Prevalence of, associations with, and prognostic value of tricuspid annular plane systolic excursion (TAPSE) among out-patients referred for the evaluation of heart failure

BackgroundPrevalence, predictors, and prognostic value of right ventricular (RV) function measured by the tricuspid annular plane systolic excursion (TAPSE) in patients with chronic heart failure (CHF) symptoms with a broad range of left ventricular ejection fraction (LVEF) are unknown.Methods and ResultsOf 1,547 patients, mean (±SD) age was 71 ± 11 years, 48% were women, median (interquartile range [IQR]) TAPSE was 18.5 (14.0–22.7) mm, mean LVEF was 47 ± 16%, 47% had LVEF ≤45% and 67% were diagnosed with CHF, defined as systolic (S-HF) if LVEF was ≤45% and as heart failure with preserved ejection fraction (HFPEF) if LVEF was >45% and treated with a loop diuretic. During a median (IQR) follow-up of 63 (41–75) months, mortality was 34%. In multivariable analysis, increasing age, N-terminal pro–B-type natriuretic peptide (NT-proBNP), New York Heart Association functional class, right atrial volume index, and transtricuspid pressure gradient; lower TAPSE, diastolic blood pressure, and hemoglobin; and atrial fibrillation (AF) or COPD were associated with an adverse prognosis. Receiver operating characteristic curve analysis identified a TAPSE of 15.9 mm as the best prognostic threshold (P = .0001); 47% of S-HF and 20% of HFPEF had a TAPSE of <15.9 mm. The main associations with a TAPSE <15.9 mm were higher NT-proBNP, presence of atrial fibrillation and presence of LV systolic dysfunction.ConclusionsIn patients with CHF, low values for TAPSE are common, especially in those with reduced LVEF. TAPSE, unlike LVEF, was an independent predictor of outcome.     

Cytopenic syndromes in chronic hepatitis

The course of chronic hepatitis complicated by cytopenia has been analyzed for 31 patients. Clinical manifestations, early and differential diagnosis, treatment policy have been specified. It is advisable that such patients be observed both by hematologists and hepatologists.     

Should Patients who have Persistent Severe Symptoms Receive a Left Ventricular Assist Device or Cardiac Resynchronization Therapy as the Next Step?

Currently, cardiac resynchronization therapy (CRT) should be considered before a left ventricular assist device for most patients who have moderate or severe left ventricular systolic dysfunction and have not responded symptomatically to conventional pharmacologic measures. There is little evidence that the severity of cardiac dyssynchrony as measured using current techniques is useful in predicting the benefits of CRT. QRS duration on the surface ECG is a surrogate marker of the severity of the left ventricular ejection fraction as well as of several types of dyssynchrony. More clinical trials are required to determine whether excluding patients who have QRS duration less than 120 msec or those who have no evidence of dyssynchrony from implantation of CRT is appropriate. Perhaps all patients who have moderate or severe left ventricular systolic dysfunction should be considered for CRT, either to improve symptoms if they are persistent or relapsing, or to improve outcome. In the longer-term future, it is possible that the development of less expensive, small, and safe left ventricular assist devices will supplant the role of both CRT and CRT-defibrillator devices.     

Clinical trials update from the European Society of Cardiology Congress 2007: 3CPO, ALOFT, PROSPECT and statins for heart failure

This article provides information and a commentary on trials relevant to the pathophysiology, prevention and treatment of heart failure, presented at the European Society of Cardiology Congress 2007. Unpublished reports should be considered as preliminary data, as analyses may change in the final publication. In the 3CPO study, non-invasive ventilation produced a more rapid resolution of symptoms in patients hospitalised with acute cardiogenic pulmonary oedema; but had no effect on survival, compared to standard oxygen therapy. The ALOFT study showed that the selective oral renin inhibitor aliskiren reduces plasma BNP levels and is well tolerated in patients with heart failure receiving ACE inhibitors or ARBs, although the study was not powered to show clinical benefit. In the PROSPECT study, no echocardiographic measure of mechanical dyssynchrony was identified that was useful for identifying patients more or less likely to respond to CRT. Low dose atorvastatin reduced the incidence of sudden cardiac death in a small placebo controlled study of patients with advanced chronic heart failure.