Melbourne Medical School Collected Works - Research Publications
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ItemMoving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age(SAGE PUBLICATIONS LTD, 2018-12-04)This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.
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ItemAtrial fibrillation detection using single lead portable electrocardiographic monitoring: a systematic review and meta-analysis(BMJ PUBLISHING GROUP, 2018-09)OBJECTIVES: Recent technology advances have allowed for heart rhythm monitoring using single-lead ECG monitoring devices, which can be used for early diagnosis of atrial fibrillation (AF). We sought to investigate the AF detection rate using portable ECG devices compared with Holter monitoring. SETTING, PARTICIPANTS AND OUTCOME MEASURES: We searched the Medline, Embase and Scopus databases (conducted on 8 May 2017) using search terms related to AF screening and included studies with adults aged >18 years using portable ECG devices or Holter monitoring for AF detection. We excluded studies using implantable loop recorders and pacemakers. Using a random-effects model we calculated the overall AF detection rate. Meta-regression analysis was performed to explore potential sources for heterogeneity. Quality of reporting was assessed using the tool developed by Downs and Black. RESULTS: Portable ECG monitoring was used in 18 studies (n=117 436) and Holter monitoring was used in 36 studies (n=8498). The AF detection rate using portable ECG monitoring was 1.7% (95% CI 1.4 to 2.1), with significant heterogeneity between studies (p<0.001). There was a moderate linear relationship between total monitoring time and AF detection rate (r=0.65, p=0.003), and meta-regression identified total monitoring time (p=0.005) and body mass index (p=0.01) as potential contributors to heterogeneity. The detection rate (4.8%, 95% CI 3.6% to 6.0%) in eight studies (n=10 199), which performed multiple ECG recordings was comparable to that with 24 hours Holter (4.6%, 95% CI 3.5% to 5.7%). Intermittent recordings for 19 min total produced similar AF detection to 24 hours Holter monitoring. CONCLUSION: Portable ECG devices may offer an efficient screening option for AF compared with 24 hours Holter monitoring. PROSPERO REGISTRATION NUMBER: CRD42017061021.
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ItemJeopardized Myocardium Defined by Late Gadolinium Enhancement Magnetic Resonance Imaging Predicts Survival in Patients With Ischemic Cardiomyopathy: Impact of Revascularization(WILEY, 2018-11-20)Background The prognostic impact of jeopardized myocardium ( JM ) in patients with advanced ischemic cardiomyopathy ( ICM ) is unclear. We hypothesized that JM is an independent predictor of mortality in patients with advanced ICM . Methods and Results Patients with ICM who underwent cardiac magnetic resonance imaging between January 2002 and January 2013 were included in our study. JM was identified as a vascular territory with <50% myocardial scarring on cardiac magnetic resonance imaging and with >70% stenosis in a major coronary vessel that was not subsequently revascularized. A propensity score was developed for revascularization. A multivariable Cox proportional hazards model was used to evaluate the association of JM with all-cause mortality. We evaluated 631 patients over a mean follow-up of 5.1 years. Overall, 336 patients underwent subsequent revascularization during the follow-up period, among whom 23% had remaining JM , while 295 patients were medically treated (57% with JM ). There were 204 deaths (32%). On multivariable analysis, JM (hazard ratio, 1.88; 95% confidence interval, 1.38-2.55 [ P<0.001]) was independently associated with all-cause mortality after adjusting for multiple other factors. The risk associated with the presence of JM increased by 5% for every 10-unit increase in left ventricular end-systolic volume index. Conclusions JM is an independent and incremental predictor of mortality in patients with advanced ICM . Patients undergoing revascularization with residual JM had similar risk of mortality compared with medically treated patients with JM . The risk associated with JM significantly increased in the presence of worsening adverse left ventricular remodeling. Cardiac magnetic resonance viability assessment may provide important risk stratification in patients with ICM .
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ItemSociety for Cardiovascular Magnetic Resonance (SCMR) expert consensus for CMR imaging endpoints in clinical research: part I - analytical validation and clinical qualification(BMC, 2018-09-20)Cardiovascular disease remains a leading cause of morbidity and mortality globally. Changing natural history of the disease due to improved care of acute conditions and ageing population necessitates new strategies to tackle conditions which have more chronic and indolent course. These include an increased deployment of safe screening methods, life-long surveillance, and monitoring of both disease activity and tailored-treatment, by way of increasingly personalized medical care. Cardiovascular magnetic resonance (CMR) is a non-invasive, ionising radiation-free method, which can support a significant number of clinically relevant measurements and offers new opportunities to advance the state of art of diagnosis, prognosis and treatment. The objective of the SCMR Clinical Trial Taskforce was to summarizes the evidence to emphasize where currently CMR-guided clinical care can indeed translate into meaningful use and efficient deployment of resources results in meaningful and efficient use. The objective of the present initiative was to provide an appraisal of evidence on analytical validation, including the accuracy and precision, and clinical qualification of parameters in disease context, clarifying the strengths and weaknesses of the state of art, as well as the gaps in the current evidence This paper is complementary to the existing position papers on standardized acquisition and post-processing ensuring robustness and transferability for widespread use. Themed imaging-endpoint guidance on trial design to support drug-discovery or change in clinical practice (part II), will be presented in a follow-up paper in due course. As CMR continues to undergo rapid development, regular updates of the present recommendations are foreseen.
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ItemAssociation of Volumetric Epicardial Adipose Tissue Quantification and Cardiac Structure and Function(WILEY, 2018-12-04)Background Epicardial adipose tissue ( EAT ) is in immediate apposition to the underlying myocardium and, therefore, has the potential to influence myocardial systolic and diastolic function or myocardial geometry, through paracrine or compressive mechanical effects. We aimed to review the association between volumetric EAT and markers of myocardial function and geometry. Methods and Results PubMed, Medline, and Embase were searched from inception to May 2018. Studies were included only if complete EAT volume or mass was reported and related to a measure of myocardial function and/or geometry. Meta-analysis and meta-regression were used to evaluate the weighted mean difference of EAT in patients with and without diastolic dysfunction. Heterogeneity of data reporting precluded meta-analysis for systolic and geometric associations. In the 22 studies included in the analysis, there was a significant correlation with increasing EAT and presence of diastolic dysfunction and mean e' (average mitral annular tissue Doppler velocity) and E/e' (early inflow / annular velocity ratio) but not E/A (ratio of peak early (E) and late (A) transmitral inflow velocities), independent of adiposity measures. There was a greater EAT in patients with diastolic dysfunction (weighted mean difference, 24.43 mL; 95% confidence interval, 18.5-30.4 mL; P<0.001), and meta-regression confirmed the association of increasing EAT with diastolic dysfunction ( P=0.001). Reported associations of increasing EAT with increasing left ventricular mass and the inverse correlation of EAT with left ventricular ejection fraction were inconsistent, and not independent from other adiposity measures. Conclusions EAT is associated with diastolic function, independent of other influential variables. EAT is an effect modifier for chamber size but not systolic function.
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ItemAssociation of ambient particulate matter with heart failure incidence and all-cause readmissions in Tasmania: an observational study(BMJ PUBLISHING GROUP, 2018-05)OBJECTIVES: We sought to investigate the relationship between air quality and heart failure (HF) incidence and rehospitalisation to elucidate whether there is a threshold in this relationship and whether this relationship differs for HF incidence and rehospitalisation. METHODS: This retrospective observational study was performed in an Australian state-wide setting, where air pollution is mainly associated with wood-burning for winter heating. Data included all 1246 patients with a first-ever HF hospitalisation and their 3011 subsequent all-cause readmissions during 2009-2012. Daily particulate matter <2.5 µm (PM2.5), temperature, relative humidity and influenza infection were recorded. Poisson regression was used, with adjustment for time trend, public and school holiday and day of week. RESULTS: Tasmania has excellent air quality (median PM2.5=2.9 µg/m3 (IQR: 1.8-6.0)). Greater HF incidences and readmissions occurred in winter than in other seasons (p<0.001). PM2.5 was detrimentally associated with HF incidence (risk ratio (RR)=1.29 (1.15-1.42)) and weakly so with readmission (RR=1.07 (1.02-1.17)), with 1 day time lag. In multivariable analyses, PM2.5 significantly predicted HF incidence (RR=1.12 (1.01-1.24)) but not readmission (RR=0.96 (0.89-1.04)). HF incidence was similarly low when PM <4 µg/m3 and only started to rise when PM2.5≥4 µg/m3. Stratified analyses showed that PM2.5 was associated with readmissions among patients not taking beta-blockers but not among those taking beta-blockers (pinteraction=0.011). CONCLUSIONS: PM2.5 predicted HF incidence, independent of other environmental factors. A possible threshold of PM2.5=4 µg/m3 is far below the daily Australian national standard of 25 µg/m3. Our data suggest that beta-blockers might play a role in preventing adverse association between air pollution and patients with HF.
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ItemAssociation of depression with evolution of heart failure in patients with type 2 diabetes mellitus(BMC, 2018-01-24)BACKGROUND: Depression is a prevalent, independent predictor of mortality in patients with heart failure (HF). Depression is also common in type 2 diabetes mellitus (T2DM), which is itself an important risk factor for HF. However, association of depression with incident HF in T2DM is undefined. The aim of the present study was to evaluate the predictive value of depression in predicting incident HF in a community-based cohort of asymptomatic patients with T2DM. METHODS: We prospectively recruited 274 asymptomatic T2DM patients ≥ 65 years (age 71 ± 4 year, 56% men) with preserved EF and no ischemic heart disease from a community-based population. The Patient Health Questionnaire 9 (PHQ-9) was used to detect depression, and LV dysfunction was sought with a comprehensive echocardiogram, including LV hypertrophy (LVH) and subclinical diastolic function (E/e'). Over a median follow-up of 1.5 years (range 0.5-3), 20 patients were lost to follow-up and 254 individuals were followed for outcomes. RESULTS: At baseline, depression was present in 9.5%, LVH was identified in 26% and reduced E/e' in 11%. Over a median follow-up of 1.5 years, 37 of 245 patients developed new-onset HF and 3 died, giving an event rate of 107/1000 person-years. In a competing-risks regression analysis, depression (adjusted HR 2.54, 95% CI 1.18-5.46; p = 0.017) was associated with incident HF and had incremental predictive power to clinical, biochemical and echocardiographic variables. CONCLUSION: Depression is prevalent in asymptomatic elderly patients with T2DM, and depression independently and incrementally predicts incident HF.
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ItemVariations in subclinical left ventricular dysfunction, functional capacity, and clinical outcomes in different heart failure aetiologies(WILEY PERIODICALS, INC, 2018-06)AIMS: Patients with heart failure (HF) risk factors are described as being in Stage A of this condition (SAHF). Management is directed towards prevention of HF progression, but to date, no evidence has been described to align the intensity of this intervention to HF risk. We sought to what extent SAHF of Type 2 diabetes mellitus (T2DM) and other HF risks showed differences in subclinical left ventricular function, exercise capacity, and prognosis. METHODS AND RESULTS: We recruited 551 elder asymptomatic SAHF patients (age 71 ± 5 years, 49% men, 290 T2DM) with at least one risk factor from a community-based population with preserved ejection fraction. All underwent a comprehensive echocardiogram including global longitudinal strain (GLS) and a 6 min walk test and were followed for 2 years. The primary endpoints were new-onset HF and all-cause mortality. The T2DM group was associated with reduced 6 min walk test distance (451 ± 111 vs. 493 ± 87 m, P < 0.001), worse diastolic function (E/e' 9.2 ± 2.7 vs. 8.7 ± 2.4, P = 0.028), and impaired GLS (-17.7 ± 2.6% vs. -19.0 ± 2.6%, P < 0.001). Over a median follow-up of 1.6 years, 49 T2DM-SAHF and 27 other-SAHF met the primary endpoint. T2DM-SAHF had significantly worse outcome than other-SAHF (P = 0.021). In Cox models, obesity [hazard ratio (HR) = 2.46; P = 0.007], atrial fibrillation (HR = 2.39; P = 0.028), 6 min walk distance (HR = 0.99; P = 0.034), and GLS (HR = 1.14; P = 0.033) were independently associated with the primary endpoint in T2DM-SAHF, independent of age and glycaemic control. CONCLUSIONS: The T2DM-SAHF has worse subclinical left ventricular function, exercise capacity, and prognosis than other-SAHF. Impaired GLS, atrial fibrillation, exercise capacity, and obesity are associated with a worse prognosis in T2DM-SAHF but not in other-SAHF.