Effects of B-Blockers on outcome of patients with Chagas' cardiomyopathy with chronic heart failure

Background

A few studies have shown a beneficial effect of B-Blocker therapy on cardiac function and functional status in patients with chronic heart failure secondary to Chagas' cardiomyopathy.

Methods

The medical charts of patients routinely followed from January, 2000 to January, 2007 were reviewed to collect clinical, standard laboratory tests, 12-lead electrocardiogram, chest X-Ray, and Doppler echochardiogram variables. A Cox proportional hazards model was used to establish independent predictors of all-cause mortality for patients with Chagas' cardiomyopathy with chronic heart failure.

Results

A total of 231 consecutive patients were enrolled in the study. Median follow up was 19 (7, 46) months. Twenty (9%) patients underwent heart transplantation and 120 (52%) died during the investigation. Left ventricular systolic dimension (hazard ratio = 1.04; 95% confidence interval = 1.02 to 1.06; p < 0.005) and need of inotropic support (hazard ratio = 1.80; 95% confidence interval 1.2 to 2.60; p = 0,03), were positively associated, whereas B-Blocker therapy (HR = 0.34; 95% confidence interval 0.23 to 0.51; p < 0.0005) was negatively associated with mortality. Mortality was significantly lower in patients taking in comparison to those not taking B-Blockers. Patients taking a mean daily dose of carvedilol > or = to 9.375 mg had a marked decrease in mortality in comparison to those not on carvedilol therapy.

Conclusion

B-Blockers are effective, not detrimental, and may improve survival in Chagas' disease patients with chronic heart failure. A randomized trial is necessary to confirm these findings.     

The effects of enhanced external counterpulsation on time- and frequency-domain measures of heart rate variability

Background and Purpose

We hypothesized that symptom improvement from enhanced external counterpulsation (EECP) is related to improved heart rate variability (HRV).

Methods

This prospective, multicenter study enrolled 27 patients with angina who underwent 48-hour ambulatory electrocardiogram monitoring at baseline, immediately after 35 hours of EECP, and at 1 month. Primary end points included change in time-domain (SD of normal-to-normal intervals) and frequency-domain HRV.

Results

Twenty-four patients completed the full course of EECP therapy and 3 ambulatory electrocardiograms. There were no significant changes in time-domain HRV measures after EECP. Patients younger than 65 years and those with heart failure had improved SD of normal-to-normal interval after EECP (P = .02). Although frequency-domain HRV measures did not change in the overall cohort, patients with diabetes had improved daytime low-frequency power (P = .016).

Conclusions

There was no significant change in the time- or frequency-domain HRV measures after EECP. In diabetic individuals, there was an increase in low-frequency HRV, which has been associated with reduced mortality.     

Time domain parameters can be estimated with less statistical error than frequency domain parameters in the analysis of heart rate variability

Introduction

Measures of heart rate variability (HRV) can be divided in time domain and frequency domain parameters. It is frequently ignored that estimation of frequency-domain parameters is a 2-step procedure where statistical error from the first step (spectral estimation) is neglected in subsequent analyses.

Methods

We performed a simulation study to quantify the statistical error by using frequency domain instead of time domain parameters. We generated tachograms from a stationary AR(1) process for a wide range of parameters and compared the resulting estimation error (in terms of precision and variability) for the standard deviation of normal RR intervals (SDNN) and low frequency (LF), high frequency (HF), and LF/HF power.

Results

Estimation of frequency domain parameters is associated with (up to 10-fold) increased variability, as compared with the SDNN. Moreover, the SDNN has higher precision.

Conclusion

Frequency domain parameters should be applied in HRV analysis only if important physiological reasons suggest their use. If used, frequency domain parameters should be interpreted with caution, taking into account the statistical weaknesses of spectral estimation.     

Depression and perceptions about heart failure predict quality of life in patients with advanced heart failure

Background

Mood is an independent predictor of mortality and quality of life (QoL) for people with heart failure. However, the underlying belief systems involved in mood are unknown.

Objective

We sought to identify psychological and clinical variables predicting mood and QoL for people diagnosed with heart failure (HF).

Methods

One hundred and forty-six HF patients were assessed with standardized measures, to determine their beliefs about HF, coping styles, mood, and QoL.

Results

Patients with more negative beliefs about the consequences of HF and with less perceived control over symptoms showed maladaptive coping styles such as denial and behavioral disengagement, and more severe levels of depression and anxiety. Depression also independently predicted QoL outcomes.

Conclusions

Anxious and depressed patients have more negative beliefs about HF, leading to negative coping behaviors and poor QoL. Our evidence suggests that changing negative beliefs may improve the psychological well-being and QoL of patients, irrespective of disease severity.     

Heart rate turbulence and other autonomic risk markers for arrhythmia risk stratification in dilated cardiomyopathy

Background

Noninvasive arrhythmia risk stratification in patients with nonischemic dilated cardiomyopathy (DCM) using autonomic markers have yielded disappointing results. Heart rate turbulence is a new method to assess cardiac autonomic function.

Aim

The aim of the study was to compare the predictive value of heart rate turbulence with those of conventional autonomic risk markers for ventricular tachyarrhythmic events in patients with DCM.

Methods

The predictive value of heart rate turbulence, baroreflex sensitivity (phenylephrine method), and heart rate variability was assessed in patients with symptomatic congestive heart failure due to DCM who were in sinus rhythm and had a 24-hour Holter recording. Patients were followed for a combined end point of ventricular tachyarrhythmic events.

Results

A total of 114 patients (mean left ventricular ejection fraction, 28 ± 11%), included in the Frankfurt DCM database between 1996 and 2000, fulfilled the criteria for inclusion in this study. Determinate test results were obtained for heart rate variability in 98%, for baroreflex sensitivity in 90%, and for heart rate turbulence in 75% of patients (P = .008). Correlation between the different autonomic markers were only modest (r values, 0.36-0.43). During a follow-up of 22 ± 17 months, an end point event occurred in 15 patients. On univariate analysis, left ventricular ejection fraction and baroreflex sensitivity were significant predictors of arrhythmic events. On multivariate analysis, only baroreflex sensitivity remained an independent predictor (χ² = 3.17; P = .07).

Conclusion

Reliable analysis of heart rate turbulence is possible in approximately 75% of eligible patients with DCM. Whereas blunted baroreflex sensitivity is a predictor of arrhythmic events, heart rate variability and turbulence do not yield predictive power in these patients.     

Aspirin use for the primary prevention of coronary heart disease in older adults

Purpose

Aspirin for the primary prevention of coronary heart disease (has a more favorable risk/benefit profile among adults with high coronary heart disease risk than among low-risk adults, but there is little information on the current patterns of aspirin use for primary prevention. We determined the prevalence of aspirin use in relation to coronary heart disease risk and changes over time.

Subjects and methods

We measured regular aspirin use in 2163 black and white older adults without cardiovascular disease in a population-based cohort from 1997 to 1998 and 2002 to 2003. We determined the 10-year coronary heart disease risk by using the Framingham risk score.

Results

In 1997-1998, 17% of the cohort were regular aspirin users. Aspirin use increased with coronary heart disease risk from 13% in persons with a 10-year risk less than 6% (low risk) to 23% in those with a 10-year risk greater than 20% (highest risk) (P for trend < .001). Blacks were less likely to use aspirin (13%) than whites (20%). In multivariate analysis, black race was still associated with lower aspirin use (odds ratio 0.66, 95% confidence interval 0.49-0.89). In 1997-1998 and 2002 to 2003, aspirin use increased from 17% to 32% among those still free of coronary heart disease (P < .001), and the association with coronary heart disease risk continued (P for trend < .001). Despite their high coronary heart disease risk, diabetic persons were not more likely to use aspirin than nondiabetic persons, even in 2002 and 2003 (odds ratio 0.89, 95% confidence interval 0.56-1.40).

Conclusion

Regular use of aspirin by older adults with no history of cardiovascular disease has increased in recent years. Individuals at higher coronary heart disease risk are more likely to take aspirin, but there is room for considerable improvement in targeting those at high risk, particularly diabetic persons and blacks.     

Long-term prognostic value of cardiac autonomic nervous activity in postoperative patients with congenital heart disease

Background

Abnormal cardiac autonomic nervous activity (CANA) is not uncommon in postoperative patients with congenital heart disease (CHD).

Methods and results

We attempted to clarify the prognostic value of the CANA variables in postoperative CHD patients and prospectively evaluated the CANA variables in 292 consecutive biventricular and 91 Fontan repair patients. The CANA variables included the heart rate variability, arterial baroreflex sensitivity (BRS), washout ratio of the myocardial metaiodobenzylguanidine scintigraphy, and plasma norepinephrine level. With a follow-up of 10 ± 2 years, 98 total events that required hospitalization, including 13 deaths and 48 unscheduled cardiac events (UCEs), occurred. In all the CHD patients, all the CANA indices predicted the total events and UCEs. Of those, the NE level (p = 0.0004) and BRS (p = 0.0373) predicted the mortality. In a multivariate analysis, the BRS was an independent CANA-predictor for the total events (p = 0.007). In the biventricular patients, the plasma NE level, heart rate variability, and BRS predicted the total events and UCEs and the BRS was the only independent CANA-predictor for the total events (p = 0.0329). In the Fontan patients, the plasma NE level was the only predictor for the UCEs (p = 0.0242) and no other CANA variables were independent predictors of the total events or UCEs.

Conclusions

All CANA variables, especially the BRS, were useful predictors for future clinical events in biventricular CHD patients, whereas no CANA variables, except for the plasma NE level, predicted future clinical events in the Fontan patients.     

Autonomic nervous system dysfunction in advanced systolic heart failure

Background

An alteration of the autonomic nervous system has been described in heart failure (HF). The aim of this study was to assess, compare and relate the impairment of both arms of the autonomic nervous systems, the sympathetic and parasympathetic (SNS and PNS) in a same group of patients.

Methods

We analyzed 23 patients with advanced HF (NYHA III-IV/IV and IV/IV) and EF < 35% who were on the waiting list for heart transplantation. We assessed the SNS by determining cardiac uptake of ¹²³I metaiodobenzylguanidine, and analyzed the heart mediastinum rate (HMR) and the myocardial washout rate (WR). The PNS was assessed by 24-hour Holter ECG recording and subsequent analyses of heart rate turbulence (HRT) in which turbulence onset (TO) and turbulence slope (TS) were determined.

Results

In the study of the SNS, HMR values were1.32 ± 0.12, and WR 0.36 ± 0.1. Higher creatinine levels were associated with a lower WR (r = −0.604; p = 0.02). In the study of the SNP, TO was higher the lower the LVEF (r = −0.410; p = 0.052), and age was associated with a lower TS (r = −0.4; p = 0.059). In the study of the relationships between the SNS and PNS, HMR was correlated in a nearly significant manner with TO (r = −0.399; p = 0.059) and WR with TS (r = −0.447; p = 0.033).

Conclusions

In stable patients with advanced HF (NYHA III-IV and IV/IV), a significant and parallel impairment occurs in both arms of the autonomic nervous system. This could have prognostic implications and would help to prioritize patients on the waiting list for heart transplantation.     

Effect of alpha lipoic acid on cardiac autonomic dysfunction and platelet reactivity in type 1 diabetes: rationale and design of the AUTOnomic function and platelet REACTivity trial (AUTO-REACT protocol)

Background

The aim of this study is to assess the relationship between cardiac autonomic dysfunction and increased platelet reactivity in patients with type 1 diabetes and whether alpha lipoic acid therapy (ALA) might improve both abnormalities in these patients.

Methods and materials

Cardiac autonomic function will be assessed by heart rate variability (HRV) analysis. Platelet reactivity will be investigated by both measuring the aggregation time on the PFA-100 method and flow cytometry. HRV and platelet reactivity will be re-assessed in the patients with depressed HRV after 4 weeks from randomization to ALA or placebo.

Discussion

The cardiovascular autonomic system might play a role in the modulation of platelet reactivity which is increased in diabetes. Within this framework, ALA might be found to exercise antithrombotic effects in addition to its known antioxidants properties.

Trial registration

Australian Clinical Trials Registry ACTRN 12610000291088.     

Impairment of autonomic reactivity is a feature of heart failure whether or not the left ventricular ejection fraction is normal

Background

Autonomic dysfunction (AD) is associated with morbidity and mortality in patients with systolic heart failure (SHF). The extent of AD when LV ejection fraction is preserved (HF-NEF), is unclear. Our objectives were: 1) quantitative assessment of autonomic function in SHF and HF-NEF; and 2) exploration of relationships among AD, symptoms and cardiac function.

Methods

This was an observational study of patients newly referred from primary care with a heart failure diagnosis; 21 SHF, 20 HF-NEF patients and 21 normal subjects were recruited. All subjects underwent clinical evaluation, 6-minute walk test (6MWT), Minnesota Questionnaire (MLWHFQ) and echocardiography. Autonomic assessment included haemodynamic responses to standing, deep breathing and handgrip. Concomitant blood pressure variability (BPV) and heart rate variability (HRV) parameters were also derived.

Results

There were significant differences in all haemodynamic responses between SHF, HF-NEF and normal. Log transformed (ln) low frequency spectral component of BPV was lower in SHF (4.1 ± 0.3) than HF-NEF (4.2 ± 0.4) and normal (4.4 ± 0.1; p = 0.001 SHF vs HF-NEF and vs normal). Ln LF/HF was greater in normal than HF-NEF and SHF (1.5 ± 0.7 vs 0.9 ± 1.0 vs 0.6 ± 0.6; p = 0.003). Autonomic modulations correlated negatively with severity of heart failure.

Conclusions

Autonomic responses in heart failure were blunted and the attenuation of responses correlated strongly with symptomatic and functional markers of disease severity. Autonomic dysfunction is a feature of the heart failure syndrome but is not dependent on ejection fraction.     

Failure in short-term prediction of ventricular tachycardia and ventricular fibrillation from continuous electrocardiogram in intensive care unit patients

Background

Patients in the intensive care unit (ICU) setting are prone to malignant ventricular arrhythmias. We sought to test whether electrocardiographic (ECG) markers of autonomic tone, ventricular irritability, and repolarization lability could be used in short-term prediction of ventricular arrhythmias in this patient population.

Methods

We studied 38 patients with sustained (>30 seconds) monomorphic ventricular tachycardia, polymorphic ventricular tachycardia, or ventricular fibrillation while monitored in the ICU and 30 patients without arrhythmia in the ICU who served as controls. All patients had at least 12 hours of continuously recorded multilead ECG before arrhythmic event. Mean heart rate and measures of heart rate variability, QT variability, and ventricular ectopy were quantified in 1-hour epochs for the 12 hours before the arrhythmic event and in 5-minute epochs for the last hour preevent (and using a random termination time point in controls).

Results

A modest downward trend in QT variability and a rise in heart rate were observed hours before polymorphic ventricular tachycardia and ventricular fibrillation events, although no significant changes heralded monomorphic ventricular tachycardia and no changes in any parameter predicted imminent ventricular arrhythmia of any type. There were no significant differences in ECG parameters between arrhythmia patients and controls.

Conclusions

In ICU patients, sustained ventricular arrhythmias are not preceded by change in ECG measures of autonomic tone, repolarization variability, and ventricular ectopy. Short-term arrhythmia prediction may be difficult or impossible in this patient population based on ECG measures alone.     

Lung biopsy findings in previously inoperable patients with severe pulmonary hypertension associated with congenital heart disease

Background

Congenital heart disease with near-systemic pulmonary arterial pressures, previously thought to have irreversible pulmonary vascular disease (PVD), has been successfully corrected at our institution recently. Whether the PVD is reversible remains unknown. This study aimed to examine the nature of the pulmonary arterial vessels in these selective patients.

Methods

All patients with congenital heart disease and severe pulmonary hypertension (PH) were selected using Diagnostic-treatment to undergo radical repair (n = 49). Lung biopsy specimens were obtained during operation. The nature of PVD was determined by Heath-Edwards classification system. All specimens were quantitatively analyzed by calculating percentage media wall area, percentage media wall thickness and arteriole density.

Results

Transcutaneous oxygen saturation of all selected patients increased significantly after Diagnostic-treatment (P < 0.001). There were no operative deaths. Mean pulmonary artery pressure and pulmonary vascular resistance regressed significantly postoperatively (P < 0.001). The incidence of postoperative PH was 59.2% (29/49). Of 49 selected patients with severe PH, 38 (77.6%) showed grade I change, 5 (10.2%) showed grade II change, 4 (8.2%) showed grade III change and only 2 (4%) showed grade IV change with plexiform lesion. The percentage media wall area, percentage media wall thickness and arteriole density were significantly increased in patients associated with PH than in normal subjects (P < 0.001). Follow-up data showed the reversal of PVD in these 2 patients with plexiform lesions.

Conclusions

The PVD in these selective patients with congenital heart disease and severe PH using a Diagnostic-treatment-and-Repair strategy is generally reversible and these patients are operable in current era.     

Operational definitions of outcome indicators related to ineffective breathing patterns in children with congenital heart disease

Objective

The development of operational definitions leads to accurate assessments of health conditions. Many health indicators in the Nursing Outcomes Classification require the development of operational definitions. We sought to determine the validity of operational definitions for indicators of nursing outcomes that assess respiratory status in children with congenital heart disease.

Patients and Methods

Eight trained nurses evaluated 45 children with congenital heart disease who were aged ≤1 year and previously diagnosed with ineffective breathing patterns. The statistical analysis included median differences, intraclass correlations, and cluster analyses.

Results and Conclusions

The nonuse of definitions produced inconsistencies in evaluations among evaluators. This inconsistency was not evident in the group using operational definitions. Two indicators were significant in all statistical analyses: asymmetrical chest expansion and percussed sounds.     

Cholinergic stimulation with pyridostigmine reduces ventricular arrhythmia and enhances heart rate variability in heart failure

Background

Increased ventricular arrhythmia density and reduced heart rate variability are associated with risk of death in patients with heart failure. Cholinesterase inhibition with pyridostigmine bromide increases heart rate variability in normal subjects, but its effect on patients with heart failure is unknown. In this study, we tested the hypothesis that short-term administration of pyridostigmine bromide, a cholinesterase inhibitor, reduces ventricular arrhythmia density and increases heart rate variability in patients with congestive heart failure.

Methods

Patients with heart failure and in sinus rhythm participated in a double-blind, cross-over protocol, randomized for placebo and pyridostigmine (30 mg orally 3 times daily for 2 days). Twenty-four hour electrocardiographic recordings were performed for arrhythmia analysis and for the measurement of time domain indices of heart rate variability. Patients were separated into 2 groups, according to their ventricular arrhythmia density. The arrhythmia group (n = 11) included patients with >10 ventricular premature beats (VPBs) per hour (VPBs/h), and the heart rate variability group (n = 12) included patients with a number of VPBs in 24 hours not exceeding 1% of the total number of R-R intervals.

Results

For the arrhythmia group, pyridostigmine resulted in a 65% reduction of ventricular ectopic activity (placebo 266 ± 56 VPBs/h vs pyridostigmine 173 ± 49 VPBs/h, P = .03). For the heart rate variability group, pyridostigmine administration increased mean R-R interval (placebo 733 ± 22 ms vs pyridostigmine 790 ± 33 ms, P = .01), and in the time domain indices of heart rate variability root-mean-square of successive differences (placebo 21 ± 2 ms vs pyridostigmine 27 ± 3 ms, P = .01) and percentage of pairs of adjacent R-R intervals differing by >50 ms (placebo 3% ± 1% vs pyridostigmine 6% ± 2%, P = .03).

Conclusion

In patients with heart failure, pyridostigmine reduced ventricular arrhythmia density and increased heart rate variability, most likely due to its cholinomimetic effect. Long-term trials with pyridostigmine in heart failure should be conducted.     

Lack of relationship between Doppler indices of diastolic function and left ventricular pressure transients in patients with definite diastolic heart failure

Objectives

The purpose of this study was to compare invasive with noninvasive indices of diastolic function in a well-defined group of patients with diastolic dysfunction and a history of diastolic heart failure.

Background

Patients with heart failure and a normal left ventricular (LV) ejection fraction comprise a very large portion of the heart failure population and most are thought to have diastolic heart failure. While clinical and Doppler criteria for diastolic dysfunction and diastolic heart failure have been developed, there remains some controversy about the need for invasive cardiac catheterization and/or echo-Doppler evaluation of LV diastolic function. To date, there is no consensus as to the utility of these 2 methods in the diagnosis of diastolic heart failure.

Methods

Forty-seven patients (mean age 58 ± 11 years) with a history of congestive heart failure and preserved ejection fraction (≥50%) by echocardiography underwent a combined hemodynamic/echo-Doppler study. Patients with coronary disease were excluded. Invasive parameters of LV diastolic function (tau, LV diastolic pressures) and Doppler parameters (peak E, peak A, E/A ratio, isovolumic relaxation time, and E deceleration time) were measured using standard techniques.

Results

There was a close correlation between invasively-determined parameters (tau vs end diastolic pressure: r = 0.62, P < .001). The relationships between standard Doppler parameters and LV diastolic pressures were uniformly poor. However, the relationship between Doppler isovolumic relaxation time and tau improved considerably when patients were subgrouped by hemodynamic load.

Conclusions

Standard echo-Doppler indices of diastolic function correlate poorly with LV diastolic pressure transients. The diagnosis of diastolic heart failure cannot be made on the basis of a single echo-Doppler parameter but, rather, all parameters must be examined in concert and used in combination with clinical observations.     

The achievement of target cholesterol level differs between coronary heart disease and diabetic patients

Background

Guidelines recommend that LDL-C level should be < 100 mg/dl among diabetes mellitus (DM) and coronary heart disease (CHD) patients.

Objective

To evaluate how patients with DM and CHD differ in attaining the target level and to examine the association between goal achievement, demographic and clinical parameters.

Methods

The study was conducted in Maccabi Healthcare Services, the second largest health maintenance organization in Israel. All patients with DM (n = 54,261), CHD (n = 24,083) or DM and CHD (n = 15,370) who were listed in the computerized database and had at least one LDL-C level measurement between January 1, 2007 and July 15, 2008 were eligible. The percentage of patients who attained LDL-C level < 100 mg/dl and its association with demographic and clinical parameters were analyzed.

Results

The rate of reaching the LDL-C target level was higher among the CHD and CHD and DM patients than DM ones (67% vs. 57% vs. 50%, p < 0.001, respectively). Male gender; 5th socioeconomic status quintile; underlying disease i.e. CHD, CHD and DM; high statins compliance; and revascularization by percutaneous coronary intervention predicted for reaching target level. DM; absence of renal function evaluation; hospitalizations; HbA1C > 7% or missing its measurements had a negative predictive value.

Conclusions

The rate of reaching LDL-C target level should be increased in all high risk patients, mainly diabetic ones. Efforts should include educational programs to physicians and patients regarding the importance, the need to adhere and to intensify the cholesterol lowering treatment.     

Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001

Background

Timely access to emergency cardiac care and survival is partly dependent on early recognition of heart attack symptoms and immediate action by calling emergency services. We assessed public recognition of major heart attack symptoms and knowledge to call 9-1-1 for an acute event.

Methods

Data are from the 2001 Behavioral Risk Factor Surveillance System, a state-based telephone survey. Participants (n = 61,018) in 17 states and the U.S. Virgin Islands indicated whether the following were heart attack symptoms: pain or discomfort in the jaw, neck, back; feeling weak, lightheaded, faint; chest pain or discomfort; sudden trouble seeing in 1 or both eyes (false symptom); pain or discomfort in the arms or shoulder; shortness of breath. Participants also indicated their first action if someone was having a heart attack.

Results

Most persons (95%) recognized chest pain as a heart attack symptom. However, only 11% correctly classified all symptoms and knew to call 9-1-1 when someone was having a heart attack. Symptom recognition and the need to call 9-1-1 was lower among men than women, persons of various ethnic groups than whites, younger and older persons than middle-aged persons, and persons with less education. Persons with high blood pressure, high cholesterol, diabetes mellitus, or prior heart attack or stroke were not appreciably more likely to recognize heart attack symptoms than were persons without these conditions.

Conclusions

Public health efforts are needed to increase recognition of the major heart attack symptoms in both the general public and groups at high risk for an acute event.     

N-terminal probrain natriuretic peptide and C-reactive protein in stable coronary heart disease

Purpose

C-reactive protein (CRP) and N-terminal pro-brain natriuretic peptide (NT-proBNP) provide prognostic information in patients with stable coronary heart disease. The aim of the study was to investigate whether combined use of NT-proBNP and CRP improves risk stratification in these patients.

Methods

This cohort study included 989 patients with stable coronary heart disease who underwent coronary stenting. CRP and NT-proBNP were measured before angiography. The primary end point of the study was all-cause mortality. Using median values of NT-proBNP (279.9 ng/L) and CRP (1.2 mg/L), patients were divided into 4 groups: low NT-proBNP-low CRP group (305 patients with NT-proBNP<median and CRP<median); low NT-proBNP-high CRP group (190 patients with NT-proBNP<median and CRP≥median; high NT-proBNP-low CRP group (237 patients with NT-proBNP≥median and CRP<median); and high NT-proBNP-high CRP group (257 patients with NT-proBNP≥median and CRP≥median).

Results

During a median follow-up of 3.6 years (interquartile range 3.3 to 4.5 years), there were 85 deaths: 6 deaths in the low NT-proBNP-low CRP group, 11 deaths in the low NT-proBNP-high CRP group, 20 deaths in the high NT-proBNP-low CRP group, and 48 deaths in the high NT-proBNP-high CRP group with Kaplan-Meier mortality estimates of 2.7%, 8.9%, 12.1% and 35.6%, respectively (P <.001). Cox proportional hazards model showed that combination NT-proBNP-CRP was the strongest independent correlate of mortality (hazard ratio [HR] 4.3, 95% confidence interval [CI], 2.0-9.3; P <.001 for high NT-proBNP-high CRP vs low NT-proBNP-low CRP).

Conclusion

Combined use of NT-proBNP and CRP improves long-term risk prediction of mortality in patients with stable coronary heart disease.     

Effect of iodixanol and ioxilan on QT interval and renal function in patients with systolic heart failure

Background

Contrast media (CM) exposure is associated with a substantial risk of arrhythmias and nephrotoxicity. These adverse effects may be exacerbated in high-risk conditions such as heart failure, although no studies have evaluated newer CM agents in this population. This study evaluated the electrophysiologic and renal effects of two newer CM agents, iodixanol and ioxilan, in heart failure patients undergoing angiography.

Methods

Eighty-seven consecutive systolic heart failure patients who received either iso-osmolar iodixanol (n = 44) or low-osmolar ioxilan (n = 43), stratified for concomitant amiodarone, were evaluated for QT interval and serum creatinine changes in comparison to baseline. QT values were corrected according to three formulae: Bazett's correction, Fridericia formula, and Framingham equation.

Results

Baseline patient characteristics were not significantly different in the iodixanol versus ioxilan groups, except for myocardial infarction and renal disease. No significant change in mean QTc was observed after exposure to either CM agent compared to baseline. These results were unaffected by amiodarone. A significant improvement in serum creatinine from baseline was observed in the iodixanol group compared to the ioxilan group (−0.121 ± 0.35 mg/dL vs. 0.033 ± 0.23 mg/dL, respectively; p = 0.045).

Conclusions

No significant change in QTc interval was observed in patients receiving either iodixanol or ioxilan during angiography. Iodixanol appeared to improve short-term renal function in patients with heart failure and should be further investigated.