Echocardiographic Assessment of Treatment for Systolic Congestive Heart Failure

Published on 21/06/2015 by admin

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Last modified 21/06/2015

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9 Echocardiographic Assessment of Treatment for Systolic Congestive Heart Failure

Echocardiographic Assessment of Systolic HF

Echocardiography is an appropriate diagnostic test to investigate symptoms and signs of suspected HF.1 Echocardiography is also appropriate for guiding therapeutic decisions in HF patients and evaluating changes in clinical status.1 In addition to diagnosis, results from an echocardiogram (i.e., left ventricular ejection fraction [LVEF]) can provide important prognostic information.2
In addition to LVEF, other echocardiographic parameters provide prognostic information. Specifically, in a study of cardiac mortality in HF patients with LVEF less than 40%, a restrictive transmitral flow pattern (Figure 9-1) by Doppler echocardiography was the best clinical predictor of cardiac death. Relative risk for cardiac death was estimated as 4.1 at 1 year and 8.6 at 2 years in the restrictive group compared with the nonrestrictive group.3 Several other markers of LV size and function (i.e., end-diastolic and end-systolic volume, myocardial performance index) and diastolic properties of the LV (i.e., pseudo-normal mitral inflow pattern) predict adverse prognosis in systolic HF.
Novel echocardiographic measures of regional LV function, such as global longitudinal strain by speckle tracking echocardiography, may have superior prognostic value in HF patients over traditional measures of global function such as LVEF.5 Longitudinal and circumferential strain rates were independent predictors of outcome in myocardial infarction patients with LV dysfunction and/or HF.6 The effect of HF therapies on these novel echocardiographic measures represents an important area of ongoing investigation.

Medications

Several classes of medications are approved for symptom relief and mortality benefit in systolic HF. These medications are summarized below.

Cardiac Resynchronization Therapy (CRT)

Key Points

In the MADIT-CRT trial,18 CRT in addition to an ICD in patients with NYHA functional class I/II, LVEF ≤ 30%, and QRS duration ≥ 130 ms resulted in improved LV function and reduced risk of worsening HF, compared to those who received an ICD alone. These effects were most pronounced in patients with a QRS complex ≥ 150 ms.
In the RethinQ trial,19 CRT was not shown to increase the primary outcome measure of peak oxygen consumption in patients with NYHA class III symptoms and a narrow (< 120 ms) QRS interval and echocardiographic evidence of dyssynchrony (opposing wall delay > 65 ms; see below).