First-Phase Ejection Fraction: A Novel Approach to Detecting Early Systolic Dysfunction in Hypertrophic Cardiomyopathy.

Left ventricular systolic dysfunction detected by speckle tracking in hypertensive patients with preserved ejection fraction (cid:2)

Pattern of use of conventional medical treatments of heart failure with reduced ejection fraction in end-stage hypertrophic cardiomyopathy.

BACKGROUND In approximately 5-10% of cases, hypertrophic cardiomyopathy (HCM) presents left ventricular remodeling with hypokinesia and dilatation, defined "end-stage" phase (ES) of the disease, typically associated with development of advanced heart failure (HF). Prescription of conventional medical treatments for HF with a reduced ejection fraction (HFrEF) have never been investigated in ES-HCM. METHODS ES-HCM patients from 11 Italian referral centres were retrospectively evaluated. We included only patients with a last clinical evaluation after 2019, to ensure all patients were potentially evaluated in the era of the "4 HFrEF pillars" (beta blockers [BB], renin-angiotensin system inhibitors [RASi], mineralocorticoid receptor antagonists [MRA], and sodium-glucose cotransporter-2 inhibitors [SGLT2i]). For all patients we collected clinical information, with a focus on medical therapy at last clinical evaluation. RESULTS The study population included 274 ES-HCM patients (59% males, mean age 60 ± 15 years). All 4 HFrEF pillars were prescribed in 26%. Specifically, 90% were treated with BB, 75% with RASi, 66% with MRA, 46% with SGLT2i. Few differences emerged when comparing patients taking versus not taking BB or RASi. Patients taking versus not taking MRA and SGLT2i more commonly had atrial fibrillation and showed worse echocardiographic features. SGLT2i use was significantly higher among ES-HCM patients with LVEF <40%. CONCLUSIONS While BB and RASi are commonly used in ES-HCM, MRA and SGLT2i are prescribed less frequently and in patients with a worse clinical profile. Combination of all classes is not common, suggesting both clinical inertia and limitations inherent to the disease pathophysiology.

Peak filling rate assessed by myocardial perfusion imaging predicts adverse outcomes in women with chronic coronary syndromes

Background Diastolic dysfunction may represent an important risk dimension beyond myocardial ischemia and systolic impairment, particularly in women with chronic coronary syndromes (CCS). However, the prognostic value of myocardial perfusion imaging (MPI)-derived diastolic parameters and their potential sex-specific differences remain uncertain. Therefore, this study aimed to evaluate the prognostic significance of single photon emission computed tomography (SPECT) MPI-derived diastolic parameters in patients with CCS without reduced ejection fraction (EF <40%). Methods In this retrospective cohort study, data of 1,446 patients undergoing resting MPI were analyzed at the First Hospital of Shanxi Medical University [2016–2021]. The diastolic parameters obtained from MPI included peak filling rate (PFR), mean filling rate over the first third of the end-systole to end-diastole phase (MFR/3), and time to peak filling from end-systole (TTPF). Propensity score matching balanced baseline clinical characteristics between sexes. Multivariable Cox regression evaluated the associations between sex, diastolic parameters, and major adverse cardiovascular events (MACEs). These analyses were further differentiated by total perfusion deficit (TPD) ≥10% and EF ≥50% groups. Results (I) Over a median 3.05-year follow-up, 519 patients (35.9%) experienced MACE. (II) No statistically significant differences were observed in the predictive value for MACE among PFR, MFR/3, TTPF, and the combination of these three parameters (P=0.956). (III) Reduced PFR independently predicted MACE in women [hazard ratio (HR) 0.61, P=0.028] but not in men (P=0.167). This sex difference persisted in patients with TPD ≥10% (HR 0.36) and EF ≥50% groups (HR 0.57, all P<0.05). Conclusions In patients of CCS without reduced EF, MPI-derived PFR demonstrates sex-specific prognostic value, serving as an independent predictor of MACE in women but not men. These findings highlight the potential of diastolic analysis to refine risk stratification in women.

Association between the E-wave propagation index and left ventricular thrombus formation in systolic heart failure.

BACKGROUND The E-wave propagation index (EPI) has been proposed as a simple risk marker of left ventricular (LV) thrombus (LVT) formation. We sought to investigate the association between EPI and LVT in patients with heart failure with reduced ejection fraction (HFrEF). METHODS This was a retrospective cohort study on 768 patients with HFrEF. The EPI was measured as the velocity time integral of the transmitral E-wave divided by the LV length. The endpoint was LVT formation. Logistic regression was applied to investigate the association between EPI and LVT. Multivariable adjustments were made for age, mitral regurgitation, apical aneurysm, prior myocardial infarction, and LV ejection fraction (LVEF). Area under receiver operating characteristic curves was used to assess the optimal cut-off value for EPI. RESULTS Of 768 HFrEF patients, 24 (3%) had developed LVT. The mean age was 66 years, 73% were men, and the mean LVEF was 28%. EPI was lower among those who had developed LVT (1.1 vs 1.3, p = 0.018), and EPI was significantly associated with LVT formation in univariable logistic regression (OR = 1.16 (1.0-1.3), per 0.1 decrease). This finding was unchanged after multivariable adjustments. The EPI provided an area under the curve of 0.68 with an optimal cutoff of 1.2. This cutoff had a sensitivity of 75%, specificity of 60%, positive predictive value of 6%, and negative predictive value of 99%. Patients with an EPI <1.2 had a four-fold increased risk of LVT (OR = 4.42 (1.73-11.25), p = 0.002). CONCLUSION In patients with HFrEF, the EPI was independently associated with LVT formation. Additionally, an EPI > 1.2 indicates a low likelihood of developing LVT.

Cardiac Magnetic Resonance Findings and NT-proBNP in Heart Failure with Reduced Ejection Fraction

Background/Objectives: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is an established heart failure biomarker, but its associations with cardiac magnetic resonance (CMR) parameters in patients with reduced ejection fraction remain unclear. This study examined the associations between serum NT-proBNP concentrations and CMR-derived functional, structural, and tissue characterization parameters in patients with HFrEF and evaluated which imaging parameters remained associated with NT-proBNP after multivariable adjustment. Methods: This retrospective single-center study included 92 consecutive patients with HFrEF who underwent CMR and NT-proBNP measurement within a 24 h window, with a median absolute interval of 6 h (range, 1–15 h) between the two assessments. CMR analysis included left ventricular ejection fraction (LVEF), left ventricular and left atrial (LA) cavity diameters, myocardial mass, extracellular volume fraction (ECV), the late gadolinium enhancement (LGE) burden, and the T2 signal intensity (T2-SI) ratio. Spearman correlation, univariate linear regression, and multivariable linear regression analyses were performed using log-transformed NT-proBNP values. Results: Log NT-proBNP demonstrated significant correlations with LVEF (rs = −0.359, p < 0.001), T2-SI ratio (rs = −0.332, p = 0.001), ECV (rs = 0.383, p < 0.001), and LA diameter (rs = 0.347, p < 0.001). No statistically significant correlations were observed between log-transformed NT-proBNP and LGE burden, LV cavity diameter, myocardial mass, LV wall thickness, age, or the recorded comorbidities. In multivariable analysis, LVEF, T2-SI ratio, and LA diameter remained associated with NT-proBNP after adjustment for the available covariates. Conclusions: Lower LVEF, a lower T2-SI ratio, and a larger LA diameter were associated with higher NT-proBNP levels in patients with HFrEF. The T2-SI ratio and LA diameter should be considered exploratory imaging markers requiring prospective validation.

Diffuse Fibrosis in Hypertrophic Cardiomyopathy: Incremental Prognostic Value of Extracellular Volume.

BACKGROUND Left ventricular (LV) myocardial extracellular volume (ECV), from cardiac magnetic resonance (CMR) T1 mapping, primarily reflects diffuse fibrosis and is a marker of adverse myocardial remodeling in hypertrophic cardiomyopathy (HCM). OBJECTIVES The authors sought to evaluate the prognostic value of ECV beyond established clinical and imaging variables in a large contemporary HCM cohort. METHODS We evaluated 1,050 consecutive patients with HCM and preserved LV ejection fraction (≥50%) who underwent CMR, including quantification of ECV (%) and late gadolinium enhancement (LGE) burden (% LV mass, >6 SDs above remote myocardium), between 2012 and 2021. The primary endpoint was a composite of mortality, appropriate implantable cardioverter-defibrillator (ICD) therapy, or heart transplantation. Statistical methods included multivariable Cox proportional hazards regression, restricted cubic spline analysis, assessment of incremental discrimination using changes in the C-statistic, and net reclassification improvement analysis. RESULTS Median age was 60 years (IQR: 49-68 years) with 44% women. Median follow-up was 5.6 years (IQR: 2.5-7.8 years). The primary endpoint occurred in 124 patients (11.8%), including 111 deaths (10.6%), 12 appropriate ICD discharges (1.1%), and 1 heart transplantation (0.1%). In multivariable Cox regression, older age (HR: 1.05, 95% CI: 1.03-1.06; P < 0.001), NYHA functional class ≥II (HR: 1.96, 95% CI: 1.23-3.11; P = 0.004), diabetes mellitus (HR: 1.89, 95% CI: 1.27-2.81; P = 0.002), and higher ECV (HR: 1.05 per 1% increase, 95% CI: 1.02-1.09; P = 0.001) were independently associated with the primary outcome. Patients with ECV ≥32% had lower event-free survival than those with ECV <32% (adjusted HR: 1.81, 95% CI: 1.24-2.64; P < 0.001). CONCLUSIONS Myocardial ECV was independently associated with long-term adverse outcomes. Multiparametric CMR assessment may improve risk stratification in HCM.