Appropriate Use and Clinical Impact of Transthoracic Echocardiography.

Appropriate Use and Clinical Impact of Transthoracic Echocardiography.

JAMA Intern Med. 2013 Jul 22. doi: 10.1001/jamainternmed.2013.8972. [Epub ahead of print]

Appropriate Use and Clinical Impact of Transthoracic Echocardiography.


Department of Medicine, The University of Texas Southwestern Medical Center, Dallas.


IMPORTANCE Transthoracic echocardiography (TTE) accounts for almost half of all cardiac imaging services and is a widely available and versatile tool. Appropriate use criteria (AUC) for echocardiography were developed to improve patient care and health outcomes. Prior studies have shown that most TTEs are appropriate by AUC. However, the associations among TTE, AUC, and their clinical impact have not been well explored. OBJECTIVES To describe the proportion of TTEs that affect clinical care in an academic medical center overall and in subgroups defined as appropriate and inappropriate by AUC. DESIGN AND SETTING Retrospective review of medical records from 535 consecutive TTEs at an academic medical center was performed. The TTEs were classified according to 2011 AUC by 2 cardiologists blinded to clinical impact and were assessed for clinical impact by 2 cardiologists blinded to AUC. Clinical impact was assigned to 1 of the following 3 categories: (1) active change in care, (2) continuation of current care, or (3) no change in care. PARTICIPANTS Five hundred thirty-five patients undergoing TTE. EXPOSURE Transthoracic echocardiography. MAIN OUTCOMES AND MEASURES Prevalence of appropriate, inappropriate, and uncertain TTEs and prevalence of clinical impact subcategories. RESULTS Overall, 31.8% of TTEs resulted in an active change in care; 46.9%, continuation of current care; and 21.3%, no change in care. By 2011 AUC, 91.8% of TTEs were appropriate; 4.3%, inappropriate; and 3.9%, uncertain. We detected no statistically significant difference between appropriate and inappropriate TTEs in the proportion of TTEs that led to active change in care (32.2% vs 21.7%; P = .29). CONCLUSIONS AND RELEVANCE Although 9 in 10 TTEs were appropriate by 2011 AUC, fewer than 1 in 3 TTEs resulted in an active change in care, nearly half resulted in continuation of current care, and slightly more than 1 in 5 resulted in no change in care. The low rate of active change in care (31.8%) among TTEs mostly classified asappropriate (91.8%) highlights the need for a better method to optimize TTE utilization to use limited health care resources efficiently while providing high-quality care.

J Thorac Cardiovasc Surg. 2013 Jul 16. pii: S0022-5223(13)00619-3. doi: 10.1016/j.jtcvs.2013.05.047. [Epub ahead of print]

Dynamic characterization of aortic annulus geometry and morphology with multimodality imaging: Predictive value for aortic regurgitation after transcatheter aortic valve replacement.


Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.



Patients undergoing transcatheter aortic valve replacement (TAVR), as compared with those undergoing surgical aortic valve replacement (AVR), have higher postprocedural aortic regurgitation (AR), associated with higher mortality. We hypothesized that reduced annular deformation is associated with higher postprocedural AR and sought to assess incremental value of assessment of aortic annular deformation in prediction of post-TAVR AR.


We included 87 patients with high-risk severe aortic stenosis (AS) (81 ± 10 years, 54% men) who underwent preprocedural echocardiography and contrast-enhanced (4-dimensional) multidetector computed tomography (MDCT) of the aortic root, followed by TAVR (n = 55) or surgical AVR (n = 32). On MDCT, minimal/maximal annular circumference, circumferential deformation (maximum-minimum over cardiac cycle), and eccentricity (largest/smallest diameter during systole) were calculated. Degree of commissural/annular calcification was graded semiquantitatively (scale 1-3). Oversizing/undersizing of the prosthesis during TAVR was assessed.


Pre-AVR aortic valve area (0.6 ± 0.1 vs 0.6 ± 0.1 cm2), mean aortic valve gradient (46 ± 14 vs 45 ± 11 mm Hg), AR (1 ± 0.8 vs 0.9 ± 0.7), maximal annular circumference (8 ± 1 vs 7.9 ± 0.8 cm), annular deformation (0.3 ± 0.1 vs 0.3 ± 0.1 cm), eccentricity (1.2 ± 0.1 vs 1.2 ± 0.1), commissural (2.1 ± 0.6 vs 2 ± 0.7), and annular calcification scores (1.7 ± 0.8 vs 1.7 ± 0.8) were similar in TAVR and surgical AVR groups (P = not significant). A higher proportion of patients had ≥ mild AR in the TAVR than in the surgical AVR group (58% vs 34%; P < .03). In TAVR patients, reduced annular deformation (P = .01) predicted postprocedural AR, in addition to prosthesis undersizing (P = .03) and higher annular calcification (P = .03).


Residual post-TAVR AR is predicted by reduced aortic annular deformity, higher annular calcification, and prosthesis undersizing. Pre-TAVR 4-dimensional annular assessment aids in prediction of post-TAVR AR.

Multicenter Randomized Double-Blind Parallel-Group Placebo-Controlled Study of the Effects of Qili Qiangxin Capsulesin Patients with Chronic Heart Failure.

Li X, Zhang J, Huang J, Ma A, Yang J, Li W, Wu Z, Yao C, Zhang Y, Yao W, Zhang B, Gao R.

J Am Coll Cardiol. 2013 Jun 6. doi:pii: S0735-1097(13)02178-5. 10.1016/j.jacc.2013.05.035. [Epub ahead of print   

PMID: 23747768





The purpose of this study was to assess the effects of Qili Qiangxin capsules in patients with chronic heart failure (CHF).


Qili Qiangxin capsules are a traditional Chinese medicine (TCM) that has been approved for the treatment of CHF, but the evidence supporting its efficacy remains unclear.


A total of 512 CHF patients were enrolled and randomly assigned to receive the placebo or Qili Qiangxin capsules in addition to their standard medications for the treatment of CHF. The primary endpoint was the reduction or percent change in the plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) level during 12 weeks of treatment.


At the 12-week follow-up, a significant reduction in the NT-proBNP level from baseline was observed in both groups, but the QiliQiangxin capsule group demonstrated a significantly greater reduction than the placebo group (p = 0.002); 47.95% of patients in the QiliQiangxin capsule group demonstrated reductions in NT-proBNP of at least 30% compared to 31.98% of patients in the placebo group (p < 0.001). Treatment with Qili Qiangxin capsules also demonstrated superior performance in comparison to the placebo with respect to New YorkHeart Association (NYHA) functional classification, left ventricular ejection fraction (LVEF), 6-minute walking distance (6MWD) and quality of life.


On a background of standard treatment, Qili Qiangxin capsules further reduced the levels of NT-proBNP. Together, our data suggest that Qili Qiangxin capsules could be used in combination therapy for CHF.


low gradient severe aortic stenosis

low gradient severe aortic stenosis

Eur Heart J. 2013 Jul;34(25):1862-3. doi: 10.1093/eurheartj/eht157. Epub 2013 May 2.

Preserved ejection fraction can accompany low gradient severe aortic stenosis: impact of pathophysiology on diagnostic imaging.


Division of Cardiology, Department of Internal Medicine III, Medical University Innsbruck, A-6020 Innsbruck, Austria.

Culprit lesion remodelling and long-term prognosis

Culprit lesion remodelling and long-term prognosis

Eur Heart J Cardiovasc Imaging. 2013 Aug;14(8):758-764. Epub 2012 Nov 9.

Culprit lesion remodelling and long-term prognosis in patients with acute coronary syndrome: an intravascular ultrasound study.


Division of Cardiology, Bell Land General Hospital, Sakai, Japan.



Positive arterial remodelling is recognized as one of the morphological characteristics of the vulnerable plaque. Limited data are available on a long-term outcome of acute coronary syndrome (ACS) patients with culprit lesion positive arterial remodelling (PR). The aim of this study was to investigate the long-term impact of culprit lesion PR in patients with ACS.


In 134 patients with ACS, intravascular ultrasound (IVUS) was performed to assess target lesion remodelling before percutaneous coronary intervention. PR was defined as the ratio of the external elastic membrane cross-sectional area at the target lesion to that of at the proximal reference of >1.05, and intermediate or negative remodelling (IR/NR) was defined as that of ≤1.05. Major adverse cardiac event (MACE) was defined as a composite of death, ACS, and target lesion revascularization. During the follow-up (median 5.8 years), MACE-free survival was significantly lower in the PR group than that in the IR/NR group (log-rank, P = 0.005). Survival and ACS-free survival were also significantly lower in the PR group than that in the IR/NR group (log-rank, both P = 0.04). By multivariable Cox regression analysis, PR (hazard ratio = 2.4, P = 0.02) and diabetes (hazard ratio = 1.9, P = 0.03) were independent predictors of MACE.


Culprit lesion PR was associated with a poor long-term prognosis in patients with ACS. PR may be a marker of vulnerable patients.


Acute coronary syndrome, Intravascular ultrasound, Remodelling, Prognosis, Vulnerable plaque





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