Efficacy and safety of a 60-week treatment with candesartan in Japanese patients with mild to moderate chronic heart failure

BackgroundChronic heart failure (CHF) is an increasingly common cardiovascular disease despite recent advances in its diagnosis and management.Methods and resultsA multicenter, open-label study was designed to assess the efficacy and safety of 60-week treatment with candesartan in Japanese patients with mild to moderate CHF. Primary efficacy endpoints were changes from baseline in plasma brain natriuretic peptide (BNP), left ventricular ejection fraction (LVEF), end-diastolic dimension, and New York Heart Association (NYHA) functional class. Two hundred and eighty-nine eligible patients were divided into 2 groups based on the daily dose at the end of treatment: high-dose (HD, 8 mg, N = 170) and low-dose (LD, 2 or 4 mg, N = 119). Neither plasma BNP levels nor LVEF changed from the baseline to the end of treatment in the LD group, whereas BNP significantly improved from 61.6 to 50.1 pg/mL (p = 0.0005) and LVEF from 57.2 to 60.1% (p = 0.0005) in the HD group. The changes in NYHA functional class were comparable between groups: 21.2% improved and 76.3% unchanged in the LD group and 20.6% improved and 79.4% unchanged in the HD group. No safety concerns were observed in either group.ConclusionsHD candesartan was more effective in improving plasma BNP levels and cardiac function than LD in Japanese CHF patients. Both LD and HD candesartan were well tolerated in CHF patients.     

Usefulness of right atrial volume index in predicting outcome in chronic systolic heart failure

BackgroundRight ventricular (RV) dysfunction is associated with poor prognosis in patients with heart failure (HF). Echocardiographic assessment of RV systolic function is challenging. The ability to visualize the right atrium (RA) allows a quantitative, highly reproducible assessment of RA volume.ObjectiveThe aim is to study the relationship between the right atrial volume index (RAVI) and prognosis in patients with chronic systolic HF.Methods120 patients with chronic systolic HF and left ventricular ejection fraction (LVEF) <40% were enrolled. The RA volume was calculated by Simpson’s method using single-plane RA area and indexed to body surface area (RAVI). RV systolic assessment was done using the RV fractional area change (RVFAC), and peak systolic velocity (Sa_tri) using tissue Doppler imaging at the tricuspid annulus. The primary endpoint was death, urgent transplantation, or acute HF episode requiring hospital admission during a follow-up of 1 year.ResultsFollow up was complete for 117 of 120 patients. Fifty-two patients reached the primary endpoint. The mean RAVI was higher in patients with adverse events (45.5 ± 15 ml/m² versus 25.2 ± 11 ml/m², p < 0.001), and increased with worsening LVEF, RVFAC, Sa_tri (Spearman’s r = −0.46, r = −0.45, r = −0.59, p < 0.001 for all). RAVI was not correlated with estimates of RV diastolic dysfunction. The cut-off threshold for RAVI to predict the primary endpoint using receiver-operating characteristic curve was 29 ml/m² (area under the curve was 0.89%, 95% confidence interval: 0.82–0.95) with a sensitivity of 92%, and a specificity of 75%. NYHA > 2 (OR = 2.1, p < 0.01), and RAVI (OR = 1.6, p < 0.05) were found to be independent predictors of adverse outcome.ConclusionIn patients with chronic systolic HF, RAVI is an independent predictor of adverse outcome with a threshold value of 29 ml/m².     

Transition from angiotensin-converting enzyme inhibitor/angiotensin-II-receptor-blocker to sacubitril/valsartan in chronic heart failure patients: Initial experiences in clinical practice

BackgroundSacubitril/valsartan (S/V) therapy has been demonstrated to improve prognosis of systolic heart failure (HF) patients when compared to standard therapy with ACEi. The purpose of this investigation was to document the safety and consequences of transition from ACEi/angiotensin-II receptor blocker (ARB) to S/V in chronic stable HF patients.MethodsA group of 12 stable HF outpatients (11 males, 1 female) was enrolled (NYHA 2.7 ± 0.7, 42% with coronary artery disease (CAD), average left-ventricle ejection fraction (LVEF) 26.5%). Patients were converted from ACEi/ARB to S/V. Laboratory evaluation, Minnesota Living with Heart Failure Questionnaire (MLHFQ), six-minute walk test (6MWT) were performed before the conversion and at 3-month follow-up visit.ResultsConversion from ACEi/ARB to S/V was not associated with any adverse event. After 3 months, S/V therapy decreased blood pressure (−14.8 mmHg for systolic BP, −9.6 mmHg for diastolic BP) and serum potassium (−0.27 mmol·l⁻¹, all p < 0.05). No worsening of renal function occurred (creatinine −7.8 μmol·l⁻¹, p = 0.12, estimated glomerular filtration rate +0.08 ml·s⁻¹·1.73 m⁻², p = 0.14). B-type natriuretic peptide (BNP) level remained unchanged (p = 0.18), but NT-proBNP level decreased significantly (median 1012 ng·l⁻¹ at baseline, 559.4 ng·l⁻¹ at follow-up, p = 0.005). A slight but significant decrease in high-sensitivity cardiac troponin T (hs-cTnT) was observed (median 14.76 ng·l⁻¹ at baseline, 12.63 ng·l⁻¹ at follow-up, p = 0.001). An improvement in MLHFQ total score (−8 points, p = 0.006) and in 6MWT by 55 m (p = 0.0007) was noted, which was not due to increased effort.ConclusionThe transition from ACEi/ARB to S/V therapy appears to be safe and leads to an improvement in exercise tolerance and quality of life.     

Metabolic manipulation in dilated cardiomyopathy: Assessing the role of trimetazidine

ObjectivesTo study the role of metabolic modulator (trimetazidine: TMZ) in dilated cardiomyopathy (DCM). Optimizing altered substrate metabolism in heart failure (HF) with metabolic modulators allows more efficacious energy production from glucose than from free fatty acids.Methods100 patients of DCM (47.7 years, NYHA class 2.17, LVEF 27.3%) were randomized to TMZ (20 mg tid, n = 50) vs conventional therapy (n = 50). Functional status, BNP and various echocardiographic parameters were assessed at 3–6 months.ResultsAt 3 months, TMZ group had significantly improved NYHA class (2.25 vs 1.85), 6 min walk test (349.7 vs 402 m), LVD-36 score (25.5 vs 21) and BNP (744.7 vs 248.3 pg/ml), all p 0.001. Significant improvement was also seen in LV end-systolic (LVESV, 87.1 ± 27.5 vs 78.5 ± 24.9 ml/m², p 0.001), LV end-diastolic volumes (LVEDV, 117.6 ± 29.3 vs 110.9 ± 27.4 ml/m², p 0.001), LVEF (27 vs 30.9%, p 0.001) and LV wall stress (90.2 ± 18.9 vs 71.1 ± 13.2 dyn/cm², p 0.0001). The % change in LVESV, LVEDV, LVEF and LV wall stress was −9.5%, −5.4%, +8.4% and −21.8%. Other echo parameters also improved after 3 months of TMZ (E/A ratio 1.9 vs 1.2, p = 0.001, E/A VTI 2.7 vs 1.6, p = 0.001, myocardial performance index, MPI 0.8 vs 0.7, p = 0.0001), Tissue Doppler parameters (E/E′ septal (19.7 vs 12.5, p = 0.001) and E/E′ lateral (13.3 vs 9.4, p = 0.0001)). Patients in control group had no change in NYHA class, LVD-36 scores, LV volumes or LVEF at 3 months although BNP and LV wall stress reduced to a slight extent. Patients on TMZ had further improvement in NYHA class, walk test, BNP levels and echocardiographic parameters at 6 months.ConclusionsMetabolic modulators (TMZ) may help in improving LV function in DCM. In this study, benefit was noted by 3 months with further improvement at 6 months.     

Evaluation of left ventricular mechanical dyssynchrony in chronic heart failure patients by two-dimensional speckle tracking imaging

The purpose of this study was to evaluate left ventricular mechanical dyssynchrony (LVMD) in chronic heart failure (CHF) patients using two-dimensional speckle tracking imaging (2D-STI), and also to compare the usefulness of three patterns of myocardial deformation in mechanical dyssynchrony assessment. Furthermore, the relationships between left ventricular ejection fraction (LVEF), QRS duration (QRSd), and LVMD were explored. In total, 78 patients and 60 healthy individuals (group 3) were enrolled. The patients were classified into two subgroups: LVEF ≤ 35% (group 1), 35% < LVEF < 50% (group 2). All participants underwent two-dimensional echocardiography, and dyssynchrony indices derived from 2D-STI were calculated. According to statistical principles, the cut-off value of LVMD was defined as mean ± 1.645 SD of the normal population. Dyssynchrony rates were calculated in CHF subgroups and compared within each subgroup, respectively. Compared with group 3, all indices in group 1 were remarkably higher (p < 0.05), and some of the indices in group 2 were significantly higher (p < 0.05). A significant difference of dyssynchrony rate was noted within both group 1 and group 2 (χ² = 25.55, p < 0.05 vs. χ² = 23.88, p < 0.05), and the highest value was derived from the longitudinal index in both subgroups. LVEF was related to all three forms of strain/strain rate (p < 0.05), whereas no relationship existed between QRSd and dyssynchrony indices (p > 0.05). CHF patients have different extents of LVMD. Longitudinal deformation shows the best detectability of dyssynchrony motion. Left ventricular systolic function was closely related to mechanical dyssynchrony, whereas QRSd showed no significant correlation.     

Clinical characteristics and one-year survival in heart failure patients more than 85 years of age compared with younger

BackgroundHeart failure (HF) is frequent in elderly patients, but few studies have focused on patients older than 84 years. The aim of this study was to evaluate major comorbidities and 1-year survival in HF patients aged ≥ 85 years compared with younger age groups.MethodsPatients included in a prospective national registry of HF (RICA) were evaluated. Sociodemographic data, Charlson comorbidity index, cognitive status, basal functional status, body mass index, NYHA functional class, and left ventricle ejection fraction (LVEF) were recorded. Patients aged ≥ 85 years were compared with the rest using the Cox regression model to detect independent predictive factors of 1-year survival.ResultsOf the 1172 patients included, 224 (19%) were aged over 84 years-old, mostly women, with hypertensive heart disease (46%, p < 0.001) and preserved LVEF (68.7%; p < 0.001). Diabetes (p < 0.001), dyslipidemia (p = 0.03) and obesity (p < 0.001) were less prevalent in this group of patients. One-year mortality in the oldest old patients was 26.3%, which was higher than the rest (p < 0.001). By multivariable analysis, a higher NYHA functional class (p = 0.038), anemia (p = 0.037), absence of obesity (p = 0.002), and a worse functional status (p = 0.049) were related to a worse 1-year survival in the oldest HF patients.ConclusionsThe oldest old HF patients have differential characteristics with lower prevalence of diabetes, dyslipidemia and obesity and a lower 1-year survival. Independent factors related to a worse 1-year survival in the oldest age group were a higher NYHA class, a worse functional status, presence of anemia and absence of obesity.     

Closing the Heart Failure Management Gap in the Community: Managing Hypotension and Impact on Outcomes

BackgroundPerception of risk in using recommended therapy in heart failure (HF) patients with hypotension adds to the problems of undertreatment in management. We aimed to determine the feasibility and outcomes of therapy in hypotensive HF patients.Methods and ResultsData were collected from HF clinic patients between 1999 and 2003. Exclusion criteria were: left ventricular ejection fraction (LVEF) >45%; myocardial infarction or revascularization within 3 months of referral; and consult-only visits. Criteria were met by 500 patients. Median follow-up was 6.8 years, with end points of total mortality and combined death and hospitalizations. Blood pressure measurements were done by the nursing staff after the patient was seated for at least 5 minutes. Two measures were taken per each patient encounter and the average of 2 systolic values is recorded for group categorization. Group 1 (hypotension, n = 112) subjects were younger (65 ± 14 vs. 69 ± 12; P = .003) and had lower mean LVEF (22 ± 10% vs. 25 ± 9%; P = .012) than group 2 (no hypotension, n = 338). Drug utilization was similar at 3 months, 1 year, and long-term. Systolic blood pressure (SBP) increased in group 1, but decreased in group 2. Mortality was similar at years 1 and 5 (12.8% vs. 9.9%, P = NS; 45.5% vs. 41.4%, P = .507); however, combined death and hospitalizations were negatively and independently affected by failure to receive therapy.ConclusionsWhen treated successfully with recommended therapy, SBP improved and patients with hypotension at baseline enjoyed significant benefits in outcomes. More effort is needed on mechanisms to implement guidelines to improve HF management.     

Ventricular twist in isolated left ventricular noncompaction

The study aimed at assessing the rotational motion of the left ventricle around the long axis in patients affected by isolated left ventricular noncompaction (LVNC) and comparing their results with those of healthy volunteers.Patients and methodsThe study comprised eight patients with LVNC confirmed by echocardiography and magnetic resonance imaging (mean age 41 ± 19 years; four males; left ventricular ejection fraction [LVEF] 45 ± 25%). The patients were divided into Group A with an LVEF above 50% (four patients; one male) and Group B with an LVEF below 50% (four patients; three males). For both groups, age- and sex-matched volunteers were found. The focus was on myocardial twist, rotation of the LV apex and base, times to reach maximal apical and maximal basal rotation and myocardial twist, as well as correlations between systolic function, rotation of individual planes and LV twist.ResultsWhen comparing LVNC patients with healthy volunteers, there were statistically significantly decreased systolic function (p = 0.004), larger diastolic dimension (p = 0.045) and decreased apical rotation (p = 0.01). Left ventricular twist was significantly decreased in the group of patients with LVNC and systolic dysfunction (p = 0.04). A statistically significant correlation was found between systolic function and LV apical rotation.ConclusionThe study showed a significant decrease in apical rotation and twist mechanism of the LV as measured using two-dimensional speckle tracking in patients with LVNC and decreased LV systolic function. Measuring these parameters could contribute to more accurate diagnosis and risk stratification of patients affected by this condition.     

Evaluation of left ventricular performance in hypertensive patients by speckle tracking echocardiography: Correlation with brain natriuretic peptide

BackgroundHypertension results in hemodynamic changes ranging from maladaptive left ventricular hypertrophy (LVH) to heart failure. Two-dimensional speckle tracking echocardiography (2D-STE) allows rapid and accurate analysis of regional and global left ventricular (LV) systolic and diastolic functions.ObjectiveAssessments of LV function in hypertensive patients with apparently preserved LV systolic function using 2D-STE in correlation with plasma brain natriuretic peptide (BNP) levels.Patients and MethodsEighty hypertensive patients were enrolled, they were classified into LVH group (group III) and non-LVH group (group II). Twenty sex and age-matched healthy individuals were recruited as controls (group I). 2D-STE was done to all subjects to assess LV longitudinal strain, and strain rate (SR). Plasma BNP levels were measured in all subjects.ResultsGlobal longitudinal systolic strain was significantly reduced in group III compared with group II (P = 0.037) and group I (P = 0.000). Furthermore, group III showed significantly reduced global LV longitudinal systolic SR and early diastolic strain rate compared with group II (P = 0.023 and 0.008 respectively), and group I (P = 0.01 and 0.0001 respectively). On the other hand, the mean values of global SRa s⁻¹ were significantly higher in both group II and group III compared to group I (P = 0.0001). A negative correlation was found between BNP level and global peak systolic strain, global systolic strain rate, early diastolic strain rate and late diastolic strain rate in hypertensive patients (groups II & III) in whom BNP level was significantly higher than controls (group I) (P = 0.000).ConclusionA substantial impairment of LV systolic and diastolic functions is detected in hypertensive patients with apparently preserved LV systolic function, especially if associated with LVH, as evidenced by two-dimensional speckle tracking echocardiography. Plasma BNP level is elevated in hypertensive patients and shows a significant negative correlation with strain and strain rate values.     

Efficacy of ivabradine in idiopathic dilated cardiomyopathy patients with chronic heart failure

BackgroundThe aim of this study was to investigate the effect of ivabradine on symptoms, quality of life, effort tolerance, and echocardiographic parameters in patients with idiopathic dilated cardiomyopathy presenting with New York Heart Association (NYHA) class III or IV heart failure (HF) symptoms.MethodsWe screened 167 patients hospitalized for NYHA class III or IV chronic HF symptoms and left ventricular (LV) ejection fraction <40%. Of these, 53 were randomly assigned to either guidelines-based medical therapy alone (23 patients, control group) or ivabradine as add-on therapy (30 patients) for 3 months with about 1 year follow up.ResultsAfter 3 months’ treatment, adding ivabradine significantly reduced the heart rate from 96 to 72 bpm (p < 0.0001 versus control group), with more improvement in echocardiographic LV dimensions, LV volumes, LV ejection fraction (p = 0.045), NYHA class symptoms (p = 0.004), exercise tolerance (p = 0.03), and quality of life (p = 0.02). The average number of hospitalizations for HF over a mean longer-term follow-up of 13.5 months was 1.0 ± 1.4 in the ivabradine group versus 2.1 ± 1.1 in the control group (p = 0.003). Heart rate reduction was significantly correlated with better exercise tolerance, quality of life, LV ejection fraction, and NYHA class, together with fewer HF hospitalizations. Multivariate analysis showed heart rate reduction to be a stronger predictor for better LV ejection fraction (p = 0.024) and decreased hospitalizations than ivabradine use.ConclusionAdding ivabradine to optimal medical treatment in HF patients improved symptoms, quality of life, effort tolerance, and echocardiographic parameters, and reduced hospitalization. This beneficial ivabradine effect is probably due to its heart rate–reducing properties.     

Tolvaptan reduces the risk of worsening renal function in patients with acute decompensated heart failure in high-risk population

BackgroundAlthough tolvaptan is a recently approved drug for heart failure and causes aquaresis without affecting renal function, its clinical efficacy for patients with acute decompensated heart failure (ADHF) is yet to be elucidated.Methods and resultsWe conducted a prospective observational study in patients with ADHF and high risk for worsening renal function (WRF). Risk stratification for WRF was done by scoring system. Of 174 patients, 114 patients were included as high-risk population for WRF. Incidence of WRF, urine output within 24 h and 48 h, and changes in brain natriuretic peptide (BNP) were recorded in 44 patients treated with tolvaptan plus conventional therapy, and 70 patients with only conventional therapy. Urine output at 24 h and 48 h after admission were both significantly higher in the tolvaptan group (p = 0.001 and <0.001, respectively), and changes in BNP were not significantly different (p = 0.351). However, the incidence of WRF was significantly lower in the tolvaptan group compared to the conventional group (22.7% vs 41.4%, p = 0.045). Logistic regression analysis showed that treatment with tolvaptan was an independent factor for reducing WRF (hazard ratio 0.28, 95% confidence interval; 0.10–0.84; p = 0.023).ConclusionIn patients with ADHF with high risk of WRF, treatment with tolvaptan could prevent WRF compared to conventional therapy.     

Impacto del bloqueo del sistema renina-angiotensina en el pronóstico del síndrome coronario agudo en función de la fracción de eyección

Introduction and objectivesFor patients with acute coronary syndrome (ACS) treated with percutaneous coronary intervention (PCI), it is unclear whether angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) are associated with reduced mortality, particularly with preserved left ventricular ejection fraction (LVEF). The goal of this study was to determine the association between ACEI/ARB and mortality in ACS patients undergoing PCI, with and without reduced LVEF.MethodsData from the BleeMACS registry were used. The endpoint was 1-year all-cause mortality. The prognostic value of ACEI/ARB was tested after weighting by survival-time inverse probability and after adjustment by Cox regression, propensity score, and instrumental variable analysis.ResultsAmong 15 401 ACS patients who underwent PCI, ACEI/ARB were prescribed in 75.2%. There were 569 deaths (3.7%) during the first year after hospital discharge. After multivariable adjustment, ACEI/ARB were associated with lower 1-year mortality, ≤ 40% (HR, 0.62; 95%CI, 0.43-0.90; P = .012). The relative risk reduction of ACEI/ARB in mortality was 46.1% in patients with LVEF ≤ 40%, and 15.7% in patients with LVEF > 40% (P value for treatment-by-LVEF interaction = .008). For patients with LVEF > 40%, ACEI/ARB was associated with lower mortality only in ST-segment elevation myocardial infarction (HR, 0.44; 95%CI, 0.21-0.93; P = .031).ConclusionThe benefit of ACEI/ARB in decreasing mortality after an ACS in patients undergoing PCI is concentrated in patients with LVEF ≤ 40%, and in those with LVEF > 40% and ST-segment elevation myocardial infarction. In non–ST-segment elevation-ACS patients with LVEF > 40%, further studies are needed to assess the prognostic impact of ACEI/ARB.     

Relationship between BNP level and renal function in diabetic nephropathy with microalbuminuria

AimsWe examined the relationship between the brain natriuretic peptide (BNP) level and renal function in diabetic nephropathy with microalbuminuria.MethodsThe subjects were 97 Japanese type 2 diabetes mellitus outpatients with microalbuminuria. Associations between the annual rate of decline in estimated glomerular filtration rate (eGFR) and various metabolic parameters at baseline (BMI, systolic blood pressure, HbA1c, LDL cholesterol, urine albumin–creatinine ratio, BNP and eGFR) were examined.ResultsAmong the baseline factors, eGFR and BNP had significant associations with the annual rate of decline in eGFR in Pearson correlation analysis (r = 0.295, p = 0.003; r = 0.223, p = 0.028, respectively). Multiple linear regression analysis also showed the significance of baseline eGFR and BNP as independent predictors of renal function (β = 0.340, p = 0.001; β = 0.278, p = 0.005, respectively). In multivariate logistic regression analysis, eGFR and BNP were independently associated with the risk of a decline in GFR (p = 0.003, p = 0.011, respectively). ROC curve analysis showed a cutoff value of BNP is 17.0 pg/mL for predicting a decline in GFR.ConclusionsThe BNP level at baseline is an independent predictor of the annual rate of decline in eGFR. Therefore, monitoring of BNP can play an important role in management of diabetic nephropathy.     

Impact of prealbumin on mortality and hospital readmission in patients with acute heart failure

BackgroundPrealbumin is a maker of nutritional status and inflammation of potential prognostic value in acute heart failure (HF). The aim of this study is to evaluate if low prealbumin levels on admission predict mortality and readmissions in patients with acute HF.MethodWe conducted a prospective observational cohort study including 442 patients hospitalized for acute HF. Patients were classified in two groups according to prealbumin levels: “normal” prealbumin (> 15 mg) and “low” prealbumin (≤ 15 mg/dL). End-points were mortality and readmissions (all-cause and HF-related) and the combined end-point of mortality/readmission at 180 days.ResultsOut of 442 patients, 159 (36%) had low and 283 (64%) had normal prealbumin levels Mean age was 79.6 (73.9–84.2, p = 0,405) years and 183 (41%, p = 0,482) were males. After a median 180 days of follow-up, 108 (24%, p = 0,021) patients died and 170 (38%, p = 0,067) were readmitted. Mortality was higher in the low prealbumin group. The combined end-point was more frequent in the low prealbumin group (57% vs. 50%, p = 0.199). In the multivariate analysis the following variables were associated with mortality or readmission: older age, exacerbated chronic HF, higher comorbidity, low systolic blood pressure and hemoglobin values and higher pro brain natriuretic peptide levels.ConclusionsLow prealbumin is common (36%) in patients with acute heart failure and it is associated with a higher short-term mortality.     

Routinely-feasible multiple biomarkers score to predict prognosis after revascularized STEMI

IntroductionWe assessed the long-term prognostic value of an easy-to-do multiple cardiac biomarkers score after a revascularized acute myocardial infarction (MI) in order to evaluate a multimarker approach to risk stratification, based on routine biomarkers.Material and methodsBlood samples from 138 patients hospitalized with acute myocardial infarction and successfully treated by primary coronary intervention (with TIMI 3 flow) were subsequently tested for creatinin level at admittance and then BNP, hsCRP, troponin I from Day 0 to day 7. The primary endpoint was a clinical evaluation comprising: new hospitalization for cardiac reasons, acute coronary events (acute coronary syndrome), and death.ResultsDuring the median follow-up period of 11.01 months [9.44–12.59], 47 events were recorded. All the following markers were able to predict events: creatinemia on admission (p = 0.0057), CRP on day 3 (p, troponin I on day 1 (p < 0.001), BNP (p < 0.0001) and biological multimarker score (p < 0.0001).Clinical events were predicted with a hazard ratio (HR) of respectively 3.30 [2.88–12.30] in BNP Q4 as compared to the three lower quartiles (Q1–3), and 3.15 [2.75–21.00] for the Multimarker approach. The multimarker score was not significantly better than BNP on day 1 alone (p = 0.77), troponin on day 1 alone (p = 0.43), creatininemia on admission (p = 0.19) or CRPhs on day 3 alone (p = 0.054). Nevertheless, the Multimarker approach leads to the selection of a smaller, hence more manageable, high-risk population (13% versus 25%).ConclusionAmong 138 subjects admitted for acute MI, and all successfully revascularized, a routinely multimarker approach with BNP, hsCRP, creatininemia, troponin I, is feasible.BNP is the most powerful marker, and this multimarker approach renders additional prognostic information helping to identify patients with high-risk to clinical events.     

Assessment of left ventricular ejection force and sympathetic skin response in normotensive and hypertensive subjects: A double-blind observational comparative case–control study

BackgroundPathophysiology of essential hypertension remains obscure. Correlation among ventricular ejection force, sympathetic activity, and hypertension is less clearly narrated in hypertensive subjects.Aims and objectivesTo assess correlation among ventricular ejection force, sympathetic activity, and hypertension in hypertensive subjects, and to be compared with normotensive subjects.MethodsThis is a case–control study to assess left ventricular ejection force (LVEF) and sympathetic skin response, in normotensive (group 1; control), and hypertensive subjects (group 2; cases). 100 cases were selected. Subjects having stages 1 and 2 hypertension were categorized in groups 2A and 2B, respectively. LVEF was calculated by using echocardiography observing aortic acceleration time (AT) and peak systolic velocity. Comparison among groups was done by using one-way ANOVA.ResultsBoth groups were comparable. In group 2, 60 cases had stage 1 hypertension and 40 had stage 2 hypertension. Significantly short AT and significantly high LVEF were found in hypertension (groups 2A and 2B) (p < 0.0001). Sympathetic activity was high in group 2A (p < 0.0001). Stroke volume (SV) was high in group 2B (p < 0.0001).ConclusionStage 1 hypertension is a stage of increased sympathetic activity, leading to increased LVEF and hypertension (resetting of baroreceptors); stage 2 hypertension is a stage of normal sympathetic activity, increased LVEF, increased SV, and hypertension (possibly a stage of shift of renal equilibrium curve/renal output curve and blood pressure to a newer level).     

Cardiovascular risk factors profile in patients with acute coronary syndrome with particular reference to left ventricular ejection fraction

BackgroundAcute coronary syndrome (ACS) remains a leading cause of death in the United States. Numerous studies have shown that the degree of LV systolic dysfunction is a major if not the most important determinant of long-term outcome in ACS.ObjectivesTo identify the most important risk factors and other clinical predictors which might have impact on left ventricular ejection fraction in patients with ACS.ResultsThe total patients (299) admitted to our center from July, 2015 till December, 2015; with established diagnosis of ACS were classified in to two groups: Group I: 193 patients with impaired LVEF < 40% (64.5%), Group II: 106 patients with LVEF equal or > 40% (35.5%). The patients of group I were significant elderly compared to those of group II (60.9 ± 11.2 vs 56.9 ± 10.6; p = 0.002), had significant history of DM and CKD (66.3% and 31.1% VS 49.1% and 19.8%; p = 0.004 and 0.036 respectively), presented mainly with STEMI- ACS (51.3% VS 28.3% respectively; p < 0.001) with +v cardiac biomarker (troponin) (90.2% VS 66.0%; p < 0.001). Moreover, patients of group I had more significant ischemic MR compared to the patients of group II (24.9% VS 3.8% respectively; p < 0.001) with higher rate of LV thrombus discovered by echocardiography (25.4% VS 1.9%; p < 0.001). Extensive significant CAD disease was observed to be higher among patients of group I (69.4% VS 57.5%; p = 0.039) and those patients treated mainly with PCI revascularization therapy (68.9% VS 52.8%; p = 0.002) compared to patients of group II who mainly treated medically (34.9% VS 17.6 %; p < 0.001). Multiple logistic regression analysis demonstrated that DM (odd ratio (OR): 2.64, 95% confidence interval (CI): 1.45-4.79, P = 0.01), presence of significant ischemic MR (OR: 13.7, 95% CI:2.84-66.1, p = 0.001)and presence of significantly diseased coronary vessels (odd ratio (OR): 5.06, 95% confidence interval (CI): 1.14-22.6, P = 0.033,) all were independent predictors for significant LV dysfunction (LVEF < 40%) which predict poor outcome in ACS patients.ConclusionWe concluded that DM, presence of significant ischemic MR, and increased number, severity of diseased coronaries all were independent predictors of LV dysfunction (LVEF < 40%) which is known to predict poor outcome. Identification of those risk predictors upon patient evaluation could be helpful to identify high risk-patients, in need of particular care, aggressive therapy and close follow-up to improve their poor outcome.     

Polymorphisms of MMP-2 Gene are Associated With Systolic Heart Failure Risk in Han Chinese

BackgroundMatrix metalloproteinases (MMPs) are a family of proteolytic enzymes responsible for protein degradation. MMP-2 has been demonstrated to play a pivotal role in myocardial remodeling process that occurs in congestive heart failure (HF). We hypothesized that MMP-2 genetic variations could be associated with systolic HF risk.MethodsTo test the association of single nucleotide polymorphisms of MMP-2 with systolic HF risk, we performed a hospital-based, case-control study of 605 patients with systolic HF and 689 controls without HF. Three single nucleotide polymorphisms of MMP-2 (rs243864, rs243866, and rs17859821) were genotyped by restriction fragment length polymorphism methods.ResultsThe genotype frequencies of MMP-2 rs243866 AA and AG in the control group were significantly higher than that in the case group (24.7% versus 17.9%, P < 0.01). Compared with the GG homozygotes, MMP-2 rs243866 A allele carriers had a significantly lower risk of systolic HF (adjusted OR 0.69, 95% CI 0.49-0.98; P = 0.035). Haplotype analysis indicated the haplotype GGG (rs243864-rs17859821-rs243866) was associated with higher risk of systolic HF (adjusted OR 2.05, 95% CI 1.08-3.89; P = 0.028).ConclusionThe findings of the current study suggest that MMP-2 rs243866 A allele was associated with lower risk of systolic HF in Han Chinese.     

Heart rate manipulation in dilated cardiomyopathy: Assessing the role of Ivabradine

BackgroundHeart rate (HR) reduction is of benefit in chronic heart failure (HF). The effect of heart rate reduction using Ivabradine on various echocardiographic parameters in dilated cardiomyopathy has been less investigated.MethodsOf 187 patients with HF (DCM, NYHA II–IV, baseline HR > 70/min), 125 patients were randomized to standard therapy (beta blockers, ACEI, diuretics, n = 62) or add-on Ivabradine (titrated to maximum 7.5 mg BD, n = 63). Beta-blockers were titrated in both the groups.ResultsAt 3 months both groups had improvement in NYHA class, 6 min walk test, Minnesota Living With Heart Failure (MLWHF) scores and fall in BNP, however the magnitude of change was greater in Ivabradine group. Those on Ivabradine also had lower LV volumes, higher LVEF (28.8 ± 3.6 vs 27.2 ± 0.5, p = 0.01) and more favorable LV global strain (11 ± 1.7vs 12.2 ± 1.1, p = <0.001), MPI (0.72 ± 0.1 vs 0.6 ± 0.1, p = <0.001), LV mass (115.2 ± 30 vs 131.4 ± 35, p = 0.007), LV wall stress (219.8 ± 46 vs 238 ± 54) and calculated LV work (366 ± 101 vs 401 ± 102, p = 0.05). The benefit of Ivabradine was sustained at 6 months follow up. The % change in HR was significantly higher in Ivabradine group (−32.2% vs −19.3%, p = 0.001) with no difference in blood pressure. Resting HR < 70/min was achieved in 96.8% vs 27.9%, respectively in the two groups.ConclusionAddition of Ivabradine to standard therapy in patients with DCM and symptomatic HF and targeting a heart rate < 70/min improves symptoms, quality of life and various echocardiographic parameters.     

Relation between serum B-type brain natriuretic peptide level and complexity & severity of coronary artery disease in non-ST elevation myocardial infarction

BackgroundNeurohumoral activation of the heart can be monitored by measurements of systemic levels of natriuretic peptides, such as BNP. Patients with non ST-elevation myocardial infarction (NSTEMI) with elevated BNP levels had an increased mortality rate when compared with those with lower levels. The SYNTAX score is a novel anatomical tool characterizing coronary vasculature and grades the complexity of coronary artery disease.Patients and methodsThe study included 58 patients with NSTEMI “Group I” (72.5%) and 22 patients as a control “Group II” (27.5%) with typical chest pain, and coronary angiography revealed healthy coronaries. Analysis of blood samples for troponin-I, CKMB, and BNP levels was performed within 24 h of hospital admission, all patients underwent echocardiographic examination to exclude systolic dysfunction. Both groups were referred to coronary angiography.ResultsThis study included 58 patients with NSTEMI “Group I” (72.5%) and 22 patients as a control “Group II” (27.5%), the serum level of BNP was significantly higher in patients with the NSTEMI “group I” (37.7 ± 32.06) than the control “group II” (1.82 ± 5.9) p value (0.0001). The levels of BNP were positively correlated with the LAD involvement in coronary angiography. There was a positive correlation between the serum level of BNP and number of coronary vessels involved (r = 0.75) and Degree of SYNTAX score (r = 0.78).ConclusionThere was a significant relationship between the serum level of BNP and number of coronary arteries involved and complexity of the lesions in NSTEMI as regards SYNTAX score.