Objectives: The aim of this study was to assess whether baseline echocardiographic measures of left ventricular (LV) size and function predict the development of symptomatic heart failure or cardiac death (major adverse cardiac events, MACE) in patients treated with anthracyclines who have a pre-chemotherapy left ventricular ejection fraction (LVEF) in the low normal range (between 50-59%). Background: Anthracycline-induced symptomatic heart failure and impaired LVEF are late and often irreversible manifestations of anthracycline-induced cardiotoxicity. The value of echocardiographic parameters of myocardial size and function before chemotherapy to identify patients at high-risk for development of symptomatic heart failure in patients with low normal LVEF was studied. Methods: Patients with a LVEF between 50 and 59% before anthracyclines were selected. In these patients, LV volumes, LVEF and peak longitudinal strain (GLS) were measured. Individuals were followed for MACE and all-cause mortality over a median of 659 days (range; 3-3704 days). Results: Of 2234 patients undergoing echocardiography for pre-anthracycline assessment, 158 (7%) had a resting ejection fraction of 50-59%. Their average LV end-diastolic volume (LVEDV) was 101±22ml, LVEF was 54 ±3% and global longitudinal strain (GLS) was -17.7±2.6%. Twelve patients experienced a MACE (congestive heart failure) at a median of 173 days (range; 15-530). Age, diabetes, previous coronary artery disease, LVEDV, LVESV and GLS were all-predictive of MACE (P= 0.015, 0.0043 and 0.0065 for LVEDV, LVESV, and GLS respectively). LVEDV and GLS remained predictive of MACE when adjusted for age. Age and GLS were also predictive of overall mortality (p<0.0001 and 0.0105 respectively). Conclusions: In patients treated with anthracyclines with an LVEF of 50-59%, both baseline EDV and GLS predict the occurrence of MACE. These parameters may help target patients who could bene[[Unable to Display Character: fi]]t from closer cardiac surveillance and earlier initiation of cardioprotective medical therapy.
Patients with left ventricular systolic dysfunction frequently show abnormal coronary vascular function, even in the absence of overt coronary artery disease. Moreover, the severity of vascular dysfunction might be related to the aetiology of cardiomyopathy. We sought to determine the incremental value of assessing coronary vascular dysfunction among patients with ischaemic (ICM) and non-ischaemic (NICM) cardiomyopathy at risk for adverse cardiovascular outcomes. Coronary flow reserve (CFR, stress/rest myocardial blood flow) was quantified in 510 consecutive patients with rest left ventricular ejection fraction (LVEF) ≤45% referred for rest/stress myocardial perfusion PET imaging. The primary end point was a composite of major adverse cardiovascular events (MACE) including cardiac death, heart failure hospitalization, late revascularization, and aborted sudden cardiac death. Median follow-up was 8.2 months. Cox proportional hazards model was used to adjust for clinical variables. The annualized MACE rate was 26.3%. Patients in the lowest two tertiles of CFR (CFR ≤ 1.65) experienced higher MACE rates than those in the highest tertile (32.6 vs. 15.5% per year, respectively, P = 0.004), irrespective of aetiology of cardiomyopathy. Impaired coronary vascular function, as assessed by reduced CFR by PET imaging, is common in patients with both ischaemic and non-ischaemic cardiomyopathy and is associated with MACE.
Importance Anthracyclines treat a broad range of cancers. Basic and retrospective clinical data have suggested that use of atorvastatin may be associated with a reduction in cardiac dysfunction due to anthracycline use. Objective To test whether atorvastatin is associated with a reduction in the proportion of patients with lymphoma receiving anthracyclines who develop cardiac dysfunction. Design, Setting, and Participants Double-blind randomized clinical trial conducted at 9 academic medical centers in the US and Canada among 300 patients with lymphoma who were scheduled to receive anthracycline-based chemotherapy. Enrollment occurred between January 25, 2017, and September 10, 2021, with final follow-up on October 10, 2022. Interventions Participants were randomized to receive atorvastatin, 40 mg/d (n = 150), or placebo (n = 150) for 12 months. Main Outcomes and Measures The primary outcome was the proportion of participants with an absolute decline in left ventricular ejection fraction (LVEF) of ≥10% from prior to chemotherapy to a final value of &lt;55% over 12 months. A secondary outcome was the proportion of participants with an absolute decline in LVEF of ≥5% from prior to chemotherapy to a final value of &lt;55% over 12 months. Results Of the 300 participants randomized (mean age, 50 [SD, 17] years; 142 women [47%]), 286 (95%) completed the trial. Among the entire cohort, the baseline mean LVEF was 63% (SD, 4.6%) and the follow-up LVEF was 58% (SD, 5.7%). Study drug adherence was noted in 91% of participants. At 12-month follow-up, 46 (15%) had a decline in LVEF of 10% or greater from prior to chemotherapy to a final value of less than 55%. The incidence of the primary end point was 9% (13/150) in the atorvastatin group and 22% (33/150) in the placebo group ( P = .002). The odds of a 10% or greater decline in LVEF to a final value of less than 55% after anthracycline treatment was almost 3 times greater for participants randomized to placebo compared with those randomized to atorvastatin (odds ratio, 2.9; 95% CI, 1.4-6.4). Compared with placebo, atorvastatin also reduced the incidence of the secondary end point (13% vs 29%; P = .001). There were 13 adjudicated heart failure events (4%) over 24 months of follow-up. There was no difference in the rates of incident heart failure between study groups (3% with atorvastatin, 6% with placebo; P = .26). The number of serious related adverse events was low and similar between groups. Conclusions and Relevance Among patients with lymphoma treated with anthracycline-based chemotherapy, atorvastatin reduced the incidence of cardiac dysfunction. This finding may support the use of atorvastatin in patients with lymphoma at high risk of cardiac dysfunction due to anthracycline use. Trial Registration ClinicalTrials.gov Identifier: NCT02943590
This study sought to analyse multislice computed tomography (MSCT) data of patients with tricuspid regurgitation and to report the variability of fluoroscopic viewing angles for several right-sided heart structures, as well as chamber views of the right heart in order to determine the optimal fluoroscopic viewing angles of six right-sided heart structures and right-heart chamber views.The MSCT data of 44 patients with mild to severe tricuspid regurgitation (TR) were retrospectively analysed. For each patient, we determined the optimal fluoroscopic viewing angles of the annulus/orifice en face view of the tricuspid valve, atrial septum, superior vena cava (SVC), inferior vena cava (IVC), coronary sinus (CS) and pulmonary valve. In this TR patient cohort, the average fluoroscopic viewing angle for the en face view of the tricuspid valve annulus was LAO 54-CAUD 15; RAO 10-CAUD 66 for the SVC orifice; LAO 27-CRA 59 for the IVC orifice; RAO 28-CRA 19 for the CS orifice; RAO 33-CAUD 33 for the atrial septum and LAO 13-CAUD 52 for the pulmonary valve annulus. The average viewing angle for right-heart chamber views was LAO 55-CAUD 15 for the one-chamber view; RAO 59-CAUD 54 for the two-chamber view; RAO 27-CRA 19 for the three-chamber view and LAO 5-CRA 60 for the four-chamber view.MSCT can provide patient-specific fluoroscopic viewing angles of right-sided heart structures. This information may facilitate transcatheter right-heart interventions.
