Relationship between cardiac symptoms, myocardial perfusion defects and coronary angiography findings in systemic lupus erythematosus

Coronary angiography is generally regarded as the 'gold standard' test for diagnosing coronary artery disease (CAD). We sought to determine the relationship between cardiac symptoms and findings of coronary angiography and myocardial perfusion scintigraphy (MPS) in patients with systemic lupus erythematosus (SLE). Medical records of all SLE patients who underwent coronary angiography while attending our clinic over 24 years were reviewed, noting the indication for the test and its findings. Among patients who had MPS within 6 months prior to coronary angiography, a contingency table was used to rate the agreement between the two tests. Among the 35 patients who underwent coronary angiography, 31 had the test to investigate cardiac symptoms. Among the symptomatic patients, 17 (55%) had an abnormal angiogram with one or more plaques, while 14 (45%) had normal angiograms. All four asymptomatic patients had normal angiograms. Compared to those with normal angiograms, patients with abnormal angiograms had a higher mean number of cardiovascular risk factors per patient (1.6?±?1.4 vs. 0.6?±?1.0, p?=?0.02). Twenty-four patients had both angiography and MPS. Overall, the agreement between angiography and MPS was poor (κ?=?0, p?=?0.0008), with 14 (58.3%) patients having perfusion defects and normal angiograms. A proportion of SLE patients with cardiac symptoms do not have plaques on coronary angiography. Overall there is poor agreement between the findings of coronary angiography and MPS in SLE, suggesting mechanisms of ischemia other than plaques.     

Epicardial fat volume in patients with left ventricular systolic dysfunction

Epicardial adipose tissue has been linked to cardiovascular metabolism and inflammation and has been shown to predict prevalence and progression of coronary artery disease. Only limited data are available on the role of epicardial fat in patients with heart failure (HF). We analyzed cardiac adiposity and its relation to markers of morbidity and clinical outcome in patients with normal and impaired left ventricular (LV) function. Epicardial fat volume (EFV) and coronary artery calcium were measured in 381 patients (210 women and 171 men, mean age 55 ± 10 years) who underwent low-dose computed tomography. HF was defined by LV ejection fraction (EF) <55%. Three hundred twenty-one patients had an EF >55% (mean 63 ± 6) and 60 patients had an EF <55% (mean 41 ± 12). Subgroup analysis was performed according to degree of LV dysfunction in patients with HF (LVEF 35% to 55% or <35%). Mean EFVs were 114.5 ± 98.5 cm(3) in patients with normal EF and 83.5 ± 67.1 cm(3) in those with decreased EF (p <0.05). Mean EFVs were 96.1 ± 73.9 cm(3) in patients with moderate HF and 52.2 ± 29.7 cm(3) in patients with severe HF (p <0.05). Subgroup analysis revealed a persistently smaller EFV in patients with HF regardless of coronary artery calcium scores, markers of renal function, lipid metabolism, fasting blood glucose, or body mass index. In conclusion, our data demonstrate a stepwise decrease in EFV in patients with impaired cardiac function.     

Clinical trials update from the American College of Cardiology 2007: ALPHA, EVEREST, FUSION II, VALIDD, PARR-2, REMODEL, SPICE, COURAGE, COACH, REMADHE, pro-BNP for the evaluation of dyspnoea and THIS-diet

This article provides information and a commentary on trials relevant to the pathophysiology, prevention and treatment of heart failure, presented at the American College of Cardiology meeting in March 2007. Unpublished reports should be considered as preliminary data, as analyses may change in the final publication. The ALPHA study suggested that patients with heart failure (HF) due to idiopathic dilated cardiomyopathy who have a negative T-wave alternans test have a good prognosis and are unlikely to benefit from ICD therapy. EVEREST provides some evidence of short-term symptom benefit of tolvaptan in patients with acute decompensated HF but no clinically important long-term benefit. FUSION II failed to show a benefit of nesiritide in patients with chronic decompensated HF. Reducing blood pressure in hypertensive patients improved diastolic dysfunction in VALIDD. Eplerenone did not improve left ventricular remodelling in mild to moderate chronic HF. Selecting HF patients for revascularisation using FDG-PET imaging did not significantly improve outcome. Crataegus extract added to standard HF therapy did not reduce morbidity or mortality in SPICE. The COURAGE study, conducted in patients without HF or major cardiac dysfunction, showed that PCI did not reduce cardiac morbidity or mortality and can be safely deferred in patients with stable coronary disease on optimal medical therapy. The COACH study failed to show that HF nurse-intervention could reduce hospitalisations but did show trends to lower mortality, especially amongst patients with reduced ejection fraction; however, the smaller REMADHE study suggested striking benefits on morbidity and mortality. A large study of BNP provided additional information on its ability to distinguish cardiac and pulmonary breathlessness. The importance of dietary intervention in post-MI patients was highlighted by the findings of THIS-diet study.     

Prevalence and impact of worsening renal function in patients hospitalized with decompensated heart failure: results of the prospective outcomes study in heart failure (POSH).

AIMS: To determine the prevalence and risk factors for worsening renal function (WRF) among patients hospitalized for decompensated heart failure (HF) and the association with subsequent re-hospitalization and mortality. METHODS AND RESULTS: We prospectively enrolled 299 patients across eight European countries (mean age 68, 74% men). HF was defined using the European Society of Cardiology criteria, but only patients with a history of ejection fraction < or =40% on echocardiography were recruited. WRF was defined as an increase in serum creatinine >26 micromol/L ( approximately 0.3 mg/dL) from admission. Follow-up was 95% complete to 6 months. Nearly one-third of patients [72 of 248 patients, 29% (95% CI 26-32%)] developed WRF during hospitalization, excluding patients who had a major in-hospital complication likely to compromise renal function. The risk of WRF in this group was independently associated with serum creatinine levels on admission [odds ratio (OR) 3.02 (95% CI 1.58-5.76)], pulmonary oedema [OR 3.35 (1.79-6.27)], and a history of atrial fibrillation [OR 0.35 (0.18-0.67)]. Although the mortality of WRF patients was not increased significantly, the length of stay was 2 days longer [median 11 days (90% range (4-41) vs. 9 days (4-34), P=0.006]. The re-hospitalization rate was similar in both groups. CONCLUSION: WRF is common in patients admitted to European hospitals with decompensated HF. Such patients have longer duration admissions, but a similar mortality and re-hospitalization rate to those without WRF (if patients experiencing a major in-hospital complication are excluded).     

Acutely decompensated heart failure: characteristics of hospitalized patients and opportunities to improve their care.

Heart failure (HF) remains a major public health problem in western countries, despite the enormous progress in its diagnosis and treatment. Acute and chronic decompensated HF are leading medical causes of hospitalization among people aged over 65 years in European countries, the USA, Australia and New Zealand. However, there have been few studies on acute and chronic decompensated HF and the European Society of Cardiology (ESC) guidelines on this subject have only just been published. AIM: To evaluate the overall prevalence of hospitalization due to HF according to its subtypes, comorbidities, and decompensating factors, in the Medical Department of a central teaching hospital in an urban area. METHODS: We performed a retrospective observational study of patients admitted consecutively to the Medical Department via the emergency room between January and June 2001. Discharge casenotes on 1038 admissions were reviewed. Those with a diagnosis of HF or cardiovascular conditions associated with or precursors of HF were analyzed. Cases with a final diagnosis of HF according to the criteria of the ESC guidelines were included in the study. We evaluated the overall prevalence of HF and subtypes of cardiac dysfunction, etiological risk factors, patients' demographic characteristics, decompensating factors, comorbidity, mean length of hospital stay, and in-hospital mortality rate. RESULTS: We identified 180 patients with HF (17.4%), mean age 74.6 +/- 14; 87 were male (48%), aged 73.7 +/- 14.2, and 93 female (52%), aged 75.6 +/- 14. Left ventricular systolic dysfunction (LVSD) was present in 42.2% of cases, preserved left ventricular systolic function in 32.6%, and valvular heart disease in 10.6%. Hypertension and coronary artery disease were the main etiological risk factors (62.2% and 42.8% respectively). Atrial fibrillation was recorded in 43.4% of the patients, diabetes was diagnosed in 21.6%, and anemia and chronic obstructive pulmonary disease in about one third. Infection, predominantly respiratory, was the main factor triggering decompensation, followed by uncontrolled hypertension and supraventricular tachyarrhythmia. At admission, 42.2% of the patients were in NYHA class III and 44.8% in NYHA class IV. HF patients had a mean hospital stay of 13.8 days, slightly shorter than the mean overall stay of patients admitted to the Medical Department in the same period (14.5 days). In-hospital mortality for HF patients was 7.7%, with HF being the first cause of admission to the Medical Department, followed by stroke (10.6%). CONCLUSIONS: This study confirms the high prevalence of acute or chronic decompensated HF in patients hospitalized in the Medical Department of a central teaching hospital in an urban area. The patients were mainly elderly, of both genders, with a slightly higher proportion of HF due to LVSD. Most patients were in NYHA classes III and IV. Mean hospital stay was no longer than that of all patients admitted in the same period. The in-hospital mortality rate was low. The age-group affected and the high prevalence of multiple comorbidities emphasize the need to establish HF clinics with multidisciplinary teams to manage these patients, and health authorities must be made aware of the burden of this syndrome.     

Relationship between peripheral arterial reactive hyperemia and residual platelet reactivity after 600?mg clopidogrel

Clopidogrel reduces long-term ischemic events in patients with acute coronary syndrome or stable angina (SA) undergoing percutaneous coronary intervention (PCI). Endothelial function improvement has been proposed, among other factors, for this beneficial effect of clopidogrel, but whether this might be associated to its anti-platelet action remains unclear. We tested the hypothesis that clopidogrel improvement of peripheral vascular endothelial function might be associated with inhibition of platelet aggregation. Endothelial function was evaluated before and at least 12?h after 600?mg clopidogrel in 43 SA pts undergoing elective PCI by: (a) reactive hyperemia peripheral arterial tonometry (measuring the Endoscore); (b) circulating endothelial microparticles (EMPs). Response to clopidogrel was measured with point-of-care VerifyNow P2Y12 assay and expressed as platelet reaction unit (PRU) and percent platelet inhibition (%PI). High platelet reactivity after clopidogrel was defined as PRU?≥?240. Endothelial function improved after clopidogrel in 20 pts. Changes in Endoscore (Δ Endoscore) were significantly correlated with both PRU (r?=?-0.61, P?相似文献   

Dipstick proteinuria is an independent predictor of high on treatment platelet reactivity in patients on clopidogrel,but not aspirin,admitted for major adverse cardiovascular events

The effectiveness of aspirin and clopidogrel in patients with chronic kidney disease (CKD) suffering from acute cardiovascular events is unclear. High on treatment platelet reactivity (HTPR) has been associated with worse outcomes. Here, we assessed the association of dipstick proteinuria (DP) and renal function on HTPR and clinical outcomes. Retrospective cohort analysis of 261 consecutive, non-dialysis patients admitted for Major Adverse Cardiovascular Events (MACE) that had VerifyNow P2Y12 and VerifyNow Aspirin assays performed. HTPR was defined as P2Y12 reactivity unit (PRU)?>?208 for clopidogrel and aspirin reaction units (ARU)?>?550 for aspirin. Renal function was classified based on the estimated glomerular filtration rate (eGFR), and dipstick proteinuria was defined as ≥30?mg/dl of albumin detected on a spot analysis. All cause mortality, readmissions, and cardiac catheterizations were reviewed over 520 days. In patients on clopidogrel (n?=?106), DP was associated with HTPR, independent of eGFR, diabetes mellitus, smoking or use of proton pump inhibitor (AOR?=?4.76, p?=?0.03). In patients with acute coronary syndromes, HTPR was associated with more cardiac catheterizations (p?=?0.009) and readmissions (p?=?0.032), but no differences in in-stent thrombosis or re-stenosis were noted in this cohort. In patients on aspirin (n?=?155), no associations were seen between DP and HTPR. However, all cause mortality was significantly higher with HTPR in this group (p?=?0.038). In this cohort, DP is an independent predictor of HTPR in patients on clopidogrel, but not aspirin, admitted to the hospital for MACE.     

Antagonism of P2Y₁₂ reduces physiological thromboxane levels

Antiplatelet therapy for the management of patients with cardiovascular risks often includes a combination therapy of aspirin and clopidogrel, acting through inhibition of thromboxane generation and blockade of G(i)-coupled P2Y?? receptor, respectively. We hypothesized that ADP acting through P2Y?? regulates physiological thromboxane levels. The serum thromboxane levels in mice (n?=?3) dosed with clopidogrel and prasugrel were decreased by 83.1?±?5.3% and 94.26?±?1.75% respectively compared to untreated mice. Pre-treatment of human blood (n?=?3) ex vivo with active metabolites of clopidogrel or prasugrel led to a reduction in thromboxane levels to 16.3?±?3.2% and 4.9?±?0.8% respectively, compared to untreated human serum. We also evaluated serum thromboxane levels in P2Y receptor null mice (n?=?4). Whereas serum thromboxane levels in P2Y? null mice were similar to those in wild type littermates, those in the P2Y?? null mice were inhibited by 83.15?±?3.8%. Finally, in a pilot study, serum thromboxane levels were reduced by 76.05?±?8.41% in healthy human volunteers (n?=?6) upon dosing with clopidogrel, compared to the levels before dosing. In conclusion, P2Y?? antagonism alone can decrease physiological thromboxane levels. Thus, this study could pave way the for newer/modified treatment regimens for the management of patients with thrombotic complications who are allergic or non-responsive to aspirin.     

Emergency department predictors of survival in decompensated heart failure patients.

BACKGROUND: Several predictors of survival have been described in stable heart failure (HF) patients. Few reports have focused on decompensated patients. METHODS: We studied 170 patients who presented to the emergency department (ED) with decompensated HF. Mean age was 72.5 +/- 13 years (range 17 to 99) and 107 (63%) were male. We evaluated clinical features, in-hospital evolution, and prognostic factors related to all-cause mortality in a mean follow-up of 14 +/- 8.6 months (range 1 to 36). RESULTS: Eighteen (10.6%) patients died during the index admission. During outpatient follow-up, 45 deaths occurred. One-year survival rate for the population as a whole was 63%. Advanced age (hazard ratio [HR] = 1.27 per 10-year increment; 95% confidence interval [CI], 1.04 to 1.55; p = 0.017), mean arterial pressure (inverse relationship with total mortality, HR = 0.83 per 10 mmHg increment; 95% CI, 0.72 to 0.95; p = 0.008) and hyponatremia (HR = 2.0; 95% CI, 1.19 to 3.36; p = 0.009) were found to be independent predictors of survival. CONCLUSION: Patients who present to the ED with decompensated HF have high mortality rates. Those at increased risk can be identified early in the ED.     

Prognostic value of frontal QRS-T angle in patients undergoing myocardial revascularization or cardiac valve surgery

Background

An abnormal frontal QRS-T angle (fQRSTa) is associated with increased risk of death in primary and secondary cardiovascular prevention. The aim of this study was to evaluate the fQRSTa prognostic role in patients undergoing myocardial revascularization and/or cardiac valve surgery.

Microembolization and myonecrosis during elective percutaneous coronary interventions in diabetic patients: an intracoronary Doppler ultrasound study with 2-year clinical follow-up

Elevation of cardiac troponin I (cTnI) is a well-known complication after percutaneous coronary interventions (PCI). The aims of this study were to quantify the extent of coronary microembolization during elective PCI, to identify predisposing anatomical and procedural factors, and to evaluate its impact on long-term outcome in diabetic patients with a high cardiovascular risk. 48 patients (pts, median 66.7?years) with type 2 diabetes and coronary artery disease underwent elective PCI with stenting to treat single-vessel lesions. Real-time microembolization during PCI ("HITS") was detected by an intracoronary Doppler guide wire. Peak levels of cTnI were measured within 24?h after PCI. Pts were followed for 2?years to record major cardiac events (MACE: death, myocardial infarction, revascularization of target and non-target vessels). In 47 patients microemboli were detected during PCI. Nineteen patients showed pathologic cTnI elevation (0.13-28.9, median 0.39?μg/l). The amount of HITS correlated with cTnI levels (r?=?0.43, p?=?0.003), but not with other clinical or angiographic data. Within 2?years MACE were detected in 9 patients, who had significantly more microemboli (15.4?±?11.8 vs. 28.2?±?16.0 HITS; p?=?0.009, OR 1.07; 95?% CI 1.011-1.13) during PCI. HITS >23, but not cTnI elevation, predicted later MACE (ROC analysis, p?=?0.025). A high amount of microembolization during elective PCI in diabetic patients appears to be an indicator of greater atherosclerotic burden and accelerated coronary artery disease progression, associated with acute biomarker elevation and adverse long-term outcomes.     

Short-term outcomes in heart failure patients with chronic obstructive pulmonary disease in the community

AIM:To establish the short term outcomes of heart failure(HF)patients in the community who have concurrent chronic obstructive pulmonary disease(COPD).METHODS:We evaluated 783 patients(27.2%)with left ventricular systolic dysfunction under the care of a regional nurse-led community HF team between June 2007 and June 2010 through a database analysis.RESULTS:One hundred and one patients(12.9%)also had a diagnosis of COPD;94% of patients were treated with loop diuretics,83% with angiotensin converting enzyme inhibitors,74% with β-blockers;10.6% with bronchodilators;and 42% with aldosterone an-tagonists.The mean age of the patients was 77.9 ± 5.7 years;43% were female and mean New York Heart Association class was 2.3 ± 0.6.The mean follow-up was 28.2 ± 2.9 mo.β-blocker utilization was markedly lower in patients receiving bronchodilators compared with those not taking bronchodilators(overall 21.7% vs 81%,P < 0.001).The 24-mo survival was 93% in patients with HF alone and 89% in those with both comorbidities(P = not significant).The presence of COPD was associated with increased risk of HF hospitalization [hazard ratio(HR):1.56;95% CI:1.4-2.1;P < 0.001] and major adverse cardiovascular events(HR:1.23;95% CI:1.03-1.75;P < 0.001).CONCLUSION:COPD is a common comorbidity in ambulatory HF patients in the community and is a powerful predictor of worsening HF.It does not however appear to affect short-term mortality in ambulatory HF patients.     

强化慢病管理门诊对冠心病患者预后的影响

目的:评估强化慢病管理门诊对冠心病患者的服药依从性,心血管事件再入院率,心功能评级的影响。方法:2012年1月2013年12月在成都医学院第一附属医院心血管内科就诊的180例明确诊断冠心病的患者,分为强化管理组和一般管理组(对照组)。强化管理组每2周通过规范化慢病管理门诊方式随访,每3个月定期检测,一般管理组通过每月门诊或电话随访。观察两组患者服药依从性、心血管事件再入院率,心功能评级(NYHA评级)。结果:随访2年后发现,强化管理组阿斯匹林/氯吡格雷(74%vs.54%,P<0.01)、他汀类药物(69%vs.46%,P<0.01)、ACEI/ARB(76%vs.46%,P<0.01)和β受体阻滞剂(63%vs.42%,P<0.05)的服药率均优于一般管理组;因心血管事件再入院率也较低(26%vs.42%,P<0.05)。结论:加强对冠心病患者的规范化管理,有助于提高患者服药依从性,减少患者心血管事件再入院率。     

Comparison of the impact of short (<1 year) and long-term (> or =1 year) clopidogrel use following percutaneous coronary intervention on mortality

The optimal duration of clopidogrel administration after percutaneous coronary intervention (PCI) remains unknown. Clopidogrel is currently recommended for minimums of 1 and 12 months after bare-metal stent and drug-eluting stent implantation, respectively. To determine the impact of clopidogrel discontinuation 1 year after PCI, the outcomes of 530 consecutive patients who underwent PCI from January 2004 to July 2006, were free of cardiovascular events for 6 months after PCI, and had follow-up available for >12 months were examined. The outcomes of patients who received clopidogrel for > or =1 year were compared with those of patients who received it for <1 year. The mean age was 65 +/- 9 years. Patients often presented with acute coronary syndromes (57%), and 85% received drug-eluting stents. Clopidogrel was used for > or =1 year and for <1 year in 341 and 189 patients, respectively. During a mean follow-up period of 2.4 +/- 0.8 years, 40 patients (8%) died, 21 (4%) had acute myocardial infarctions, and 89 (17%) underwent repeat coronary revascularization. Compared with patients with clopidogrel administration for <1 year after PCI, those who received clopidogrel for > or =1 year had lower mortality (14.8% vs 3.5%, p <0.001). On multivariate analysis, clopidogrel use for > or =1 year was associated with lower mortality (hazard ratio 0.28, 95% confidence interval 0.14 to 0.59), independent of traditional cardiovascular risk factors, clinical presentation, and the use of drug-eluting stents. In conclusion, the use of clopidogrel for > or =1 year after PCI was associated with lower mortality.     

Impact of troponin I-autoantibodies in chronic dilated and ischemic cardiomyopathy

The aim of this study was to investigate the prognostic value of circulating troponin I (TNI)-autoantibodies in plasma of patients with chronic heart failure. Sera of 390 heart failure patients were tested for the presence of anti-TNI antibodies by enzyme-linked immunosorbent assay (ELISA), including 249 (63.8% of total) patients with dilated cardiomyopathy (DCM) and 141 (36.2% of total) patients with ischemic cardiomyopathy (ICM). A total of 72 patients (18.5% of total) were female and 318 (81.5% of total) were male. Mean patient age was 54.6?±?11.3?years and mean follow-up time was 3.8?±?3.2?years. TNI-autoantibodies (titer of ≥1:40) were detected in 73 out of 390 patients (18.7% of total). In TNI-autoantibody positive patients mean left ventricular ejection fraction (LVEF) was 27.6?±?5.8%, compared to 25.8?±?5.9% in TNI-autoantibody negative patients, P?=?0.03. The combined end-point of death (n?=?118, 30.3% of total) or heart transplantation (HTX) (n?=?44, 11.3% of total) was reached in 162 patients (41.5% of total). Kaplan-Meier analysis demonstrated superior survival (combined end-point of death or HTX) in patients with DCM versus ICM (P?=?0.0198) and TNI-autoantibody positive patients versus TNI-autoantibody negative patients (P?=?0.0348). Further subgroup analysis revealed a favorable outcome in TNI-positive patients with heart failure if the patients suffered from DCM (P?=?0.0334), whereas TNI-autoantibody status in patients with ICM was not associated with survival (P?=?0.8486). In subsequent multivariate Weibull-analysis, a positive TNI serostatus was associated with a significantly lower all-cause mortality in DCM patients (P?=?0.0492). The presence of TNI-autoantibodies in plasma is associated with an improved survival in patients with chronic DCM, but not ICM. This might possibly indicate a prophylactic effect of TNI-autoantibodies in this subgroup of patients, encouraging further studies into possible protective effects of antibodies against certain cardiac target structures.     

Urgent cardiac resynchronization therapy in patients with decompensated chronic heart failure receiving inotropic therapy. A case series

BACKGROUND: It remains unknown whether patients with severe decompensated class IV heart failure (HF) receiving intravenous inotropic treatment benefit from cardiac resynchronization therapy (CRT). METHODS: We identified patients who underwent urgent CRT implantation due to decompensated class IV HF necessitating intravenous inotropic therapy. RESULTS: Of 10 patients with chronic ischemic cardiomyopathy (median QRS duration of 170 ms), CRT implantation was associated with symptomatic improvement in 8 patients. The mortality rate was 50% during a median follow-up of 9.5 months, with a median CRT-to-death duration of 6 months. CONCLUSIONS: CRT was feasible among class IV patients receiving inotropic treatment and was associated with clinical improvement.     

Prognostic evaluation of ambulatory patients with advanced heart failure

Previous heart failure (HF) risk models have included clinical and noninvasive variables and have been derived largely from clinical trial databases or decompensated HF registries. The importance of hemodynamic assessment is less established, particularly in ambulatory patients with advanced HF. In this study, 513 consecutive ambulatory patients (mean age 54+/-11 years, mean left ventricular ejection fraction 20+/-9%) with symptomatic HF who underwent diagnostic right-sided cardiac catheterization as part of outpatient assessment from 2000 to 2005 were reviewed. After a total of 1,696 patient-years of follow-up, 139 (27%) patients had died and 116 (23%) had undergone cardiac transplantation. The 1- and 2-year overall survival rates (defined as freedom from death or cardiac transplantation) were 77% and 67%, respectively. Overall, 65% of patients had elevated intracardiac filling pressures, and 40% had cardiac indexes<2.2 L/min/m2. In multivariate analysis, mean pulmonary arterial pressure, cardiac index, and the severity of mitral regurgitation were the 3 strongest predictors of all-cause mortality and cardiac transplantation. Renal dysfunction was also an independent predictor of all-cause mortality. When a clinical model for Cox multivariate analysis of all-cause mortality was compared with a model that also included cardiac index and mean pulmonary arterial pressure, the chi-square score increased from 45 to 69 (p<0.0001). In conclusion, in ambulatory patients with advanced HF, hemodynamic and renal function assessments remain strong independent predictors of all-cause mortality.     

Management of clopidogrel hypersensitivity without drug interruption

Clopidogrel hypersensitivity affects up to 6% of treated patients, often leading to discontinuation of the drug. Conventional desensitization protocols incorporate a washout period off medication that may be problematic after percutaneous coronary intervention because premature discontinuation of dual antiplatelet therapy is a major risk factor for stent thrombosis. The purpose of this study was to evaluate a strategy for treating clopidogrel hypersensitivity without drug interruption using corticosteroids and antihistamines to facilitate development of physiologic tolerance. The study population consisted of 25 consecutive patients who developed clopidogrel hypersensitivity after percutaneous coronary intervention and were managed with suppressive therapy using corticosteroids and antihistamines. Treatment success (resolution of hypersensitivity symptoms without interrupting clopidogrel) was assessed, in addition to duration of clopidogrel therapy and adverse cardiac events during late follow-up (mean 670 ± 630 days). The cohort included 19 men and 6 women with a mean age of 62 ± 9 years. Drug-eluting stents were used in 16 patients (64%). Clopidogrel hypersensitivity occurred 6 ± 2 days after drug initiation. Treatment included corticosteroids (5 patients), antihistamines (5 patients), or corticosteroids and antihistamines (15 patients). Patients treated with corticosteroids received tapering courses for a mean of 10 ± 8 days. Treatment was successful with sustained symptom resolution in 22 of 25 patients (88%). Clopidogrel therapy was continued in successfully desensitized patients for 417 ± 369 days and in patients with drug-eluting stents for 529 ± 376 days. There were no deaths, myocardial infarctions, or stent thrombosis during extended follow-up. In conclusion, clopidogrel hypersensitivity can be successfully treated using short-course corticosteroids and antihistamines without interrupting drug therapy. This technique enables long-term continuation of clopidogrel and confers a low risk of adverse cardiac events.     

Prognostic significance of fragmented QRS in patients with non-ST elevation myocardial infarction

Objectives

The aim of this study was to evaluate the predictive value of fragmented QRS (fQRS) among non-ST elevation acute coronary syndrome (ACS) patients.

Design

The fQRS on standard 12-lead ECGs in 179?patients (63% males, mean age 60.9?±?12.3?years) were analyzed. Cardiac events and cardiac mortality were regarded as two outcomes to determine whether fQRS was a clinical prognostic factor; its prognostic value was then assessed adjusting for other covariates.

Results

Cardiac mortality (18 (17.0%) vs. 4 (5.5%)) and major cardiac event rate (46 (43.4%) vs. 22 (30.1%)) were higher in the fQRS group compared with the non-fQRS group during a mean follow-up of 12?months. A Kaplan–Meier survival analysis revealed significantly lower event-free survival for cardiac events (p?=?0.030) and cardiac mortality (p?=?0.020). Multivariate Cox regression analysis revealed that significant fQRS was an independent significant predictor for cardiac events and cardiac mortality.

Conclusion

These results indicate that the occurrence of fQRS in the ECG is a powerful predictor of decreased survival in NSTEMI. The prognostic importance of fQRS was incremental to clinical and conventional factors.     

Heart rate turbulence and death due to cardiac decompensation in patients with chronic heart failure

BACKGROUND: As treatment strategies for patients with chronic heart failure (HF) become more sophisticated, identifying patients at high risk of death and predicting mode of death is important. The aim of this study was to explore the potential utility of heart rate turbulence (HRT) to identify patients with HF at high risk of death. METHODS AND RESULTS: In a prospective study, 553 ambulant outpatients age 63+/-10 with symptoms of HF and evidence of cardiac dysfunction were recruited. All patients underwent 24-h Holter ECG recordings, which were analysed for arrhythmias, heart rate variability and HRT a measurement that is thought to quantify cardiac autonomic regulatory mechanisms. Baseline chest radiograph, biochemistry and 12-lead electrocardiograms were also obtained. In patients with HRT measurements at 5 years follow up, 146 patients had died, 59 due to decompensated HF. Independent predictors of death from decompensated HF at 5-year follow up (Cox proportional hazard model) were HRT slope (HR for 10% increment 0.84, 95% CI 0.77-0.91), serum sodium (HR for 10% increment 0.75, 95% CI 0.62-0.91) and serum creatinine (for 10% increment HR 1.14, 95% CI 1.08-1.19) all P<0.01. These 3 variables combined had excellent discrimination between patients dying of decompensated HF and other patients, C-statistic=0.82. CONCLUSIONS: In patients with mild-to-moderate HF, HRT slope is an independent predictor of death due to decompensated HF. HRT may have the potential to help tailor therapy in this patient group.