Pontage coronaire chez les patients en dysfonction systolique sévère du ventricule gauche : résultats à court et à long terme

BackgroundIschemic heart disease with severe left ventricular systolic dysfunction is a poor prognosis. Coronary artery bypass grafting is the gold treatment in this population, despite high surgical risk.AimThe aim of our study is to evaluate the short- and long-term outcomes of coronary artery bypass grafting in patients with ischemic heart disease and severe left ventricular systolic dysfunction (LVEF ≤ 35%).MethodsBetween May 1995 and December 2010, 171 patients with ischemic heart disease and severe left ventricular systolic dysfunction (LVEF ≤ 35%) underwent isolated coronary artery bypass grafting. Hospital mortality, postoperative morbidity, all-cause death, cardiovascular death, and major adverse cardiovascular events (heart failure, recurrent angina, myocardial infarction, stroke) were evaluated. The mean follow-up was 9.3 ± 5 years.ResultsHospital mortality was 9.9%. Postoperative morbidity was 36.9%. Overall survival at 1-, 5- and 10-years was 97.4%, 90.5% and 43.4%, respectively. Freedom from cardiovascular death at 1-, 5- and 10-years was 98.1%, 91.8% and 55.4%, respectively. Freedom from recurrent angina at 1-, 5- and 10-years was 95.5%, 84.8% and 44.9%, respectively. Freedom from heart failure at 1-, 5- and 10-years was 89.9%, 86,8% and 53.3%, respectively. Freedom from major adverse cardiovascular events at 1-, 5- and 10-years was 88%, 82.1% and 38.2%, respectively.ConclusionBased on our findings, coronary artery bypass grafting can be performed in patients with ischemic heart disease and severe left ventricular systolic dysfunction with acceptable hospital morbidity and mortality and long-term survival.     

Validación de la utilidad de los parámetros de deformación miocárdica para excluir el rechazo agudo tras el trasplante cardiaco: un estudio multicéntrico

Introduction and objectivesTwo-dimensional speckle-tracking echocardiography has emerged as a promising alternative to endomyocardial biopsy to rule out acute cellular rejection after orthotopic heart transplantation (OHT) in single center studies. In an original cohort, 15.5% and 17% of cutoff points for left ventricular global longitudinal strain (LVGLS) and free-wall right ventricular longitudinal strain, respectively, achieved 100% negative predictive value to exclude moderate or severe acute cellular rejection (ACR ≥ 2 R). Our objective was to demonstrate the usefulness of speckle-tracking and validate these cutoff points in an external cohort.MethodsA prospective, multicenter study that included patients who were monitored during their first year after OHT was conducted. Echocardiographic studies analyzed by local investigators were compared with simultaneous paired endomyocardial biopsies samples.ResultsA total of 501 endomyocardial biopsy-echocardiographic studies were included in 99 patients. ACR ≥ 2R was present in 7.4% of samples. LVGLS and free-wall right ventricular longitudinal strain were significantly reduced during ACR ≥ 2R on univariate analysis. On multivariate analysis, LVGLS was independently associated with the presence of ACR ≥ 2R. The original cutoff points demonstrated a negative predictive value of 94.3% to exclude ACR ≥ 2R.ConclusionsThis study maintained a strong negative predictive value to exclude ACR ≥ 2R after OHT and LVGLS was independently associated with the presence of ACR ≥ 2R. We propose the use of speckle-tracking, especially LVGLS, as part of the noninvasive diagnosis and management of ACR.     

A one-year mortality clinical prediction rule for patients with heart failure

AimsTo create and validate a clinical prediction rule which is easy to manage, reproducible and that allows classifying patients admitted for heart failure according to their one-year mortality risk.MethodsA prospective cohort study carried out with 2565 consecutive patients admitted with heart failure in 13 hospitals in Spain. The derivation cohort was made up of 1283 patients and 1282 formed the validation cohort. In the derivation cohort, we carried out a multivariate logistic model to predict one-year mortality. The performance of the derived predictive risk score was externally validated in the validation cohort, and internally validated by K-fold cross-validation. The risk score was categorized into four risk levels.ResultsThe mean age was 77.2 years, 49.7% were female and there were 611 (23.8%) deaths in the follow-up period. The variables included in the predictive model were: age ≥ 75, systolic blood pressure < 135, New York Heart Association class III–IV, heart valve disease, dementia, prior hospitalization, haemoglobin < 13, sodium < 136, urea ≥ 86, length of stay ≥ 14 and Physical dimension of Minnesota Living with Heart Failure questionnaire. The AUC for the risk score were 0.73 and 0.70 in the derivation and validation cohorts, respectively, and 0.73 in the K-fold cross-validation. The percentage of mortality ranged from 8.08% in the low-risk to 58.20% in the high-risk groups (p < 0.0001; AUC, 0.72).ConclusionsThis model based on routinely available data, for admitted patients and with a follow-up at one year is a simple and easy-to-use tool for improving management of patients with heart failure.     

Impact of left atrial and diastolic ventricular dysfunction on mortality in patients with aortic stenosis

BackgroundDiastolic dysfunction (DD) is common in severe aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF ≥ 50%).AimTo determine the impact of American Society of Echocardiography/European Association of Cardiovascular Imaging-recommended DD grading and left atrial strain on mortality in a cohort of patients with severe AS and preserved LVEF.MethodsWe studied patients with severe AS (aortic valve area indexed < 0.6 cm²/m² and/or aortic valve area < 1 cm²), LVEF ≥ 50% and no or mild AS-related symptoms. The endpoint was all-cause mortality.ResultsA total of 387 patients (median age 76 years; 53% women) were studied. During a median follow-up of 57 (interquartile range 37; 83) months, 158 patients died. After adjustment for prognostic factors, patients with grade II or III DD had an increased mortality risk versus patients with grade I DD (adjusted hazard ratio (aHR) 1.62, 95% confidence interval (CI) 1.11–2.38; P = 0.013; aHR 4.73, 95% CI 2.49–8.99; P < 0.001; respectively). Adding peak atrial longitudinal strain (PALS) ≤ 14% to a multivariable model including DD grade improved predictive performance, with better global model fit, reclassification and discrimination. Patients with grade III DD or grade II DD + PALS ≤ 14% displayed an increased mortality risk versus patients with grade I DD + PALS > 14% (aHR 4.17, 95% CI 2.46–7.06; P < 0.0001). Those with grade I DD + PALS ≤ 14% or grade II DD + PALS > 14% were at intermediate risk (aHR 1.63, 95% CI 1.07–2.49; P = 0.024).ConclusionsOur results demonstrate the strong relationship between DD and mortality in patients with severe AS and preserved LVEF. Patients with grade III or grade II DD and impaired PALS are at very high risk. These data demonstrate the importance of a comprehensive assessment of diastolic function in patients with severe AS.     

Safety and efficacy of adaptive servo-ventilation in patients with severe systolic heart failure

Background and purposeIt is unclear whether adaptive servo-ventilation (ASV) is safe and effective in patients with severe systolic heart failure (HF). Our aim in this study was to estimate the safety and efficacy of ASV therapy for patients with severe systolic HF.Methods and subjectsSeventy-six HF patients (age: 69 ± 12 years; 53 men), categorized as New York Heart Association (NYHA) Class II–IV, with left ventricular ejection fraction (LVEF) of <50%, received ASV therapy after optimal medical therapy to determine the safety and efficacy of ASV. Patients were divided into 2 groups based on their LVEF: group L (LVEF < 30%; n = 42) and group H (LVEF ≥ 30%; n = 34). After 6 months of ASV therapy, we compared the changes in LVEF, brain natriuretic peptide (BNP), and incidence of fatal cardiovascular events between the groups.ResultsThe groups differed significantly with respect to beta-blocker treatment before ASV therapy (p < 0.0001). After 6 months of ASV therapy, LVEF and BNP levels had improved in both groups. In group L, LVEF had improved from 24.1 ± 5.6% to 35.2 ± 10.6% (p < 0.0001) and BNP from 591 (273–993) pg/ml to 142 (39–325) pg/ml (p = 0.002). Moreover, 1-year follow-up data showed a tendency toward improvement of NYHA classification in group L (group L: 50%; group H: 29%; p = 0.07), and showed no significant difference with regard to fatal cardiovascular events between the 2 groups (group L: 11.9%; group H: 5.9%; p = 0.36).ConclusionsOur study demonstrated that ASV therapy is safe and effective for use in very severe systolic HF patients as well as in relatively mild systolic HF patients.     

Examination of the appropriate timing of reperfusion therapy for recent myocardial infarction: a Japanese single-center retrospective study

BackgroundThe various guidelines clearly mention the treatment strategies for in patient of acute myocardial infarction (MI) presenting more than 24 h from symptom onset (recent myocardial infarction, RMI). However, the appropriate timing of reperfusion for RMI is unclear.MethodsWe retrospectively evaluated 525 consecutive MI patients who underwent percutaneous coronary intervention (PCI) in our hospital between January 2008 and December 2012.ResultsSixty RMI patients were more frequently associated with cardiac complications such as myocardial rupture (3.3% vs. 0%; p < 0.01), ventricular septal rupture (3.3% vs. 0.4%; p < 0.05), and congestive heart failure (15% vs. 2.6%; p < 0.001) than 272 consecutive ST-elevation myocardial infarction (STEMI) patients. Of the 60 RMI patients, 33 (55.0%) underwent PCI within 7 days (early-PCI group) and 27 (45.0%) underwent PCI after 7 days (late-PCI group). Left ventricular ejection fraction measured by echocardiography at second hospital day was similar between the groups. The early-PCI group was more significantly associated with cardiogenic shock and heart failure and more frequently required intra-aortic balloon pumping (24.2% vs. 3.7%; p < 0.05) than the late-PCI group. There were no significant differences in 30-day mortality, cardiac complications, and major cardiac events during long-term follow-up (12–36 months) between the groups.ConclusionRMI patients had a higher incidence of cardiac complications than AMI patients. Clinical outcomes were similar between patients undergoing early revascularization and those undergoing late revascularization, although the former group included a higher proportion of patients with severe cardiac failure.     

Correlation of NT-proBNP levels and cardiac iron concentration in patients with transfusion-dependent thalassemia major

Iron-induced cardiotoxicity remains the leading cause of morbidity and mortality in patients with transfusion-dependent β-thalassemia major. Heart failure in these patients, which may be reversible but has a poor prognosis, is characterized by myocardial iron deposition-related early diastolic dysfunction. Amino-terminal pro-brain natriuretic peptide (NT-proBNP) is a sensitive biomarker for the detection of asymptomatic left ventricular dysfunction. In this study, we prospectively evaluated plasma NT-proBNP levels in 187 adult patients aged 19–54 years with β-TM. Possible correlations with the proposed recently cardiac iron concentration based on an equation derived from heart T2* assessment by MRI: [Fe] = 45.0 × [T2*]^? 1.22 with [Fe] in milligrams per gram dry weight and T2* in milliseconds were explored. We found that: 143 patients had no cardiac hemosiderosis, defined as [Fe] < 1.1 mg/g dry weight, corresponding to T2* > 20 ms and 44 patients had cardiac hemosiderosis, defined as [Fe] > 1.2 mg/g dry weight. The main results of the study showed that: a) NT-proBNP levels were markedly increased in thalassemic patients (152.2 ± 190.1 pg/mL, ranged from 6.0 to 1336.0 pg/mL compared to normal control levels 40.1 ± 19.7 pg/mL, p < 0.001, b) NT-proBNP levels were significantly higher in patients with cardiac hemosiderosis compared to patients without cardiac hemosiderosis (185.1 ± 78.0 vs 128.9 ± 20.2 pg/mL, p < 0.05), c) NT-proBNP levels correlated with [Fe] values (r = 0.387, p < 0.001). This correlation was significant in patients with cardiac hemosiderosis (r = 0.520, p < 0.001), but not in patients without cardiac hemosiderosis (p > 0.1), and d) no significant correlation was found between NT-proBNP levels and left ventricular ejection fraction values, (p > 0.3). Our study demonstrated for first time the significant association of NT-proBNP levels and cardiac iron concentration in patients with β-thalassemia major linking blood chemistry and imaging techniques. Multicenter studies of these parameters during iron chelation therapies are needed to validate their association and further exploit its clinical use.     

Frequency of Positive XmnI Gγ polymorphism and coinheritance of common alpha thalassemia mutations do not show statistically significant difference between thalassemia major and intermedia cases with homozygous IVSII-1 mutation

From 362 thalassemia cases referred to adult thalassemia clinic of the Iranian blood transfusion organization (IBTO) for genotyping, 103 cases (28.5%) had a common primary disease factor, IVSII-1 mutation in homozygous state. 61 (59.2%) of these individuals represented thalassemia major and 42 (40.8%) thalassemia intermedia clinical phenotype. To re-evaluate our current diagnostic criteria, XmnI ^Gγ polymorphism and coexistence of alpha thalassemia mutations, frequently recalled as important factors modifying the clinical phenotype of homozygous beta zero thalassemia cases in our country, were examined in both groups. No statistically significant difference in the frequency of positive XmnI ^Gγ polymorphism was observed between thalassemia intermedia and thalassemia major patients. Double gene deletion --^Med was observed in only one thalassemia major case, while ? a^3.7 in heterozygous state (? a^3.7/aa) was identified in 6 (9.8%) of thalassemia major and 8 (19%) of thalassemia intermedia patients. ? a^4.2 was observed in only one thalassemia major case. No statistically significant difference in the frequency of coinheritance of alpha thalassemia was observed between the two groups. These results imply that other interacting mechanisms which modify the phenotype of thalassemia patients is still in the dark in our current diagnostic criteria of thalassemia.     

Impacto del bloqueo del sistema renina-angiotensina en el pronóstico del síndrome coronario agudo en función de la fracción de eyección

Introduction and objectivesFor patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), it is unclear whether angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are associated with reduced mortality, particularly with preserved left ventricular ejection fraction (LVEF). The goal of this study was to determine the association between ACEI/ARB and mortality in ACS patients undergoing PCI, with and without reduced LVEF.MethodsData from the BleeMACS registry were used. The endpoint was 1-year all-cause mortality. The prognostic value of ACEI/ARB was tested after weighting by survival-time inverse probability and after adjustment by Cox regression, propensity score, and instrumental variable analysis.ResultsAmong 15 401 ACS patients who underwent PCI, ACEI/ARB were prescribed in 75.2%. There were 569 deaths (3.7%) during the first year after hospital discharge. After multivariable adjustment, ACEI/ARB were associated with lower 1-year mortality, ≤ 40% (HR, 0.62; 95%CI, 0.43-0.90; P = .012). The relative risk reduction of ACEI/ARB in mortality was 46.1% in patients with LVEF ≤ 40%, and 15.7% in patients with LVEF > 40% (P value for treatment-by-LVEF interaction = .008). For patients with LVEF > 40%, ACEI/ARB was associated with lower mortality only in ST-segment elevation myocardial infarction (HR, 0.44; 95%CI, 0.21-0.93; P = .031).ConclusionThe benefit of ACEI/ARB in decreasing mortality after an ACS in patients undergoing PCI is concentrated in patients with LVEF ≤ 40%, and in those with LVEF > 40% and ST-segment elevation myocardial infarction. In non–ST-segment elevation-ACS patients with LVEF > 40%, further studies are needed to assess the prognostic impact of ACEI/ARB.     

Clinical significance of myocardial contraction fraction in significant primary mitral regurgitation

BackgroundThe optimal timing for mitral valve (MV) surgery in asymptomatic patients with primary mitral regurgitation (MR) remains a matter of debate. Myocardial contraction fraction (MCF) − the ratio of the left ventricular (LV) stroke volume to that of the myocardial volume − is a volumetric measure of LV myocardial shortening independent of size or geometry.AimTo assess the relationship between MCF and outcome in patients with significant chronic primary MR due to prolapse managed in contemporary practice.MethodsClinical, Doppler-echocardiographic and outcome data prospectively collected in 174 patients (mean age 62 years, 27% women) with significant primary MR and no or mild symptoms were analysed. The impact of MCF< or ≥30% on cardiac events (cardiovascular death, acute heart failure or MV surgery) was studied.ResultsDuring an estimated median follow-up of 49 (22–77) months, cardiac events occurred in 115 (66%) patients. The 4-year estimates of survival free from cardiac events were 21 ± 5% for patients with MCF <30% and 40 ± 6% for those with ≥30% (P < 0.001). MCF <30% was associated with a considerable increased risk of cardiac events after adjustment for established clinical risk factors, MR severity and current recommended class I triggers for MV surgery (adjusted hazard ratio: 2.33, 95% confidence interval: 1.51−3.58; P < 0.001). Moreover, MCF < 30% improved the predictive performance of models, with better global fit, reclassification and discrimination.ConclusionsMCF < 30% is strongly associated with occurrence of cardiac events in patients with significant primary MR due to prolapse. Further studies are needed to assess the direct impact of MCF on patient management and outcomes.     

Relation entre pression artérielle,fréquence cardiaque et dysfonction autonome cardiaque chez les obèses non diabétiques

RationaleSome studies suggest that a high heart rate (HR) would be predictive of the incidence of an elevated blood pressure (BP). Cardiac autonomic dysfunction (CAD) affects a high proportion of obese patients. CAD could be involved in BP increase. Our aim was to examine the relationship between CAD, HR and BP in obese patients without known diabetes.Patients and methodsWe included 428 overweight or obese patients. CAD was assessed by analyzing HR variations during three standard tests (Valsalva, deep breathing, lying-to-standing), which are mostly dependent on vagal control. An oral load in glucose was performed and the Matsuda index was calculated.ResultsThe population was separated in 4 groups according to the grade of CAD (no or only one abnormal test, 2 or 3 abnormal tests) and HR (< or ≥ 75 bpm). Age was similar in the four groups. Systolic (P = 0.05), diastolic (P < 0.005) and mean BP (P < 0.001) differed significantly between the 4 groups, and was the highest in the group of patients who had 2 or 3 abnormal tests and HR ≥ 75 bpm. Matsuda index differed across the groups (P = 0.018) and was the lowest in this group.ConclusionThese data indicate that among overweight or obese patients with a defect in cardiac vagal activity BP is elevated only in those with a high heart rate, which is indicative of a more marked insulin resistance and probably an excess in sympathetic activity.     

Retrospective cohort study evaluating exenatide twice daily and long-acting insulin analogs in a Veterans Health Administration population with type 2 diabetes

AimThis was a retrospective cohort study that evaluated the differences in glycated haemoglobin (HbA_1c) and body mass index (BMI) in veterans with type 2 diabetes mellitus (T2DM), prescribed exenatide twice daily (BID) versus long-acting insulin analog (LAIA) two years after initiation in the United States (US) veteran population.Materials and methodsPatients were included if they were ≥ 18 years old with T2DM, and initiated exenatide BID or LAIA at the Veterans Health Administration between January 1, 2006 and December 31, 2010. Multivariate models were used to evaluate the changes in HbA_1c and BMI between groups, controlling for potential confounders. Logistic regression was used to evaluate the odds of achieving ≥ 0.5% HbA_1c reduction based on baseline HbA_1c stratifications: low, < 7%; moderate, 7% to < 9%; and high, ≥ 9%.ResultsA total of 446 exenatide BID and 51,531 LAIA patients met inclusion/exclusion criteria. On average, exenatide BID patients were significantly older (64 versus 60 years) with a higher BMI (37.8 versus 32.9 kg/m²). Baseline HbA_1c was 8.2% and 8.8% for exenatide BID and LAIA patients, respectively (P < 0.001); otherwise, patients were similar for all other characteristics. Exenatide BID treatment was significantly associated with a 0.32% (95%CI: 0.18–0.47%) greater reduction in HbA_1c at two years compared with LAIA. Similar findings were observed for BMI reduction (0.68 kg/m²; 95%CI: 0.42–0.95 kg/m²). Exenatide BID patients with moderate baseline HbA_1c had significantly higher odds of achieving ≥ 0.5% HbA_1c reduction compared with LAIA patients (OR = 1.5; 95%CI: 1.2–2.0).ConclusionsVeterans treated with exenatide BID had significantly greater reduction in HbA_1c and BMI compared with patients treated with LAIA patients two years after initiation.     

Predictive Value of Immune Cell Functional Assay for Non-Cytomegalovirus Infection in Lung Transplant Recipients: A Multicenter Prospective Observational Study

IntroductionImmune cell functional assay (ImmuKnow®) is a non-invasive method that measures the state of cellular immunity in immunosuppressed patients. We studied the prognostic value of the assay for predicting non-cytomegalovirus (CMV) infections in lung transplant recipients.MethodsA multicenter prospective observational study of 92 patients followed up from 6 to 12 months after transplantation was performed. Immune cell functional assay was carried out at 6, 8, 10, and 12 months.ResultsTwenty-three patients (25%) developed 29 non-CMV infections between 6 and 12 months post-transplant. At 6 months, the immune response was moderate (ATP 225–525 ng/mL) in 14 (15.2%) patients and low (ATP < 225 ng/mL) in 78 (84.8%); no patients had a strong response (ATP ≥ 525 ng/mL). Only 1 of 14 (7.1%) patients with a moderate response developed non-CMV infection in the following 6 months compared with 22 of 78 (28.2%) patients with low response, indicating sensitivity of 95.7%, specificity of 18.8%, positive predictive value (PPV) of 28.2%, and negative predictive value (NPV) of 92.9% (AUC 0.64; p = 0.043). Similar acute rejection rates were recorded in patients with mean ATP ≥ 225 vs. <225 ng/mL during the study period (7.1% vs. 9.1%, p = 0.81).ConclusionAlthough ImmuKnow® does not seem useful to predict non-CMV infection, it could identify patients with a very low risk and help us define a target for an optimal immunosuppression.     

Prevalence and determinants of elevated high-sensitivity cardiac troponin T in hypertrophic cardiomyopathy

BackgroundThis study was designed to evaluate the prevalence and determinants of increased high-sensitivity cardiac troponin T (hs-cTnT) as a marker of cardiac injury in patients with hypertrophic cardiomyopathy (HCM).MethodsA total of 98 consecutive patients with HCM (71.4% males; mean age 51.18 ± 15.47 years) between 2012 and 2013 were evaluated by measuring the level of serum hs-cTnT along with other clinical assessments.ResultsThere were 42 (42.9%) patients with a minimum serum hs-cTnT level of 14 ng/L. The mean hs-cTnT level was 12.37 ng/L (6.94–24.26 ng/L). There were significant differences in chest pain New York Heart Association functional class, left ventricular hypertrophy in the surface electrocardiogram, non-sustained ventricular tachycardia in 24-h electrocardiogram-Holter monitoring, left atrial (LA) area index, ratio of peak early (E) transmitral filling velocity to peak early diastolic annular velocity (Ea septal) at the level of the septal mitral annulus (E/Ea septal), maximum left ventricular (LV) wall thickness ≥ 30 mm, and peak LV outflow gradient ≥ 30 mmHg in echocardiography between the patients with hs-cTnT < 14 ng/L and those with hs-cTnT ≥ 14 ng/L. However, after multivariate analysis, age, maximum LV wall thickness, LA area index, and E/Ea septal remained as the independent determinants of elevated hs-cTnT in HCM.ConclusionsThe results demonstrated that hs-cTnT was elevated in a significant number of our HCM patients; therefore, hs-cTnT can be introduced as a valuable marker of myocardial injury in HCM patients.     

Evaluation of left ventricular mechanical dyssynchrony in chronic heart failure patients by two-dimensional speckle tracking imaging

The purpose of this study was to evaluate left ventricular mechanical dyssynchrony (LVMD) in chronic heart failure (CHF) patients using two-dimensional speckle tracking imaging (2D-STI), and also to compare the usefulness of three patterns of myocardial deformation in mechanical dyssynchrony assessment. Furthermore, the relationships between left ventricular ejection fraction (LVEF), QRS duration (QRSd), and LVMD were explored. In total, 78 patients and 60 healthy individuals (group 3) were enrolled. The patients were classified into two subgroups: LVEF ≤ 35% (group 1), 35% < LVEF < 50% (group 2). All participants underwent two-dimensional echocardiography, and dyssynchrony indices derived from 2D-STI were calculated. According to statistical principles, the cut-off value of LVMD was defined as mean ± 1.645 SD of the normal population. Dyssynchrony rates were calculated in CHF subgroups and compared within each subgroup, respectively. Compared with group 3, all indices in group 1 were remarkably higher (p < 0.05), and some of the indices in group 2 were significantly higher (p < 0.05). A significant difference of dyssynchrony rate was noted within both group 1 and group 2 (χ² = 25.55, p < 0.05 vs. χ² = 23.88, p < 0.05), and the highest value was derived from the longitudinal index in both subgroups. LVEF was related to all three forms of strain/strain rate (p < 0.05), whereas no relationship existed between QRSd and dyssynchrony indices (p > 0.05). CHF patients have different extents of LVMD. Longitudinal deformation shows the best detectability of dyssynchrony motion. Left ventricular systolic function was closely related to mechanical dyssynchrony, whereas QRSd showed no significant correlation.     

Prevalencia de déficit de alfa-1 antitripsina en pacientes con EPOC en Argentina. Estudio DAAT.AR

IntroductionAlpha-1 antitrypsin deficiency (AATD) is still underdiagnosed, despite the recommendation to determine AAT in patients with chronic obstructive pulmonary disease (COPD).ObjectiveTo estimate the prevalence of AATD in COPD patients adjusted according to the population of the COPD prevalence study in Argentina (EPOC.AR).Material and methodsThis was a multicenter prospective cross-sectional study of a population aged ≥ 30 years of age diagnosed with COPD, involving AAT quantification in dry blood spot and subsequent genotyping in subjects with < 1.5 mg/dL AAT in dry blood spot (< 80 mg/dL in serum). AAT was defined as the detection of variants ZZ or SZ on genotyping. The EPOC.AR study population was used to calculate local adjusted prevalence.ResultsWe included 3,254 patients (544 with AAT < 80 mg/dL) with a spirometric diagnosis of COPD. The prevalence of AATD in the total study population was 1.29% (95% CI 0.93-1.74), of which 0.92% (95% CI 0.62-1.31) were Pi*ZZ and 0.37% (95% CI 0.19-0.64) Pi*SZ. The adjusted prevalence of AATD in COPD patients ≥ 40 years of age was 0.83% (95% CI 0.23-2.08). We found that AATD was negatively associated with age (OR 0.94; 95% CI 0.90-0.98; P = .006), smoking habit (OR 0.98; 95% CI 0.96-0.99; P = .009), and FEV₁% (OR 0.95; 95% CI 0.91-0.99; P = .015).ConclusionsThe prevalence of AATD in the adult population with COPD in Argentina is estimated to be 0.83%, which could represent 17,000 cases in our country.     

Hemoglobin A1c,comorbid conditions and all-cause mortality in older patients with diabetes: A retrospective 9-year cohort study

AimsTo examine whether hemoglobin A_1c levels and comorbid conditions are related to all-cause mortality in a cohort of patients with type 1 or 2 diabetes receiving continuous care for 9 years. In patients with comorbid congestive heart failure (CHF), we test for ‘reverse epidemiology,’ or whether greater HbA_1c values are associated with lower risk of mortality.MethodsThe population for this longitudinal cohort study was 8820 Group Health enrollees in the Seattle area with type 1 or 2 diabetes in 1997 and enrolled continuously from 1997 to 2006. Comorbid conditions were hypertension, coronary artery disease, congestive heart failure, depression, and chronic pulmonary disease. Mistimed HbA_1c scores were addressed by multiple imputation, and Cox proportional hazards models estimated associations controlling for other risk factors.ResultsAbout 30% of the enrollees died in 1998–2006. CHF had the strongest association with all-cause mortality. Compared to enrollees with HbA_1c ≥ 7.1% (54 mmol/mol) and <7.5% (58 mmol/mol; 5th decile), enrollees with HbA_1c < 6.4% (46 mmol/mol) had a significantly greater risk of death (HR range: 1.28–2.26). HbA_1c > 7.5% had HR < 1.0 but were not significant. For enrollees with diabetes and CHF at baseline, HbA_1c scores ≥ 8.7% (72 mmol/mol) had a significantly lower risk of death (HR range: 0.64–0.69).ConclusionsIn our patient population, HbA_1c scores < 6.4% have significantly higher all-cause mortality. CHF is a major determinant of all-cause mortality. Adults with comorbid CHF and high HbA_1c scores have lower all-cause mortality.     

Waiting time for transfer of patients with prostaglandin dependant congenital heart defects to tertiary cardiac centers

Worldwide congenital heart defects (CHD) are the leading cause of infant deaths owing to congenital anomalies. Delay in diagnosing and operating in neonates with prostaglandin dependant CHD may lead to significant morbidity and mortality.Objectives: To assess the time interval needed for acceptance and transfer of patients with critical CHD to a tertiary cardiac center and the impact on the patient’s survival.Study design: Retrospective database reviews of all cases diagnosed to have prostaglandin dependant (PG) CHD at Prince Sultan Cardiac Center-Qassim during a 43 months period (from May 2007 to December 2010).Results: During the study period 104 patients were diagnosed to have PG dependant CHD. Patients with PG dependant systemic circulation constitute 60% of patients. Patients with ventricular septal defect (VSD) associated with coarctation of the aorta constituted 16% of patients. The mean waiting time for transfer to a tertiary cardiac center was 10 ± 10 days. Twenty-two (21%) patients died while waiting for acceptance and transfer. Eleven patients were diagnosed with hypoplastic left heart syndrome (HLHS). There was no significant difference in the waiting time for those with or without HLHS, with a mean of 9 days for both. Six of our patients had infections with positive blood cultures. The mean waiting period for those with proved infection was 25 days compared with 8 days for those with no proved infection (p value < 0.005).Conclusion: There are a significant number of patients with severe CHD who die while waiting for acceptance and transfer to a tertiary cardiac center. The causes for delay could be the presence of infection, prematurity and low birth weight. The limited numbers of tertiary cardiac centers in Saudi Arabia as well as cardiac ICU beds are among the factors delaying the acceptance of patients requiring cardiac surgery.     

Sleep duration is a significant predictor of cardiac autonomic neuropathy in type 2 diabetes mellitus

AimTo investigate the association between sleep quality outcomes and measures of cardiac autonomic function and to assess the predictive ability of sleep quality outcomes for cardiac autonomic neuropathy (CAN) in type 2 diabetes mellitus (T2DM).MethodsFifty patients with T2DM (age, 51.3 ± 7.01 years; glycemic control, 8.4 ± 1.65%) completed the study. Patients were diagnosed for CAN using the standard clinical autonomic test battery and were also assessed for heart rate variability (HRV) under resting conditions. Sleep quality was examined using the Pittsburg Sleep Quality Index (PSQI).ResultsSleep duration, sleep onset latency, sleep efficiency, daytime dysfunction and global PSQI score showed significant correlations with measures of cardiac autonomic control (p < 0.05). At an optimal cut-off of ≤ 5.83 h (area under the curve: 0.76, p = 0.0003; sensitivity: 50%; specificity: 94.4%), sleep duration predicted occurrence of CAN (odds ratio, confidence interval: 0.18, 0.04–0.70; p = 0.01) in T2DM after adjusting for various clinical confounders.ConclusionFindings of the present study suggest that subjective sleep outcomes such as sleep duration, sleep onset latency, sleep efficiency, daytime dysfunction and overall sleep quality are associated with the indices of cardiac autonomic function in T2DM. Moreover, short sleep duration may be considered a predictor in the occurrence of CAN in these patients. Considering the role of sleep in the pathophysiology of CAN, sleep should be routinely examined in patients with T2DM and appropriate therapeutic interventions should be implemented particularly in case of reduced sleep duration.