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1
De Sutter, Johan, Piotr Lipiec, and Christine Henri. Heart failure: preserved left ventricular ejection fraction. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0028.
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Nearly half of all patients with heart failure present with a preserved left ventricular ejection fraction (HFPEF). HFPEF is a pathophysiologically and clinically heterogeneous disease with an overall similar outcome to heart failure patients with a reduced ejection fraction. It is predominantly seen in elderly patients and comorbidities such as obesity, diabetes, hypertension, a sedentary lifestyle, and myocardial ischaemia play important roles in its development. In this chapter the conventional echocardiographic hallmarks of HFPEF including a preserved ejection fraction, left ventricular hypertrophy, left atrial dilatation, diastolic dysfunction, and pulmonary hypertension are presented. For the evaluation of left ventricular diastolic dysfunction, it is important to keep in mind that no single echocardiographic parameter is sufficiently accurate and reproducible to be used in isolation to make a diagnosis of diastolic dysfunction. The value of newer techniques including three-dimensional echocardiography and longitudinal strain assessment for the diagnosis and follow-up of HFPEF patients are promising but require further evaluation. As exercise-induced dyspnoea may be the first manifestation of HFPEF, the role of exercise echo (or diastolic stress testing) with evaluation of exercise-induced changes in left ventricular filling pressure and pulmonary artery systolic pressure is also presented. This chapter ends with a discussion on the echocardiographic parameters that can be used for risk stratification and follow-up of HFPEF patients.
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Katritsis, Demosthenes G., Bernard J. Gersh, and A. John Camm. Heart failure with preserved left ventricular ejection fraction. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199685288.003.0805_update_003.
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3
Garcia, Mario J., and Allan L. Klein. Diastology: Clinical Approach to Heart Failure with Preserved Ejection Fraction. Elsevier, 2021.
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4
Hummel, Scott L., and Matthew C. Konerman. Heart Failure with Preserved Ejection Fraction, an Issue of Cardiology Clinics. Elsevier - Health Sciences Division, 2022.
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5
Heart Failure with Preserved Ejection Fraction, An Issue of Heart Failure Clinics. Elsevier, 2021.
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6
Lam, Carolyn S. P. Heart Failure with Preserved Ejection Fraction, an Issue of Heart Failure Clinics. Elsevier - Health Sciences Division, 2014.
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7
Lancellotti, Patrizio, and Bernard Cosyns. Assessment of Diastolic Function. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713623.003.0005.
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Diastole is the part of the cardiac cycle starting at aortic valve closure and ending at mitral valve closure. Evaluation of diastolic function by echocardiography is useful to diagnose heart failure with preserved ejection fraction, and regardless of ejection fraction, echocardiography can be used to estimate left ventricular filling pressure. Assessment of diastolic function includes analysis of left ventricular relaxation and compliance, left atrial and left ventricular filling pressures. This chapter describes the phases of diastole and covers the integrated approach of LV diastolic function through M-Mode and 2D/3D echocardiography, pulsed-wave Doppler echocardiography, and pulsed-wave tissue Doppler echocardiography.
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Gawlinski, Anna Frances. EFFECT OF POSITIONING ON VENOUS OXYGEN SATURATION IN THE CRITICALLY ILL PATIENT WITH A LOW EJECTION FRACTION. 1993.
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9
Hausenloy, Derek, and Derek Yellon, eds. Coronary No-Reflow and Microvascular Obstruction. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199544769.003.0005.
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• Following an AMI, the restoration of TIMI III coronary blood flow using thrombolytic therapy or primary percutaneous coronary intervention does not guarantee actual myocardial perfusion• In 40–60% of reperfused AMI cases, myocardial perfusion is impeded at the level of the capillaries due to microvascular obstruction (MVO)- a phenomenon termed coronary no-reflow• The presence of coronary no-reflow can be detected as impaired myocardial perfusion using non-invasive imaging modalities such as nuclear myocardial perfusion scanning, myocardial contrast echocardiography or contrast-enhanced cardiac magnetic resonance imaging• The presence of microvascular obstruction post-AMI is associated with a larger infarct size, impaired LV ejection fraction, adverse LV remodelling and poorer clinical outcomes• Current treatment strategies include; vasodilator therapy such as adenosine, calcium-channel blockers, and nitrates; distal protection to prevent microemboli; and glycoprotein IIb/IIIa inhibitors• Novel treatment strategies are required to prevent and treat coronary no-reflow, thereby improving myocardial perfusion, reducing myocardial infarct size, preserving LV ejection fraction, preventing LV remodeling and improving clinical outcomes.
10
Smiseth, Otto A., Maurizio Galderisi, and Jae K. Oh. Left ventricle: diastolic function. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0021.
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Evaluation of diastolic function by echocardiography is useful to diagnose heart failure with preserved ejection fraction by showing signs of diastolic dysfunction, and regardless of ejection fraction, echocardiography can be used to estimate left ventricular (LV) filling pressure. Diastolic dysfunction occurs in a number of cardiac diseases other than heart failure and mild diastolic dysfunction is part of the normal ageing process. The fundamental disturbances in diastolic dysfunction are slowing of myocardial relaxation, loss of restoring forces, and reduced LV chamber compliance. As a compensatory response there is elevated LV filling pressure. Slowing of relaxation and loss of restoring forces are reflected in reduction in LV early diastolic lengthening velocity (e?) by tissue Doppler. The reduced diastolic compliance is reflected in faster deceleration of early diastolic transmitral velocity by pulsed wave Doppler. Elevated LV filling pressure is reflected in a number of Doppler indices and in enlarged left atrium. This chapter reviews the physiology of diastolic function, the clinical methods and indices which are available, and how these should be applied.
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Galiuto, L., R. Senior, and H. Becher. Contrast echocardiography. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199599639.003.0007.
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Contrast echocardiography is a non-invasive, well tolerated echocardiographic technique which employs ultrasound contrast agent in order to improve the quality of echocardiographic images, by enhancing blood flow signal.Clinical usefulness of this echocardiographic imaging modality resides in the possibility of providing better acoustic signal in cases of poor quality images, with additional important information related to assessment of myocardial perfusion. Indeed, about one-third of echocardiographic images are affected by poor quality due to high acoustic impedance of the chest wall of the patients secondary to obesity or pulmonary diseases, not allowing detection of left ventricular endocardial border. Moreover, in patients with low ejection fraction and apical left ventricular aneurysm, intraventricular thrombus could be undetectable with standard echocardiography. Furthermore, coronary microcirculation cannot be assessed by standard echocardiography. Contrast echocardiography can be performed in all such conditions to improve diagnostic power of echocardiography.The adjunctive role of contrast echocardiography is well defined in both rest and stress echocardiography in order to detect the endocardial border and intraventricular thrombi, to accurately measure ejection fraction, wall motion, and to assess myocardial perfusion.The purpose of this chapter is to explain basic principles, feasibility, safety, major clinical applications, current indications, and further developments of contrast echocardiography.
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Mebazaa, Alexandre, and Mervyn Singer. Pathophysiology and causes of cardiac failure. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780199600830.003.0151.
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Organ congestion upstream of the dysfunctional left and/or right ventricle, with preserved stroke volume, is the most frequkeywordent feature of myocardial failure.Clinical manifestations do not necessarily correlate with the degree of left ventricular systolic dysfunction (i.e. left ventricular ejection fraction).Systolic and/or diastolic dysfunction may be present, with systolic dysfunction usually predominating.Pulmonary oedema is related to left ventricular diastolic dysfunction. Compensatory mechanisms (within the heart and/or periphery) may prove paradoxically disadvantageous on ventricular stroke work and stroke volume.
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Moonen, Marie, Nico Van de Veire, and Erwan Donal. Heart failure: risk stratification and follow-up. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0027.
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An increasing number of two- and three-dimensional echocardiographic, Doppler, and speckle imaging-derived parameters and values can be related to prognosis in heart failure with left ventricular (LV) systolic dysfunction. This chapter discusses both conventional and new indices, including their advantages and potential limitations. There is increasing evidence for the use of new indices, including three-dimensional LV ejection fraction and global longitudinal strain. The follow-up and monitoring of heart failure patients using two-dimensional transthoracic echocardiography is also discussed in this chapter, including how to estimate the LV filling pressures and quantify LV reverse remodelling.
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Lancellotti, Patrizio, and Bernard Cosyns. The Standard Transthoracic Echo Examination. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198713623.003.0002.
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Functional imaging by modern echocardiography offers a variety of methods to assess regional and global myocardial function beyond classic dimension, volume and ejection fraction measurements. This chapter shows how various modalities of Doppler echocardiography can be used for assessment of valves, haemodynamics, and coronary flow reserve. It also provides information on myocardial function can be extracted from echo images using a tissue Doppler or speckle tracking approach. 3Dechocardiography provides real-time 3D images of the heart in motion. Various types of examination and quantification are also shown. A brief explanation of contrast imaging is included as well as practical considerations such as administration protocols and the safety of ultrasound contrast.
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Paneni, Francesco, and Massimo Volpe. Co-morbidity (HFrEF and HFpEF): hypertension. Oxford University Press, 2019. http://dx.doi.org/10.1093/med/9780198784906.003.0415_update_001.
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Hypertensive heart disease is a major cause of heart failure (HF) and mortality. Hypertension precedes HF occurrence in 75% of cases, and carries a sixfold increase in HF risk as compared to non-hypertensive individuals. Most importantly, a minority of patients survive 5 years after the onset of hypertensive HF. In hypertensive patients, the heart may present different patterns of adaptive remodelling: concentric remodelling, concentric hypertrophy, and eccentric hypertrophy. Although most hypertensive patients are at high risk of developing concentric hypertrophy, a growing proportion of subjects display a concentric-to-eccentric progression eventually leading to left ventricular dilation and systolic dysfunction. Several factors including myocardial ischaemia, ethnicity, genetic background, history of diabetes, and blood pressure pattern may significantly influence the pathway from hypertension to left ventricular dilation. Patients with a concentric hypertrophy usually develop HF with preserved ejection fraction (HFpEF), whereas those with an eccentric (dilated) phenotype develop HF with reduced ejection fraction (HFrEF). Lowering blood pressure has a striking effect in reducing the risk of HF. Although available antihypertensive drugs are all successful in lowering blood pressure, angiotensin-converting enzyme inhibitors, angiotensin receptor blocker (ARBs), and diuretics are more effective than other drug classes in preventing HF. The combination of the neprilysin inhibitor sacubitril with the ARB valsartan (LCZ696) has recently been shown to be highly effective in reducing HF-related outcomes in hypertensive subjects. An individualized treatment scheme taking into account blood pressure levels, type of HF (HFpEF or HFrEF), and relevant co-morbidities (i.e. renal disease, diabetes) is currently the best approach to improve morbidity and mortality in hypertensive patients with HF.
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Sabharwal, Nikant, Parthiban Arumugam, and Andrew Kelion. Radionuclide ventriculography. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780198759942.003.0005.
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Radionuclide ventriculography (RNV) was the first reliable non-invasive method of assessing left ventricular (LV) function, and established nuclear cardiology as a clinical discipline. The subsequent development of other imaging modalities, particularly echocardiography, has led to a sharp decline in the number of studies performed, but RNV still has a role in situations where reproducible serial assessments of LV ejection fraction are required. Equilibrium RNV (ERNV) is the most straightforward and commonly performed style of RNV, and this chapter therefore focuses on ERNV, covering blood-pool labelling, principles of electrocardiogram (ECG) gating, acquisition, processing and interpretation, and clinical value in relation to ERNV. A section on first-pass radionuclide ventriculography is also included.
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Rigo, Fausto, Covadonga Fernández-Golfín, and Bruno Pinamonti. Dilated cardiomyopathy. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0043.
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Dilated cardiomyopathy (DCM) is characterized by a globally dilated and dysfunctioning left ventricle (LV). Therefore, echocardiographic diagnostic criteria for DCM are a LV end-diastolic diameter greater than 117% predicted value corrected for age and body surface area and a LV ejection fraction less than 45% (and/or fractional shortening less than 25%). Usually, the LV is also characterized by a normal or mildly increased wall thickness with eccentric hypertrophy and increased mass, a spherical geometry (the so-called LV remodelling), a dyssynchronous contraction (typically with left bundle branch block), and diastolic dysfunction with elevated LV filling pressure. Other typical echocardiographic features of DCM include functional mitral and tricuspid regurgitation, right ventricular dysfunction, atrial dilatation, and secondary pulmonary hypertension. Several echocardiographic parameters, measured both at baseline and at follow-up, are valuable for prognostic stratification of DCM patients. Furthermore, re-evaluation of echocardiographic parameters during the disease course under optimal medical therapy is valuable for tailoring medical treatment and confirming indications for invasive treatments at follow-up. The stress echo can play a pivotal role in the different phases of DCM helping us in stratifying the prognosis of these patients. Finally, familial screening is an important tool for early diagnosis of DCM in asymptomatic patients.
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Randerath, Winfried J., and Shahrokh Javaheri. Sleep and the heart. Edited by Sudhansu Chokroverty, Luigi Ferini-Strambi, and Christopher Kennard. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199682003.003.0040.
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Heart function and sleep are closely associated. While NREM sleep reduces cardiac workload, phasic REM sleep increases sympathetic activity and cardiac vulnerability. Heart failure (HF) patients suffer from disturbed sleep due to frequent awakenings, periodic limb movements, sleep apnea, and depression. Insomnia seems to be associated with incident HF, and, when comorbid, results in a vicious circle. There is much evidence of a relationship between breathing disturbances during sleep and heart diseases. At least 50% of HF patients suffer from obstructive (OSA) or central (CSA) sleep apnea, both associated with impaired prognosis. OSA is a risk factor for arterial hypertension, atrial fibrillation, and HF. Continuous positive airway pressure devices reduce adverse cardiac events and improve outcome in severe OSA in compliant subjects. Adaptive servoventilation (ASV) is superior to other therapeutic options for CSA. However, the use of ASV is contraindicated in severe HF with reduced, but not preserved, ejection fraction.
19
Reffelmann, Thorsten, and Robert Kloner. Adjunctive Reperfusion Therapy Post-AMI. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199544769.003.0009.
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• Reperfusion of the occluded coronary artery in an ST-segment-elevation myocardial infarction is the most effective approach for reducing infarct size, preserving left ventricular ejection fraction, lowering the incidence and severity of congestive heart failure and improving prognosis• Hence, several pharmacologic agents intended to improve target vessel patency as an adjunct to thrombolysis or primary percutaneous coronary intervention have been shown to be beneficial in patients with reperfusion therapy for acute myocardial infarction, namely antiplatelet and anticoagulation agents• Animal investigations have suggested that coronary reperfusion may also result in undesirable cardiac alterations, termed ‘reperfusion injury’, such as reversible contractile dysfunction (‘stunning’), microvascular obstruction (‘no-reflow’), and in several studies the progression of myocardial necrosis (‘lethal reperfusion injury’)• Clinical investigations of various pharmacologic interventions as an adjunctive therapy to reperfusion to reduce final infarct size, the amount of contractile dysfunction and to improve prognosis have been mostly inconsistent; only a few interventions, e.g. adenosine and atrial natriuretic peptide seem to show promise at least in certain subgroups.
20
Farmakis, Dimitrios, John Parissis, George Papingiotis, and Gerasimos Filippatos. Acute heart failure. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199687039.003.0051_update_001.
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Acute heart failure is defined as the rapid development or change of symptoms and signs of heart failure that requires urgent medical attention and usually hospitalization. Acute heart failure is the first reason for hospital admission in individuals aged 65 or more and accounts for nearly 70% of the total health care expenditure for heart failure. It is characterized by an adverse prognosis, with an in-hospital mortality rate of 4–7%, a 2–3-month post-discharge mortality of 7–11%, and a 2–3-month readmission rate of 25–30%. The majority of patients have a previous history of heart failure and present with normal or increased blood pressure, while about half of them have preserved left ventricular ejection fraction. A high prevalence of cardiovascular or non-cardiovascular comordid conditions is further observed, including coronary artery disease, arterial hypertension, atrial fibrillation, diabetes mellitus, renal dysfunction, chronic lung disease, and anaemia.
21
Gielen, Stephan, Alessandro Mezzani, Paola Pontremoli, Simone Binno, Giovanni Q. Villani, Massimo F. Piepoli, Josef Niebauer, and Daniel Forman. Physical activity and inactivity. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199656653.003.0012.
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In this chapter the current evidence for regular aerobic exercise in primary prevention is discussed and recommendations for exercise interventions in the general population are given. Regular physical exercise is an established therapeutic strategy in a number of cardiovascular diseases and with stable chronic heart failure. In these disease entities moderate-intensity aerobic endurance training is the basis of most training programmes. However, high-intensity interval training is more effective in improving cardiovascular exercise capacity without any measurable additional risks. Resistance training can be used as an optional training component in patients with pronounced loss of lean muscle. In recent years new areas for application of exercise-based intervention have been explored: training interventions proved to be safe and effective in pulmonary hypertension, heart failure with preserved ejection fraction, and compensated subcritical valvular heart disease. However, in contrast to training in coronary artery disease and heart failure, the prognostic benefit is not yet established.
22
Haugaa, Kristina H., Francesco Faletra, and João L. Cavalcante. Cardiac rhythm disorders. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0063.
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Cardiac rhythm disorders require diagnostic, prognostic, and guidance of therapeutic procedures by echocardiography. The most common sustained cardiac arrhythmia is atrial fibrillation (AF) leading to an increased risk for mortality, heart failure, and thromboembolic events. Echocardiography is performed to assess the aetiology of AF which most commonly is associated with diseases leading to enlarged atria. Furthermore, echocardiography is crucial to evaluate thromboembolic risk by assessing the morphology and function of the left atrial appendage among other parameters. Non-invasive imaging modalities including two-dimensional transthoracic (TTE) and transoesophageal echocardiography (TOE) with three-dimensional imaging are often indicated. Finally, TOE can help in the preprocedural planning and providing guidance for interventions such as pulmonary vein ablation and percutaneous left atrial appendage closure. In patients with ventricular arrhythmias, TTE is the first-line diagnostic tool for assessing the aetiology of ventricular arrhythmias. Ischaemic heart disease, either acute or chronic fibrosis, is the most common causes of ventricular tachycardias. Left ventricular ejection fraction remains the most important parameter for indication of an implantable cardioverter defibrillator for primary prevention therapy, although newer strain echocardiographic measures may add incremental prognostic information.
23
Galderisi, Maurizio, and Sergio Mondillo. Assessment of diastolic function. Oxford University Press, 2011. http://dx.doi.org/10.1093/med/9780199599639.003.0009.
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Modern assessment of left ventricular (LV) diastolic function should be based on the estimation of degree of LV filling pressure (LVFP), which is the true determinant of symptoms/signs and prognosis in heart failure.In order to achieve this goal, standard Doppler assessment of mitral inflow pattern (E/A ratio, deceleration time, isovolumic relaxation time) should be combined with additional manoeuvres and/or ultrasound tools such as: ◆ Valsalva manoeuvre applied to mitral inflow pattern. ◆ Pulmonary venous flow pattern. ◆ Velocity flow propagation by colour M-mode. ◆ Pulsed wave tissue Doppler of mitral annuls (average of septal and lateral E′ velocity).In intermediate doubtful situations, the two-dimensional determination of left atrial (LA) volume can be diagnostic, since LA enlargement is associated with a chronic increase of LVFP in the absence of mitral valve disease and atrial fibrillation.Some new echocardiographic technologies, such as the speckle tracking-derived LV longitudinal strain and LV torsion, LA strain, and even the three-dimensional determination of LA volumes can be potentially useful to add further information. In particular, the reduction of LV longitudinal strain in patients with LV diastolic dysfunction and normal ejection fraction demonstrates that a subclinical impairment of LV systolic function already exists under these circumstances.
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Cardinale, Daniela, and Carlo Maria Cipolla. Anthracycline-related cardiotoxicity: epidemiology, surveillance, prophylaxis, management, and prognosis. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780198784906.003.0290.
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Anthracycline-induced cardiotoxicity is of considerable concern, as it may compromise the clinical effectiveness of treatment, affecting both quality of life and overall survival in cancer patients, independently of the oncological prognosis. It is probable that anthracycline-induced cardiotoxicity is a unique and continuous phenomenon starting with myocardial cell injury, followed by progressive left ventricular ejection fraction (LVEF) decline that, if disregarded and not treated progressively leads to overt heart failure. The main strategy for minimizing anthracycline-induced cardiotoxicity is early detection of high-risk patients and prompt prophylactic treatment. According to the current standard for monitoring cardiac function, cardiotoxicity is usually detected only when a functional impairment has already occurred, precluding any chance of its prevention. At present, anthracycline-induced cardiotoxicity can be detected at a preclinical phase, very much before the occurrence of heart failure symptoms, and before the LVEF drops by measurement of cardiospecific biochemical markers or by Doppler myocardial and deformation imaging. The role of troponins in identifying subclinical cardiotoxicity and treatment with angiotensin-converting enzyme inhibitors, in order to prevent LVEF reduction is an effective strategy that has emerged in the last 15 years. If cardiac dysfunction has already occurred, partial or complete LVEF recovery may still be achieved if cardiac dysfunction is detected early after the end of chemotherapy and heart failure treatment is promptly initiated.
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Galderisi, Maurizio, Juan Carlos Plana, Thor Edvardsen, Vitantonio Di Bello, and Patrizio Lancellotti. Cardiac oncology. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0064.
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Cancer therapeutics may induce cardiac damage in the left and the right ventricle. Radiotherapy most frequently induces valvular damage, carotid stenosis, and coronary artery disease. Pericardial disease may be due to both chemo- and radiotherapy. The manifestations of both chemo- and radiotherapy can develop acutely but also become overt years after their performance, in particular after radiotherapy. The main cardiac damage of cancer therapeutics-related cardiac dysfunction (CTRCD) corresponds to the reduction of left ventricular (LV) systolic function. The Expert Consensus document from ASE and EACVI has defined CTRCD as a decrease in LV ejection fraction (LVEF) of greater than 10 percentage points, to a value less than 53%. The accurate calculation of LVEF at baseline and during follow-up is extremely important. The assessment of LV longitudinal function, in particular of speckle tracking-derived global longitudinal strain (GLS), can provide additional information, allowing early, subclinical detection of CTRCD. The ideal strategy could be to compare the measurements of GLS obtained during chemotherapy, with the one obtained at baseline. An integrated approach with the use of echocardiography at standardized, clinical preselected intervals with biomarker (ultrasensitive troponin) assessment prior to each chemotherapy cycle could be suggested in patients at high risk of CTRCD. Follow-up after therapy should depend on the type of chemotherapy/radiotherapy and the presence/absence of on-therapy CTRCD. Long-term follow-up should be planned after radiotherapy.
26
Sidhu, Kulraj S., Mfonobong Essiet, and Maxime Cannesson. Cardiac and vascular physiology in anaesthetic practice. Edited by Jonathan G. Hardman. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199642045.003.0001.
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This chapter discusses key components of cardiovascular physiology applicable to clinical practice in the field of anaesthesiology. From theory development to ground-breaking innovations, the history of cardiac and vascular anatomy, as well as physiology, is presented. Utilizing knowledge of structure and function, parameters created have allowed adequate patient clinical assessment and guided interventions. A review of concepts reveals the impact of multiple physiological variables on a patient’s haemodynamic state and the need for more accurate and efficient measurements. In particular, it is noted that a more reliable index of ventricular contractility is the end-systolic elastance rather than the ejection fraction. Constant direct preload assessment has not yet been achieved but continues to be determined through surrogate variables, and continuous cardiac output monitoring for oxygen delivery, although advancing, has limitations. Considering the effect of compound factors perioperatively, especially heart failure, modifies the goals and interventions of anaesthetists to achieve improved outcomes. Therefore, medical management prior to surgery and complete assessment through history, physical examination, and diagnostic tests are a priority. This chapter also details the expectations following volume expansion to augment haemodynamics during surgery, the concept of functional haemodynamic monitoring, and limitations to the parameters applied in assessing fluid responsiveness. Challenging the accuracy of conventional indices to predict volume status led to the use of goal-directed therapy, reducing morbidity and minimizing length of hospital stay. The mainstay of this chapter is to reinforce the relevance of advances in haemodynamic monitoring and homeostasis optimization by anaesthetists during surgery, using fundamental concepts of cardiovascular physiology.
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Pierard, Luc A., and Lauro Cortigiani. Stress echocardiography: diagnostic and prognostic values and specific clinical subsets. Oxford University Press, 2016. http://dx.doi.org/10.1093/med/9780198726012.003.0015.
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Stress echocardiography is a widely used method for assessing coronary artery disease, due to its high diagnostic and prognostic value. While inducible ischaemia predicts an unfavourable outcome, its absence is associated with a low risk of future cardiac events. The method provides superior diagnostic and prognostic information than standard exercise electrocardiography and perfusion myocardial imaging in specific clinical subsets, such as women, hypertensive patients, and patients with left bundle branch block. Stress echocardiography allows effective risk assessment also in the diabetic population. The evaluation of coronary flow reserve of the left anterior descending artery by transthoracic Doppler adds diagnostic and prognostic information to that of standard stress test. Stress echocardiography is indicated in the cases when exercise electrocardiography is unfeasible, uninterpretable or gives ambiguous result, and when ischaemia during the test is frequently a false-positive response, as in hypertensive patients, women, and patients with left ventricular hypertrophy. Viability detection represents another application of stress echocardiography. The documentation of a large amount of viable myocardium predicts improved ejection fraction, reverse remodelling, and improved outcome following revascularization in patients with ischaemic cardiomyopathy. Moreover, stress echocardiography can aid significantly in clinical decision-making in patients with valvular heart disease through dynamic assessment of primary or secondary mitral regurgitation, transvalvular gradients, and pulmonary artery systolic pressure, as well as before vascular surgery due to the excellent negative predictive value. Finally, stress echocardiography allows effective risk stratification in patients with hypertrophic cardiomyopathy through evaluation of inducible ischaemia, coronary flow reserve, and intraventricular gradient.
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Noutsias, Michel, and Bernhard Maisch. Myocarditis and pericarditis. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0058.
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Transition of acute myocarditis to dilated cardiomyopathy occurs in approximately 20% of patients within a follow-up period of 33 months. Recent research has revealed the adverse prognostic impact of several clinical parameters for this scenario. Acute myocarditis and its sequelae dilated cardiomyopathy and inflammatory cardiomyopathy are often caused by viral infections. Histological evaluation of endomyocardial biopsies is critical for the diagnosis of the cardiomyopathy entity and for the clinical management of around 20% of the patients. Additionally, contemporary diagnostic procedures of endomyocardial biopsies are indispensable for the selection of inflammatory cardiomyopathy patients who will likely benefit from immunosuppression or antiviral (interferon) treatment. Immunoadsorption, with subsequent immunoglobulin substitution, is a further promising immunomodulatory treatment option for dilated cardiomyopathy patients, targeting primarily the anticardiac autoantibodies. Cardiac magnetic resonance has emerged as a valuable diagnostic approach for myocarditis and pericarditis. Myocardial late gadolinium enhancement has been associated with adverse outcome and sudden cardiac death. Bridging of the first 3–6 months with a wearable cardioverter–defibrillator, until a definitive decision on the implantation of an implantable cardioverter–defibrillator, is a growingly recognized cornerstone in the clinical management of patients with acute myocarditis with depressed left ventricular ejection fraction of <40% and new-onset dilated cardiomyopathy, respectively. Acute pericarditis is labelled idiopathic or suspected viral without adequate proof of the respective aetiology. Non-steroidal anti-inflammatory drugs and colchicine are proven and safe therapeutic mainstays for pericarditis, including the first attack. Pericardiocentesis is a lifesaving treatment of cardiac tamponade. Pericardioscopy and epicardial biopsies can contribute to the aetiological differentiation of pericardial effusions.
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Noutsias, Michel, and Bernhard Maisch. Myocarditis and pericarditis. Oxford University Press, 2017. http://dx.doi.org/10.1093/med/9780199687039.003.0058_update_001.
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Transition of acute myocarditis to dilated cardiomyopathy occurs in approximately 20% of patients within a follow-up period of 33 months. Recent research has revealed the adverse prognostic impact of several clinical parameters for this scenario. Acute myocarditis and its sequelae dilated cardiomyopathy and inflammatory cardiomyopathy are often caused by viral infections. Histological evaluation of endomyocardial biopsies is critical for the diagnosis of the cardiomyopathy entity and for the clinical management of around 20% of the patients. Additionally, contemporary diagnostic procedures of endomyocardial biopsies are indispensable for the selection of inflammatory cardiomyopathy patients who will likely benefit from immunosuppression or antiviral (interferon) treatment. Immunoadsorption, with subsequent immunoglobulin substitution, is a further promising immunomodulatory treatment option for dilated cardiomyopathy patients, targeting primarily the anticardiac autoantibodies. Cardiac magnetic resonance has emerged as a valuable diagnostic approach for myocarditis and pericarditis. Myocardial late gadolinium enhancement has been associated with adverse outcome and sudden cardiac death. Bridging of the first 3 months with a wearable cardioverter–defibrillator, until a definitive decision on the implantation of an implantable cardioverter–defibrillator, is a growingly recognized cornerstone in the clinical management of patients with acute myocarditis with depressed left ventricular ejection fraction of <40% and new-onset dilated cardiomyopathy, respectively. Acute pericarditis is labelled idiopathic or suspected viral without adequate proof of the respective aetiology. Non-steroidal anti-inflammatory drugs and colchicine are proven and safe therapeutic mainstays for pericarditis, including the first attack. Pericardiocentesis is a lifesaving treatment of cardiac tamponade. Pericardioscopy and epicardial biopsies can contribute to the aetiological differentiation of pericardial effusions.
30
AlJaroudi, Wael. Risk Assessment in Acute Coronary Syndromes. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199392094.003.0013.
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Acute coronary syndromes (ACS) include unstable angina pectoris (UAP), non-ST elevation (NSTEMI), and ST elevation acute myocardial infarction (STEMI). Each year, more than 2 million people are hospitalized with ACS in the United States. The initial treatment has evolved over the last few decades from conservative management to early reperfusion therapy. Medical therapy has also significantly changed with the use of newer more potent antiplatelet agents, beta-blockers, angiotensin converting enzyme inhibitors, statins, and anti-anginal drugs, which have resulted in improvement of patient care and survival. There is no role for stress myocardial perfusion imaging (MPI) in the acute presentation; however, rest MPI may be used to identify the culprit lesion and risk stratify patients if injected during chest pain. In stable patients for ACS, submaximal exercise or vasodilator MPI can be performed as early as 48 hours after the event. Several gated MPI-derived variables such as left ventricular (LV) ejection fraction (EF), LV volumes, infarct size, mechanical dyssynchrony, and residual ischemic burden can risk stratify patients and provide prognostic data incremental to validated clinical risk scores such as GRACE (Global Registry of Acute Coronary Syndrome) and TIMI (Thrombolysis in Myocardial Infarction). Patients with depressed LVEF, remodeled LV, and large perfusion defects are at particularly high- risk for subsequent cardiac death or recurrent myocardial infarction. In such setting, MPI plays a pivotal role in the management of patients and guiding therapeutic decisions. The current chapter will review the clinical and MPI predictors of outcomes in patients presenting with ACS according to updated guidelines and a proposed algorithm integrating the role of MPI in guiding therapeutic decisions and management.
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Farmakis, Dimitrios, John Parissis, and Gerasimos Filippatos. Acute heart failure: epidemiology, classification, and pathophysiology. Oxford University Press, 2015. http://dx.doi.org/10.1093/med/9780199687039.003.0051.
Full textAbstract:
Acute heart failure is defined as the rapid development or change of symptoms and signs of heart failure that requires urgent medical attention and usually hospitalization. Acute heart failure is the first reason for hospital admission in individuals aged 65 or more and accounts for nearly 70% of the total health care expenditure for heart failure. It is characterized by an adverse prognosis, with an in-hospital mortality rate of 4-7%, a 2-3-month post-discharge mortality of 7-11%, and a 2-3-month readmission rate of 25-30%. The majority of patients have a previous history of heart failure and present with normal or increased blood pressure, while about half of them have a preserved left ventricular ejection fraction. A high prevalence of cardiovascular or non-cardiovascular comordid conditions is further observed, including coronary artery disease, arterial hypertension, atrial fibrillation, diabetes mellitus, renal dysfunction, chronic lung disease, and anaemia. Different classification systems have been proposed for acute heart failure, reflecting the clinical heterogeneity of the syndrome; the categorization to acutely decompensated chronic heart failure vs de novo acute heart failure and to hypertensive, normotensive, and hypotensive acute heart failure are among the most widely used and clinically relevant classifications. The pathophysiology of acute heart failure involves several pathogenetic mechanisms, including volume overload, pressure overload, myocardial loss, and restrictive filling, while several cardiovascular and non-cardiovascular causes or precipitating factors lead to acute heart failure through a single of these mechanisms or a combination of them. Regardless of the underlying mechanism, peripheral and/or pulmonary congestion is the hallmark of acute heart failure, resulting from fluid retention and/or fluid redistribution. Myocardial injury and renal dysfunction are also involved in the precipitation and progression of the syndrome.
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Zoccali, Carmine, Davide Bolignano, and Francesca Mallamaci. Left ventricular hypertrophy in chronic kidney disease. Edited by David J. Goldsmith. Oxford University Press, 2018. http://dx.doi.org/10.1093/med/9780199592548.003.0107_update_001.
Full textAbstract:
Alterations in left ventricular (LV) mass and geometry and LV dysfunction increase in prevalence from stage 2 to stage 5 in CKD. Nuclear magnetic resonance is the most accurate and precise technique for measuring LV mass and function in patients with heart disease. Quantitative echocardiography is still the most frequently used means of evaluating abnormalities in LV mass and function in CKD. Anatomically, myocardial hypertrophy can be classified as concentric or eccentric. In concentric hypertrophy, the muscular component of the LV (LV wall) predominates over the cavity component (LV volume). Due to the higher thickness and myocardial fibrosis in patients with concentric LVH, ventricular compliance is reduced and the end-diastolic volume is small and insufficient to maintain cardiac output under varying physiological demands (diastolic dysfunction). In those with eccentric hypertrophy, tensile stress elongates myocardiocytes and increases LV end-diastolic volume. The LV walls are relatively thinner and with reduced ability to contract (systolic dysfunction). LVH prevalence increases stepwisely as renal function deteriorates and 70–80% of patients with kidney failure present with established LVH which is of the concentric type in the majority. Volume overload and severe anaemia are, on the other hand, the major drivers of eccentric LVH. Even though LVH may regress after renal transplantation, the prevalence of LVH after transplantation remains close to that found in dialysis patients and a functioning renal graft should not be seen as a guarantee of LVH regression. The vast majority of studies on cardiomyopathy in CKD are observational in nature and the number of controlled clinical trials in these patients is very small. Beta-blockers (carvedilol) and angiotensin receptors blockers improve LV performance and reduce mortality in kidney failure patients with LV dysfunction. Although current guidelines recommend implantable cardioverter-defibrillators in patients with ejection fraction less than 30%, mild to moderate symptoms of heart failure, and a life expectancy of more than 1 year, these devices are rarely offered to eligible CKD patients. Conversion to nocturnal dialysis and to frequent dialysis schedules produces a marked improvement in LVH in patients on dialysis. More frequent and/or longer dialysis are recommended in dialysis patients with asymptomatic or symptomatic LV disorders if the organizational and financial resources are available.