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CLINICAL STUDY: HEART FAILURE

The prevalence of treatable left ventricular systolic dysfunction in patients who present with noncardiac vascular episodes

A case-control study

Robert Kelly, MD, MRCPI^*, Anthony Staines, PhD, MRCPI^||, Ron MacWalter, FRCP, Peter Stonebridge, MCh, FRCS, Hugh Tunstall-Pedoe, MD, FRCP and Allan D. Struthers, MD, FRCP^*,*

^* Department of Clinical Pharmacology, University of Dundee and Medical School, Ninewells Hospital, Dundee, Scotland, United Kingdom
Department of Medicine, University of Dundee and Medical School, Ninewells Hospital, Dundee, Scotland, United Kingdom
Department of Surgery, University of Dundee and Medical School, Ninewells Hospital, Dundee, Scotland, United Kingdom
Cardiovascular Epidemiology Unit, University of Dundee and Medical School, Ninewells Hospital, Dundee, Scotland, United Kingdom
^|| Department of Public Health Medicine, University College, Dublin, Ireland

Manuscript received May 8, 2001; revised manuscript received September 21, 2001, accepted October 19, 2001.

^* Reprint requests and correspondence: Prof. Allan D. Struthers, Department of Clinical Pharmacology, Ninewells Hospital, Dundee, Scotland DD1 9SY, United Kingdom.
a.d.struthers{at}dundee.ac.uk

OBJECTIVES: We sought to determine the prevalence of treatable left ventricular (LV) systolic dysfunction (LVSD) in patients who present with their first noncardiac vascular episode.

BACKGROUND: Screening for LV dysfunction in patients who present with their first stroke (cerebrovascular accident), their first transient ischemic attack (TIA) or their first manifestation of peripheral vascular disease (PVD) may represent a golden opportunity to identify treatable LV dysfunction, and so their known high incidence of sudden cardiac death may be reduced.

METHODS: Participating in this study were 522 (75%) of 700 consecutive patients (302 patients with stroke, TIA or PVD and 220 age- and gender-matched control subjects). Each underwent a full clinical assessment, 12-lead electrocardiography and two-dimensional echocardiography. Left ventricular dysfunction was defined as LV ejection fraction 40%.

RESULTS: Seventy-two (28%) patients with vascular disease and 11 (5.5%) control subjects were found to have LVSD. Twenty-six (28%) stroke patients, 22 (26%) patients with TIA and 24 (31%) patients with PVD had LVSD. Left ventricular systolic dysfunction was symptomatic in 44% of patients and in 35% of control subjects.

CONCLUSIONS: Left ventricular systolic dysfunction is five times more common among patients with stroke, TIA and PVD than among age- and gender-matched control subjects. Asymptomatic LVSD is more common than symptomatic LVSD in these patients. These findings suggest that routine screening of all patients with noncardiac vascular episodes for LVSD should now be considered. Future studies should investigate whether identifying and treating LVSD in these patients would reduce their known high rate of cardiac death.

Abbreviations and Acronyms   ACE   angiotensin-converting enzyme   CI   confidence interval   ECG   electrocardiogram   HOPE   Heart Outcomes Prevention Evaluation study   ICD   implantable cardioverter-defibrillator   IHD   ischemic heart disease   LV   left ventricular   LVEF   left ventricular ejection fraction   LVSD   left ventricular systolic dysfunction   MI   myocardial infarction   PVD   peripheral vascular disease   TIA   transient ischemic attack

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