Are angiotensin converting enzyme inhibitors beneficial in patients with aortic stenosis?

Angiotensin converting enzyme (ACE) inhibitors may become an accepted form of treatment for aortic stenosis in the future.     

Long-term outcome in patients with Marfan syndrome: is aortic dissection the only cause of sudden death?

OBJECTIVES: We sought to assess outcomes in a series of young patients with Marfan syndrome and to define the prevalence of ventricular arrhythmias in this patient population. BACKGROUND: While sudden death is a well-recognized outcome in Marfan syndrome, ventricular arrhythmias are not well described. METHODS: Patients were followed with echocardiography, electrocardiography, and ambulatory electrocardiography. The prevalence and associated factors for ventricular dysrhythmias were defined. RESULTS: Seventy patients with Marfan syndrome diagnosed at birth to 52 years were followed for a period of up to 24 years. All patients had cardiovascular involvement and were started on medical therapy. No patient died from aortic dissection, while 4% died from arrhythmias. Ventricular arrhythmias were present in 21% and were associated with increased left ventricular size, mitral valve prolapse, and abnormalities of repolarization. CONCLUSIONS: Cardiac complications are rare in young patients with Marfan syndrome receiving medical therapy and close clinical follow-up. Sudden death still occurs, and appears more common in patients with a dilated left ventricle. Left ventricular dilation may predispose to alterations of repolarization and fatal ventricular arrhythmias.     

Effects of renin–angiotensin–aldosterone system inhibitors on mortality,hospitalization, and diastolic function in patients with HFpEF

Aim

The purpose of this meta-analysis was to evaluate the effects of renin–angiotensin–aldosterone system (RAAS) inhibitors on mortality, hospitalization, diastolic function, and exercise capacity in heart failure with preserved ejection fraction (HFpEF).

Methods

Thirteen randomized controlled trials (RCTs), totaling 12,532 patients with HFpEF, were selected. All-cause and cardiovascular mortality, all-cause and heart failure-related hospitalization, diastolic function, and the 6-min walk distance were assessed. The risk ratios (RR) of the dichotomous data, weighted mean difference (WMD) of continuous data, and 95?% confidence intervals (CI) were calculated to assess the effects of RAAS inhibitors.

Results

RAAS inhibitors significantly decreased heart failure-related hospitalization (RR 0.89; 95?% CI 0.82–0.97; p?=?0.01) and improved the diastolic function, as reflected in a reduced E/e’ index (MD ?1.38; 95?% CI ?2.01 to ?0.74; p?<?0.0001). However, there were no beneficial effects on all-cause cardiovascular mortality and all-cause hospitalization. Other diastolic parameters had few changes compared with the controls. The 6-min walk distance was not improved by the use of RAAS inhibitors.

Conclusion

In patients with HFpEF, RAAS inhibitors decreased heart-failure hospitalization and the E/e’ index without affecting mortality, all-cause hospitalization, other diastolic function parameters, and the 6-min walk distance.

     

Lack of prior antiretroviral therapy is associated with increased mortality among hospitalized patients with AIDS in São Paulo, Brazil,

The death rate in adults with acquired immune deficiency syndrome (AIDS) at the Institute of Infectious Diseases "Emilio Ribas" in S?o Paulo City has decreased significantly from 29% in 1995 to 19.8% in 1999, and hospitalization time has been reduced by 4 days in the period from 1998 to 1999. Lack of antiretroviral treatment (ART) before hospitalization was associated with death during hospitalization (odds ratio [OR] = 3.8), and survival was associated with previous use of three or more antiretrovirals (OR = 0.15). Therefore, we recommend an aggressive campaign for human immunodeficiency virus (HIV) antibody screening among the at-risk populations in Brazil to assure that ART is provided when necessary.     

Sudden cardiac death in dogs with remodeled hearts is associated with larger beat–to–beat variability of repolarization

Increased proarrhythmia in dogs with chronic AV block (AVB) has been explained by ventricular remodeling causing a decrease in repolarization reserve. Beat–to–beat variability of repolarization (BVR) has been suggested to reflect repolarization reserve, in which high variability represents diminished reserve and larger propensity for repolarization–dependent ventricular arrhythmia. A subset of chronic AVB dogs (10%) suffers sudden cardiac death (SCD). With the assumption that repolarization defects constitute a potentially lethal proarrhythmic substrate, we hypothesized that BVR in SCD dogs are larger than in matched control chronic AVB dogs.From a population of 200 chronic AVB dogs, initially two groups were chosen retrospectively: 8 dogs that died suddenly (SCD) and 8 control dogs. Control dogs had a longer lifespan after AVB (10 to 18 weeks) than SCD dogs (5 to 10 weeks). All dogs had undergone electrophysiological testing under anesthesia where ECG, left and right ventricular endocardial monophasic action potentials (MAP) were recorded. BVR was assessed from 30 consecutive beats, illustrated by Poincaré plots and was the only parameter discriminating between SCD and control group. All other electrophysiological parameters (RR, QT and MAP durations) were comparable for the two groups. Extending the number of animals and groups confirmed a larger BVR in the SCD group (SCD: 5.1 ± 2.7; n = 11 versus control: 2.5 ± 0.4 ms; n = 61; P < 0.05) and showed reverse–use dependence of BVR. In comparison, dogs with acute AVB had low variability (1.3 ± 0.3 ms; n = 9; P < 0.05 versus chronic AVB).Cardiac electrical remodeling after AVB is associated with an increase in beat–to–beat variability of repolarization. Chronic AVB dogs displaying further elevated variability of repolarization are prone to arrhythmia–related SCD.Mr. Thomsen and Dr. Truin contributed equally to this study     

How could we improve the increased cardiovascular mortality in patients with overt and subclinical hyperthyroidism?

Over the past five years several meta-analyses have evaluated the cardiovascular mortality in patients with hyperthyroidism. They assessed various studies in which different inclusion criteria were used for the analysis of the cardiovascular mortality. More selective criteria have been used in recent meta-analyses. Only prospective cohort studies were included and only cohorts using second and third generation TSH assays were chosen. In addition, only the studies where the TSH evaluation was repeated during the follow-up were selected. The results of these recent meta-analyses provide evidence that overt and subclinical hyperthyroidism, particularly in patients with undetectable serum TSH, may increase the cardiovascular mortality. However, still today, the results remain inconclusive and not sufficient enough to recommend treatment for patients with low-detectable serum TSH. The high cardiovascular risk and mortality in presence of thyroid hormone excess suggest that this dysfunction is an important health problem and requires guidelines for the treatment of patients at high cardiovascular risk. Rigorous studies are necessary to evaluate the effects of the various causes of hyperthyroidism on the clinical outcomes. Randomized controlled clinical trials are needed to assess the benefits of treatment to improve the cardiovascular mortality and morbidity of mild and overt hyperthyroidism.     

What is the risk of sudden cardiac death in patients presenting with hemodynamically stable sustained ventricular tachycardia after myocardial infarction?

Objectives. This study sought to determine the long-term risk of sudden cardiac death in patients with hemodynamically stable sustained ventricular tachycardia complicating coronary artery disease.Background. The prognosis and risk of sudden cardiac death in patients with a history of myocardial infarction and ventricular tachyarrhythmias have not been clearly defined. Prior studies are limited by a short follow-up period and by inclusion of patients with heterogeneous cardiac diseases and presenting arrhythmias.Methods. A retrospective cohort analysis was performed on data from 124 patients, followed up for a mean of 36 ± 30 months, who received electrophysiologically guided therapy for hemodynamically stable ventricular tachycardia after remote myocardial infarction.Results. Seventy-eight patients were treated pharmacologically (medical group), and 46 patients underwent map-guided subendocardial resection (surgical group). Nine patients (7.3%) died suddenly, 5 (4.0%) died of noncardiac causes, 9 (7.3%) died of a perioperative complication, and 20 (23.4%) died of other cardiac causes. At 1, 2 and 3 years, sudden death occured at cumulative rates of 2 ± 1%, 3 ± 2% and 7 ± 3%, whereas total mortality was 20 ± 4%, 28 ± 4% and 32 ± 5% (mean ± SD). Sudden cardiac death (p = 0.047) and total mortality (p = 0.036) were higher in patients with multivessel disease and were similar for both treatment groups.Conclusions. Although the overall mortality in postinfarction patients presenting with hemodynamically stable ventricular tachycardia treated with electrophysiologically guided antiarrhythmic therapy is high, the risk of sudden death in these patients appears to be low (average 2.4%/year).     

Community-onset bloodstream infection during the ‘after hours’ is not associated with an increased risk for death

BACKGROUND/OBJECTIVE:

Patients admitted to hospital during the ‘after hours’ (weekends and evenings) may be at increased risk for adverse outcome. The objective of the present study was to assess whether community-onset bloodstream infections presenting in the after hours are associated with death.

METHODS:

All patients in the Victoria area of British Columbia, who had first admissions with community-onset bloodstream infections between 1998 and 2005 were included. The day of admission to hospital, the day and time of culture draw, and all-cause, in-hospital mortality were ascertained.

RESULTS:

A total of 2108 patients were studied. Twenty-six per cent of patients were admitted on a weekend. Blood cultures were drawn on a weekend in 27% of cases and, in 43%, 33%, and 25% of cases, cultures were drawn during the day (08:00 to 17:59), the evening (18:00 to 22:59) and night (23:00 to 07:59), respectively. More than two-thirds (69%) of index cultures were drawn during the after hours (any time Saturday or Sunday and weekdays 18:00 to 07:59). The overall in-hospital case fatality rate was 13%. No difference in mortality was observed in relation to the day of the week of admission or time period of sampling. After-hours sampling was not associated with mortality in a multivariable logistic regression model examining factors associated with death.

CONCLUSION:

Presentation with community-onset, bloodstream infection during the after hours does not increase the risk of death.     

Obstructive sleep apnea and sudden unexpected death in epilepsy in unselected patients with epilepsy: are they associated?

Purpose

We aimed to determine (1) the frequency of high-risk sudden unexpected death in epilepsy (SUDEP) in patients with epilepsy who have had obstructive sleep apnea (OSA) in different stages of sleep using the revised SUDEP risk inventory (rSUDEP-7) score instrument and (2) the factors associated with high risk SUDEP in patients with epilepsy who have had OSA.

Methods

We conducted a cross-sectional study of consecutive subjects who are more than 15 years old without known sleep disorders, recruited from a single epilepsy clinic in a tertiary care facility. Participants underwent polysomnography. Scoring was performed by two blinded board-certified sleep physicians. The relationships between rSUDEP-7 scores and OSA measures were evaluated using Wilcoxon rank-sum test, chi-squared test, and quantile regression.

Results

Our study population consisted of 95 participants. Overall median (IQR) apnea-hypopnea index (AHI) of our populations was 2.3 (0.7,7.5) events rate per hour; 12 (75%) patients had moderate OSA and 4 (25%) patients had severe OSA. Nine patients had a rSUDEP-7 score of 5 to 7. There was no significant difference between total rSUDEP-7 score or rSUDEP-7 score of > 5 or < 5 and total AHI, supine AHI, non-supine AHI, NREM AHI, or REM AHI; similarly, (2) there was no significant difference in total rSUDEP-7 score between AHI of < 15 or > 15.

Conclusion

Our study reveals no association between AHI score, OSA, and total rSUDEP-7 score or rSUDEP-7 score of > 5. The pathophysiology underlying SUDEP appears complex. We need further studies on SUDEP to help elucidate the cardiorespiratory mechanisms and predisposing factors.