Echocardiographic Risk-

stratification to Predict Heart

Failure in Patients with
Stable CAD
Renan Sukmawan, MD, PhD
Department of Cardiology and Vascular Medicine, Faculty of Medicine
University of Indonesia / Harapan Kita National Cardiovascular Center
Alternative projections of mortality and disability by cause
19902020: Global Burden of Disease Study
Christopher J L, et al. Lancet 1997, 349,
We projected that non-communicable
disease mortality will increase from 281
million deaths in 1990 to 497 million in
2020. Deaths from injury may increase
from 51 million to 84 million. Leading
causes of disability-adjusted life years
(DALYs) predicted by the baseline model
were (in descending order): ischaemic
heart disease, unipolar major depression,
road-traffic accidents, cerebrovascular
disease, chronic obstructive pulmonary
disease, lower respiratory infections,
tuberculosis, war injuries, diarrhoeal
diseases, and HIV.
NCC Harapan Kita In-patient data
0
500
1000
1500
2000
2500
CAD CHF
2005
2006
2007
2008
2009
R & D Division, NCC Harapan Kita , 2010
NCC Harapan Kita Out-patient data
0
2000
4000
6000
8000
10000
12000
14000
CAD CHF
2005 2006 2007 2008 2009
- Which and when ?
- How to prevent ?
R & D Division, NCC Harapan Kita , 2010
Heart Failure Stages
ACC AHA Guidelines on CHF. Circulation, 2005
Yancy CW. J Am Coll Cardiol 2006;47:76-84
The first hospitalization for HF
worsens survival for most patients,
regardless of resting EF
Bhatia RS. N Engl J Med 2006;355:260-269
Owan TE. N Engl J Med 2006;355:251-259
Development of an Echocardiographic Risk-Stratification
Index to Predict Heart Failure in Patients With Stable
Coronary Artery Disease
(The Heart and Soul Study)
To determine TTE measurements most strongly predict HF
and to develop an index for risk-stratification in stable CAD
Conducted in 1024 pts with stable CAD
Defined association of 15 TTE measurements with
subsequent HF stay
Developing scoring system using independent predictors
from multivariate analysis
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
(The Heart and Soul Study)
Inclusion Criteria
1. History of myocardial infarction
2. Stenoses > 50% in at least 1
vessel from cor-angiography
3. Stress-induced ischemia from
TMT or nuclear perfusion
4. History of coronary
revascularization
5. Prior diagnosis of CAD
Exclusion Criteria
1. Prior myocardial infarction
within the last 6 months
2. Unable to walk 1 block
3. Plan to move out from the local
area
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
(The Heart and Soul Study)
Resting 2D-echo completed in all subjects
The 15 chosen candidate echo variables :
1. LV end-systolic volume index
2. LV end-diastolic volume index
3. LVEF
4. Left atrial volume index (LAVI)
5. Right atrial volume index
6. LV Mass Index (LVMI)
7. PA peak systolic pressure
8. Right atrial volume index
9. VTI RVOT
10. VTI LVOT
11. Aortic valve area
12. Right atrial pressure
13. Diastolic Dysfunction
14. MR severity
14. tricuspid regurgitation severity
15. resting wall motion score index
Correlate with LVES Vol Index
Correlate with VTI LVOT
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
(The Heart and Soul Study)
Results
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
(The Heart and Soul Study)
Results
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
(The Heart and Soul Study)
Results
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
(The Heart and Soul Study)
Results
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
(The Heart and Soul Study)
Results
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
Heart Failure Risk Index (HFRI) by resting echo
Summary
Stevens MS, et al. J Am Coll Cardiol Img 2009;2;11-20
IMAGE of INTEREST MEASUREMENTS SCORE
LV Mass Index
> 90 g/m
2
3
Diastolic Dysfunction
Pseudonormal or
Restrictive
2
Mitral Regurgitation
> Mild
1
LVOT VTI
< 22 cm
1
LA Volume Index
29 ml/m
2
1
Heart Failure Risk Index (HFRI) by resting echo
Limitations
Studied in caucasian (60%) and men (82%)
Primary outcome was only HF hospital stay
Not incorporate newer techniques, i.e. TDI, strain
Defining diastolic function solely by E/A ratio
LA volume index using biplane method of discs,
which may be different to the area-length method
Dichotomous cut-offs for each measurements
Unclear gained to restratifying class A & B of HF
by echocardiographic measures only
Clinical Impact of HFRI
Simplifying data from routine TTE in stable CAD
Enhance assessment for HF risk
Predicting HF in a patient population with relatively
preserved systolic function
Complementary to other HF measures, i.e. BNP
Perhaps guiding for aggressive treatment in high-
risk patients based on HFRI
CONCLUSIONS
The TTE Heart Failure Risk Index provides method to
predict development of heart failure in patients with stable
CAD
This index represents an important step in simplifying
data from a routine TTE and using it to enhance our
assessment of risk for heart failure
Further studies needed to define the value of TTE Heart
Failure Risk Index in clinical decision-making