Diálisis peritoneal ambulatoria continua y evolución clínica de pacientes con insuficiencia cardiaca congestiva refractaria

Introduction and objectives

Peritoneal dialysis has been proposed as a therapeutic alternative for patients with refractory congestive heart failure. The objective of this study was to assess its effect on long-term clinical outcomes in patients with advanced heart failure and renal dysfunction.

Methods

A total of 62 patients with advanced heart failure (class III/IV), renal dysfunction (glomerular filtration<60 mL/min/1.73 m²), persistent fluid congestion despite loop diuretic treatment and at least 2 previous hospitalizations for heart failure were invited to participate in a continuous ambulatory peritoneal dialysis program. Of these, 34 patients were excluded and adjudicated as controls. The most important reasons for exclusion were refusal to participate, inability to perform the technique and abdominal wall defects. The primary endpoint was all-cause mortality and the composite of death/readmission for heart failure. To account for baseline imbalance, a propensity score was estimated and used as a weight in all analyses.

Results

The peritoneal dialysis (n=28) and control groups (n=34) were alike in all baseline covariates. During a median follow-up of 16 months, 39 (62.9%) died, 21 (33.9%) patients were rehospitalization for heart failure, and 42 (67.8%) experienced the composite endpoint. In the propensity score-adjusted models, peritoneal dialysis (vs control group) was associated with a substantial reduction in the risk of mortality using complete follow-up (hazard ratio=0.40; 95% confidence interval, 0.21-0.75; P=.005), mortality using days alive and out of hospital (hazard ratio=0.39; 95% confidence interval, 0.21-0.74; P=.004) and the composite endpoint (hazard ratio=0.32; 95% confidence interval, 0.17-0.61; P=.001).

Conclusions

In refractory congestive heart failure with concomitant renal dysfunction, peritoneal dialysis was associated with long-term improvement in clinical outcomes.Full English text available from:www.revespcardiol.org     

Cronobiología de la muerte en insuficiencia cardiaca

Introduction and objectives

In the general population, heart events occur more often during early morning, on Mondays, and during winter. However, the chronobiology of death in heart failure has not been analyzed. The aim of this study was to determine the circadian, day of the week, and seasonal variability of all-cause mortality in chronic heart failure.

Methods

This was an analysis of all consecutive heart failure patients followed in a heart failure unit from January 2003 to December 2008. The circadian moment of death was analyzed at 6-h intervals and was determined by reviewing medical records and by information provided by the relatives.

Results

Of 1196 patients (mean [standard deviation] age, 69 [13] years; 62% male), 418 (34.9%) died during a mean (standard deviation) follow-up of 29 (21) months. Survivors were younger, had higher body mass index, left ventricular ejection fraction, glomerular filtration rate, hemoglobin and sodium levels, and lower Framingham risk scores, amino-terminal pro-B type natriuretic peptide, troponin T, and urate values. They were more frequently treated with angiotensin receptor blockers, beta-blockers, mineralocorticoids receptor antagonists, digoxin, nitrates, hydralazine, statins, loop diuretics, and thiazides. The analysis of the circadian and weekly variability did not reveal significant differences between the four 6-h intervals or the days of the week. Mortality occurred more frequently during the winter (30.6%) compared with the other seasons (P = .024).

Conclusions

All cause mortality does not follow a circadian pattern, but a seasonal rhythm in patients with heart failure. This finding is in contrast to the circadian rhythmicity of cardiovascular events reported in the general population.Full English text available from:www.revespcardiol.org/en     

Supervivencia de pacientes ambulatorios con insuficiencia cardiaca crónica del área mediterránea. Un estudio de base poblacional

Introduction and objectives

Scarce research has been performed in ambulatory patients with chronic heart failure in the Mediterranean area. Our aim was to describe survival trends in our target population and the impact of prognostic factors.

Methods

We carried out a population-based retrospective cohort study in Catalonia (north-east Spain) of 5659 ambulatory patients (60% women; mean age 77 [10] years) with incident chronic heart failure. Eligible patients were selected from the electronic patient records of primary care practices from 2005 and were followed-up until 2007.

Results

During the follow-up period deaths occurred in 950 patients (16.8%). Survival after the onset of chronic heart failure at 1, 2, and 3 years was 90%, 80%, 69%, respectively. No significant differences in survival were found between men and women (P=.13). Cox proportional hazard modelling confirmed an increased risk of death with older age (hazard ratio=1.06; 95% confidence interval, 1.06-1.07), diabetes mellitus (hazard ratio=1.53; 95% confidence interval, 1.33-1.76), chronic kidney disease (hazard ratio=1.73; 95% confidence interval, 1.45-2.05), and ischemic heart disease (hazard ratio=1.18; 95% confidence interval, 1.02-1.36). Hypertension (hazard ratio=0,73; 95% confidence interval, 0,64-0,84) had a protective effect.

Conclusions

Service planning and prevention programs should take into consideration the relatively high survival rates found in our area and the effect of prognostic factors that can help to identify high risk patients.Full English text available from:www.revespcardiol.org/en     

Epidemiología de la insuficiencia cardiaca en España en los últimos 20 años

Heart failure is a major health care problem in Spain, although its precise impact is unknown due to the lack of data from appropriately designed studies. In contrast with the 2% prevalence of heart failure elsewhere in Europe and in the United States, studies in Spain report figures of 5%, probably because of methodological limitations. Heart failure consumes enormous quantities of health care resources; it is the first cause of hospitalization in persons aged 65 years or older and represents 3% of all hospital admissions and 2.5% of health care costs. There are two patterns of heart failure: one with preserved systolic function, more often associated with high blood pressure, and another with depressed systolic function, more often associated with ischemic heart disease. In 2010, heart failure accounted for 3% of all deaths in men and for 10% of all deaths in women. In recent years, the mortality rate from heart failure has gradually fallen. The rise in hospital admissions for heart failure and the decrease in mortality from this cause could partly be explained by temporary changes in diagnostic coding, but there is evidence that the reduced mortality could also be due to adherence to clinical practice guidelines.     

Biopsia pulmonar por videotoracoscopia en el diagnóstico de la enfermedad pulmonar intersticial. Estudio prospectivo y multicéntrico en 224 pacientes

Objectives

To evaluate whether the location and number of lung biopsies obtained by video-assisted thoracoscopy (VAT) influence the diagnosis of diffuse interstitial lung disease (ILD). To assess the applicability of an Ambulatory Surgery Program (ASP).

Methods

Prospective, multicenter study of VAT lung biopsies due to suspected ILD from January 2007 to December 2009, including 224 patients from 13 Spanish centers (mean age 57.1 years; 52.6% females). Data were prospectively collected in every institution and sent to the coordination center for analysis.

Results

The most affected areas in high resolution chest CT were the lower lobes (55%). Bronchoscopy was performed in 84% and transbronchial biopsy in 49.1%. In 179 cases (79.9%), more than one biopsy was performed, with a diagnostic agreement of 97.2%. A definitive histopathologic diagnosis was obtained in 195 patients (87%). Idiopathic pulmonary fibrosis was the most frequent diagnosis (26%). There were no statistically significant factors that could predict a greater diagnostic yield (neither anatomical location nor number of biopsies). Seventy patients (31.3%) were included in an ASP. After discharge, there were complications in 12 patients (5.4%), similar between patients admitted postoperatively (9/154: 5.8%) and those included in an ASP (3/70: 4.3%).

Conclusions

Anatomical location and number of lung biopsy specimens did not seem to influence the diagnosis. The patients included in an ASP had a complication rate comparable to that of the hospitalized, so this procedure can be included in a surgical outpatient program. Lung biopsy obtained by VAT is a powerful and safe tool for diagnosis of suspected ILD, resulting in a definitive diagnosis for the majority of patients with a low morbidity rate.     

Actualización en insuficiencia cardiaca,trasplante cardiaco,cardiopatías congénitas y cardiología clínica

In the year 2012, 3 scientific sections—heart failure and transplant, congenital heart disease, and clinical cardiology—are presented together in the same article. The most relevant development in the area of heart failure and transplantation is the 2012 publication of the European guidelines for heart failure. These describe new possibilities for some drugs (eplerenone and ivabradine); expand the criteria for resynchronization, ventricular assist, and peritoneal dialysis; and cover possibilities of percutaneous repair of the mitral valve (MitraClip^®). The survival of children with hypoplastic left heart syndrome in congenital heart diseases has improved significantly. Instructions for percutaneous techniques and devices have been revised and modified for the treatment of atrial septal defects, ostium secundum, and ventricular septal defects. Hybrid procedures for addressing structural congenital heart defects have become more widespread. In the area of clinical cardiology studies have demonstrated that percutaneous prosthesis implantation has lower mortality than surgical implantation. Use of the CHA₂DS₂-VASc criteria and of new anticoagulants (dabigatran, rivaroxaban and apixaban) is also recommended. In addition, the development of new sequencing techniques has enabled the analysis of multiple genes.     

Cambios en la expresión de adrenoceptores y GRK en pacientes con insuficiencia pulmonar valvular crónica

Introduction and objectivesPulmonary regurgitation (PR) is a frequent complication after repair of congenital heart disease. Lymphocyte expression of adrenoceptors (β1 and β2) and kinases (GRK2, GRK3, and GRK5) reflects the neurohumoral changes that occur in heart failure (HF). The main objective of this study was to describe the gene expression of these molecules in circulating lymphocytes in patients with severe PR.MethodsA prospective study was conducted to analyze lymphocyte expression of these molecules in patients with severe PR and compare it with expression in healthy controls and patients with advanced HF.ResultsWe studied 35 patients with severe PR, 22 healthy controls, and 13 patients with HF. Multiple comparisons analysis showed that β2-adrenoceptor gene expression levels were higher in the control group than in patients in the PR and HF groups and that expression in the latter 2 groups was similar (748.49 [rank 1703.87] vs 402.80 [rank 1210.81] vs 287.46 [rank 685.69] P = .001). Similar findings were obtained in gene expression of GRK2 (760.89 [rank 1169.46] vs 445.17 [rank 1190.69] vs 284.09 [rank 585.27] P < .001). There were no differences in expression levels of these molecules according to clinical variables in patients with PR.ConclusionsThe gene expression pattern of GRK2 and β2-adrenoceptor as molecular markers of cardiac dysfunction was altered in patients with severe PR compared with controls and was similar to expression in patients with advanced HF.Full English text available from: www.revespcardiol.org/en     

Actualización 2013 en cardiopatías congénitas,cardiología clínica e insuficiencia cardiaca y trasplante

This article presents the most relevant developments in 2013 in 3 key areas of cardiology: congenital heart disease, clinical cardiology, and heart failure and transplant. Within the area of congenital heart disease, we reviewed contributions related to sudden death in adult congenital heart disease, the importance of specific echocardiographic parameters in assessing the systemic right ventricle, problems in patients with repaired tetralogy of Fallot and indication for pulmonary valve replacement, and confirmation of the role of specific factors in the selection of candidates for Fontan surgery. The most recent publications in clinical cardiology include a study by a European working group on correct diagnostic work-up in cardiomyopathies, studies on the cost-effectiveness of percutaneous aortic valve implantation, a consensus document on the management of type B aortic dissection, and guidelines on aortic valve and ascending aortic disease. The most noteworthy developments in heart failure and transplantation include new American guidelines on heart failure, therapeutic advances in acute heart failure (serelaxin), the management of comorbidities such as iron deficiency, risk assessment using new biomarkers, and advances in ventricular assist devices.     

Pérdida de estimulación biventricular continua en pacientes con terapia de resincronización cardiaca: incidencia,causas y resultados

Introduction and objectives

In recent years, implantation of cardiac resynchronization therapy devices has significantly increased. The benefits of this therapy are directly related to the maintenance of continuous biventricular pacing. This study analyzed the incidence, causes, and outcomes of loss of continuous biventricular pacing, and the approach adopted.

Methods

We analyzed the clinical and follow-up data of a series of consecutive patients from a single center who underwent implantation of a cardiac resynchronization therapy device.

Results

The study included 136 patients. During a mean follow-up of 33.4 months, loss of continuous biventricular pacing occurred in 45 patients (33%). The most common causes included atrial tachyarrhythmias (21.3%), lead macrodislodgement (18%), and loss of left ventricular capture (13.1%). In most patients (88.5%), loss of continuous biventricular pacing was transient and correctable, and occurred earlier in the follow-up when the cause was lead macrodislodgement, oversensing, or extracardiac stimulation. There were no significant differences in mortality between patients with and without loss of continuous biventricular pacing (P=.88).

Conclusions

Despite technical advances in cardiac resynchronization therapy, loss of continuous biventricular pacing is common; however, this loss can usually be corrected. In most patients, continuous biventricular pacing can be ensured by close monitoring and follow-up and a proactive approach.Full English text available from:www.revespcardiol.org/en     

No inferioridad de la titulación de enfermera de insuficiencia cardiaca en comparación con la de cardiólogo de insuficiencia cardiaca. Ensayo aleatorizado multicéntrico ETIFIC

Introduction and objectivesBeta-blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin-II-receptor-blockers (ARB), and mineralocorticoid-receptor antagonists decrease mortality and heart failure (HF) hospitalizations in HF patients with reduced left ventricular ejection fraction. The effect is dose-dependent. Careful titration is recommended. However, suboptimal doses are common in clinical practice. This study aimed to compare the safety and efficacy of dose titration of the aforementioned drugs by HF nurses vs HF cardiologists.MethodsETIFIC was a multicenter (n = 20) noninferiority randomized controlled open label trial. A total of 320 hospitalized patients with new-onset HF, reduced ejection fraction and New York Heart Association II-III, without beta-blocker contraindications were randomized 1:1 in blocks of 4 patients each stratified by hospital: 164 to HF nurse titration vs 156 to HF cardiologist titration (144 vs 145 analyzed). The primary endpoint was the beta-blocker mean relative dose (% of target dose) achieved at 4 months. Secondary endpoints included ACE inhibitors, ARB, and mineralocorticoid-receptor antagonists mean relative doses, associated variables, adverse events, and clinical outcomes at 6 months.ResultsThe mean ± standard deviation relative doses achieved by HF nurses vs HF cardiologists were as follows: beta-blockers 71.09% ± 31.49% vs 56.29% ± 31.32%, with a difference of 14.8% (95%CI, 7.5-22.1), P < .001; ACE inhibitors 72.61% ± 29.80% vs 56.13% ± 30.37%, P < .001; ARB 44.48% ± 33.47% vs 43.51% ± 33.69%, P = .93; and mineralocorticoid-receptor antagonists 71% ± 32.12% vs 70.47% ± 29.78%, P = .86; mean ± standard deviation visits were 6.41 ± 2.82 vs 2.81 ± 1.58, P < .001, while the number (%) of adverse events were 34 (23.6) vs 30 (20.7), P = .55; and at 6 months HF hospitalizations were 1 (0.69) vs 9 (5.51), P = .01.ConclusionsETIFIC is the first multicenter randomized trial to demonstrate the noninferiority of HF specialist-nurse titration vs HF cardiologist titration. Moreover, HF nurses achieved higher beta-blocker/ACE inhibitors doses, with more outpatient visits and fewer HF hospitalizations.Trial registry number: NCT02546856.     

Valor pronóstico de la ecografía de pulmón en pacientes ambulatorios con insuficiencia cardiaca crónica estable

Introduction and objectivesThe role of lung ultrasound (LUS) in acute heart failure (HF) has been widely studied, but little is known about its usefulness in chronic HF. This study assessed the prognostic value of LUS in a cohort of chronic HF stable ambulatory patients.MethodsWe included consecutive outpatients who attended a scheduled follow-up visit in a HF clinic. LUS was performed in situ. The operators were blinded to clinical data and examined 8 thoracic areas. The sum of B-lines across all lung zones and the quartiles of this addition were used for the analyses. Linear regression and Cox regression analyses were performed. The main clinical outcomes were a composite of all-cause death or hospitalization for HF and mortality from any cause.ResultsA total of 577 individuals were included (72% men; 69 ± 12 years). The mean number of B-lines was 5 ± 6. During a mean follow-up of 31 ± 7 months, 157 patients experienced the main clinical outcome and 111 died. Having ≥ 8 B-lines (Q4) doubled the risk of experiencing the composite primary event (P < .001) and increased the risk of death from any cause by 2.6-fold (P < .001). On multivariate analysis, the total sum of B-lines remained independent predictive factor of the composite endpoint (HR, 1.04; 95%CI, 1.02-1.06; P = .002) and of all-cause death (HR, 1.04; 95%CI, 1.02-1.07; P = .001), independently of whether or not N-terminal pro-B-type natriuretic peptide (NT-proBNP) was included in the model (P = .01 and P = .008, respectively), with a 3% to 4% increased risk for each 1-line addition.ConclusionsLUS identified patients with stable chronic HF at high risk of death or HF hospitalization.     

Beneficio clínico de la terapia de resincronización cardiaca con desfibrilador para pacientes con fracción de eyección > 35% por resonancia magnética

Introduction and objectives

Cardiac resynchronization therapy with a defibrillator prolongs survival and improves quality of life in advanced heart failure. Traditionally, patients with ejection fraction > 35% estimated by echocardiography have been excluded. We assessed the prognostic impact of this therapy in a group of patients with severely depressed systolic function as assessed by echocardiography but with an ejection fraction > 35% as assessed by cardiac magnetic resonance.

Methods

We analyzed consecutive patients admitted for decompensated heart failure between 2004 and 2011. The patients were in functional class II-IV, with a QRS ≥ 120 ms, ejection fraction ≤ 35% estimated by echocardiography, and a cardiac magnetic resonance study. We included all patients (n = 103) who underwent device implantation for primary prevention. Ventricular arrhythmia, all-cause mortality and readmission for heart failure were considered major cardiac events. The patients were divided into 2 groups according to systolic function assessed by magnetic resonance.

Results

The 2 groups showed similar improvements in functional class and ejection fraction at 6 months. We found a nonsignificant trend toward a higher risk of all-cause mortality in patients with systolic function ≤ 35% at long-term follow-up. The presence of a pattern of necrosis identified patients with a worse prognosis for ventricular arrhythmias and mortality in both groups.

Conclusions

We conclude that cardiac resynchronization therapy with a defibrillator leads to a similar clinical benefit in patients with an ejection fraction ≤ 35% or > 35% estimated by cardiac magnetic resonance. Analysis of the pattern of late gadolinium enhancement provides additional information on arrhythmic risk and long-term prognosis.Full English text available from:www.revespcardiol.org/en