A New Tissue Doppler Index to Predict Cardiac Death in Patients with Heart Failure

Background

It has been shown that a new tissue Doppler index, E/(E''×S''), including the ratio between early diastolic transmitral and mitral annular velocity (E/E''), and the systolic mitral annular velocity (S''), has a good accuracy to predict left ventricular filling pressure.

Objectives

We investigated the value of E/(E''×S'') to predict cardiac death in patients with heart failure.

Methods

Echocardiography was performed in 339 consecutive hospitalized patients with heart failure, in sinus rhythm, after appropriate medical treatment, at discharge and after one month. Worsening of E/(E''×S'') was defined as any increase of baseline value. The end point was cardiac death.

Results

During the follow-up period (35.2 ± 8.8 months), cardiac death occurred in 51 patients (15%). The optimal cut-off value for the initial E/(E''×S'') to predict cardiac death was 2.83 (76% sensitivity, 85% specificity). At discharge, 252 patients (74.3%) presented E/(E''×S'') ≤ 2.83 (group I) and 87 (25.7%) presented E/(E''×S'') > 2.83 (group II), respectively. Cardiac death was significantly higher in group II than in group I (38 deaths, 43.7% vs 13 deaths, 5.15%, p < 0.001). By multivariate Cox regression analysis, including variables that affected outcome in univariate analysis, E/(E''×S'') at discharge was the best independent predictor of cardiac death (hazard ratio = 3.09, 95% confidence interval = 1.81-5.31, p = 0.001). Patients with E/(E''×S'') > 2.83 at discharge and its worsening after one month presented the worst prognosis (all p < 0.05).

Conclusions

In patients with heart failure, the E/(E''×S'') ratio is a powerful predictor of cardiac death, particularly if it is associated with its worsening.     

Temporal Variation in the Prognosis and Treatment of Advanced Heart Failure - Before and After 2000

Background

The treatment of heart failure has evolved in recent decades suggesting that survival is increasing.

Objective

To verify whether there has been improvement in the survival of patients with advanced heart failure.

Methods

We retrospectively compared the treatment and follow-up data from two cohorts of patients with systolic heart failure admitted for compensation up to 2000 (n = 353) and after 2000 (n = 279). We analyzed in-hospital death, re-hospitalization and death in 1 year of follow-up. We used Mann-Whitney U test and chi-square test for comparison between groups. The predictors of mortality were identified by regression analysis through Cox proportional hazards model and survival analysis by the Kaplan-Meier survival analysis.

Results

The patients admitted until 2000 were younger, had lower left ventricular impairment and received a lower proportion of beta-blockers at discharge. The survival of patients hospitalized before 2000 was lower than those hospitalized after 2000 (40.1% vs. 67.4%; p<0.001). The independent predictors of mortality in the regression analysis were: Chagas disease (hazard ratio: 1.9; 95% confidence interval: 1.3-3.0), angiotensin-converting-enzyme inhibitors (hazard ratio: 0.6; 95% confidence interval: 0.4-0.9), beta-blockers (hazard ratio: 0.3; 95% confidence interval: 0.2-0.5), creatinine ≥ 1.4 mg/dL (hazard ratio: 2.0; 95% confidence interval: 1.3-3.0), serum sodium ≤ 135 mEq/L (hazard ratio: 1.8; 95% confidence interval: 1.2-2.7).

Conclusions

Patients with advanced heart failure showed a significant improvement in survival and reduction in re-hospitalizations. The neurohormonal blockade, with angiotensin-converting-enzyme inhibitors and beta-blockers, had an important role in increasing survival of these patients with advanced heart failure.     

Death and Disability in Patients with Sleep Apnea - A Meta-analysis

Background

Several studies have been attempting to ascertain the risks of Sleep Apnea Syndrome (SAS) and its morbidity and mortality.

Objective

The main objective was to verify whether SAS increases the risk of death; the secondary objective was to evaluate its morbidity in relation to cardiovascular disease and the number of days hospitalized.

Methods

A systematic review and a meta-analysis were performed of the published literature. The research focused on studies comparing the number of deaths in patients with untreated SAS and in patients with non-SAS.

Results

The meta-analysis was based on 13 articles, corresponding to a total of 13394 participants divided into two groups (non-SAS = 6631; SAS = 6763). The meta-analysis revealed a clear association of SAS with the occurrence of fatal events, where the presence of SAS corresponded to a 61% higher risk of total mortality (OR=1.61; CI: 1.43 - 1.81; p < 0.00001), while the risk of death from cardiac causes was 2.52 times higher in these patients (OR = 2.52; IC: 1.80 - 3.52; p < 0.00001). Similar results were obtained for mortality from other causes (OR = 1.68; CI: 1.08 - 2.61; p = 0.02). Resembling results were obtained in the remaining outcomes: non-fatal cardiovascular events were higher in the SAS group (OR = 2.46; IC: 1.80 - 3.36; p < 0.00001), the average number of days hospitalized was also higher in the SAS group (IV = 18.09; IC: 13.34 - 22.84; p < 0.00001).

Conclusion

The results show that untreated SAS significantly increases the risk of death, cardiovascular events and the average number of days hospitalized.     

Sudden Cardiac Death in Brazil: A Community-Based Autopsy Series (2006-2010)

Background

Sudden cardiac death (SCD) is a sudden unexpected event, from a cardiac cause, that occurs in less than one hour after the symptoms onset, in a person without any previous condition that would seem fatal or who was seen without any symptoms 24 hours before found dead. Although it is a relatively frequent event, there are only few reliable data in underdeveloped countries.

Objective

We aimed to describe the features of SCD in Ribeirão Preto, Brazil (600,000 residents) according to Coroners’ Office autopsy reports.

Methods

We retrospectively reviewed 4501 autopsy reports between 2006 and 2010, to identify cases of SCD. Specific cause of death as well as demographic information, date, location and time of the event, comorbidities and whether cardiopulmonary resuscitation (CPR) was attempted were collected.

Results

We identified 899 cases of SCD (20%); the rate was 30/100000 residents per year. The vast majority of cases of SCD involved a coronary artery disease (CAD) (64%) and occurred in men (67%), between the 6^th and the 7^th decades of life. Most events occurred during the morning in the home setting (53.3%) and CPR was attempted in almost half of victims (49.7%). The most prevalent comorbidity was systemic hypertension (57.3%). Chagas’ disease was present in 49 cases (5.5%).

Conclusion

The majority of victims of SCD were men, in their sixties and seventies and the main cause of death was CAD. Chagas’ disease, an important public health problem in Latin America, was found in about 5.5% of the cases.     

Aortic Counterpulsation Therapy in Patients with Advanced Heart Failure: Analysis of the TBRIDGE Registry

Background

The use of aortic counterpulsation therapy in advanced heart failure is controversial.

Objectives

To evaluate the hemodynamic and metabolic effects of intra-aortic balloon pump (IABP) and its impact on 30-day mortality in patients with heart failure.

Methods

Historical prospective, unicentric study to evaluate all patients treated with IABP betwen August/2008 and July/2013, included in an institutional registry named TBRIDGE (The Brazilian Registry of Intra-aortic balloon pump in Decompensated heart failure - Global Evaluation). We analyzed changes in oxygen central venous saturation (ScvO₂), arterial lactate, and use of vasoactive drugs at 48 hours after IABP insertion. The 30-day mortality was estimated by the Kaplan-Meier method and diferences in subgroups were evaluated by the Log-rank test.

Results

A total of 223 patients (mean age 49 ± 14 years) were included. Mean left ventricle ejection fraction was 24 ± 10%, and 30% of patients had Chagas disease. Compared with pre-IABP insertion, we observed an increase in ScvO₂ (50.5% vs. 65.5%, p < 0.001) and use of nitroprusside (33.6% vs. 47.5%, p < 0.001), and a decrease in lactate levels (31.4 vs. 16.7 mg/dL, p < 0.001) and use of vasopressors (36.3% vs. 25.6%, p = 0.003) after IABP insertion. Thirty-day survival was 69%, with lower mortality in Chagas disease patients compared without the disease (p = 0.008).

Conclusion

After 48 hours of use, IABP promoted changes in the use of vasoactive drugs, improved tissue perfusion. Chagas etiology was associated with lower 30-day mortality. Aortic counterpulsation therapy is an effective method of circulatory support for patients waiting for heart transplantation.     

Preditores de Mortalidade Total e Eventos Arrítmicos Graves em Pacientes com Insuficiência Cardíaca Não Isquêmica: O Papel da Galectina-3

Background:Risk stratification remains clinically challenging in patients with heart failure (HF) of non-ischemic etiology. Galectin-3 is a serum marker of fibrosis that might help in prognostication.Objective:To determine the role of galectin-3 as a predictor of major arrhythmic events and overall mortality.Methods:We conducted a prospective cohort study that enrolled 148 non-ischemic HF patients. All patients underwent a comprehensive baseline clinical and laboratory assessment, including levels of serum galectin-3. The primary outcome was the occurrence of arrhythmic syncope, appropriate implantable cardioverter defibrillator therapy, sustained ventricular tachycardia, or sudden cardiac death. The secondary outcome was all-cause death. For all statistical tests, a two-tailed p-value<0.05 was considered significant.Results:In a median follow-up of 941 days, the primary and secondary outcomes occurred in 26 (17.5%) and 30 (20%) patients, respectively. Serum galectin-3>22.5 ng/mL (highest quartile) did not predict serious arrhythmic events (HR: 1.98, p=0.152). Independent predictors of the primary outcome were left ventricular end-diastolic diameter (LVEDD)>73mm (HR: 3.70, p=0.001), exercise periodic breathing (EPB) on cardiopulmonary exercise testing (HR: 2.67, p=0.01), and non-sustained ventricular tachycardia (NSVT)>8 beats on Holter monitoring (HR: 3.47, p=0.027). Predictors of all-cause death were galectin-3>22.5 ng/mL (HR: 3.69, p=0.001), LVEDD>73mm (HR: 3.35, p=0.003), EPB (HR: 3.06, p=0.006), and NSVT>8 beats (HR: 3.95, p=0.007). The absence of all risk predictors was associated with a 91.1% negative predictive value for the primary outcome and 96.6% for total mortality.Conclusions:In non-ischemic HF patients, elevated galectin-3 levels did not predict major arrhythmic events but were associated with total mortality. Absence of risk predictors revealed a prevalent subgroup of HF patients with an excellent prognosis.     

Reverse Cardiac Remodeling: A Marker of Better Prognosis in Heart Failure

In heart failure syndrome, myocardial dysfunction causes an increase in neurohormonalactivity, which is an adaptive and compensatory mechanism in response to thereduction in cardiac output. Neurohormonal activity is initially stimulated in anattempt to maintain compensation; however, when it remains increased, it contributesto the intensification of clinical manifestations and myocardial damage. Cardiacremodeling comprises changes in ventricular volume as well as the thickness and shapeof the myocardial wall. With optimized treatment, such remodeling can be reversed,causing gradual improvement in cardiac function and consequently improvedprognosis.     

钙通道自身抗体预测慢性心力衰竭患者死亡风险的研究

目的目前的研究发现钙通道A身抗体（CC—AAbs）参与r扩张型心肌病（DCM）的发病并起到重要作用,其在缺血性心肌病（ICM）所敛慢性心力衰竭（CHF）中是否具有作用尚不清楚,本研究旨在评价CC—AAbs在ICM导致的CHF患者中的表达水平及作用方法共人选1255例CHF组患者及834例对照组受斌者,酶联免疫法检测CC—AAbs的表达水平,应用Kaplan—Meier曲线及CoxⅫ¨愉验进行组问比较,并分析CC—AAbs表达与1CM病人预后的相关性,确定CC—AAbs是否为ICM患者猝死（SCD）、非猝死性死广（NSCD）和全因死亡的独立预测因子结果完成随访1099例,失访156例（失访率12．4％）,发生死亡330例,猝死121例．随访中位数为52月（0．40—92月）CHF患者中CC—AAbs的阳性表达明显高于正常对照（4．64％VS．1．20％,p〈0．001）。Cox回归分析表明阳性CC—AAbs‘jCHF患者的死亡呈明显正相关,CC—AAbs阳性可以预测ICM患者的猝死（HR：2．805,95％CI：1．488—5．288）、菲猝死性死亡（HR：1．887．95％CI：I．081—3．293）及全因死亡（HR：2．219,95％CI：1．461—3,371）。结论我们的研究表明：ICM导致的CHF患曹中CC—AAbs的水平明显增加．并HCC．AAbs的表达与CHF患者的SCD、NSCD及伞因北亡具有明最相关性．是CHF患者SCD、NSCD和伞因北亡的独市预测因子     

Optimized Treatment and Heart Rate Reduction in Chronic Heart Failure

Background

Heart failure (HF) is a syndrome that leads to poor outcome in advanced forms. The neurohormonal blockade modifies this natural history; however, it is often suboptimal.

Objective

The aim of this study is to assess at what percentage cardiologists used to treating HF can prescribe target doses of drugs of proven efficacy.

Methods

A total of 104 outpatients with systolic dysfunction were consecutively enrolled, all under stabilized treatment. Demographic and treatment data were evaluated and the doses achieved were verified. The findings are shown as percentages and correlations are made between different variables.

Results

The mean age of patients was 64.1 ± 14.2 years, with SBP =115.4 ± 15.3, HR = 67.8 ± 9.4 bpm, weight = 76.0 ± 17.0 kg and sinus rhythm (90.4%). As for treatment, 93.3% received a RAS blocker (ACEI 52.9%), all received beta-blockers (BB), the most often prescribed being carvedilol (92.3%). As for the doses: 97.1% of those receiving an ARB were below the optimal dose and of those who received ACEI, 52.7% received an optimized dose. As for the BB, target doses were prescribed to 76.0% of them. In this group of patients, most with BB target dose, it can be seen that 36.5% had HR ≥ 70 bpm in sinus rhythm.

Conclusion

Cardiologists used to treating HF can prescribe target doses of ACEI and BB to most patients. Even though they receive the recommended doses, about one third of patients persists with HR > 70 bpm and should have their treatment optimized.     

Sudden Unexpected Death in Children with Heart Disease

Objective. To review a mortality database, and identify all sudden unexpected deaths in patients followed by the cardiac program. Design. Retrospective review of prospectively maintained database. Results. Over 8 years, we identified 80 sudden unexpected deaths, among which there were sufficient data in 69 (24 females). Patients died at a median age of 17.2 months (28 days?18.8 years). Forty‐six patients had 2 functional ventricles and 23 had received palliation for a single‐functional ventricle. Patients with a single ventricle died at a younger age (median 120 days; 28 days?17.2 years) and sooner after last assessment (median 27 days; 1–146 days) than patients in the biventricular group (median age 2 years; 43 days?18.8 years; median time since last assessment 49 days, 1 days?1 year) (P < .01; P = .01). Thrombosis was the most common cause (61%) of death in the single‐ventricle group. Arrhythmia or presumed arrhythmia was the most common cause (46%) of death in the biventricular group. Fifty‐one patients had undergone surgery. Six patients had primary electrophysiological disease, and 5 had cardiomyopathy. Eight deaths occurred in patients with pulmonary vascular disease. Conclusion. Our study demonstrates that sudden unexpected death occurred at a frequency of at least 10 patients per year over an 8‐year period with 55 730 patient encounters. We were able to determine a clinical cause of death in most patients. Arrhythmias (30%) and pulmonary vascular disease (13%) are important causes of sudden death. Simple aortic valve disease and hypertrophic cardiomyopathy are rare (4%) causes of sudden death in childhood. Infants and young children with surgical shunts comprise 23% of sudden unexpected deaths that occur within a month of the last evaluation. Close surveillance of these patients is warranted.     

Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure

Introduction

Although diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF.

Objective

The aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure.

Methods

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome.

Results

A total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): −2.65 to −0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = −0.25 mg/dL; 95% CI: −0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64–1.56; p = 0.993).

Conclusion

Compared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality was observed.     

Sudden Cardiac Arrest in a Young Patient with Hypertrophic Cardiomyopathy and Zero Canonical Risk Factors: The Inherent Limitations of Risk Stratification in Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy is the most common heritable cardiovascular disease and a common cause of sudden cardiac death (SCD) in young adolescents and athletes. Clinical risk stratification for SCD is predicated on the presence of established risk factors; however, this assessment is far from perfect. Herein, we present a 16‐year‐old male who was resuscitated successfully from his sentinel event of out‐of‐hospital cardiac arrest. Prior to this event, he was asymptomatic and lacked all traditional SCD‐predisposing risk factors for hypertrophic cardiomyopathy.