Predicting cardiovascular events in out-of-hospital patients presenting with atypical chest pain and complete left bundle branch block: role of CTA and echocardiographic Global Longitudinal Strain

Background Out-of-hospital patients presenting with atypical chest pain and complete left bundle branch block(LBBB)have to be stratified for the presence of coronary artery disease and the risk of developing heart failure(HF).We investigated the pro-gnostic role of coronary CT-angiography(CTA)and echocardiographic global longitudinal strain(GLS)in those patients in a mid-term follow-up.Methods Out-of-hospital patients with LBBB underwent echocardiography and a 64-slice CT angiography were evaluated ret-rospectively.Development of HF or a cardiovascular death were the events scheduled.Results Seventy-eight patients(32 female;mean age:66.0±10.4 years were enrolled.During a follow-up of 33 months(IQR:17-77),one patient(1.5%)experienced a cardiovascular death,14 patients(17.9%)required urgent outpatient visits due to acute de-compensated HF(12 hospitalizations).Echocardiography showed a slightly reduced left ventricular ejection fraction(LVEF)(50.0%±9.8%)and GLS within the normal range(-16.2%±4.1%).CTA analysis showed coronary stenosis>50%in 28 patients(35.9%).A high Agatston score(>100)was observed in 29.5%.Notably,25 patients(32.1%)were diagnosed with left main coron-ary artery disease and 15 patients(16.7%)underwent revascularization during the follow up.Significant associations were ob-served between events and LVEF(P=0.001),diastolic dysfunction grade≥2(P=0.02),GLS(P<0.001),multiple coronary stenos-is(P=0.04)and Agatston score(P=0.05).Multivariate analysis confirmed the relationships with LVEF(R^(2)=0.89,P<0.001),dia-stolic dysfunction(R^(2)=3.30,P=0.04),GLS(R^(2)=1.43,P<0.001),and Agatston score(R^(2)=1.01,P=0.05).Conclusions In patients with complete LBBB,CTA and GLS identified those at a high risk of development HF.

Echocardiography and impedance cardiography as determinants of successful slow levosimendan infusion in advanced older heart failure patients

Despite new therapeutic options,patients with heart failure(HF)still progress to advanced stage.In particular,patients who developed a severe left ventricular(LV)systolic and/or diastolic dysfunction with higher degree of NYHA class,recurrent hospitalizations for HF and showing a severe impairment of exercise capacity were defined as“advanced HF”.[1]Levosimendan was recently approved in order to treat patients hospitalized for acute decompensated HF(ADHF)with severe systolic dysfunction.The pharmacolo-gical effects of levosimendan consists of inotropy,vasodilatation and cardioprotection increasing of calcium sensitivity.[2]These effects should be mon-itored with echocardiography.[3]In particular,in ad-vanced HF patients,levosimendan showed positive effects in reducing mortality and three months hos-pitalization;about quality of life and symptoms im-provement,levosimendan showed contrasting ef-fect among the studies on advanced HF patients available.