Long-term efficacy of implantable cardiac resynchronization therapy plus defibrillator for primary prevention of sudden cardiac death in patients with mild heart failure: an updated meta-analysis

Previous studies of implantable cardiac resynchronization therapy plus defibrillator (CRT-D) therapy used for primary prevention of sudden cardiac death have suggested that CRT-D therapy is less effective in patients with mild heart failure and a wide QRS complex. However, the long-term benefits are variable. We performed a meta-analysis of randomized trials identified in systematic searches of MEDLINE, EMBASE, and the Cochrane Database. Three studies (3858 patients) with a mean follow-up of 66 months were included. Overall, CRT-D therapy was associated with significantly lower all-cause mortality than was implantable cardioverter defibrillator (ICD) therapy (OR, 0.78; 95 % CI, 0.63–0.96; P = 0.02; I ² = 19 %). However, the risk of cardiac mortality was comparable between two groups (OR, 0.74; 95 % CI, 0.53–1.01; P = 0.06). CRT-D treatment was associated with a significantly lower risk of hospitalization for heart failure (OR, 0.67; 95 % CI, 0.50–0.89; P = 0.005; I ² = 55 %). The composite outcome of all-cause mortality and hospitalization for heart failure was also markedly lower with CRT-D therapy than with ICD treatment alone (OR, 0.67; 95 % CI, 0.57–0.77; P < 0.0001; I ² = 0 %). CRT-D therapy decreased the long-term risk of mortality and heart failure events in patients with mild heart failure with a wide QRS complex. However, long-term risk of cardiac mortality was similar between two groups. More randomized studies are needed to confirm these findings, especially in patients with NYHA class I heart failure or patients without LBBB.     

Smoking and physical inactivity patterns during midlife as predictors of all-cause mortality and disability: a 39-year prospective study

This study estimated the long-term mortality hazards and disability risks associated with various combinations of smoking and physical inactivity measured over time in a sample of middle-aged adults. Data have been collected from a national sample of Swedish adults, originally interviewed in 1968 and followed until 2007 (N = 1,682). Smoking and physical activity status were measured at baseline and 13 years later (1981). Different patterns of change and stability in smoking and physical inactivity over this 13 year period were used as predictors of mortality through 2007. Also, associations between different patterns of these health behaviors and the odds of disability (measured in 2004) were estimated among survivors (n = 925). Results suggest that mortality rates were elevated among persistent (HR = 1.7; 95 % CI = 1.5–2.0) and new smokers (HR = 2.5; 95 % CI = 1.6–4.1), but not among discontinued smokers. However, mortality rates remained elevated among discontinued smokers who were also persistently inactive (HR = 1.9; 95 % CI = 1.3–2.6). Additional findings suggest that persistent physical inactivity during midlife was associated with increased odds of late life disability (OR = 1.8; 95 % CI = 1.1–2.7), but that smoking had no clear additive or multiplicative effects on disability. As such, these findings indicate that while persistent smoking during midlife primarily impacts subsequent mortality, persistent physical inactivity during midlife appears to counteract the survival benefits of smoking cessation, while also imposing a long-term risk on late life disability among those who do survive to old age.     

Smoking and the risk of systemic lupus erythematosus

This study aims to study the association of smoking with the development of systemic lupus erythematosus (SLE). The study included 223 SLE patients (92 % women, mean age 47 years) and 1,538 population controls of similar age and socioeconomic status living in the metropolitan area of Finland. The history of smoking in patients and controls was obtained by personal interview. The prevalence of current and past smoking was more common in patients with SLE than in controls. In women with a history of daily smoking for more than 1 year, the odds ratio (OR) for SLE was 1.45 (95 % CI 1.07–1.97), in current daily smokers as compared to never smokers, the OR was 1.55 (1.00–2.40), and in ex-smokers versus never smokers 1.80 (1.15–2.83). The number of men with SLE, who had smoked more than 100 cigarettes during their lifetime was higher than in male controls (p?=?0.026). A history of smoking is significantly though modestly associated with the development of SLE.     

Influence of diabetes on cardiac resynchronization therapy with or without defibrillator in patients with advanced heart failure

ObjectivesWe performed a post hoc analysis to determine the influence of cardiac resynchronization therapy with a defibrillator (CRT-D) or without a defibrillator (CRT-P) on outcomes among diabetic patients with advanced heart failure (HF).BackgroundIn patients with systolic HF, diabetes is an independent predictor of morbidity and mortality. No data are available on its impact on CRT-D or CRT-P in advanced HF.MethodsThe database of the Comparison of Medical Therapy, Pacing and Defibrillation in Heart Failure trial was examined to determine the influence of CRT (CRT-D and CRT-P) on outcomes among diabetic patients. All-cause mortality or hospitalization, all-cause mortality or cardiovascular hospitalization, all-cause mortality or HF hospitalization, and all-cause mortality were analyzed among diabetic patients (n = 622). A Cox proportional hazard model, adjusting for age, gender, New York Heart Association, ischemic status, body mass index, left ventricular ejection fraction, heart rate, QRS, left or right bundle branch block, blood pressure, comorbidities (renal failure, carotid artery disease, peripheral vascular disease, hypertension, coronary artery bypass grafting, and atrial fibrillation), medications, and device (with or without defibrillator), was used to estimate hazard ratios (HRs) and significance.ResultsThe overall outcome of diabetic patients was similar to that of nondiabetic patients in the optimal pharmacologic therapy arm. With CRT, diabetic patients experienced a substantial reduction in all-cause mortality or all-cause hospitalization (HR = 0.77, 95% confidence interval [CI] 62–0.97), all-cause mortality or cardiovascular hospitalization (HR = 0.67, 95% CI 0.53–0.85), all-cause mortality or HF hospitalization (HR = 0.52, 95% CI 0.40–0.69), and all-cause mortality (HR = 0.67, 95% CI 0.45–0.99) compared with optimal pharmacologic therapy. Procedure-related complications and length of stay were identical in diabetic and nondiabetic patients.ConclusionIn diabetic patients with advanced HF, there is a substantial benefit from device therapy with significant improvement in all end points.     

Obesity is associated with lower mortality risk in elderly diabetic subjects: the Casale Monferrato study

The relationship between obesity and mortality in people with type 2 diabetes has not been definitely assessed. We have examined this issue in a well-characterized population-based cohort of Mediterranean diabetic people. Standardized anthropometric data from the population-based Casale Monferrato Study have been prospectively analyzed. The cohort included 1,475 people (62.6% aged ≥65 years) who had been recruited in 1991 and followed-up to December 31, 2006. Cox proportional hazards modeling was employed to estimate the independent associations between all-cause and cardiovascular mortality and BMI. Out of 1,475 people, 972 deaths occurred during a 15-year follow-up. Cox regression analyses showed that with respect to BMI <24.2 kg/m², values of 30.0 kg/m² and over were associated with lower all-cause and cardiovascular mortality risk (HR = 0.68, 95% CI 0.56–0.85, P for trend = 0.001; HR = 0.59, 0.44–0.80, P for trend = 0.002), independently of classical and new risk factors. As interaction between age and BMI was significant, we performed a stratified analysis by age, providing evidence that our finding was entirely due to a significant protective effect of BMI of 30.0 kg/m² and over in the elderly (all-cause mortality HR = 0.75, 95% CI 0.58–0.96; cardiovascular mortality HR = 0.67, 95% CI 0.45–0.95). In contrast, obesity was not significantly associated with mortality risk in diabetic subjects aged <65 years. Results were confirmed even excluding from the analysis individuals who died within 2 years of follow-up, smokers and those with CHD. In Mediterranean diabetic people aged ≥65 years, obesity is significantly associated with lower 15-year mortality risk. In contrast, it was not significantly associated with mortality risk in diabetic subjects aged <65 years. As more than two-thirds of people with type 2 diabetes are elderly, our findings, if confirmed, could have clinical implications.     

Effect of smoking status on coronary artery disease among Chinese post-menopausal women

Smoking is a prominent risk factor of cardiovascular diseases. The occurrence of myocardial infarction and mortality in smokers with cardiovascular diseases is several times higher than that in non-smokers. Smoking is associated with gender-independent enhanced mortality. We determined the effect of smoking status on coronary artery disease (CAD) and coronary computed tomography angiography (CCTA) in Chinese post-menopausal women. Among these patients, those with significant CAD (≥50 % luminal narrowing) were further classified into one-, two-, or three-vessel disease according to CCTA results. The following events were recorded: all-cause mortality, non-fatal infarction and unstable angina. 2332 patients evaluated with CCTA included 1668 never smokers (71.5 %), 475 former smokers (20.4 %), and 189 current smokers (8.1 %). The current smokers exhibit greater luminal narrowing as observed on CCTA (p < 0.001) than the other subjects. During the median 685 ± 269.8 days follow-up period, never-smoking women have a low incidence of events, whereas former and current smokers are associated with an increased incidence of such event (p < 0.001). Furthermore, current smoking and the presence of multiple-vessel disease on CCTA are independently associated with the events in the logistic regression analysis. Smoking status is related to significant CAD and luminal narrowing on CCTA in the Chinese post-menopausal smoking women. In addition, current smoking and the presence of multiple-vessel disease on CCTA can independently predict events of all-cause mortality, non-fatal infarction or unstable angina.     

De novo implantation vs. upgrade cardiac resynchronization therapy: a systematic review and meta-analysis

Patients with conventional pacemakers or implanted defibrillators are often considered for cardiac resynchronization therapy (CRT). Our aim was to summarize the available evidences regarding the clinical benefits of upgrade procedures. A systematic literature search was performed from studies published between 2006 and 2017 in order to compare the outcome of CRT upgrade vs. de novo implantations. Outcome data on all-cause mortality, heart failure events, New York Heart Association (NYHA) Class, QRS narrowing and echocardiographic parameters were analysed. A total of 16 reports were analysed comprising 489,568 CRT recipients, of whom 468,205 patients underwent de novo and 21,363 upgrade procedures. All-cause mortality was similar after CRT upgrade compared to de novo implantations (RR 1.19, 95% CI 0.88–1.60, p = 0.27). The risk of heart failure was also similar in both groups (RR 0.96, 95% CI 0.70–1.32, p = 0.81). There was no significant difference in clinical response after CRT upgrade compared to de novo implantations in terms of improvement in left ventricular ejection fraction (ΔEF de novo ? 6.85% vs. upgrade ? 9.35%; p = 0.235), NYHA class (ΔNYHA de novo ? 0.74 vs. upgrade ? 0.70; p = 0.737) and QRS narrowing (ΔQRS de novo ? 9.6 ms vs. upgrade ? 29.5 ms; p = 0.485). Our systematic review and meta-analysis of currently available studies reports that CRT upgrade is associated with similar risk for all-cause mortality compared to de novo resynchronization therapy. Benefits on reverse remodelling and functional capacity improved similarly in both groups suggesting that CRT upgrade may be safely and effectively offered in routine practice. Clinical Trial Registration: Prospero Database—CRD42016043747     

Impact of oral beta-blocker therapy on mortality after primary percutaneous coronary intervention for Killip class 1 myocardial infarction

The use of beta-blockers therapy has been recommended to reduce mortality in patients with left ventricular dysfunction after acute myocardial infarction (AMI). Primary percutaneous coronary intervention (PCI), which has become the mainstay of treatment for AMI, is associated with a lower mortality than fibrinolysis. The benefits of beta-blockers after primary PCI in AMI patients without pump failure are unclear. We hypothesized that oral beta-blocker therapy after primary PCI might reduce the mortality in AMI patients without pump failure. The assessment of lipophilic vs. hydrophilic statin therapy in acute myocardial infarction (ALPS-AMI) study was a multi-center study that enrolled 508 AMI patients to compare the efficacy of hydrophilic and lipophilic statins in secondary prevention after myocardial infarction. We prospectively tracked cardiovascular events for 3 years in 444 ALPS-AMI patients (median age 66 years; 18.2 % women) who had Killip class 1 on admission and were discharged alive. The primary endpoint was all-cause mortality. The 3-year follow-up was completed in 413 patients (93.0 %). During this follow-up, 21 patients (4.7 %) died. In Kaplan–Meier analysis, patients on beta-blockers had a significantly lower incidence of all-cause mortality (2.7 vs. 7.3 %, log-rank p = 0.025). After adjusting for the calculated propensity score for using beta-blockers, their use remained an independent predictor of all-cause mortality (hazard ratio 0.309; 95 % confidence interval 0.116–0.824; p = 0.019). In the statin era, the use of beta-blocker therapy after primary PCI is associated with lower mortality in AMI patients with Killip class 1 on admission.     

Patients with left ventricular ejection fraction greater than 58 % have fewer incidences of future acute decompensated heart failure admission and all-cause mortality

Based on our previous observation, inertia stress (IS) of late systolic aortic flow was often observed in left ventricles with relatively higher left ventricular (LV) ejection fraction (EF). Most left ventricles with relatively lower LVEF did not have IS. Accordingly, lack of IS may correlate with LV diastolic dysfunction through the loss of LV elastic recoil and may contribute to the pathogenesis of heart failure (HF) and reduced survival. We enrolled 144 consecutive patients that underwent cardiac catheterization for the diagnosis of coronary artery disease. Left ventricular ejection fraction (LVEF) was obtained from left ventriculography. The IS was calculated from the LV pressure (P)?dP/dt relation. The study endpoint of this retrospective outcome-observational study was combined subsequent acute decompensated heart failure (ADHF) and all-cause mortality. During the follow-up period (median 6.1 years), seven unscheduled hospitalizations for ADHF and nine all-cause deaths were observed. The event-free survival rate was significantly higher among patients with IS than among patients without IS (log-rank, p = 0.001). On a multivariate Cox regression analysis, lack of IS was a prime predictor of the endpoint during follow-up (hazard ratio: 6.98; 95 % confidence interval: 1.48–33.03; p = 0.01). An LVEF ≥ 58 % was a surrogate indicator for the presence of IS, and patients with LVEF ≥ 58 % had fewer incidences of the endpoint than patients with LVEF < 58 %. In conclusion, lack of IS or LVEF < 58 % should be a predictor of future ADHF and all-cause mortality.     

Platelet-lymphocyte ratio (PLR) and all-cause mortality in general population: insights from national health and nutrition education survey

Platelet lymphocyte ratio (PLR) is a novel marker of inflammation that has gained popularity, especially in prognostication of cardiac diseases and malignant conditions. Several studies have examined the relationship between PLR and disease-specific mortality but none has examined this relationship with all-cause mortality in general population. Therefore, we examined the relationship between PLR and all-cause mortality using data from the National Health and Nutrition Examination Survey (NHANES) from the year 1999 to 2010. The role of PLR in predicting all-cause mortality was evaluated using Cox proportional hazards model adjusting for age, race, gender, smoking history, diabetes, hypertension, serum cholesterol, estimated glomerular filtration rate, serum c-reactive protein, and body mass index. Differential effect of age was examined using difference of differences analysis. Of the 27321 individuals, 2581 died during 171223 person-year follow-up. Mean PLR was significantly higher in participants who died than those who were living at the end of follow-up (145.7 vs. 133.0, respectively, p < 0.001). Individuals in the fourth quartile of PLR were at significantly higher risk of mortality than those in the first quartile (HR = 1.26, 95% CI: 1.08–1.47, p = 0.004 and adjusted HR = 1.33, HR, 95% CI: 1.15–1.54, p < 0.001, respectively). When examining the differential effect of age, association between PLR and mortality was seen in the elderly but not in the middle age or younger participants. Elevated PLR is associated with increased all-cause mortality, especially in the elderly. Further studies examining the mechanism through which PLR may increase mortality are needed.     

Soluble ST2 and Risk of Arrhythmias,Heart Failure,or Death in Patients with Mildly Symptomatic Heart Failure: Results from MADIT-CRT

Soluble ST2 is an established biomarker of heart failure (HF) progression. Data about its prognostic implications in patients with mildly symptomatic HF eligible to receive cardiac resynchronization therapy defibrillators (CRT-D) are limited. In a cohort of 684 patients enrolled in Multicenter Automated Defibrillator Implantation Trial (MADIT)-CRT, levels of soluble ST2 (sST2) were serially assessed at baseline and 1 year (n?=?410). In multivariable-adjusted models, elevated baseline sST2 was associated with an increased risk of death, death or HF, and death or ventricular arrhythmia (VA) even when adjusting for baseline brain natriuretic protein (BNP) levels. In addition, patients with lower baseline sST2 levels had greater risk reduction with CRT-D (p?=?0.006). Serial assessment revealed increased risk of VA and death or VA (HR per 10 % increase in sST2 1.11 (1.04–1.20), p?=?0.004). Among patients with mildly symptomatic HF and eligibility for CRT-D, baseline and serial assessments sST2 may provide important information for risk stratification.     

Paced QRS duration and myocardial scar amount: predictors of long-term outcome of right ventricular apical pacing

Long-term right ventricular apical pacing (RVAP) is reportedly associated with heart failure (HF) development. However, the predictors of pacing-induced HF (PHF) remained unclear. We retrospectively enrolled 234 patients without structural heart disease who underwent a permanent pacemaker implantation with RVAP between 1982 and 2004. RVAP-induced HF was defined as left ventricular ejection fraction decrease >5 % with HF symptom without other HF development etiology. The QRS duration of a paced beat (pQRSd) and myocardial scar score were analyzed from each patient’s 12-lead ECG. During a mean 15.6 years (range 3.3–30.0 years), 48 patients (20.5 %) patients developed RVAP-induced HF. The PHF group patients had a longer pQRSd (192.4 ± 13.5 vs. 175.7 ± 14.7 ms in non-PHF patients, p < 0.001) and a higher myocardial scar score (5.2 ± 1.9 vs. 2.7 ± 1.9, respectively p < 0.001). In multivariate Cox regression analysis, old age at implantation [Hazard ratio (HR) 1.62, 95 % confidential interval (CI) 1.22–2.16, p = 0.001], a longer pQRSd (HR 1.54, 95 % CI 1.15–2.05, p = 0.003), a higher myocardial scar score (HR 1.23, 95 % CI 1.03–1.49, p = 0.037), and a higher percentage of ventricular pacing (HR 1.31, 95 % CI 1.01–1.49, p = 0.010) were independent predictors of PHF. Based on the results of the receiver-operating characteristic (ROC) curve, the pQRSd cutoff was 185 ms (AUC 0.79, sensitivity 66.7 %, specificity 76.3 %) and myocardial scar score cutoff value was 4 (AUC 0.81, sensitivity 81.3 %, specificity 66.1 %). The pQRSd was positively correlated with scar score (r = 0.70, p < 0.001). pQRSd ≥185 ms and/or myocardial scar score ≥4 might be independent long-term prognostic markers of PHF.     

The Effect of Weight Loss on Clinical Outcomes in Patients Implanted With a Cardiac Resynchronization Therapy Device—A MADIT-CRT Substudy

BackgroundThere are no data regarding the effect of weight loss on clinical outcomes in patients undergoing cardiac resynchronization therapy. This study was designed to evaluate the effect of weight loss on clinical outcomes in patients implanted with a cardiac resynchronization therapy with defibrillator (CRT-D).Methods and ResultsThe risk of heart failure (HF) or death, and of death alone, was compared between patients with and without weight loss of ≥2 kg or more at 1 year in the CRT-D arm of the Multicenter Automatic Defibrillator Implantation Trial–Cardiac Resynchronization Therapy (MADIT-CRT). Weight loss was observed in 170 of 994 patients (17%) implanted with a CRT-D. Multivariate analysis showed a significant increase in the risk of HF or death among patients with weight loss compared with those without weight loss (hazard ratio [HR] 1.82, 95% confidence interval [CI] 1.26–2.63; P = .001). Weight loss was associated with a 79% increase in the risk of all-cause mortality (HR 1.79, 95% CI 1.16–3.34; P = .01). When analyzed in a continuous fashion, each kg of weight loss was associated with a 4% increase in the risk of HF or death (P = .03). In left bundle branch block (LBBB) patients with a CRT-D, weight loss was associated with an especially high risk of HF or death (HR 2.23, 95% CI 1.36–3.65; P = .002) and of death alone (HR 2.33, 95% CI 1.07–5.06; P = .03; interaction P = .26).ConclusionsIn patients with mild symptoms of HF receiving CRT-D, weight loss observed at 1 year is associated with adverse clinical outcomes, especially in those with a LBBB electrocardiographic pattern.     

Pneumonia After Endoscopic Resection for Gastric Neoplasm

Background

Pneumonia following endoscopic procedures may affect the clinical course and prolong hospital stay.

Aim

To investigate the incidence and risk factors for pneumonia after endoscopic resection (ER) for gastric neoplasm.

Methods

Subjects who underwent ER for gastric neoplasm at the Asan Medical Center from January 1997 to March 2013 were included. To investigate risk factors, control patients were randomly selected from these subjects.

Results

Of the 7,149 subjects who underwent ER for gastric neoplasm, 44 (0.62 %) developed pneumonia. The median age of these 44 patients was 68 years (range 31–82 years), and the male to female ratio was 3:1. Twenty-five of the pneumonia patients (56.8 %) were smokers, and 8 (18.2 %) had underlying pulmonary diseases. The median procedure time was 23 min (range 2–126 min), and pathologic diagnoses included adenocarcinoma (n = 29), dysplasia (n = 10), and hyperplastic polyp (n = 5). Compared with the control group, smoking (current smoker vs. never smoker, odds ratio [OR] 2.366, p = 0.021), total procedure time (OR 1.011, p = 0.048), and hemostasis time (OR 1.026, p = 0.028) were risk factors for the development of pneumonia. In multivariate analysis, age >65 years (OR 2.073, p = 0.031), smoking (current smoker vs. never smoker, OR 2.324, p = 0.023), and hemostasis time (OR 1.025, p = 0.038) were independent risk factors. All patients recovered from pneumonia, and the duration of hospital stay did not differ between patients with pneumonia and the control group (p = 0.077).

Conclusions

Whereas old age, smoking, and longer hemostasis time are risk factors for pneumonia, its incidence after ER is not associated with clinically significant adverse outcomes.     

Effects of cigarette smoking on older chinese men treated with clopidogrel monotherapy or aspirin monotherapy: a prospective study

Abstract

We investigated the comparative effects of smoking status on outcomes in older Chinese men receiving aspirin or clopidogrel monotherapy. This was a prospective observational study of outcomes in 668 men aged ≥ 60 years undergoing annual health examination in the Chinese People’s Liberation Army General Hospital from March–April 2017. All patients received regular treatment with aspirin or clopidogrel. Platelet aggregation and phenotyping for rs762551 were measured in all patients. We recorded all major adverse cardiovascular and cerebrovascular events; namely, all-cause death, myocardial infarction, stroke, transient ischemic attack, and unstable angina. In the clopidogrel subgroup, homozygous carriers (AA) of the CYP1A2*1F gene (rs762551, 163C>A) appeared more frequently in smokers than in nonsmokers (45.6% vs 32.7%, p = .035). Adenosine diphosphate-induced platelet aggregation using light transmittance aggregometry was lower in smokers compared with nonsmokers (44.97 ± 20.05% vs 51.98 ± 19.38%, respectively; p = .0018). Smokers (n = 103) had a decreased risk of major adverse cardiovascular and cerebrovascular events, compared with nonsmokers [n = 159; hazard ratio, 0.466; 95% confidence interval: 0.262–0.829, p = .008]. In the aspirin subgroup, AA-induced platelet aggregation showed no significant difference regarding smoking vs nonsmoking status (30.90 ± 32.21 vs 29.78 ± 31.47, respectively; p = .771). However, we saw a significant increase in adverse clinical events in the smoking group (n = 148) compared with the nonsmoking group (n = 258; hazard ratio = 1.907, 95% confidence interval: 1.128–3.225; p = .016). In older Chinese men, active smokers benefitted from clopidogrel therapy compared with aspirin. Long-term cigarette smoking may contribute to increased variations in CYP1A2*1F, but the variations do not fully explain the smoking paradox.     

At least partial hematological response after first cycle of treatment predicts organ response and long-term survival for patients with AL amyloidosis receiving bortezomib-based treatment

AL amyloidosis is a rare plasma cell dyscrasia characterized by multi-organ involvement and poor prognosis. We retrospectively evaluated the organ response (OR) and long-term survival of newly diagnosed AL amyloidosis patients who received first-line bortezomib-containing induction therapy, aiming to identify the clinical indication of a 50% reduction in the difference between involved and uninvolved free light chains (dFLC) after first cycle of treatment. Among the 89 patients included, 78.7% had cardiac involvement and 42.7% were diagnosed with 2004 Mayo stage III disease, while 75.3% of patients achieved a hematological response, including 37.1% with complete response and a median response time of 1 month. Cardiac and renal responses were observed in 44.3 and 53.1% of patients, respectively. Sixty-one (68.5%) patients achieved at least 50% reduction in dFLC after the first cycle of therapy. After a median follow-up duration of 12 months, the estimated 3-year progression-free survival (PFS) and overall survival (OS) rates were 61.3 and 61.7% respectively. At least 50% reduction in dFLC after the first cycle of therapy was predictive of achieving an OR (p = 0.002), as well as superior PFS (HR = 0.119; 95% CI = 0.045–0.313; p < 0.001) and OS (HR = 0.206; 95% CI = 0.078–0.541; p = 0.001). Additionally, the median PFS and OS were not reached for patients with rapid reduction of dFLC. These results demonstrated that early reduction of dFLC after the first cycle of treatment is predictive of achieving an OR and long-term survival in AL patients receiving bortezomib.     

Cardiovascular medicine heart failure (CVM-HF) index as prognostic model for candidates to MitraClip therapy

Transcatheter MitraClip repair is a new tool for the management of severe mitral regurgitation in patients at very high risk for conventional surgery. Aim of our study was reporting one-year clinical outcomes in candidates to MitraClip procedures, divided into three groups according to the cardiovascular medicine heart failure (CVM-HF) index. The study population consists of 46 consecutive patients, divided, in accordance with CVM-HF index, as follows: one patient in the low-risk category (group A); 27 patients in the medium-risk (group B) and 18 patients in high-risk category (group C). The primary study endpoint was a combined of all-cause mortality and re-hospitalization rate. Secondary endpoints were all-cause mortality and cardiac mortality. Patients of group B and group C were compared. Regarding the primary endpoint, patients in group C had significantly poorer outcomes than patients in group B, with a 12-month survival freedom from events of 44.4  and 74.1 %, respectively (log-rank test, p = 0.039); survival freedom from cardiac mortality was 100 and 83.3 % in group B and C, respectively (log-rank test, p = 0.027). One-year survival free from re-hospitalization was 74.1 % in group B and 39.9 % in group C (log-rank test; p = 0.036). Survival free from all-cause of mortality was 92.6 and 77.8 %, respectively (log-rank test; p = 0.129). In our initial experience the CVM-HF index showed to be valuable for understanding if the patient with advanced heart failure and functional mitral regurgitation can really benefit by MitraClip therapy.     

Chronic obstructive pulmonary disease: an emerging comorbidity in HIV-infected patients in the HAART era?

Purpose

The objective of our study was to evaluate the presence of respiratory symptoms and chronic obstructive pulmonary disease (COPD) in a human immunodeficiency virus (HIV)-infected outpatient population and to further investigate the role of highly active antiretroviral therapy (HAART) and other possibly associated risk factors.

Methods

We consecutively enrolled in a cross-sectional study HIV-infected patients and HIV-negative age, sex and smoking status matched controls. All participants completed a questionnaire for pulmonary symptoms and underwent a complete spirometry.

Results

We enrolled 111 HIV-infected patients and 65 HIV-negative age- and sex-matched controls. HIV-infected patients had a significantly higher prevalence of any respiratory symptom (p = 0.002), cough (p = 0.006) and dyspnoea (p = 0.02). HIV-infected patients also had a significantly higher prevalence of COPD in respect of HIV-negative controls (p = 0.008). Furthermore, HIV-infected individuals had significantly (p = 0.002) lower forced expiratory volume at one second (FEV1) and FEV1/forced vital capacity (FVC) ratio (Tiffeneau index) (p = 0.028), whereas the total lung capacity (TLC) was significantly higher (p = 0.018). In the multivariate analysis, significant predictors of respiratory symptoms were current smoking [adjusted odds ratio (AOR) 11.18; 95 % confidence interval (CI) 3.89–32.12] and previous bacterial pneumonia (AOR 4.41; 95 % CI 1.13–17.13), whereas the only significant predictor of COPD was current smoking (AOR 5.94; 95 % CI 1.77–19.96). HAART receipt was not associated with respiratory symptoms nor with COPD.

Conclusions

We evidenced a high prevalence of respiratory symptoms and COPD among HIV-infected patients. HIV infection, current cigarette smoking and previous bacterial pneumonia seem to play a significant role in the development of respiratory symptoms and COPD. Thus, our results suggest that the most at-risk HIV-infected patients should be screened for COPD to early identify those who may need specific treatment.     

Lower extremity muscular strength,sedentary behavior,and mortality

To examine whether lower extremity strength (LES) is predictive of all-cause mortality, independent of physical activity and among those with vary levels of sedentary behavior. Data from the 1999–2002 National Health and Nutrition Examination Survey was used (N = 2768; 50–85 years). Peak isokinetic knee extensor strength was objectively measured, sedentary behavior and physical activity were self-reported, and mortality was assessed via the National Death Index, with follow-up through 2011. Participants were followed for up to 12.6 years with the weighted average follow-up period lasting 9.9 years (standard error, 1.13). In the sample, 321,996 person-months occurred with a mortality rate of 2.1 deaths per 1000 person-months. After adjustments (including physical activity), for every 15 N increase in LES, participants had a 7 % reduced risk of all-cause mortality (HR = 0.93; 95 % CI 0.91–0.95; P < 0.001). When adding a three-level sedentary behavior variable (< 2, 2–4, 5+ h/day) as a covariate in this model, results were unchanged (HR = 0.93; 95 % CI 0.92–0.96; P < 0.001). Similarly, when sedentary behavior was included as a continuous covariate in the model, results regarding the relationship between LES and mortality were unchanged (HR = 0.94; 95 % CI 0.91–0.96; P < 0.001). There was no evidence of statistical interaction between LES and sedentary behavior on all-cause mortality (HR_interaction = 1.01; 95 % CI 0.92–1.10; P = 0.88). LES was inversely associated with all-cause mortality, and this association was unchanged when considering the participant’s sedentary behavior.