Thermal hydrotherapy improves quality of life and hemodynamic function in patients with chronic heart failure

Background

Chronic heart failure is characterized by increased peripheral vascular resistance and reduced peripheral perfusion due to adrenergic and renin angiotensin activation and impaired endothelial function. Recent studies have shown that nonpharmacological peripheral vasodilation with thermal therapy by means of warm-water baths and sauna has beneficial effects in chronic heart failure. European hydrotherapy (according to Kneipp) additionally uses short cold water stimuli, which lead to prolonged vasodilation and adaptive responses. Studies on the efficacy of hydrotherapy in chronic heart failure are lacking.

Methods

We studied 15 patients (5 men, 10 women, mean (± SD) age 64.3 ± 1.8 years) with mild chronic heart failure (NYHA functional class II to III, ejection fraction 30%-40%). Patients were randomly assigned to 6 weeks of intensive home-based hydrotherapy or 6 weeks restriction in a crossover intervention trial. Quality of life and heart-failure-related symptoms were assessed by means of a validated questionnaire (PLC). Graded bicycle exercise test with incremental workloads (0, 50, 75, 100 watts) was performed at the end of each treatment period. The hydrotherapeutic program consisted of a structured combination of daily home-based external warm- and cold-water applications.

Results

Baseline characteristics were balanced between the groups. With hydrotherapy, a significant (P ≤ .05) improvement in 3 of 6 dimensions of quality of life (mood, physical capacity, enjoyment) and a significant reduction in heart-failure-related symptoms was found. Heart rates at rest and at 50-Watt workload were significantly reduced by hydrotherapy; blood pressure decreased nonsignificantly at rest and during exercise. The hydrotherapeutic treatment was well accepted and no relevant adverse effects were observed.

Conclusions

A home-based hydrotherapeutic thermal treatment program improves quality of life, heart-failure-related symptoms and heart rate response to exercise in patients with mild chronic heart failure. The results of this investigation suggest a beneficial adaptive response to repeated brief cold stimuli in addition to enhanced peripheral perfusion due to thermal hydrotherapy in patients with chronic heart failure.     

Change in circulating cytokines after 2 forms of exercise training in chronic stable heart failure

Background

A proinflammatory state is recognized in chronic heart failure and the degree of immune activation corresponds to disease severity and prognosis. Training is known to improve symptoms in heart failure but less is known about the effects of specific forms of training on the proinflammatory state.

Methods

Forty-six patients with stable chronic heart failure underwent a home-based program of exercise training for 30 minutes a day, 5 days per week over a 6-week period. Twenty-four used a bicycle ergometer and 22 used an electrical muscle stimulator applied to quadriceps and gastrocnemius muscles. Tumour necrosis factor-α (TNF-α), TNF-α soluble receptors 1 and 2, interleukin 6, and C-reactive protein were measured before and after the training period.

Results

Significant improvements in markers of exercise performance were seen in both training groups. Soluble TNF-α receptor 2 levels decreased after training in the bike group only (2900 ± 1069 pg/mL to 2625 ± 821 pg/mL, P = .013). Trends towards a decrease in levels of TNF-α and soluble receptor 1 were also seen in the bike group only. No change in circulating inflammatory markers was observed after stimulator training.

Conclusions

Physical training improves exercise capacity for patients with chronic heart failure but degree of attenuation of the proinflammatory response may depend on the mode of training despite similar improvements in exercise capacity.     

Rehabilitation: Periodic somatosensory stimulation increases arterial baroreflex sensitivity in chronic heart failure patients

Background

One of the beneficial effects of exercise training in chronic heart failure (CHF) is an improvement in baroreflex sensitivity (BRS), a prognostic index in CHF. In our hypothesis-generating study we propose that at least part of this effect is mediated by neural afferent information, and more specifically, by exercise-induced somatosensory nerve traffic.

Objective

To compare the effects of periodic electrical somatosensory stimulation on BRS in patients with CHF with the effects of exercise training and with usual care.

Methods

We compared in stable CHF patients the effect of transcutaneous electrical nerve stimulation (TENS, N = 23, LVEF 30 ± 9%) with the effects of bicycle exercise training (EXTR, N = 20, LVEF 32 ± 7%). To mimic exercise-associated somatosensory ergoreceptor stimulation, we applied periodic (2/s, marching pace) burst TENS to both feet. TENS and EXTR sessions were held during two successive days.

Results

BRS, measured prior to the first intervention session and one day after the second intervention session, increased by 28% from 3.07 ± 2.06 to 4.24 ± 2.61 ms/mm Hg in the TENS group, but did not change in the EXTR group (baseline: 3.37 ± 2.53 ms/mm Hg; effect: 3.26 ± 2.54 ms/mm Hg) (P(TENS vs EXTR) = 0.02). Heart rate and systolic blood pressure did not change in either group.

Conclusions

We demonstrated that periodic somatosensory input alone is sufficient and efficient in increasing BRS in CHF patients. This concept constitutes a basis for studies towards more effective exercise training regimens in the diseased/impaired, in whom training aimed at BRS improvement should possibly focus more on the somatosensory aspect.     

B-type natriuretic peptide levels are not a surrogate marker for invasive hemodynamics during management of patients with severe heart failure

Background

We sought to assess the utility of serial BNP measurements in patients with severe heart failure and attempted to correlate values with invasively derived data.

Methods

In a retrospective study, we analyzed serial BNP levels in patients receiving hemodynamically guided therapy for severe heart failure and sought correlation with invasively derived data.

Results

Thirty-nine patients with New York Heart Association Class III-IV, with an ejection fraction of 35% or less, who had a pulmonary artery catheter inserted for hemodynamically tailored heart failure therapy, were identified and serial BNP measurements reviewed. BNP was estimated on admission, at 12 and 36 hours. Normally distributed variables are expressed as mean ± SD and otherwise as median ± interquartile range. Mean ejection fraction was 16% ± 6%. Mean pulmonary artery occlusion pressures (PAOP) fell with therapy and were 25 ± 7 mmHg, 18 ± 7 mmHg and 19 ± 7 mmHg at admission, 12 hours and 36 hours respectively (P < 0.05). Median BNP levels fell from 1200 ± 641 to 771 ± 803 at 12 hours and to 805 ± 771 at 36 hours (P < .001). There was no correlation between BNP and any hemodynamically derived variable. A change in BNP was not associated with a change in PAOP in any individual patient. Only 42% remained alive on medical therapy at 30 days.

Conclusions

In patients with severe heart failure, BNP levels do not accurately predict serial hemodynamic changes and do not obviate the need for pulmonary artery catheterization.     

Electrogram-based optimal atrioventricular and interventricular delays of cardiac resynchronization change individually during exercise

Background

Limited data suggest that optimal atrioventricular (AV) and interventricular (VV) delays are different at rest than during exercise in patients with heart failure. We assessed the feasibility and reproducibility of an electrogram-based method of optimization called QuickOpt at rest and during exercise.

Methods

Patients with a St Jude Medical cardiac resynchronization therapy implantable cardioverter-defibrillator were subjected to a graded treadmill test, and QuickOpt was repeatedly measured prior to, during, and after the exercise.

Results

Twenty-four patients (16 males, aged 67.4 ± 7.7 years) participated. At rest, delays (in ms) were 110.4 ± 20.1 for sensed AV delay and -70 (LV pacing first) to +20 (RV pacing first) for VV delay. The changes in QuickOpt-derived delays at rest were not significant despite change in body position. During exercise, QuickOpt-derived AV delays did not change in 11 patients, were shorter during peak exercise in 8 patients, and were longer in 3 patients (average value during peak exercise was 126.5 ± 15.8 ms, P = 0.04 compared to baseline). The QuickOpt-derived VV delay gradually shifted toward earlier right ventricular pacing during exercise in 19 patients, while no changes were seen in 3 patients, and a shift occurred toward earlier left ventricular pacing in 2 patients (average value during peak exercise was -30.7 ± 22.2; P = 0.001 compared to baseline). There was no correlation between changes in the QuickOpt-derived AV and VV delays and heart rate.

Conclusions

The application of electrogram-based algorithm is feasible both at rest and during exercise. The results are reproducible. QuickOpt-derived AV and VV delays individually change during exercise.     

Randomized trial of a daily electronic home monitoring system in patients with advanced heart failure: the Weight Monitoring in Heart Failure (WHARF) trial

Background

Heart failure treatment guidelines emphasize daily weight monitoring for patients with heart failure, but data to support this practice are lacking. Using a technology-based heart failure monitoring system, we determined whether daily reporting of weight and symptoms in patients with advanced heart failure would reduce rehospitalization and mortality rates despite aggressive guideline-driven heart failure care.

Methods

This was a randomized, controlled trial. Patients hospitalized with New York Heart Association class III or IV heart failure, with a left ventricular ejection fraction ≤35% were randomized to receive heart failure program care or heart failure program care plus the AlereNet system (Alere Medical, Reno, Nev) and followed-up for 6 months. The primary end point was 6-month hospital readmission rate. Secondary end points included mortality, heart failure hospitalization readmission rate, emergency room visitation rate, and quality of life.

Results

Two hundred eighty patients from 16 heart failure centers across the United States were randomized: 138 received the AlereNet system and 142 received standard care. Mean age was 59 ± 15 years and 68% were male. The population had very advanced heart failure, New York Heart Association class III (75%) or IV (25%), as evidenced by serum norepinepherine levels, 6-minute walk distance and outcomes. No differences in hospitalization rates were observed. There was a 56.2% reduction in mortality (P < .003) for patients randomized to the AlereNet group.

Conclusions

This is the largest multicenter, randomized trial of a technology-based daily weight and symptom-monitoring system for patients with advanced heart failure. Despite no difference in the primary end point of rehospitalization rates, mortality was significantly reduced for patients randomized to the AlereNet system without an increase in utilization, despite specialized and aggressive heart failure care in both groups.     

Mechanisms of exercise training in patients with heart failure

Background

The reduction of exercise capacity because of fatigue and dyspnea in patients with heart failure can be improved with exercise training. We sought to examine the mechanisms of exercise training as an adjunctive treatment strategy for patients with heart failure.

Methods

We reviewed the published data on the possible mechanisms of effect of exercise training in heart failure.

Results

Symptoms of heart failure may be explained on the basis of abnormal skeletal muscle perfusion and structure and endothelial function. Exercise training has been shown to engender changes in muscle structure and biochemistry and vascular function, although effects on cardiac function have not been detected uniformly and may require longer training periods.

Conclusions

A suitable, long-term program of exercise training may reverse unfavorable interactions among the heart, vessels, and skeletal muscles. These improvements may be preserved with an ongoing maintenance program.     

Safety and efficiency of chronic ACE inhibition in symptomatic heart failure patients with a systemic right ventricle

Background

ACE inhibition is an established treatment regimen in patients with congestive heart failure due to left ventricular dysfunction which improves morbidity and mortality. However, little is known about the beneficial effects of ACE inhibition in adult patients after Mustard procedure for transposition of the great arteries with heart failure symptoms. Therefore, we investigated the effects of ACE inhibition in these patients on heart failure symptoms, echocardiographic diameters, NT-proBNP and exercise capacity.

Methods

In 14 patients (age 25.2 ± 3.5 years), after Mustard procedure for transposition of the great arteries (age at operation 1.1 ± 1.3 years) with heart failure NYHA II (New York Heart Association class), an ACE inhibition was initiated. At baseline and 13.3 ± 4.0 months after treatment with enalapril (10 mg twice a day), echocardiography, exercise test and NT-proBNP measurements were performed and compared to an age- and sex-matched control group.

Results

Maximum oxygen uptake and echocardiographic parameters did not change significantly in both groups. However, NT-proBNP showed a significant decrease in the treatment group (242 ± 105 vs. 151 ± 93 ng/l, p = 0.004), while in the control group a significant increase (120 ± 89 vs. 173 ± 149 ng/l, p < 0.05) was observed. Furthermore, ACE inhibitor treatment did not result in a deterioration of heart failure symptoms or renal function.

Conclusions

Thus, ACE inhibitor treatment of heart failure symptoms in patients with a systemic right ventricle is safe and reduces NT-proBNP levels significantly as a marker for ventricular overload. Nevertheless, larger scale trials are warranted to show effects on morbidity and mortality in this highly selected patient group.     

Echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction: role of mitral regurgitation

Introduction and objectives

Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction.

Methods

We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2, ≥290 m.

Results

Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1 cm²), mitral E amplitude (88±5 vs 72±3 cm/s) and systolic pulmonary pressure (37±1 vs 32±1 mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: −6.52 ± 2, P<.01).

Conclusions

In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.Full English text available from:www.revespcardiol.org     

Is systolic blood pressure recovery after exercise a predictor of mortality?

Background

An attenuated systolic blood pressure recovery after exercise has been associated with the severity of atherosclerotic heart disease.

Methods

For 6 years, we observed 12,379 patients who underwent symptom-limited exercise testing. We excluded patients receiving antihypertensive medication and patients with valvular disease, emphysema, end-stage renal disease, heart failure, left ventricular systolic dysfunction, and atrial fibrillation. Blood pressure recovery ratio was defined as the ratio of systolic blood pressure at 3 minutes into recovery to systolic blood pressure at peak exercise; this has been shown to correlate with angiographic severity of coronary disease.

Results

The blood pressure recovery ratios ranged from 0.36 to 1.62, with values for increasing quartiles of 0.72 ± 0.05, 0.82 ± 0.02, 0.88 ± 0.02, and 0.99 ± 0.07. During follow-up, there were 430 deaths (3%). Five-year Kaplan Meier survival rates were 0.975, 0.974, 0.969, and 0.966 in quartiles 1 to 4, respectively. Compared with patients in the lowest quartile of blood pressure recovery ratio, patients in the highest quartile were at somewhat increased risk (hazard ratio, 1.71; 95% CI, 1.31-2.24; P <.001). However, after adjusting for age, sex, body mass index, resting heart rate and blood pressure, peak systolic blood pressure, heart rate recovery, exercise chronotropic response, cardiac history, and standard risk factors, this association was no longer present (adjusted hazard ratio, 1.05; 95% CI, 0.8-1.38; P = .74).

Conclusions

In this low-risk population, abnormal systolic blood pressure recovery after exercise was not independently predictive of mortality after correcting for differences in baseline and exercise characteristics.     

Differential effects of exercise training in men and women with chronic heart failure

Background

Abnormalities of myosin heavy chain (MHC) isoforms, enzyme activity, and capillarity contribute to the exercise intolerance that is characteristic of patients with heart failure. To what extent these changes can be reversed with exercise training and whether differences exist in the responses of men and women remains uncertain. We described and compared the effects of exercise training on exercise capacity and skeletal muscle histochemistry in men and women with chronic heart failure.

Methods

Fifteen patients (10 male) undergoing standard medical therapy completed a 14- to 24-week exercise training program. Peak oxygen consumption, MHC isoforms, capillary density, and selected metabolic enzymes were assessed before and after training.

Results

Peak oxygen consumption was improved 14% (P <.05); however, this increase was mostly because of the improvement observed in men versus women (+20% versus +2%, respectively, P < .01). At baseline, MHC I content was lower in men than in women (33% ± 3% vs 49.6% ± 5.5%, P < .05). MHC I improved with training in men, to 45.6% ± 4.5% (+38%, P < .05), versus women (−3%, P = .82), and the increase in men tended (P = .12) to be significant when compared with that in women. There were no significant changes in capillary density or muscle enzyme activity with training in the group as a whole or in men and women separately.

Conclusion

Among patients with chronic heart failure, improvements in peak exercise capacity may be more pronounced in men than in women. This difference in response of functional capacity to training paralleled differences observed between men and women for changes in MHC I isoforms.     

Event-free survival in adults with heart failure who engage in self-care management

Background

Self-care management in heart failure (HF) involves decision-making to evaluate, and actions to ameliorate symptoms when they occur. This study sought to compare the risks of all-cause mortality, hospitalization, or emergency-room admission among HF patients who practice above-average self-care management, those who practice below-average self-care management, and those who are symptom-free.

Methods

A secondary analysis was conducted of data collected on 195 HF patients. A Cox proportional hazards model was used to examine the association between self-care management and event risk.

Results

The sample consisted of older (mean ± standard deviation = 61.3 ± 11 years), predominantly male (64.6%) adults, with an ejection fraction of 34.7% ± 15.3%; 60.1% fell within New York Heart Association class III or IV HF. During an average follow-up of 364 ± 288 days, 4 deaths, 82 hospitalizations, and 5 emergency-room visits occurred as first events. Controlling for 15 common confounders, those who engaged in above-average self-care management (hazard ratio, .44; 95% confidence interval, .22 to .88; P < .05) and those who were symptom-free (hazard ratio, 0.48; 95% confidence interval, .24 to .97; P < .05) ran a lower risk of an event during follow-up than those engaged in below-average self-care management.

Conclusion

Symptomatic HF patients who practice above-average self-care management have an event-free survival benefit similar to that of symptom-free HF patients.     

The effect of hormone replacement on physical performance in community-dwelling elderly women

Purpose

Our aim was to determine the effect of hormone replacement on physical performance measures, functional ability, physical activity, falls, and cognitive function in elderly women.

Subjects and methods

Following a 3-month, open-label, run-in phase, we randomized 373 community-dwelling women aged 65 years and older to receive conjugated equine estrogen 0.625 mg/day plus or minus medroxyprogesterone 2.5 mg/day vs placebo for 3 years in a double-blind fashion. We assessed time to rise from a chair, timed walking, balance, Instrumental Activities of Daily Living, Physical Activity Scale of the Elderly, Folstein Mini-Mental State Examination, and falls.

Results

Over 3 years, except for balance scores, performance measures declined significantly (all P<.05). There were no significant mean differences between women on hormone replacement versus placebo for rising time (0.1, −0.5 to 0.7 seconds [mean, 95% confidence interval]), walking normal (0.0, −0.4 to 0.4 seconds), and walking fast (0.2, −0.1 to 0.6 seconds). There were no significant mean differences between the two groups for the Instrumental Activities of Daily Living (0.1, −0.1 to 0.3 points), Physical Activity Scale of the Elderly (−3, −15 to 8 points), Folstein Mini-Mental State Examination (−0.1, −0.3 to 0.3 points), or the proportion of participants reporting falls (−1, −11 to 9%).

Conclusion

In elderly women, hormone replacement had no statistically significant effect on cognition or balance, nor did it prevent the age-related decline in physical measures of mobility, ability to rise from a chair, self-reported activities of daily living, physical activity scores, or falls.     

Recommendation of Low-Salt Diet and Short-term Outcomes in Heart Failure with Preserved Systolic Function

Background

Dietary sodium indiscretion frequently contributes to hospitalizations in elderly heart failure patients. Animal models suggest an important role for dietary sodium intake in the pathophysiology of heart failure with preserved systolic function. The documentation and effects of hospital discharge recommendations, particularly for sodium-restricted diet, have not been extensively investigated in heart failure with preserved systolic function.

Methods

We analyzed 1700 heart failure admissions to Michigan community hospitals. We compared documentation of guideline-based discharge recommendations between preserved systolic function and systolic heart failure patients with chi-squared testing, and used logistic regression to identify predictors of 30-day death and hospital readmission in a prespecified follow-up cohort of 443 patients with preserved systolic function. We hypothesized that patients who received a documented discharge recommendation for sodium-restricted diet would have lower 30-day adverse event rates.

Results

Heart failure patients with preserved systolic function were significantly less likely than systolic heart failure patients to receive discharge recommendations for weight monitoring (33% vs 43%) and sodium-restricted diet (42% vs 53%). Upon propensity score-adjusted multivariable analysis, patients with preserved systolic function who received a documented sodium-restricted diet recommendation had decreased odds of 30-day combined death and readmission (odds ratio 0.43, 95% confidence interval, 0.24-0.79; P = .007). No other discharge recommendations predicted 30-day outcomes.

Conclusions

Clinicians document appropriate discharge instructions less frequently in heart failure with preserved systolic function than systolic heart failure. Selected heart failure patients with preserved systolic function who receive advice for sodium-restricted diet may have improved short-term outcomes after hospital discharge.     

Comparative study of ambient air particles in patients hospitalized for heart failure and acute coronary syndrome

Introduction and objectives

Currently air pollution is considered as an emerging risk factor for cardiovascular disease. Our objective was to study the concentrations of particulate matter in ambient air and analyze their relationship with cardiovascular risk factors in patients admitted to a cardiology department of a tertiary hospital with the diagnosis of heart failure or acute coronary syndrome (ACS).

Methods

We analyzed 3950 consecutive patients admitted with the diagnosis of heart failure or ACS. We determined the average concentrations of different sizes of particulate matter (<10, <2.5, and <1 μm and ultrafine particles) from 1 day or up to 7 days prior to admission (1 to 7 days lag time).

Results

There were no statistically significant differences in mean concentrations of particulate matter <10, <2.5 and <1 μm in size in both populations. When comparing the concentrations of ultrafine particles of patients admitted due to heart failure and acute coronary syndrome, it was observed that the former had a tendency to have higher values (19 845.35 ± 8 806.49 vs 16 854.97 ± 8005.54 cm⁻³, P <.001). The multivariate analysis showed that ultrafine particles are a risk factor for admission for heart failure, after controlling for other cardiovascular risk factors (odds ratio = 1.4; confidence interval 95%, from 1.15 to 1.66 P = .02).

Conclusions

In our study population, compared with patients with ACS, exposure to ultrafine particles is a precipitating factor for admission for heart failure.Full English text available from: www.revespcardiol.org     

High-intensity aerobic training improves endothelium-dependent vasodilation in patients with metabolic syndrome and type 2 diabetes mellitus

Background

The aim of this study is to compare the effect of physical exercise program on the endothelial function of patients with metabolic syndrome and type 2 diabetes mellitus.

Methods

Patients were randomized for high intensity aerobic training (HI: 80% maximum heart rate, n = 10), low intensity aerobic training (LI: 55% of maximum heart rate, n = 10) and control (n = 11). Before and after 6 weeks of training, subjects performed the maximal exercise test and a study of the endothelial function, through a high resolution ultrasound of the brachial artery, which was assessed after reactive hyperemia (endothelium dependent vasodilation) and nitrate administration (endothelium independent vasodilation).

Results

A total of 31 patients with metabolic syndrome and type 2 diabetes mellitus were studied, with mean age of 58 ± 6 years, The percentage diameter difference of the vessel after hyperemia was significantly higher for the high intensity group (HI before 2.52 ± 2.85% and after 31.81 ± 12.21%; LI before 3.23 ± 3.52% and after 20.61 ± 7.76%; controls before 3.56 ± 2.33% and after 2.43 ± 2.14%; p < 0.05).

Conclusions

High intensity aerobic training improved the functional capability and endothelium dependent vasodilator response, but it does not improve the endothelium independent vasodilation in patients with metabolic syndrome and type 2 diabetes mellitus.     

Reliability of reporting left ventricular systolic function by echocardiography: a systematic review of 3 methods

Background

An accurate assessment of left ventricular (LV) systolic function is of central importance to the diagnosis and management of heart failure. Echocardiography is currently the technique most widely used for this purpose.

Methods

A systematic review was performed of the evidence for the accuracy of 3 echocardiographic methods—Simpson's rule, wall motion index (WMI), and subjective visual assessment—compared with radionuclide or contrast ventriculography for the assessment of LV ejection fraction (LVEF).

Results

Twenty-five studies were identified in which data on agreement between echocardiography and reference methods were obtainable. A further 18 studies provided correlation data alone. For Simpson's rule, Bland-Altman limits of agreement (95% CI) ranged from LVEF ±7% to ±25% (median ±18%); for WMI ±13% to ±20% (median ±16%); and for subjective visual assessment ±16% to ±24% (median ±19%). Subject echogenicity, the nature of underlying disease, and the use of additional imaging technology, including secondary harmonic imaging and contrast agents, is likely to influence the accuracy of different methods. No method appears to systematically under- or overestimate LVEF to any major extent.

Conclusion

These findings have important implications for the investigation of heart failure and for the practice and reporting of echocardiography.     

Left ventricular lead position and nonspecific conduction delay are predictors of mortality in patients during cardiac resynchronization therapy

Background

Cardiac resynchronization therapy (CRT) is an established treatment of severe systolic heart failure with intraventricular conduction delay. The influence on mortality of the left ventricular (LV) pacing site and the type of bundle-branch block during CRT is unclear.

Objectives

This study investigates the clinical significance of LV lead position, as well as nonspecific conduction delay, in CRT.

Methods

143 consecutive patients (mean age, 63.9 ± 8.9 years; 121 men) underwent implantation of a CRT device according to established criteria. At the time of implantation, the LV lead position and the type of bundle-branch block were recorded. The etiology of the heart failure was ischemic in 49 patients (34.3%) and nonischemic in 94 patients (65.7%).

Results

After a median follow-up of 19 months, 39 patients (27.3%) died, most of them (72%) of cardiovascular causes. The mortality was significantly higher in patients with an anterior or anterolateral LV lead position (P = 0.03). Multivariate analysis suggests that an anterior or anterolateral LV lead position, a nonspecific conduction delay, male sex, and a New York Heart Association functional class worse than III, are all independent predictors of mortality during the follow-up period.

Conclusion

LV lead position and nonspecific conduction delay are predictors of mortality in patients during cardiac resynchronization therapy.     

Beta-blocker therapy for heart failure outside the clinical trial setting: findings of a community-based registry

Background

β-Blockers reduce morbidity and mortality rates in heart failure (HF) clinical trials, but it is unknown whether these findings persist in the community setting.

Methods

A registry was created to survey tolerability and outcomes during initiation and 1-year follow-up of β-blocker treatment with carvedilol in patients with HF treated by cardiologists (CARD) and primary care physicians (PCP) in the community.

Results

A total 4280 patients were enrolled (3121 by 259 CARD, 1159 by 129 PCP). Patient age averaged 67 ± 13 years; 35% were women and 12% were black. The left ventricular ejection fraction averaged 31 ± 12; New York Heart Association class was II-III in 86% and IV in 3%. Patients of PCP had higher left ventricular ejection fraction, were older, and more frequently were female, black, diabetic, hypertensive, and in New York Heart Association class III/IV. Minimal difficulty titrating carvedilol was noted by >80% of CARD and PCP. Significantly more CARD-treated patients reached carvedilol doses of 25 mg twice daily (49% vs 27%). Kaplan-Meier all-cause mortality rate was 8.5% at 1 year and did not differ between CARD-treated and PCP-treated patients (8.2% vs 9.3%, P = .254). At least one HF hospitalization occurred in 11% of patients during follow-up, compared with 28% in the preceding year.

Conclusions

Community-based physicians use carvedilol with success approaching that of clinical trials. Overall mortality rates and HF hospitalizations were in the same low range as in clinical trials. Thus, it appears that results of clinical trials with carvedilol for HF can be translated to the community setting.     

Factors associated with a prolonged QT interval in liver cirrhosis patients

Aim

The aim of this study was to identify factors associated with prolonged QT interval in liver cirrhosis patients.

Materials and Methods

Thirty-eight patients with liver cirrhosis were enrolled in this study. The maximal QT interval (QTmax), heart rate-corrected QT interval (QTc), QT interval in lead DII (QTII), and mean QT interval (QTm) were determined manually, using 12-lead electrocardiogram. Additional laboratory tests were also performed.

Results

The following values were obtained: QTmax, 435 ± 43 milliseconds; QTc, 493 ± 46 milliseconds; QT interval in lead DII, 405 ± 46 milliseconds; and mean QT interval, 400 ± 40 milliseconds. Ten (6%) patients had a prolonged QTmax, and 27 (71%) had a prolonged QTc. The highest values were obtained for QTc and QTmax in patients with alcoholic cirrhosis and Child-Pugh class C, respectively. A moderate correlation was observed between QTmax and serum uric acid (URCA; r = 0.504), and multiple linear regression analysis revealed that URCA was significantly associated with QTc and heart rate.

Conclusions

Liver disease severity, alcoholic etiology, and URCA are associated with prolonged QT interval in patients with liver cirrhosis.