revealed a stenotic segment with an aneurysmal dilated area between the left common carotid artery to just distal of the left subclavian artery. Cardiac catheterization demonstrated a 40 mm Hg peak gradient across the stenotic segment, and aneurysmal degeneration of the proximal descending thoracic aorta, as well. Because of the complex anatomy from the recurrent coarctation and associated aneurysm, repair via endovascular stenting was not favored. The 2 operative approaches considered included (1) resection with interposed graft reconstruction and (2) ascending to descending aortic bypass. Given the expected dense adhesions, and the concern for the inability to gain proximal control of the aorta from …

Background Cardiotoxicity is a major limiting factor preventing dose-effective use of multiple cytotoxic agents in cancer treatment. Current cardiotoxicity diagnosis is based on functional changes that occur late in the course of the disease. In this pre-clinical pilot study, we hypothesize myocardial T1 and T2 mapping will identify mice at risk of death secondary to doxorubicin-induced cardiotoxicity prior to cardiac function deterioration. Methods Eleven healthy, 10-week-old C57BL/6 female mice were included in the study. All procedures are in accordance with an Institutional Animal Care and Use Committee approved protocol. Doxorubicin-induced cardiotoxicity was generated by giving 8 mg/kg of doxorubicin via intraperitoneal (IP) injection weekly for 4 weeks in n = 8 randomly selected mice. A control group of n = 3 mice was given a weekly volume equivalent dose of IP normal saline. Each mouse underwent ECG-gated CMR on a 7T small animal scanner (ClinScan, Bruker, Billerica, MA) prior to treatment, at 2 weeks, and post-treatment. Steady-state free precession images were acquired at the left ventricular base, mid-ventricle, and apex and ejection fraction (EF) was calculated (Figure 1). Gadopentetate Dimeglumine contrast was injected via the tail vein at a dose of 1 mL/kg. Myocardial T1 and T2 maps were generated using dedicated offline software to calculate the pixel-wise relaxation

133 Background: Improvements in early detection, screening, and treatment of cancer translate into survivors living longer, highlighting the need for guidelines to address the late and long-term effects of cancer treatment. A particularly concerning effect is Cancer Therapeutics-Related Cardiac Dysfunction (CTRCD). Cancer treatments can result in a range of cardiovascular toxicity including left ventricular dysfunction, heart failure and radiation-induced heart disease (RIHD). Various consensus statements related to cardiovascular care for adult cancer survivors exist; however there are no globally accepted follow-up guidelines. Our purpose is to create a protocol to stratify a survivor’s cardiac risk and provide a basis for follow-up recommendations. Methods: We first evaluated existing resources within our institution and identified key stakeholders who were recruited to form a multidisciplinary workgroup (2 survivorship advanced practice providers, an oncologist, a radiation oncologist, and 2 cardio-oncologists). We then reviewed current research and literature on cardiotoxic cancer therapies and identified two consensus statements from the American Society of Echocardiography and the European Association of Cardiovascular Imaging which helped inform our protocol. Finally, we created a cardiac assessment that could be applied in the pre-treatment phase and extend into the post-treatment phase. Results: Two assessment tools were developed. The first is an algorithm initiated in the pre-treatment setting by an oncologist when a Type I or Type II cardiotoxic agent is planned. The second is a risk assessment tool that is initiated in the post-treatment setting to stratify cardiac risk and provide follow-up recommendations. Conclusions: Development of standardized guidelines for assessment and treatment of late and long-term effects of treatment is critical. This protocol has been developed to account for the many factors that contribute to overall cardiac risk after various anti-cancer therapies. Further data is needed to evaluate long-term cardiac and survival outcomes based on this protocol.

Cardiac multimodality imaging offers new opportunities to display composite information not available with any of the imaging modalities alone. We tested the feasibility of fusion of coronary anatomy and left ventricular (LV) function obtained from computed tomography coronary angiography (CTCA) and 3D echocardiography (3DE). Twenty-four patients underwent CTCA and transthoracic 3DE imaging on the same day. CTCA images were processed using custom software to extract the coronary tree. LV endocardial surfaces were obtained from 3DE and co-registered with the coronary tree using a rigid transformation. Three patients (12%) were excluded because of suboptimal CTCA quality. The composite display of coronary arteries and parametric images of regional LV function allowed visual appreciation of the LV functional abnormality secondary to the stenosis when present. Fusion of CT coronary angiography and parametric imaging of LV regional function derived from 3DE is feasible, potentially providing physiologically meaningful and easy-to-interpret combined display of coronary abnormalities and their functional impact.

Aims Heart failure has been demonstrated in previous studies to have a dismal prognosis. However, the modern-day prognosis of patients with new onset heart failure diagnosed in the community managed within a disease management programme is not known. The purpose of this study is to report on prognosis of patients presenting with new onset heart failure in the community who are subsequently followed in a disease management program. Methods and Results A review of patients referred to a rapid access heart failure diagnostic clinic between 2002 and 2012 was undertaken. Details of diagnosis, demographics, medical history, medications, investigations and mortality data were analysed. A total of 733 patients were seen in Rapid Access Clinic for potential new diagnosis of incident of heart failure. 38.9% (n=285) were diagnosed with heart failure, 40.7% (n=116) with HF-REF and 59.3% (n=169) with HF-PEF. There were 84 (29.5%) deaths in the group of patients diagnosed with heart failure; 41 deaths (35.3%) occurred in patients with HF-REF and 43 deaths (25.4%) occurred in patients with HF-PEF. In patients with heart failure, 52.4% (n=44) died from cardiovascular causes. 63.8% of HF patients were alive after 5 years resulting on average in a month per year loss of life expectancy over that period compared with aged matched simulated population. Conclusions In this community-based cohort, the prognosis of heart failure was better than reported in previous studies. This is likely due to the impact of prompt diagnosis, the improvement in therapies and care within a disease management structure.

Paravalvular leaks are an uncommon but serious complication of prosthetic valves. Transthoracic echocardiography is used in the assessment of prosthetic valves but can be limited by acoustic shadowing from the prosthesis and poor acoustic windowing. Small case series have previously shown cardiac CT to have promising results in detecting paravalvular leaks. We assessed 32 valves in our institution on cardiac CT using echocardiography results as standard and developed methods for improved evaluation of prosthetic valves. These include optimizing prescan drug therapy for heart rate control, optimum window and center adjustments, and carefully selected image planes to best demonstrate the valve ring and valve annulus. Recognition of surgical material is also important to recognize. In this review, we provide a detailed description of these techniques with imaging examples of prosthetic valve evaluation using cardiac CT.

Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) can identify patients with cardiac sarcoidosis (CS), even in the presence of preserved left ventricular (LV) ejection fraction (EF). However, the prognosis of these patients is not well defined. In patients with CS and

Background The presence of myocardial late gadolinium enhancement (LGE) in patients with sarcoidosis is a powerful predictor of major adverse events (MAE: death, ventricular tachycardia, or appropriate ICD therapy). In this study, we aim to determine if the burden of LGE, left ventricular (LV) and right ventricular (RV) end-diastolic and end-systolic volume index (EDVi & ESVi) and ejection fraction (EF) can be used to improve risk stratification in patients with cardiac sarcoidosis (CS). Methods We identified 25 consecutive subjects with a diagnosis of CS (biopsy-proven extra-cardiac sarcoidosis and presence of LGE on cardiovascular magnetic resonance). Imaging was performed on a 1.5T scanner. Short axis cines (6 mm thickness, 4 mm gap, temporal resolution 5 standard deviations above the mean SI of normal remote myocardium. The total amount of LGE as a percentage of LV mass (%LGE) was determined using Diagnosoft Virtue software (Figure 1). Medical records were reviewed to identify MAE. Area under the curve (AUC) was determined from receiver-operator characteristics demonstrating the ability of %LGE, LVEDVi, LVESVi, LVEF, RVEDVi, RVESVi, and RVEF to detect MAE. Patients were divided into 2 groups; with MAE and without MAE. Each parameter was evaluated using unpaired T-tests. Continuous variables are presented as mean ± standard deviation. Results The mean age was 58 ±7y ears, 18 (72%) were female. Mean follow up was 39 ± 15 months. Six (24%) of patients had MAE. There was a significant difference in %LGE, RVEF and RVESVi but not LVEF, LVESVi, LVEDVi or RVEDVi between those who had MAE and those who did not (Table 1). The AUC for each of the following parameter’s ability to predict MAE was: LVEF 0.54, LVEDVi 0.58, LVESVi 0.62, LGE 0.67, RVEDVi 0.76, RVESVi 0.85, and RVEF 0.56. Notably, in terms of predicting death, the AUC for %LGE, RVEDVi and RVESVi were high at 0.87, 0.86 and 0.89 respectively, while that for LVEF was 0.61, RVEF 0.61, LVEDVi 0.54 and LVESVi 0.55. Conclusions The burden of LGE and RV size and function (not LV size and function) further improve prediction of death and significant ventricular arrhythmia in patients with cardiac sarcoidosis Funding None.

Importance Prevention strategies for heart failure are needed. Objective To determine the efficacy of a screening program using brain-type natriuretic peptide (BNP) and collaborative care in an at-risk population in reducing newly diagnosed heart failure and prevalence of significant left ventricular (LV) systolic and/or diastolic dysfunction. Design, Setting, and Participants The St Vincent’s Screening to Prevent Heart Failure Study, a parallel-group randomized trial involving 1374 participants with cardiovascular risk factors (mean age, 64.8 [SD, 10.2] years) recruited from 39 primary care practices in Ireland between January 2005 and December 2009 and followed up until December 2011 (mean follow-up, 4.2 [SD, 1.2] years). Intervention Patients were randomly assigned to receive usual primary care (control condition; n=677) or screening with BNP testing (n=697). Intervention-group participants with BNP levels of 50 pg/mL or higher underwent echocardiography and collaborative care between their primary care physician and specialist cardiovascular service. Main Outcomes and Measures The primary end point was prevalence of asymptomatic LV dysfunction with or without newly diagnosed heart failure. Secondary end points included emergency hospitalization for arrhythmia, transient ischemic attack, stroke, myocardial infarction, peripheral or pulmonary thrombosis/embolus, or heart failure. Results A total of 263 patients (41.6%) in the intervention group had at least 1 BNP reading of 50 pg/mL or higher. The intervention group underwent more cardiovascular investigations (control, 496 per 1000 patient-years vs intervention, 850 per 1000 patient-years; incidence rate ratio, 1.71; 95% CI, 1.61-1.83; P P =.01). The primary end point of LV dysfunction with or without heart failure was met in 59 (8.7%) of 677 in the control group and 37 (5.3%) of 697 in the intervention group (odds ratio [OR], 0.55; 95% CI, 0.37-0.82; P = .003). Asymptomatic LV dysfunction was found in 45 (6.6%) of 677 control-group patients and 30 (4.3%) of 697 intervention-group patients (OR, 0.57; 95% CI, 0.37-0.88; P = .01). Heart failure occurred in 14 (2.1%) of 677 control-group patients and 7 (1.0%) of 697 intervention-group patients (OR, 0.48; 95% CI, 0.20-1.20; P = .12). The incidence rates of emergency hospitalization for major cardiovascular events were 40.4 per 1000 patient-years in the control group vs 22.3 per 1000 patient-years in the intervention group (incidence rate ratio, 0.60; 95% CI, 0.45-0.81; P = .002). Conclusion and Relevance Among patients at risk of heart failure, BNP-based screening and collaborative care reduced the combined rates of LV systolic dysfunction, diastolic dysfunction, and heart failure. Trial Registration clinicaltrials.gov Identifier:NCT00921960

Withdrawn by Author Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr OT3-3-03.