Echo Prediciton of HF in Stable CAD

7/29/2019 Echo Prediciton of HF in Stable CAD

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Echocardiographic Risk-

stratification to Predict Heart

Failure in Patients withStable CAD

Renan Sukmawan, MD, PhD

Department of Cardiology and Vascular Medicine, Faculty of Medicine

University of Indonesia / Harapan Kita National Cardiovascular Center


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Alternative projections of mortality and disability by cause

19902020: Global Burden of Disease Study

Chris toph er J L , et al. Lancet 1997, 349,

We projected that non-communicable

disease mortality will increase from 281

million deaths in 1990 to 497 million in

2020. Deaths from injury may increase

from 51 million to 84 million. Leading

causes of disability-adjusted life years

(DALYs) predicted by the baseline model

were (in descending order): ischaemic

heart disease, unipolar major depression,

road-traffic accidents, cerebrovascular

disease, chronic obstructive pulmonary

disease, lower respiratory infections,tuberculosis, war injuries, diarrhoeal

diseases, and HIV.


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NCC Harapan Kita In-patient data

0

500

1000

1500

2000

2500

CAD CHF

20052006200720082009

R & D Divis ion, NCC Harapan Kita , 2010


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NCC Harapan Kita Out-patient data

0

2000

4000

6000

8000

10000

12000

14000

CAD CHF

2005 2006 2007 2008 2009

- Which and when ?

- How to prevent ?

R & D Divis ion, NCC Harapan Kita , 2010


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Heart Failure Stages

ACC AHA Guid elines on CHF. Circulat io n, 2005


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Yancy CW. J Am Col l Card io l 2006;47:76-84

The first hospitalization for HF

worsens survival for most patients,

regardless of resting EF

Bhatia RS. N Engl J Med 2006;355:260-269

Owan TE. N Engl J Med 2006;355:251-259


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Development of an Echocardiographic Risk-Stratification

Index to Predict Heart Failure in Patients With Stable

Coronary Artery Disease

(The Heart and Soul Stud y)

To determine TTE measurements most strongly predict HF

and to develop an index for risk-stratification in stable CAD

Conducted in 1024 pts with stable CAD

Defined association of 15 TTE measurements with

subsequent HF stay

Developing scoring system using independent predictors

from multivariate analysis

Stevens MS, et al. J Am Coll Cardio l Img 2009;2;11-20


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Inclusion Criteria

1. History of myocardial infarction

2. Stenoses > 50% in at least 1

vessel from cor-angiography3. Stress-induced ischemia from

TMT or nuclear perfusion

4. History of coronary

revascularization

5. Prior diagnosis of CAD

Exclusion Criteria

1. Prior myocardial infarction

within the last 6 months

2. Unable to walk 1 block3. Plan to move out from the local

area



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Resting 2D-echo completed in all subjects

The 15 chosen candidate echo variables :1. LV end-systolic volume index

2. LV end-diastolic volume index

3. LVEF

4. Left atrial volume index (LAVI)

5. Right atrial volume index6. LV Mass Index (LVMI)

7. PA peak systolic pressure8. Right atrial volume index

9. VTI RVOT

10. VTI LVOT

11. Aortic valve area

12. Right atrial pressure

13. Diastolic Dysfunction

14. MR severity

14. tricuspid regurgitation severity

15. resting wall motion score index

Correlate with LVES Vol Index

Correlate with VTI LVOT



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Results



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Results



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Results



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Results



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Results



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Heart Failure Risk Index (HFRI) by resting echoSummary


IMAGE of INTEREST MEASUREMENTS SCORE

LV Mass Index

> 90 g/m23

Diastolic Dysfunction

Pseudonormal orRestrictive

2

Mitral Regurgitation

> Mild

1

LVOT VTI< 22 cm

1

LA Volume Index

29 ml/m21


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Heart Failure Risk Index (HFRI) by resting echoLimitations

Studied in caucasian (60%) and men (82%)

Primary outcome was only HF hospital stay

Not incorporate newer techniques, i.e. TDI, strain Defining diastolic function solely by E/A ratio

LA volume index using biplane method of discs,

which may be different to the area-length method

Dichotomous cut-offs for each measurements Unclear gained to restratifying class A & B of HF

by echocardiographic measures only


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Clinical Impact of HFRI

Simplifying data from routine TTE in stable CAD

Enhance assessment for HF risk

Predicting HF in a patient population with relativelypreserved systolic function

Complementary to other HF measures, i.e. BNP

Perhaps guiding for aggressive treatment in high-

risk patients based on HFRI


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CONCLUSIONS

The TTE Heart Failure Risk Index provides method to

predict development of heart failure in patients with stable

CAD

This index represents an important step in simplifying

data from a routine TTE and using it to enhance our

assessment of risk for heart failure

Further studies needed to define the value of TTE HeartFailure Risk Index in clinical decision-making

Echo Prediciton of HF in Stable CAD

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