Heart Rate Turbulence as a Predictor of Cardiac Mortality and Arrhythmic Events in Patients with Dilated Cardiomyopathy: A Prospective Study

Background: Few studies have described the clinical usefulness of heart rate turbulence (HRT), an autonomic predictor of mortality, in stratifying patients with dilated cardiomyopathy (DCM) at risk of cardiac mortality and arrhythmic events. We prospectively assessed the utility of HRT for risk stratification in patients with ischemic or nonischemic DCM.
Methods: We enrolled 375 consecutive patients with DCM including ischemic (n = 241) and nonischemic causes (n = 134). HRT was measured using an algorithm based on routine 24-hour Holter electrocardiograms, assessing 2 parameters: turbulence onset (TO) and turbulence slope (TS). HRT was considered positive when both TO was ≥0% and TS was ≤ 2.5 ms/R-R interval. The primary endpoint was defined as cardiac mortality and the secondary endpoint as occurrence of hemodynamically stable sustained ventricular tachyarrhythmias.
Results: Of patients enrolled, 83 patients (22.1%) were not utilized for HRT assessment because there were too few ventricular premature beats, or for other reasons. Eighty-one of 292 patients (27.7%) were HRT-positive. During follow-up of 445 ± 216 days, 30 patients (10.3%) reached the primary endpoint and 17 patients, the secondary endpoint. The hazard ratio (HR) of patients with an HRT-positive outcome was 6.4 (95%CI, 3.0–14.1; P < 0.0001) for the primary endpoint and 5.1 (95%CI, 2.8–9.3; P < 0.0001) for combined endpoints. On subanalysis, HRT positivity was significantly associated in both the ischemic and nonischemic DCM patients with both the primary endpoint (HR = 4.9, P = 0.0006 and HR = 12.3, P = 0.002, respectively) and with combined endpoints.
Conclusions: HRT is a powerful risk stratification marker for cardiac mortality and arrhythmic events in patients with DCM whether ischemia is present or not.     

Rate Versus Rhythm Control in Heart Failure Patients with Post-Operative Atrial Fibrillation After Cardiac Surgery

BackgroundWhether rhythm control for post-operative atrial fibrillation after cardiac surgery (POAF) is superior to rate control in patients with heart failure or systolic dysfunction (HF) is not known.MethodsWe performed a post-hoc analysis of a trial by the Cardiothoracic Surgical Trials Network, which randomized patients with POAF after cardiac surgery to rate control or rhythm control with amiodarone/cardioversion. We assessed subgroups of trial participants defined by heart failure/cardiomyopathy history or left ventricular ejection fraction (LVEF) < 50%. We conducted a stratified analysis in patients with and without HF to explore outcomes of rhythm versus rate control strategy.ResultsOf 523 subjects with POAF after cardiac surgery, 131 (25%) had HF. 49% of HF patients were randomized to rhythm control. In HF patients, rhythm control was associated with less atrial fibrillation within the first 7 days. There were no differences in rhythm at 30- and 60-day follow-up. In the HF group, there were significantly more subjects with AF < 48 hours in the rhythm control group compared to rate control group- 68.8% compared to 46.3%, P=0.009. By comparison, in the non-HF stratum, 54.4% of the rate control group had AF < 48 hours compared to 63.5% of the rhythm control group (P=0.067).), though there was no significant interaction of heart failure with cardiac rhythm at 7 days (Pinteraction 0.16).ConclusionRhythm control for HF patients with POAF after cardiac surgery increases early restoration of sinus rhythm. Rate and rhythm control are both reasonable for HF patients with AF after cardiac surgery     

Admission Hypoglycemia and Increased Mortality in Patients Hospitalized with Pneumonia

Background

The relationship between spontaneous admission hypoglycemia and mortality in patients hospitalized with community-acquired pneumonia is unclear.

Methods

From 2000 to 2002, clinical data were prospectively collected on all patients with community-acquired pneumonia who were admitted to all 6 hospitals in Edmonton, Alberta, Canada. Patients with admission glucose greater than 6.1 mmol/L (n = 1996) were excluded; the remaining patients were categorized as having admission hypoglycemia (<4.0 mmol/L [n = 54]) or normoglycemia (4.0 to ≤ 6.1 mmol/L [n = 902]). Multivariable Cox proportional hazards models were used to examine the relationship between hypoglycemia and all-cause mortality in-hospital, at 30 days, and at 1 year.

Results

The mean age was 65 (standard deviation = 20) years, 48% were female, 8% had diabetes, and 56% had severe pneumonia. Overall, admission hypoglycemia was present in 2% (54/2990) of the entire cohort and 6% of those with glucose of 6.1 mmol/L or less. Total deaths were 89 (9%) in-hospital, 96 (10%) at 30 days, and 247 (26%) at 1 year. In-hospital mortality was higher among patients with admission hypoglycemia (11 [20%] deaths) compared with those with normoglycemia (78 [9%]; adjusted hazards ratio [aHR] 2.96; 95% confidence interval [CI], 1.39-6.31; P = .005). An increased risk of mortality was observed at 30 days (11 [20%] vs 85 [10%]; aHR 2.89; 95% CI, 1.32-6.29) and remained elevated at 1 year (19 [35%] vs 228 [25%]; aHR1.80; 95% CI, 1.02-3.17). These results were not influenced by treatment for diabetes (P > .4 for interaction).

Conclusion

In a population-based sample of patients with community-acquired pneumonia, spontaneous admission hypoglycemia was independently associated with increased mortality during hospitalization that persisted to 1 year. Patients with hypoglycemia are an easily identified group that may warrant more intensive inpatient and postdischarge follow-up.     

Exercise Testing Identifies Patients at Increased Risk for Morbidity and Mortality Following Fontan Surgery

Objective. The objective of this study was to examine the relationship between exercise test data and mortality in patients who have had the Fontan procedure. Design. The study was designed as a retrospective cohort study. Setting. The study was set in a tertiary care center. Patients. All study participants were Fontan patients ≥16 years old who had cardiopulmonary exercise tests at our institution between November 2002 and March 2010. The first exercise test with adequate effort during the study period was retained for analysis. We enrolled 146 patients at a median age of 21.5 years (16.0–51.6); 15.8 years (1.2–29.9) after Fontan surgery. Outcome Measures. The outcome measures were exercise test data (peak oxygen consumption, peak heart rate, etc.); mortality. Results. Peak oxygen consumption averaged 21.2 ± 6.2 mL/kg/min, 57.1 ± 14.1% predicted. Follow‐up data were collected 4.0 ± 2.0 years (range 0.3–7.7) after the exercise test. Sixteen patients (11%) died during follow‐up; their peak oxygen consumption (16.3 ± 4.0 mL/kg/min) was significantly less than the survivors' (21.8 ± 6.2 mL/kg/min; P < .0001). Recursive partitioning and Cox proportional hazards modeling revealed that the hazard for death for patients with a peak oxygen consumption of <16.6 mL/kg/min was 7.5 (95% confidence interval: 2.6, 21.6; P < .0002) times that of patients with a higher peak oxygen consumption. Similarly, the hazard ratio for patients with peak‐exercise heart rates of <122.5 bpm was 10.6 (3.0, 37.1; 0 < 0.0002). Data from exercise tests could also identify patients at increased risk for a combined morbidity/mortality end point. Conclusions. In adults with Fontan surgery, exercise test data can identify patients at increased risk of midterm morbidity and mortality.     

Fluvastatin Reduces Cardiac Mortality in Patients with Coronary Heart Disease

PURPOSE: To test the effectiveness of fluvastatin, 40-80 mg, in reducing the occurrence of cardiac and all-cause mortality in patients with coronary heart disease (CHD). METHODS: Meta-analysis of all clinical trials that assessed the effects of fluvastatin in CHD patients on major adverse cardiac events (MACE) as a prespecified endpoint was performed. A pooled analysis of four studies (n = 3525) was performed on an intent-to-treat basis. Clinical endpoints were the incidence, and time to first occurrence, of MACE (cardiac death, nonfatal MI, revascularization), noncardiac death, or all-cause death. Lipid parameters were also analyzed. RESULTS: Fluvastatin treatment significantly prolonged the time to cardiac death (p = 0.0174) and the time to cardiac death or nonfatal MI (p = 0.0055) compared with placebo. Fluvastatin significantly reduced the risk of any MACE (Cox risk ratio [RR], 0.85; 95% confidence interval [CI], 0.73-0.98), cardiac death (RR, 0.53; 95% CI, 0.31-0.90), cardiac death or MI (RR, 0.66; 95% CI, 0.49-0.89), all-cause death (RR, 0.65; 95% CI, 0.45-0.94) and all-cause death or MI (RR, 0.69; 95% CI, 0.53-0.90). Fluvastatin significantly lowered total cholesterol and low-density lipoprotein cholesterol levels and was well tolerated, with no cases of rhabdomyolysis in any of the studies assessed in the meta-analysis. CONCLUSIONS: This meta-analysis demonstrates clear beneficial effects of fluvastatin on cardiac and all-cause mortality in CHD patients, and supports the use of fluvastatin to reduce the incidence of MACE in a wide range of at-risk patients.     

Progression of Hyponatremia is Associated With Increased Cardiac Mortality in Patients Hospitalized for Acute Decompensated Heart Failure

BackgroundAlthough hyponatremia during hospitalization for acute decompensated heart failure (ADHF) has been reported to correlate with poor prognosis, few studies have examined the effect of progression of hyponatremia on cardiac prognosis in ADHF patients who were normonatremic at admission.Methods and ResultsConsecutive ADHF patients (n = 662) categorized as New York Heart Association Class III or IV were investigated retrospectively. Of these patients, 634 who survived to discharge were examined and 531 were normonatremic (serum sodium concentration [Na] ≥ 135 and ≤ 145 mmol/L) at admission. The 531 patients were divided into 2 groups: the non-developed group, who remained normonatremic at discharge (n = 455), and the developed group, who had progressed to hyponatremia (Na < 135 mmol/L) at discharge (n = 76). The cardiac event–free rate after 12 months was significantly lower in the developed group than in the non-developed group (22% vs. 71%; P < .0001). Although their baseline levels of brain natriuretic peptide and left ventricular ejection fraction were similar before discharge, the patients in the developed group exhibited higher fractional excretion of sodium and received higher doses of diuretics than did those in the non-developed group.ConclusionOur data suggest that progression to hyponatremia during hospitalization is a robust predictor of poor cardiac prognosis in ADHF patients who were normonatremic at admission.     

The Cytokine Expression in Patients with Cardiac Complication after Immune Checkpoint Inhibitor Therapy

We herein report the cytokine expression at different stages for three patients who developed cardiac complications after immune checkpoint inhibitor (ICI) therapy. Case 1 with biopsy-proven myocarditis showed increased levels of interleukin (IL)-8, monocyte chemotactic and activating factor, and granulocyte macrophage colony-stimulating factor (GM-CSF) when he developed Takotsubo cardiomyopathy. Case 2 with subclinical myocarditis showed predominant activation of IL-8 during the progressive clinical course. Case 3 with cytokine-releasing syndrome showed substantial activations of IL-6, IL-8, GM-CSF, and interferon-γ. Our data suggest the development of unique cytokine activation in individual patients with cardiac complications after ICI therapy.     

Cardiac Surgery in HIV Patients: State of the Art

The clinical status of HIV infection has changed dramatically with the introduction of combined antiretroviral therapy. Patients with HIV are now living long enough to be susceptible to chronic illnesses, such as coronary disease and nonischemic cardiomyopathy, which can be consequences of the combined antiretroviral therapy treatment itself. Cardiovascular diseases are a major source of morbidity and mortality in HIV-positive patients. Increasingly, such patients might be candidates for the full range of cardiac surgical interventions, including coronary bypass, valve surgery, and heart transplantation. There has been a shift from offering palliative procedures such as pericardial window and balloon valvuloplasty, to more conventional and durable surgical therapies in HIV-positive patients. We herein provide an overview of the contemporary outcomes of cardiac surgery in this complex and unique patient population. We review some of the ethical issues around the selection and surgical care of HIV-positive patients. We also discuss strategies to best protect the surgical treatment team from the risks of HIV transmission. Finally, we highlight the need for involvement of dedicated infectious disease professionals in a multidisciplinary heart team approach, aiming at the comprehensive care of these unique and complex patients.     

Increased Risk of Post-Transplant Malignancy and Mortality in Transplant Tourists: A Nationwide Population-Based Cohort Study in Taiwan

Information on post-transplant malignancy and mortality risk in kidney transplant tourists remains controversial and is an important concern. The present study aimed to evaluate the incidence of post-transplant malignancy and mortality risk between tourists and domestic transplant recipients using the claims data from Taiwan''s universal health insurance.A retrospective study was performed on 2394 tourists and 1956 domestic recipients. Post-transplant malignancy and mortality were defined from the catastrophic illness patient registry by using the International Classification of Diseases, 9th Revision. Cox proportional hazard regression and Kaplan–Meier curves were used for the analyses.The incidence for post-transplant de novo malignancy in the tourist group was 1.8-fold higher than that of the domestic group (21.8 vs 12.1 per 1000 person-years). The overall cancer recurrence rate was approximately 11%. The top 3 post-transplant malignancies, in decreasing order, were urinary tract, kidney, and liver cancers, regardless of the recipient type. Compared with domestic recipients, there was significant higher mortality risk in transplant tourists (adjusted hazard ratio = 1.2, 95% confidence interval: 1.0–1.5). In addition, those with either pre-transplant or post-transplant malignancies were associated with increased mortality risk.We suggest that a sufficient waiting period for patients with pre-transplant malignancies should be better emphasized to eliminate recurrence, and transplant tourists should be discouraged because of the possibility of higher post-transplant de novo malignancy occurrence and mortality.     

Increased Morbidity and Mortality Associated with Falls Among Patients with Cirrhosis

Background

Injuries are more morbid and complicated to manage in patients with cirrhosis. However, data are limited regarding the relative risk of injury and severity of injury from falls in patients with cirrhosis compared with those without cirrhosis.

More Non-Q-wave Myocardial Infarctions but Similar Infarct Sizes in Patients with Hypertension

Of 350 consecutive patients without previous symptoms of coronary artery disease, admitted to hospital with an acute myocardial infarction, 109 of them (31%) reported a history of previous hypertension. Hypertensive patients were older than their normotensive counterparts, more of them were females, and thrombolytic treatment was administered to significantly fewer. Blood pressure values at admission to hospital were higher in hypertensive patients; this difference was significant in hypertensive males. Altogether 44 out of 49 female (90%) and 42 out of 60 male hypertensive patients (70%) reported using antihypertensive medication. A previous history of hypertension did not change infarct size as assessed by peak enzyme levels, neither in the bivariate nor in the multivariate analysis. In contrast to this, the adjusted odds ratio for developing a non-Q-wave infarct was 2.51 (p = 0.003), i.e. the chance of developing a non-Q-wave infarct in hypertensives was increased by 151%. Thus, in spite of similar infarct size in normotensive and hypertensive patients, a relative smaller proportion of the probably hypertrophied left ventricular wall developed necrosis in the hypertensive population. The propensity towards non-Q-wave infarctions may contribute to the observed less use of fibrinolytic drug treatment in the presently observed patients with hypertension.     

Proctocolectomy Is Associated with a Higher Complication Rate but Carries a Lower Recurrence Rate Than Total Colectomy and Ileorectal Anastomosis in Crohn Colitis

Background: Most patients with extensive colonic Crohn disease are treated with total colectomy and ileorectal anastomosis or, when there is severe anorectal disease, with proctocolectomy. This study was undertaken to compare postoperative complications and recurrence rates for these two operations. Methods: Eighty-six patients who underwent a single-stage proctocolectomy and 65 who underwent total colectomy and ileorectal anastomosis for colonic Crohn disease were retrospectively reviewed. Results: Anorectal disease (severe proctitis, perianal sepsis, complex fistula) was seen in 77 patients (90%) at proctocolectomy, compared with 7 patients (11%) at colectomy and ileorectal anastomosis (P &lt; 0.0001). After proctocolectomy the commonest complication was perineal wound sepsis (36%). After colectomy and ileorectal anastomosis only three patients (5%) developed anastomotic leak. The overall complication rate was 53% after proctocolectomy compared with 32% after colectomy and ileorectal anastomosis (P = 0.02). Twenty-four patients (29%) after proctocolectomy and 43 patients (68%) after colectomy and ileorectal anastomosis developed symptomatic recurrence (P &lt; 0.0001). After proctocolectomy the 5-, 10-, and 15-year cumulative reoperation rate for recurrence were 13%, 16%, and 26%, which were significantly lower than the 29%, 46%, and 48% after colectomy and ileorectal anastomosis (P = 0.002). Conclusions: The overall complication rate was lower after colectomy and ileorectal anastomosis than after proctocolectomy. However, proctocolectomy was associated with a lower incidence of reoperation for recurrence than colectomy and ileorectal anastomosis.