Long-Term Survival in Patients Treated with Cardiac Resynchronization Therapy: A 3-Year Follow-Up Study from the InSync/InSync ICD Italian Registry

Background: Studies reporting the long-term survival of patients treated with cardiac resynchronization therapy (CRT) outside the realm of randomized controlled trials are still lacking. The aim of this study was to quantify the survival of patients treated with CRT in clinical practice and to investigate the long-term effects of CRT on clinical status and echocardiographic parameters.
Methods: The study population consisted of 317 consecutive patients with implanted CRT devices from eight Italian University/Teaching Hospitals. The patients were enrolled in a national observational registry and had a minimum follow-up of 2 years. A visit was performed in surviving patients and mortality data were obtained by hospital file review or direct telephone contact.
Results: During the study period, 83 (26%) patients died. The rate of all-cause mortality was significantly higher in ischemic than nonischemic patients (14% vs 8%, P = 0.002). Multivariate analysis showed that ischemic etiology (HR 1.72, CI 1.06–2.79; P = 0.028) and New York Heart Association (NYHA) class IV (HR 2.87, CI 1.24–6.64; P = 0.014) were the strongest predictors of all-cause mortality. The effects of CRT persisted at long-term follow-up (for at least 2 years) in terms of NYHA class improvement, increase of left ventricular ejection fraction, decrease of QRS duration (all P = 0.0001), and reduction of left ventricular end-diastolic and end-systolic diameters (P = 0.024 and P = 0.011, respectively).
Conclusions: During long-term (3 years) follow-up after CRT, total mortality rate was 10%/year. The outcome of ischemic patients was worse mainly due to a higher rate of death from progressive heart failure. Ischemic etiology along with NYHA class IV was identified as predictors of death. Benefits of CRT in terms of clinical function and echocardiographic parameters persisted at the time of long-term follow-up.     

Prediction of Response to Cardiac Resynchronization Therapy: The Selection of Candidates for CRT (SCART) Study

Background: The aim of this study was to evaluate the ability of baseline clinical and echocardiographic parameters to predict a positive response to CRT.
Methods: We analyzed 6-month data from the first 133 consecutive patients enrolled in a multicenter prospective study. These patients had symptomatic heart failure (HF) refractory to pharmacological therapy (NYHA class II–IV), left ventricular ejection fraction (LVEF) ≤35%, and prespecified electrocardiographic, echocardiographic or tissue Doppler imaging markers of left ventricular (LV) dyssynchrony.
Results: After a follow-up period of 6 months, 1 patient died and 13 were hospitalized for worsening HF. There were significant (P < 0.01) clinical, functional, and echocardiographic improvements that included: New York heart Association Class, Quality-of-Life Score, QRS duration, LVEF, LV end-diastolic and end-systolic diameter (LVESD), and severity of mitral regurgitation A positive response was documented in 90/133 (68%) patients who presented an improved clinical composite score associated to an increase in LVEF ≥ 5 units. A multivariate analysis identified that a smaller LVESD (OR = 0.957, 95% CI 0.920–0.996; P = 0.030) and longer interventricular mechanical delay (IVMD) (OR = 1.017, 95% CI 1.005–1.029, P = 0.007) as independent predictors of a positive response. Receiver-operating curve analysis showed that a positive response to CRT may be predicted in patients with IVMD > 44 ms (with a sensitivity of 66% and a specificity of 55%) or with LVESD < 60 mm (with a sensitivity of 66% and a specificity of 61%).
Conclusions: Our results confirm the limited value of QRS duration in the selection of patients for CRT.
A less-advanced stage of disease and echocardiographic evidence of interventricular dyssynchrony demonstrated to predict response to CRT, while intraventricular dyssynchrony did not predict response.     

Depression of Heart Rate Variability in Patients with Increased Ventricular Wall Stress

Background: Heart failure is characterized by neurohumoral dysfunction that can be assessed by measurement of heart rate variability (HRV). Depression of HRV is related to several hemodynamic parameters. We hypothesized that an increased left ventricular (LV) wall stress is related to a depressed HRV in patients with LV dilatation or dysfunction.
Methods: Cardiac function and mass were measured in 31 patients with LV dilatation or dysfunction and 21 controls using cardiac magnetic resonance (CMR) imaging. LV wall stress was calculated using a CMR-based thick-walled sphere model. Standard deviation of normal-to-normal (NN) intervals (SDNN) and average NN intervals over 5 minutes (SDANN-i) were calculated.
Results: LV end-diastolic (ED) and end-systolic (ES) wall stress were significantly increased in patients with SDNN < 75 ms (P < 0.05). SDNN and SDANN-i were decreased (P = 0.001, P < 0.001) in patients with LVED wall stress >8 kPa and LVES wall stress >30 kPa (P < 0.05). To examine potential effects of LVEF, LVED and LVES volume, and wall stress on HRV, a multiple linear regression analysis was performed, which revealed LVED wall stress as the only independent parameter influencing SDNN (P = 0.039). LV ejection fraction, LV mass, and volumes were not significantly related to HRV.
Conclusions: LV wall stress was independently related with depression of HRV. Therefore, LV wall stress might be prognostically important and a therapeutic target in heart failure.     

Heart rate variability following neonatal heart surgery for complex congenital heart disease

BACKGROUND: Altered cardiac autonomic control may play a role in the morbidity and mortality suffered by neonates who undergo surgery for complex congenital heart disease (CHD). The purpose of this study was to evaluate cardiac autonomic activity, as measured by spectral indices of heart rate variability (HRV), prior to and early after infant surgery for CHD and attempt to correlate HRV indices with clinical outcome. In addition, we assessed the hypothesis that single-ventricle physiology and surgical interruption of the great arteries negatively affects HRV. METHODS: Sixty neonates prospectively wore 24-hour Holter monitors at three time points: before and early after CHD surgery, and at 3- to 6-month follow-up. Standard spectral indices of HRV were measured. RESULTS: In the early postoperative time point, patients with single-ventricle physiology had lower low-frequency power (LF) compared to patients with two ventricles (P=0.040). Surgical interruption of the great arteries did not affect HRV in this cohort. For the entire cohort, LF (P=0.004) and high-frequency power (HF) (P<0.001) increased over the three time points, while LF/HF (P=0.119) did not significantly change. In the multivariable linear regression model, significant predictors of longer postoperative hospital stay included longer total support time (P=or<0.001), longer duration of inotrope support (P=0.012), elevated mean heart rate at postoperative time point (P=0.002), and lower LF/HF ratio at the postoperative time point (P=0.014). CONCLUSION: Patients with single-ventricle physiology have a significant physiologic reduction in LF in the early postoperative period compared to patients with two ventricles. Diminished cardiac autonomic control is associated with longer hospitalization following neonatal cardiac surgery.     

Long-Term Outcomes of CRT-PM Versus CRT-D Recipients

Objective: To compare the rates of all-cause mortality in recipients of cardiac resynchronization therapy devices without (CRT-PM) versus with defibrillator (CRT-D).
Methods: Between February 1999 and July 2004, 233 patients (mean age = 69 ± 8 years, 180 men) underwent implantation of CRT-PM or CRT-D devices. New York Heart Association (NYHA) heart failure functional class II was present in 11%, class III in 69%, and class IV in 20% of patients; mean left ventricle ejection fraction (LVEF) was 26.5 ± 6.5 %, 48% presented with idiopathic dilated cardiomyopathy and 49% with ischemic heart disease. Cox multiple variable regression analysis was performed in search of predictors of death.
Results: The clinical characteristics of the 117 CRT-PM and 116 CRT-D recipients were similar, except for LVEF (28.2 ± 6.2% vs 25.0 ± 6.5%, respectively; P < 0.001), and ischemic versus nonischemic etiology of heart failure (41% vs 56%, respectively P = 0.02). Over a mean follow-up of 58 ± 15 months, no significance difference in overall mortality rate was observed between the two study groups. Male sex, NYHA functional class IV, and atrial fibrillation at implant were significant predictors of death.
Conclusions: There was no difference in long-term survival rate among patients with CRT-D versus CRT-PM, although CRT-D more effectively lowered the sudden death rate. Male sex, NYHA functional class IV, and atrial fibrillation predicted the worst prognosis.     

Elevated serum creatinine at baseline predicts poor outcome in patients receiving cardiac resynchronization therapy

Background: Renal insufficiency is recognized as a predictor of mortality and poor outcome in heart failure patients. We sought to study the impact of baseline serum creatinine on subsequent outcome in cardiac resynchronization therapy ( CRT) recipients.
Methods: We retrospectively reviewed hospital records of all CRT recipients at Pittsburgh Veterans Affairs (VA) Healthcare System (2003–2005) and University of Pittsburgh Medical Center (2004) . We recorded clinical characteristics at the time of implantation including demographics, New York Heart Association (NYHA) functional class, ejection fraction, QRS duration, cardiomyopathy etiology, medical history, medication use, and serum creatinine. Mortality alone and mortality combined with heart failure hospitalization were the study endpoints.
Results: Out of the 330 patients studied, a total of 66 (20.0%) patients died over a mean follow-up duration of 19.7 ± 9.0 months (range 1–44). The cohort was studied by three creatinine tertiles (0.6–1.0, 1.1–1.3, 1.4–3.0 mg/dL). Both study endpoints were observed more frequently in patients in the highest creatinine tertile compared to others (28.7% vs 14.0%, P = 0.008 for death and 41.6% vs 21.5%, P = 0.001 for the combined endpoint). High creatinine remained an independent predictor of mortality (hazard ratio [HR] 1.89, 95% confidence interval [CI] 1.06–3.39, P = 0.032) and the combined endpoint (HR 1.94, 95% CI 1.20–3.13, P = 0.007) in multivariate adjusted models. Studied as a continuous variable, increase in creatinine level by 0.1 mg/dL was associated with an 11% increase in mortality risk and a 7% increase in the combined endpoint.
Conclusion: In an unselected cohort of CRT recipients, the baseline creatinine was found to predict worse survival and poor outcome over a modest follow-up duration.     

Extraordinarily favorable left ventricular reverse remodeling through long-term cardiac resynchronization: super-response to cardiac resynchronization

Background: Some chronic heart failure (CHF) patients show remarkable improvement in left ventricular (LV) remodeling after cardiac resynchronization therapy (CRT), for unclear reasons. This study aimed at identifying predictors of an extraordinarily favorable response to CRT. Methods: We studied 136 CRT patients (104 men, median 66 years, QRS 162 ms, left ventricular ejection fraction 24 ± 7%, 70% coronary disease, all left bundle branch block [LBBB]). We measured LV end diastolic diameter (LVEDD) before and after long‐term (9.4 ± 6.3 months) CRT. At baseline, LV pre‐ejection interval (LVPEI), interventricular mechanical delay (IVMD), LV dyssynchrony (standard deviation of electromechanical delays [SDEMD] in eight LV segments), exercise capacity (pVO₂), and ventilatory efficiency (VE/VCO₂) were assessed. Patients with a LVEDD reduction beyond the 80th percentile (high responders [HR]) were compared to low responders (LR). Results: In the HR group (n = 22), LVEDD was reduced from 71 to 52 mm (LR 64–61 mm, P < 0.001). HR had predominantly nonischemic heart disease (HR: 72%, LR: 44%, P = 0.019), tended to have a wider QRS (HR: 178 ms, LR: 162 ms, P = 0.066), had a longer LVPEI (HR: 179 ms, LR: 155 ms, P = 0.004), wider IVMD (HR: 60 ms, LR 48 ms, P = 0.05), larger LVEDD (P = 0.002), higher SDEMD (HR: 69 ms, LR: 46 ms, P = 0.044), but higher pVO₂ (HR: 17.5 mL/min/kg, LR: 13.5 mL/kg/min, P = 0.025) and lower VE/VCO₂ (HR: 31, LR: 35, P = 0.043), all compared to LR patients. Conclusion: Extraordinarily favorable reverse LV remodeling through CRT in CHF and LBBB appears to require a particularly dilated LV due to nonischemic heart disease with pronounced electromechanical alteration, but with a fairly preserved functional capacity before CRT. (PACE 2012;XX:1–7)     

Left Ventricular Ejection Fraction as Criterion for Implantation of an Implantable Cardioverter-Defibrillator in Heart Failure Patients Undergoing Surgical Left Ventricular Reconstruction

Background: Besides implantation of an implantable cardioverter-defibrillator (ICD), a proportion of patients with left ventricular (LV) dysfunction due to ischemic cardiomyopathy are potential candidates for surgical LV reconstruction (Dor procedure), which changes LV ejection fraction (LVEF) considerably. In these patients, LVEF as selection criterium for ICD implantation may be difficult. This study aimed to determine the value of LVEF as criterium for ICD implantation in heart failure patients undergoing surgical LV reconstruction.
Methods: Consecutive patients with end-stage heart failure who underwent ICD implantation and LV reconstruction were evaluated. During admission, two-dimensional (2D) echocardiography (LV volumes and LVEF) was performed before surgery and was repeated at 3 months after surgery. Over a median follow-up of 18 months, the incidence of ICD therapy was evaluated.
Results: The study population consisted of 37 patients (59 ± 11 years). At baseline, mean LVEF was 23 ± 5%. Mean left ventricular end-systolic volume (LVESV) and left ventricular end-diastolic volume (LVEDV) were 175 ± 73 mL and 225 ± 88 mL, respectively. At 3-month follow-up, mean LVEF was 41 ± 9% (P < 0.0001 vs. baseline), and mean LVESV and LVEDV were 108 ± 65 mL and 176 ± 73 mL, respectively (P < 0.0001 vs. baseline). During 18-month follow-up, 12 (32%) patients had ventricular arrhythmias, resulting in appropriate ICD therapy. No significant relations existed between baseline LVEF (P = 0.77), LVEF at 3-month follow-up (P = 0.34), change in LVEF from baseline to 3-month follow-up (P = 0.28), and the occurrence of ICD therapy during 18-month follow-up.
Conclusion: LVEF before and after surgical LV reconstruction is of limited use as criterium for ICD implantation in patients with end-stage heart failure.     

Lack of diurnal variation of P-wave and QT dispersions in patients with heart failure

Background: P-wave dispersion (PWD) is a new parameter for the assessment of risk of atrial fibrillation and has been reported to be increased in heart failure. Diurnal variation of the PWD has been reported in patients with coronary artery disease (CAD). QT dispersion (QTD) has also a circadian variation. In this study we aimed to search diurnal variation of PWD and QTD in patients with heart failure.
Methods: Fifty-three clinical heart failure patients having left ventricular ejection fraction (LVEF) <40% were divided into two groups according to presence of CAD. Twelve-lead ECGs were obtained in the morning (07:00–08:00 hours), at noon (12:00–14:00 hours), and at night (22:00–24:00 hours).
Results: All the patients were in New York Heart Association class II except one in class I. β-blocker and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker usage was over 80% and spiranolactone usage was around 75% in the study group. PWD and QTD were not significantly different between patients with (n = 27) and without (n = 26) CAD. There was no significant diurnal variation of P wave and QT parameters.
Conclusions: We found that PWD and QTD do not show diurnal variation in patients having either ischemic or nonischemic origin of heart failure treated with optimal drug therapy.     

Three Years of Cardiac Resynchronization Therapy: Could Superior Benefits be Obtained in Patients with Heart Failure and Narrow QRS?

Aim of the study: To examine the long-term effects of cardiac resynchronization therapy (CRT) in patients presenting with heart failure (HF) and QRS ≤120 ms.
Methods: This was a prospective, longitudinal study of 376 patients [mean age = 65 years, mean left ventricular (LV) ejection fraction (EF) = 29%, mean QRS duration =165 ms, mean distance covered during a 6-minute hall walk (6-MHW) = 325 m], who underwent successful implantation of CRT systems. The QRS duration at baseline was ≤120 ms in 45 patients (12%) who were not pre-selected by echocardiographic criteria of dyssynchrony, and >120 ms in the remaining 331 patients. The baseline characteristics of the 2 groups were similar. We evaluated indices of cardiac function, percentage of responders, and survival rates over a mean 28-month follow-up.
Results: Both groups experienced similar long-term increases in 6-MHW, and decreases in New York Heart Association functional class and LV end-systolic volume (all comparisons P < 0.0001 in both groups). Time interaction of changes in LVEF and percentage of responders were significantly different (P = 0.03 and P = 0.004, respectively), in favor of the narrow QRS group, where the changes were sustained and persisted at 2 and 3 years. The long-term death rate from HF was lower in the group with narrow than in the group with wide QRS complex (P = 0.04; log-rank test).
Conclusions: CRT confers considerable long-term clinical, functional, and survival benefits in patients presenting with HF and narrow QRS, not preselected by echocardiographic criteria of dyssynchrony. Caution is advised before denying CRT to these patients on the basis of QRS width only.     

Cardiac resynchronization therapy: gender related differences in left ventricular reverse remodeling

AIM: Gender related differences in epidemiology, treatment, and prognosis of heart failure (HF) have been reported. We examined the sex influence in patients treated with cardiac resynchronization therapy (CRT). METHODS AND RESULTS: Out of 334 consecutive HF patients (19.7% women) who underwent CRT, 195 patients reached clinical and echocardiographic evaluation at six and 12 months and were selected for analysis. A reduction in left ventricular (LV) end-diastolic volume/m(2) (EDVi) and end systolic volume/m(2) (ESVi) was evident in the overall population at six months (P < 0.001) and from six to 12 months (P < 0.001). Compared to men, women showed significantly greater changes in LV volumes at mid (P < 0.05) and long-term (P < 0.001) follow-up and a significantly higher LV ejection fraction (EF) (40.8 +/- 12.3 vs 34.1 +/- 10.1, P < 0.01) at one year. Multiple regression analysis, including several demographic and clinical parameters, revealed that female gender is independently associated with greater reduction in LV ESVi. At the 12-month follow-up, the proportion of responders (defined in terms of ESV reduction by at least 10%) was higher in women than in men (76.1% vs 59.3%, P < 0.05). CONCLUSIONS: CRT induced a gender specific LV remodeling response.     

Effects of Cardiac Resynchronization Therapy on Heart Rate Turbulence

Background: Cardiac resynchronization therapy (CRT) improves the clinical status of patients with heart failure (HF), though its effects on heart rate turbulence (HRT) are unknown.
Methods: We measured HRT indices in 58 recipients of CRT systems (mean age = 56 ± 9 years, 41 men) in New York Heart Association HF functional class III–IV, and with a left ventricular (LV) ejection fraction ≤35%. At 6 months of follow-up, 42 patients were responders and 13 nonresponders to CRT, and three patients died suddenly. The HRT indices turbulence onset (TO%) and turbulence slope (TS ms/RR interval) were calculated from digital 24-hour electrocardiogram before and after 6 months of CRT. TO ≥ 0% and TS ≤ 2.5 ms/RR interval were considered abnormal.
Results: Mean TO in the entire population was 0.4 ± 1.5 before CRT, and decreased to −0.8 ± 7.0 during the 6 months of CRT (ns). TS increased significantly from 2.0 ± 1.7 at baseline, to 3.9 ± 3.1 (P < 0.05), and a significantly lower proportion of patients had abnormal HRT indices at 6 months. In contrast to the significant increase observed in responders, not significant change in TS was observed among the nonresponders.
Conclusions: During 6 months of CRT, improvements in HRT indices and a decrease in the proportion of patients with abnormal HRT were observed. CRT may have beneficial effects on baroreflex sensitivity.     

The Effects of Trimetazidine on P-Wave Duration and Dispersion in Heart Failure Patients

Background: P-wave duration and dispersion (PWD) have been shown to be noninvasive predictors for development of atrial fibrillation. Thus, it may be possible to attenuate atrial fibrillation risk through normalization of P-wave duration and dispersion. Trimetazidine, a metabolic modulator, has been reported to improve cardiac function in heart failure (HF) patients.
Methods: Thirty-six HF patients being treated with angiotensin inhibitors, carvedilol, spironolactone, and furosemide were prescribed trimetazidine, 20 mg three times a day. Electrocardiographic and echocardiographic examinations were obtained before and 6 months after addition of trimetazidine in HF patients and 36 healthy control group patients having normal echocardiographic examination.
Results: Maximum P-wave duration (Pmax) (106.7 ± 15.8 vs. 91.7 ± 12.7 ms) and PWD (57.2 ± 15.4 vs. 37.9 ± 16.7 ms) were significantly longer in HF patients compared to the control group. There were significant correlations of Pmax and PWD with left atrial diameter (r = 0.508, P = < 0.001 and r = 0.315, P = 0.029), left ventricular ejection fraction (LVEF) (r = 0.401, p = 0.005 and r = 0.396, P = 0.005), deceleration time (r = 0.296, P = 0.032 and r = 0.312, P = 0.035), and isovolumetric relaxation time (r = 0.265, P = 0.038 and r = 0.322, P = 0.015). There were significant improvements in LVEF (32.7 ± 6.5% to 37.2 ± 5.5%, P = 0.036), left atrial diameter (41.5 ± 6.7 to 40.3 ± 6.1 mm, P < 0.001), and Pmax (106.7 ± 15.8 to 102.2 ± 11.5 ms, P = 0.006) and PWD (57.2 ± 15.4 to 48.9 ± 10.1 ms, P < 0.001) during follow-up.
Conclusions: Trimetazidine added to optimal medical therapy in HF may improve Pmax and PWD in association with improved left ventricular function. Longer-term and larger studies are necessary to evaluate whether these findings may have clinical implications on prevention of atrial fibrillation.     

Response to Cardiac Resynchronization Therapy in Patients with Heart Failure and Renal Insufficiency

Background: Renal insufficiency (RI) adversely impacts prognosis in heart failure (HF) patients, partly because renal and cardiac dysfunction are intertwined, yet few cardiac resynchronization therapy (CRT) studies have examined patients with moderate‐to‐severe RI. Methods: We analyzed 787 CRT‐defibrillator (CRT‐D) recipients with a glomerular filtration rate (GFR) measured prior to implant. Patients were grouped by GFR (in mL/min/1.73 m²): ≥60 (n = 376), 30–59 (n = 347), and <30 (n = 64). Overall survival, changes in left ventricular (LV) ejection fraction and LV end‐systolic diameter, and GFR change at 3–6 months were compared among CRT‐D groups and with a control cohort (n = 88), also stratified by GFR, in whom LV lead implant was unsuccessful and a standard defibrillator (SD) was placed. All patients met clinical criteria for CRT‐D. Results: Among CRT‐D recipients, overall survival improved incrementally with higher baseline GFR (for each 10 mL/min/1.73 m² increase, corrected hazard ratio [HR] 1.21, 95% confidence interval [CI] 1.13–1.30, P < 0.0001). Survival among SD and CRT‐D patients within GFR < 30 and GFR ≥ 60 groups was similar, whereas CRT‐D recipients with GFR 30–59 had significantly better survival compared to SD counterparts (HR 2.23, 95% CI 1.34–3.70; P = 0.002). This survival benefit was associated with improved renal and cardiac function. CRT recipients with GFR ≥ 60 derived significant echocardiographic benefit but experienced a GFR decline, whereas those with GFR < 30 had no echocardiographic benefit but did improve GFR. Conclusions: CRT may provide the largest survival benefit in HF patients with moderate RI, perhaps by improving GFR and LV function. Severe baseline RI predicts poor survival and limited echocardiographic improvement despite a modest GFR increase, such that CRT may not benefit those with GFR < 30 mL/min/1.73 m². CRT recipients with normal renal function derive echocardiographic benefit but no overall survival advantage. (PACE 2010; 850–859)     

Relevance of Echocardiographic Evaluation of Right Ventricular Function in Patients Undergoing Cardiac Resynchronization Therapy

Aims: Right ventricular (RV) dysfunction is a marker of poor prognosis in heart failure (HF) patients. It is still unclear whether RV function might influence response to cardiac resynchronization therapy (CRT).
Methods: Forty-four consecutive patients with HF, large QRS, and either intraventricular or interventricular dyssynchrony underwent echocardiographic evaluation before, 1 month after, and 6 months after CRT. Response to CRT was considered in case of significant LV reverse remodeling, defined as the occurrence of LV end-systolic volume (LVESV) reduction ≥15% at 6 months.
Results: All echocardiographic indexes of baseline RV function and dimensions were significantly more impaired in nonresponders versus responders to CRT: tricuspid annular plane systolic excursion (TAPSE 15 ± 4 mm vs 20 ± 5 mm, P = 0.001), RV systolic pulmonary artery pressure (RVSP 39 ± 14 mmHg vs 27 ± 8 mmHg, P = 0.02), RV end-diastolic area (RVEDA 23 ± 6 cm² vs 16 ± 3 cm² P < 0.001), RV end-systolic area (RVESA 16 ± 6 cm² vs 8 ± 2 cm², P = 0.001), and RV fractional area change (30 ± 12% vs 48 ± 8%, P < 0.001). All the indexes of RV function significantly correlated with the percentage of LVESV reduction after CRT. Severe RV dysfunction was defined as TAPSE ≤14 mm and the population was stratified into two groups based on baseline TAPSE ≤ or > 14 mm. As compared to those with high TAPSE (n = 30), patients with low TAPSE (n = 14) were less likely to show LV reverse remodeling after CRT (76% vs 14%, P < 0.001).
Conclusions: Our study suggests that RV function significantly affects response to CRT. Poor LV reverse remodeling occurs after CRT in patients with HF having severe RV dysfunction at baseline.     

衰弱对住院老年冠心病患者短期预后的影响:前瞻性队列研究

目的 探讨衰弱对住院老年冠心病患者短期预后的影响.方法 前瞻性收集并分析2017年12月至2018年11月在北京协和医院住院治疗的老年冠心病患者临床资料.根据是否合并衰弱,将患者分为衰弱组和非衰弱组.对两组患者随访,终点事件包括非常规就诊、主要不良心脑血管事件(major adverse cardiac and cer...     

Perceived Discrimination and Cardiovascular Outcomes in Older African Americans: Insights From the Jackson Heart Study

Objective

To assess the associations of perceived discrimination and cardiovascular (CV) outcomes in African Americans (AAs) in the Jackson Heart Study.

Autonomic response to cardiac dysfunction in chronic heart failure: a risk predictor based on autonomic information flow

Background: Chronic heart failure (CHF) is associated with a complex dysfunction of cardiac, cardiovascular, autonomic, and other mechanisms. Autonomic information flow (AIF) characteristics calculated from heart rate patterns were recently found as promising predictors of outcome in several cardiovascular diseases.
Aim: To assess the prognostic value of AIF indices in CHF patients.
Methods: We analyzed 24-hour Holter recordings from 200 consecutive CHF patients in sinus rhythm and computed AIF over the shortest possible interval of an interbeat series, namely over one heart beat interval (BDnn), and over longer intervals (12.5–166.7 seconds, PDmVLF), which reflect slower heart rate modulations. End-point for survival analysis over three years (Cox model) was total cardiac death. A prognostic model was built (backward elimination) considering known clinical and functional risk factors, and the ability of AIF indices to add prognostic information to this model assessed.
Results: Out of candidate predictors, New York Heart Association class, left ventricular ejection fraction, peak VO_2, and systolic pressure were selected as the variables with the highest joint predictive value. When entered into this model, both BDnn and PDmVLF added prognostic information (HR (95%CI): 1.76 (1.00–3.09), P = 0.05, 1.73 (1.05–2.85), P = 0.031 respectively). High risk was associated with reduced fast AIF and increased slower AIF.
Conclusion: In CHF patients, AIF indices provide prognostic information independent of known risk factors.     

Cardiac resynchronization induces favorable neurohumoral changes

AIM: The aim of this article is to examine whether cardiac resynchronization therapy (CRT) induces improvements in the neurohumoral system. METHODS AND RESULTS: Thirteen patients with HF (left ventricular (LV) ejection fraction <35%) were included. Before and after 6 months of CRT, myocardial (123)I-metaiodobenzylguanidine ((123)I-MIBG) uptake indices, used as an index of neural norepinephrine reuptake and retention, and brain natriuretic peptide (BNP) levels, used as an index of LV end-diastolic pressure, NYHA classification and echocardiographic indices were assessed. Six months of CRT resulted in significant improvement in (1) NYHA classification and reduction in QRS width (P < 0.001), (2) decrease of LV end-diastolic diameter (P = 0.005), LV end-systolic diameter (P = 0.005), septal to lateral delay (P = 0.01) and mitral regurgitation (MR, P = 0.04), (3) delayed (123)I-MIBG heart/mediastinum ratios improved (P = 0.03) and (123)I-MIBG washout decreased (P = 0.001), and (4) BNP levels decreased (P = 0.001). CONCLUSIONS: Parallel to significant functional improvement and echocardiographic reverse remodeling and resynchronization, our data indicate that CRT induces favorable changes in the neurohumoral system.