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Heartbeat: Cardiac resynchronization therapy with or without defibrillation: are women different?

2017-04-26T04:38:56-07:00

Cardiac resynchronization therapy (CRT) reduces symptoms and improves survival in heart failure patients with a low left ventricular ejection fraction and wide QRS complex. CRT devices can be configured to provide only pacing (CRT-P) or to include a defibrillator (CRT-D) with the goal of reducing the risk of sudden cardiac death (SCD). However, it is not clear which clinical parameters best distinguish those patients who will benefit from CRT-D versus those who should receive CRT-P. In this issue of Heart, Barra and colleagues1 report an observational study of 5307 consecutive patients undergoing CRT implantation for ischaemic or non-ischaemic dilated cardiomyopathy with no history of prior sustained ventricular arrhythmias. Propensity score matching was used to compare outcomes of those with CRT-D versus CRT-P with the aim of assessing whether outcomes differ by sex. In their analysis, the benefit of CRT-D was seen only in men (not women) with...




Integrated care of patients with atrial fibrillation: the 2016 ESC atrial fibrillation guidelines

2017-04-26T04:38:56-07:00

Atrial fibrillation (AF) is one of the evolving epidemics in cardiovascular medicine. AF is projected to develop in 25% of currently 40-year-old adults,1 2 provokes many, often severe strokes, is associated with increased mortality and often leads to heart failure or sudden death even in well-anticoagulated patients.3 4 The last few years have seen the development of new approaches to detect and treat patients with AF, from ECG screening to surgical procedures to prevent recurrent AF. While these improvements provide tools to improve outcomes and quality of life in affected patients, they often need multidisciplinary input into patient management. It therefore seems timely that the European Society of Cardiology (ESC) has issued new AF guidelines in August 2016.5

Good management of patients with AF requires a team effort

Reflecting the need for multidisciplinary input, the 2016 ESC AF...




Gender-specific outcomes of cardiac resynchronisation therapy with or without defibrillator

2017-04-26T04:38:56-07:00

Cardiac resynchronisation therapy has been shown to significantly reduce heart failure (HF) symptoms, prevent HF hospitalisations and improve survival in HF patients with severely reduced left ventricular ejection fraction (LVEF) and a wide QRS.1 Sudden cardiac death (SCD) is also prevalent in HF patients with severely reduced LVEF, and therefore, combined protection from HF and SCD is generally warranted in this cohort. It is however not well known whether adding a defibrillator function to cardiac resynchronisation therapy provides incremental benefit, especially in the context of gender.

In their Heart publication Barra et al.2 reported retrospective analyses of outcomes of 5307 consecutive patients with ischaemic or non-ischaemic cardiomyopathy and no history of sustained ventricular tachyarrhythmia implanted either with cardiac resynchronisation therapy with defibrillator (CRT-D) or without a defibrillator (CRT-P). The primary focus of their report was to assess incremental survival benefit of CRT-D versus CRT-P by...




Through the looking glass of rheumatoid arthritis to study inflammation and high-density lipoprotein

2017-04-26T04:38:56-07:00

Destruction of bone and soft tissue in rheumatoid arthritis (RA) occurs as a result of unchecked systemic inflammation. While swollen and deformed joints are easy to see, less obvious to the naked eye is the impact of this same inflammatory process on the cardiovascular (CV) system. Cardiovascular disease (CVD) is the leading cause of death in patients with RA. The mortality rate from CVD in RA is approximately 1.5 times that of individuals from the general population with the same age, sex and CV risk factors.1 The excess CV risk has been attributed to inflammation; however, the pathways and mechanisms linking inflammation to CV events are less clear. Lipids, specifically low-density lipoprotein cholesterol (LDL-C), are considered part of the causal pathway for atherosclerosis and CVD in the general population. However, the established relationships between LDL-C and CV risk are altered in RA. As expected, elevated levels of...




Cardiac involvement in ankylosing spondylitis. Can new magnetic resonance indices interpret cardiac pathophysiology beyond echocardiography?

2017-04-26T04:38:56-07:00

Ankylosing spondylitis (AS) associates with various cardiac lesions, including aortitis/aortic regurgitation, conduction abnormalities and myocardial involvement, due to either coronary artery disease or primary cardiomyopathy.1 The cornerstone tool for the non-invasive evaluation of heart involvement has, until recently, been echocardiography.1 Echocardiographic evaluation in AS is mainly focused on valve and ventricular function assessment, with the pattern of ‘diastolic dysfunction with preserved ejection fraction’ being the most common preclinical finding. A strong correlation has also been shown between several indices of vascular pathology associated with the development of cardiovascular disease (CVD) and increased disease activity in patients with AS.2

Cardiovascular magnetic resonance (CMR), a non-invasive, non-radiating, operator-independent technique, currently represents the gold standard for ventricular function and tissue characterisation in patients with CVD, including those in whom CVD develops in the context of a connective tissue disease (CTD).3 4 Recently,...




Natriuretic peptides in the evaluation and management of degenerative mitral regurgitation: a systematic review

2017-04-26T04:38:56-07:00

Progression of degenerative mitral regurgitation (MR) leads to irreversible cardiac damage. Therefore, longitudinal follow up to determine the optimal timing of surgery is critical. Current data indicates that in addition to the standard of care—assessing for symptoms and signs of left ventricular (LV) decompensation with routine echocardiography—serial measurement of natriuretic peptides offers a quantitative means to identify patients who may benefit from closer supervision, if not surgery. Natriuretic peptide levels, and specifically changes from baseline, identify both symptomatic patients and others likely to develop cardiac dysfunction. Moreover, because natriuretic peptides are complimentary to the echocardiographic assessment of MR. Finally, changes in natriuretic peptides levels are predictive of pre- and post-operative outcomes. In short, natriuretic peptides add objectivity to the management of degenerative MR, which may aid practitioners in identifying patients who could benefit from intensive monitoring, stress testing, and perhaps mitral surgery.




Ambulance telephone triage using 'NHS Pathways to identify adult cardiac arrest

2017-04-26T04:38:56-07:00

Background

UK ambulance services are called to 30 000 cardiac arrests (CAs) annually where resuscitation is attempted. Correct identification by the ambulance service trebles survival by facilitating bystander-cardiopulmonary resuscitation (CPR) and immediate ambulance dispatch. Identification of CA by telephone is challenging and involves algorithms to identify key features. ‘NHS Pathways’ is now used for triage by six of 12 UK ambulance services, covering a population of 20 million. With the significant improvements in survival when CA is accurately identified, it is vital that ‘NHS Pathways’ is able to identify CA correctly.

Methods

All ‘999’ emergency calls to South Central Ambulance Service (SCAS) over a 12-month period screened by NHS Pathways v9.04 were identified. All actual or presumed CAs identified by the emergency call taker were cross-referenced with the ambulance crew's Patient Report Form to identify all confirmed CAs.

Results

A total of 469 400 emergency (999) calls were received by SCAS. Of the 3119 CA identified by ambulance crew, 753 were not initially classified as CA by NHS Pathways (24.1%). Overall, sensitivity=0.759 (95% CI 0.743 to 0.773); specificity=0.986 (95% CI 0.9858 to 0.98647); and positive predictive value=26.80% (95% CI 25.88 to 27.73%).

Conclusions

NHS Pathways accurately identifies 75.9% of adult CAs. The remainder represents approximately 7500 treatable CAs in the UK annually where the diagnosis is missed, with significant implications for patient outcome. Further work is required to improve this first link in the chain of survival.




Insights into cardiac involvement in ankylosing spondylitis from cardiovascular magnetic resonance

2017-04-26T04:38:56-07:00

Objective

To evaluate cardiac involvement in patients with ankylosing spondylitis using cardiac magnetic resonance (CMR).

Methods

Patients with ankylosing spondylitis without cardiovascular symptoms or known cardiovascular disease were screened by transthoracic echocardiography (TTE) for participation in this exploratory CMR study. We prospectively enrolled 15 ankylosing spondylitis patients with an abnormal TTE for further tissue characterisation using late gadolinium enhancement (LGE) and T1 mapping. T1 mapping was used to calculate myocardial extracellular volume (ECV). Disease activity was assessed by C reactive protein (CRP) and erythrocyte sedimentation rate (ESR) measurements.

Results

In the total of 15 included patients, 14 had a complete CMR exam (mean age 62 years, 93% male and mean disease duration 21 years). Left ventricular (LV) diastolic dysfunction was the most common finding on TTE (79%), followed by aortic root dilatation (14%), right ventricular (RV) dilatation (7%) and RV dysfunction (7%). CMR revealed focal hyperenhancement in three patients (21%), all with a particular pattern of enhancement. LV dysfunction, as defined by a LV ejection fraction below 55%, was observed in five patients (36%). Myocardial ECV was correlated with the CRP concentration (R=0.78, p<0.01) and ESR level (RS=0.73, p<0.01).

Conclusions

In patients with ankylosing spondylitis, CMR with cine imaging and LGE identified global LV dysfunction and focal areas of hyperenhancement. Myocardial ECV, quantified by CMR T1 mapping, was associated with the degree of disease activity. These results may suggest the presence of cardiac involvement in ankylosing spondylitis and may show the potential of ECV as a marker for disease monitoring.




Sex-specific outcomes with addition of defibrillation to resynchronisation therapy in patients with heart failure

2017-04-26T04:38:56-07:00

Objective

Among primary prevention patients with heart failure receiving cardiac resynchronisation therapy (CRT), the impact of additional implantable cardioverter defibrillator (ICD) treatment on outcomes and its interaction with sex remains uncertain. We aim to assess whether the addition of the ICD functionality to CRT devices offers a more pronounced survival benefit in men compared with women, as previous research has suggested.

Methods

Observational multicentre cohort study of 5307 consecutive patients with ischaemic or non-ischaemic dilated cardiomyopathy and no history of sustained ventricular arrhythmias having CRT implantation with (cardiac resynchronisation therapy defibrillator (CRT-D), n=4037) or without (cardiac resynchronisation therapy pacemaker (CRT-P), n=1270) defibrillator functionality. Using propensity score (PS) matching and weighting and cause-of-death data, we assessed and compared the outcome of patients with CRT-D versus CRT-P. This analysis was stratified according to sex.

Results

After a median follow-up of 34 months (interquartile range 22–60 months) no survival advantage, of CRT-D versus CRT-P was observed in both men and women after PS matching (HR=0.95, 95% CI 0.77 to 1.16, p=0.61, and HR=1.30, 95% CI 0.83 to 2.04, p=0.25, respectively). With inverse-probability weighting, a benefit of CRT-D was seen in male patients (HR 0.78, 95% CI 0.65 to 0.94, p=0.012) but not in women (HR 0.87, 95% CI 0.63 to 1.19, p=0.43). The excess unadjusted mortality of patients with CRT-P compared with CRT-D was related to sudden cardiac death in 7.4% of cases in men but only 2.2% in women.

Conclusions

In primary prevention patients with CRT indication, the addition of a defibrillator might convey additional benefit only in well-selected male patients.




A 24-year-old male with a painful and cold lower extremity

2017-04-26T04:38:56-07:00

Clinical introduction

A 24-year-old male presented to the emergency department with intense pain in his right lower extremity. He has a medical history significant for systemic lupus erythematosus and antiphospholipid syndrome. He also had four prior episodes of deep venous thromboses on rivaroxaban. The patient stated that early in the morning, he started to feel intense pain that started from his knee and progressed to his calf, with associated numbness and paraesthesia. On physical examination, the limb felt cold with absent right popliteal and dorsalis pedis pulses. He was immediately taken for embolectomy after discovery of a distal common femoral artery occlusion. The patient's blood cultures remained negative. X-plane imaging on real-time three-dimensional transoesophageal echocardiography (RT-3DTEE) of the aortic valve (figure 1A) and colour Doppler (figure 1B) are shown.

Question

What is the diagnosis and management for this patient (assuming the patient will stay anticoagulated for life)?

  • Infective endocarditis (IE); antibiotics and valve replacement

  • Libman-Sacks endocarditis; corticosteroids

  • IE; antibiotics only

  • Libman-Sacks endocarditis; valve replacement

  • Libman-Sacks endocarditis; continuing anticoagulation only

  • Figure 1

    Visualisation of the aortic valve on (A) X-plane imaging on real-time three-dimensional transoesophageal echocardiography (RT-3DTEE) and (B) colour Doppler.




    Anti-inflammatory treatment improves high-density lipoprotein function in rheumatoid arthritis

    2017-04-26T04:38:56-07:00

    Objective

    Patients with rheumatoid arthritis (RA) are at increased cardiovascular risk. Recent studies suggest that high-density lipoprotein (HDL) may lose its protective vascular phenotype in inflammatory conditions. However, the effects of common anti-inflammatory treatments on HDL function are not yet known.

    Methods

    We compared the function of HDL in 18 patients with RA and 18 matched healthy controls. Subsequently, patients were randomised to (methotrexate+infliximab (M+I) (5 mg/kg)) or methotrexate+placebo (M+P) infusions for 54 weeks. At week 54 and thereafter, all patients received infliximab therapy until completion of the trial (110 weeks), enabling assessment of the impact of 1 year of infliximab therapy in all patients. HDL functional properties were assessed at baseline, 54 weeks and 110 weeks by measuring the impact on endothelial nitric oxide (NO) bioavailability and superoxide production (SO), paraoxonase activity (PON-1) and cholesterol efflux.

    Results

    All HDL vascular assays were impaired in patients compared with controls. After 54 weeks, NO in response to HDL was significantly greater in patients who received M+I compared with those who received M+P. Endothelial SO in response to HDL was reduced in both groups, but PON-1 and cholesterol efflux remained unchanged. All vascular measures improved compared with baseline after ≥1 infliximab therapy in the analysis at 110 weeks. No significant trend was noted for cholesterol efflux.

    Conclusions

    HDL function can be improved with anti-inflammatory treatment in patients with RA. The M+I combination was superior to the M+P alone, suggesting that the tumour necrosis factor-α pathway may have a role in HDL vascular properties.




    Cardiopulmonary exercise testing for detecting pulmonary arterial hypertension in systemic sclerosis

    2017-04-26T04:38:56-07:00

    Objectives

    Pulmonary arterial hypertension (PAH) is a devastating disease with limited survival and occurs as a frequent complication in patients with systemic sclerosis (SSc). A definite diagnosis of PAH is obtained by right heart catheterisation (RHC); however, the initial suspicion is raised by non-invasive methods. We assessed the diagnostic accuracy of key parameters derived from cardiopulmonary exercise testing (CPET) for detecting and ruling out SSc-associated PAH.

    Methods

    In a multicentre setting, we prospectively evaluated 173 consecutive patients with SSc without known PAH, but with clinical suspicion of PAH. Each patient underwent CPET and RHC.

    Results

    RHC identified PAH in 48 patients (27.8%), postcapillary pulmonary hypertension (PH) in 10 patients (5.8%) and ruled out PH in 115 patients (66.5%). CPET parameters correlated significantly with pulmonary haemodynamics. PeakVO2 and VE/VCO2 showed highest correlations with pulmonary arterial pressure, transpulmonary pressure gradient and pulmonary vascular resistance. Several parameters showed high sensitivity and specificity for PAH detection by receiver operating characteristic analysis. However, peakVO2 showed highest diagnostic accuracy (sensitivity 87.5%, specificity 74.8% at a threshold level of 13.8 mL/min/kg). A peakVO2 of >18.7 mL/kg/min was reached by 38/173 patients (22%) and excluded PAH in our cohort (negative predictive value 1.0). A nadir VE/VCO2 ratio of >45.5 showed a positive predictive value of 1.0. Diagnostic accuracy was highest in patients with low pulmonary arterial wedge pressure (<12 mm Hg). There were no study-related serious adverse events.

    Conclusions

    CPET is a safe and valuable method in the non-invasive detection of SSc-associated PAH. It may be particularly beneficial for reducing unnecessary RHC procedures.




    Tea consumption and risk of ischaemic heart disease

    2017-04-26T04:38:56-07:00

    Objective

    To prospectively examine the association between tea consumption and the risk of ischaemic heart disease (IHD).

    Methods

    Prospective study using the China Kadoorie Biobank; participants from 10 areas across China were enrolled during 2004–2008 and followed up until 31 December 2013. After excluding participants with cancer, heart disease and stroke at baseline, the present study included 199 293 men and 288 082 women aged 30–79 years at baseline. Information on IHD incidence was collected through disease registries and the new national health insurance databases.

    Results

    During a median follow-up of 7.2 years, we documented 24 665 (7.19 cases/1000 person-years) incident IHD cases and 3959 (1.13 cases/1000 person-years) major coronary events (MCEs). Tea consumption was associated with reduced risk of IHD and MCE. In the whole cohort, compared with participants who never consumed tea during the past 12 months, the multivariable-adjusted HRs and 95% CIs for less than daily and daily tea consumers were 0.97 (0.94 to 1.00) and 0.92 (0.88 to 0.95) for IHD, 0.92 (0.85 to 1.00) and 0.90 (0.82 to 0.99) for MCE. No linear trends in the HRs across the amount of tea were observed in daily consumers for IHD and MCE (PLinear >0.05). The inverse association between tea consumption and IHD was stronger in rural (PInteraction 0.006 for IHD, <0.001 for MCE), non-obese (PInteraction 0.012 for MCE) and non-diabetes participants (PInteraction 0.004 for IHD).

    Conclusions

    In this large prospective study, daily tea consumption was associated with a reduced risk of IHD.




    State of the art in nuclear cardiology

    2017-04-26T04:38:56-07:00

    Learning objectives

  • To review the wealth of knowledge associated with myocardial perfusion scintigraphy and the newer positron emission tomography techniques

  • To understand the role of Nuclear Cardiology with other complementary techniques

  • To appreciate the other expanding roles of Nuclear Cardiology in heart failure, device infection, sympathetic innervation and dyssynchrony.

  • Introduction

    Nuclear Cardiology is the most frequently used functional imaging test in the UK and throughout the world. It was the first test used to localise and quantify myocardial ischaemia. The wealth of evidence related to diagnosis and long-term prognosis in varying subgroups is unparalleled.1 Radionuclide ventriculography (RNV) provides a geometrically independent assessment of ventricular function which remains the gold standard. Nuclear techniques can be used in patients with renal dysfunction, obesity, dysrhythmias and claustrophobia.

    Up until a few years ago, gamma camera hardware relied on the inexpensive technology of the 1960s,...




    A 72-year-old male with recurrent syncope

    2017-04-26T04:38:56-07:00

    Clinical introduction

    A 72-year-old patient presented with recurrent syncope 1 year after a myocardial infarction. Two recent falls resulted in fractures to the femur. Serial troponins were negative and ECG demonstrated fixed inferior ST-segment elevation and pathological Q waves. A Holter monitor recorded non-sustained ventricular tachycardia. A subsequent echocardiogram was abnormal, and further investigation with a three-dimensional (3D) cardiac CT coronary angiogram was performed (figure 1).

    Question

    What is the most likely diagnosis?

  • Cardiac tumour

  • Hypertrophic obstructive cardiomyopathy

  • Ventricular aneurysm

  • Ventricular diverticulum

  • Figure 1

    Cardiac CT coronary angiogram—three-dimensional reconstruction.