Showing papers in "European Heart Journal in 2005"
TL;DR: Recent surveys of Guidelines and Expert Consensus Documents published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases.
Abstract: ESC Committee for Practice Guidelines (CPG), Silvia G. Priori (Chairperson) (Italy), Jean-Jacques Blanc (France), Andrzej Budaj (Poland), John Camm (UK), Veronica Dean (France), Jaap Deckers (The Netherlands), Kenneth Dickstein (Norway), John Lekakis (Greece), Keith McGregor (France), Marco Metra (Italy), Joao Morais (Portugal), Ady Osterspey (Germany), Juan Tamargo (Spain), Jose Luis Zamorano (Spain) Document Reviewers, Marco Metra (CPG Review Coordinator) (Italy), Michael Bohm (Germany), Alain Cohen-Solal (France), Martin Cowie (UK), Ulf Dahlstrom (Sweden), Kenneth Dickstein (Norway), Gerasimos S. Filippatos (Greece), Edoardo Gronda (Italy), Richard Hobbs (UK), John K. Kjekshus (Norway), John McMurray (UK), Lars Ryden (Sweden), Gianfranco Sinagra (Italy), Juan Tamargo (Spain), Michal Tendera (Poland), Dirk van Veldhuisen (The Netherlands), Faiez Zannad (France)
Guidelines and Expert Consensus Documents aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making.
A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and by different organizations and other related societies. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents.
In spite of the fact that standards for issuing good quality Guidelines and Expert Consensus Documents are well defined, recent surveys of Guidelines and Expert Consensus Documents published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are …
5,700 citations
TL;DR: Overall, the superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium.
Abstract: In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is recommended, if thrombolysis failed within 45-60 min after starting the administration. After successful thrombolysis, the use of routine coronary angiography within 24 h and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischaemia to improve patients' outcome. If a PCI centre is not available within 24 h, patients who have received successful thrombolysis with evidence of spontaneous or inducible ischaemia before discharge should be referred to coronary angiography and revascularized accordingly--independent of 'maximal' medical therapy.
1,619 citations
TL;DR: Nebivolol, a beta-blocker with vasodilating properties, is an effective and well-tolerated treatment for heart failure in the elderly.
Abstract: Aims Large randomized trials have shown that beta-blockers reduce mortality and hospital admissions in patients with heart failure. The effects of beta-blockers in elderly patients with a broad range of left ventricular ejection fraction are uncertain. The SENIORS study was performed to assess effects of the beta-blocker, nebivolol, in patients ≥70 years, regardless of ejection fraction.
Methods and results We randomly assigned 2128 patients aged ≥70 years with a history of heart failure (hospital admission for heart failure within the previous year or known ejection fraction ≤35%), 1067 to nebivolol (titrated from 1.25 mg once daily to 10 mg once daily), and 1061 to placebo. The primary outcome was a composite of all cause mortality or cardiovascular hospital admission (time to first event). Analysis was by intention to treat. Mean duration of follow-up was 21 months. Mean age was 76 years (SD 4.7), 37% were female, mean ejection fraction was 36% (with 35% having ejection fraction >35%), and 68% had a prior history of coronary heart disease. The mean maintenance dose of nebivolol was 7.7 mg and of placebo 8.5 mg. The primary outcome occurred in 332 patients (31.1%) on nebivolol compared with 375 (35.3%) on placebo [hazard ratio (HR) 0.86, 95% CI 0.74–0.99; P =0.039]. There was no significant influence of age, gender, or ejection fraction on the effect of nebivolol on the primary outcome. Death (all causes) occurred in 169 (15.8%) on nebivolol and 192 (18.1%) on placebo (HR 0.88, 95% CI 0.71–1.08; P =0.21).
Conclusion Nebivolol, a beta-blocker with vasodilating properties, is an effective and well-tolerated treatment for heart failure in the elderly.
1,397 citations
TL;DR: It is of great importance that guidelines and recommendations are presented in formats that are easily interpreted and their implementation programmes must also be well conducted.
Abstract: Guidelines and Expert Consensus documents aim to present all the relevant evidence on a particular issue in order to help physicians to weigh the benefits and risks of a particular diagnostic or therapeutic procedure. They should be helpful in everyday clinical decision-making.
A great number of Guidelines and Expert Consensus Documents have been issued in recent years by the European Society of Cardiology (ESC) and by different organizations and other related societies. This profusion can put at stake the authority and validity of guidelines, which can only be guaranteed if they have been developed by an unquestionable decision-making process. This is one of the reasons why the ESC and others have issued recommendations for formulating and issuing Guidelines and Expert Consensus Documents.
In spite of the fact that standards for issuing good quality Guidelines and Expert Consensus Documents are well defined, recent surveys of Guidelines and Expert Consensus Documents published in peer-reviewed journals between 1985 and 1998 have shown that methodological standards were not complied with in the vast majority of cases. It is therefore of great importance that guidelines and recommendations are presented in formats that are easily interpreted. Subsequently, their implementation programmes must also be well conducted. Attempts have been made to determine whether guidelines improve the quality of clinical practice and the utilization of health resources.
The ESC Committee for Practice Guidelines (CPG) supervises and coordinates the preparation of new Guidelines and Expert Consensus Documents produced by Task Forces, expert groups or consensus panels. The chosen experts in these writing panels are asked to provide disclosure statements of all relationships they may have which might be perceived as real or potential conflicts of interest. These disclosure forms are kept on file at the European Heart House, headquarters of the ESC. The Committee is also responsible for the …
1,172 citations
TL;DR: Surgery was denied in 33% of elderly patients with severe, symptomatic AS, and older age and LV dysfunction were the most striking characteristics of patients who were denied surgery, whereas comorbidity played a less important role.
Abstract: Aims To analyse decision-making in elderly patients with severe, symptomatic aortic stenosis (AS).
Methods and results In the Euro Heart Survey on valvular heart disease, 216 patients aged ≥75 had severe AS (valve area ≤0.6 cm2/m2 body surface area or mean gradient ≥50 mmHg) and angina or New York Heart Association class III or IV. Patient characteristics were analysed according to the decision to operate or not. A decision not to operate was taken in 72 patients (33%). In multivariable analysis, left ventricular (LV) ejection fraction [OR=2.27, 95% CI (1.32–3.97) for ejection fraction 30–50, OR=5.15, 95% CI (1.73–15.35) for ejection fraction ≤30 vs. >50%, P =0.003] and age [OR=1.84, 95% CI (1.18–2.89) for 80–85 years, OR=3.38, 95% CI (1.38–8.27) for ≥85 vs. 75–80 years, P =0.008] were significantly associated with the decision not to operate; however, the Charlson comorbidity index was not [OR=1.72, 95% CI (0.83–3.50), P =0.14 for index ≥2 vs. <2]. Neurological dysfunction was the only comorbidity significantly linked with the decision not to operate.
Conclusion Surgery was denied in 33% of elderly patients with severe, symptomatic AS. Older age and LV dysfunction were the most striking characteristics of patients who were denied surgery, whereas comorbidity played a less important role.
1,101 citations
TL;DR: Sixty-four-slice CT provides a high diagnostic accuracy in assessing coronary artery stenoses and correctly identified all 20 patients having no significant stenosis on invasive angiography.
Abstract: Aims The aim of our study was to investigate the accuracy of 64-slice computed tomography (CT) for assessing haemodynamically significant stenoses of coronary arteries.
Methods and results CT angiography was performed in 67 patients (50 male, 17 female; mean age 60.1±10.5 years) with suspected coronary artery disease and compared with invasive coronary angiography. All vessels ≥1.5 mm were considered for the assessment of significant coronary artery stenosis (diameter reduction >50%). Forty-seven patients were identified as having significant coronary stenoses on invasive angiography with 18% (176/1005) affected segments. None of the coronary segments needed to be excluded from analysis. CT correctly identified all 20 patients having no significant stenosis on invasive angiography. Overall sensitivity for classifying stenoses was 94%, specificity was 97%, positive predictive value was 87%, and negative predictive value was 99%.
Conclusion Sixty-four-slice CT provides a high diagnostic accuracy in assessing coronary artery stenoses.
998 citations
TL;DR: Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2) : effects on mortality and morbidity.
Abstract: Intense metabolic control by means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2) : effects on mortality and morbidity.
957 citations
TL;DR: In this paper, the authors present the consensus statement of the Study Group on Sports Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the working group on Myocardial and Pericardial diseases of the European Society of Cardiology, which comprises cardiovascular specialists and other physicians from different European countries with extensive clinical experience with young competitive athletes, as well as with pathological substrates of sudden death.
Abstract: The 1996 American Heart Association consensus panel recommendations stated that pre-participation cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. The present article represents the consensus statement of the Study Group on Sports Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology, which comprises cardiovascular specialists and other physicians from different European countries with extensive clinical experience with young competitive athletes, as well as with pathological substrates of sudden death. The document takes note of the 25-year Italian experience on systematic pre-participation screening of competitive athletes and focuses on relevant issues, mostly regarding the relative risk, causes, and prevalence of sudden death in athletes; the efficacy, feasibility, and cost-effectiveness of population-based pre-participation cardiovascular screening; the key role of 12-lead ECG for identification of cardiovascular diseases such as cardiomyopathies and channelopathies at risk of sudden death during sports; and the potential of preventing fatal events. The main purpose of the consensus document is to reinforce the principle of the need for pre-participation medical clearance of all young athletes involved in organized sports programmes, on the basis of (i) the proven efficacy of systematic screening by 12-lead ECG (in addition to history and physical examination) to identify hypertrophic cardiomyopathy-the leading cause of sports-related sudden death-and to prevent athletic field fatalities; (ii) the potential screening ability in detecting other lethal cardiovascular diseases presenting with ECG abnormalities. The consensus document recommends the implementation of a common European screening protocol essentially based on 12-lead ECG.
933 citations
TL;DR: This survey provides a unique snapshot of current AF management in ESC member countries and found Discordance between guidelines and practice was found regarding several issues on stroke prevention and antiarrhythmic therapy.
Abstract: Aims To describe atrial fibrillation (AF) management in member countries of the European Society of Cardiology (ESC) and to verify cardiology practices against guidelines. Methods and results Among 182 hospitals in 35 countries, 5333 ambulant and hospitalized AF patients were enrolled, in 2003 and 2004. AF was primary or secondary diagnosis, and was confirmed on ECG in the preceding 12 months. Clinical type of AF was reported to be first detected in 978, paroxysmal in 1517, persistent in 1167, and permanent in 1547 patients. Concomitant diseases were present in 90% of all patients, causing risk factors for stroke to be also highly prevalent (86%). As many as 69% of patients were symptomatic at the time of the survey; among asymptomatic patients, 54% were previously experienced symptoms. Oral anticoagulation was prescribed in 67 and 49% of eligible and ineligible patients, respectively. A rhythm control strategy was applied in 67% of currently symptomatic patients and in 44% of patients who never experienced symptoms. Conclusion This survey provides a unique snapshot of current AF management in ESC member countries. Discordance between guidelines and practice was found regarding several issues on stroke prevention and antiarrhythmic therapy.
858 citations
Katholieke Universiteit Leuven1, University of Bergen2, National and Kapodistrian University of Athens3, University of Brescia4, University of Gothenburg5, University of Padua6, Ludwig Maximilian University of Munich7, University of Pavia8, University of Oslo9, Uppsala University10, Aristotle University of Thessaloniki11, Sheba Medical Center12, University of Basel13, Children's National Medical Center14, University College London15, University of L'Aquila16
TL;DR: A consensus document from the Study Group of Sports Cardiology and the Working Group of Cardiac Rehabilitation and Exercise Physiology of the European Society of Cardiology has been published in this paper.
Abstract: A consensus document from the Study Group of Sports Cardiology of the Working Group of Cardiac Rehabilitation and Exercise Physiology and the Working Group of Myocardial and Pericardial Diseases of the European Society of Cardiology.
807 citations
TL;DR: High resting heart rate is a predictor for total and cardiovascular mortality independent of other risk factors in patients with stable coronary artery disease, while adjusting for risk factors.
Abstract: Aims Heart rate reduction is the cornerstone of the treatment of angina. The purpose of this study was to explore the prognostic value of heart rate in patients with stable coronary artery disease (CAD).
Methods and results We assessed the relationship between resting heart rate at baseline and cardiovascular mortality/morbidity, while adjusting for risk factors. A total of 24 913 patients with suspected or proven CAD from the Coronary Artery Surgery Study registry were studied for a median follow-up of 14.7 years. All-cause and cardiovascular mortality and cardiovascular rehospitalizations were increased with increasing heart rate ( P <0.0001). Patients with resting heart rate ≥83 bpm at baseline had a significantly higher risk for total mortality [hazard ratio (HR)=1.32, CI 1.19–1.47, P <0.0001] and cardiovascular mortality (HR=1.31, CI 1.15–1.48, P <0.0001) after adjustment for multiple clinical variables when compared with the reference group. When comparing patients with heart rates between 77–82 and ≥83 bpm with patients with a heart rate ≤62 bpm, the HR values for time to first cardiovascular rehospitalization were 1.11 and 1.14, respectively ( P <0.001 for both).
Conclusion Resting heart rate is a simple measurement with prognostic implications. High resting heart rate is a predictor for total and cardiovascular mortality independent of other risk factors in patients with CAD.
TL;DR: The potential of DE-CMR to distinguish between ischaemic and NICM as well as to differentiate non-ischaemic aetiologies is reviewed, to demonstrate how this approach is based on the underlying relationships between contrast enhancement and myocardial pathophysiology.
Abstract: Non-ischaemic cardiomyopathies (NICMs) are chronic, progressive myocardial diseases with distinct patterns of morphological, functional, and electrophysiological changes. In the setting of cardiomyopathy (CM), determining the exact aetiology is important because the aetiology is directly related to treatment and patient survival. Determining the exact aetiology, however, can be difficult using currently available imaging techniques, such as echocardiography, radionuclide imaging or X-ray coronary angiography, since overlap of features between CMs may be encountered. Cardiovascular magnetic resonance (CMR) imaging has recently emerged as a new non-invasive imaging modality capable of providing high-resolution images of the heart in any desired plane. Delayed contrast enhanced CMR (DE-CMR) can be used for non-invasive tissue characterization and may hold promise in differentiating ischaemic from NICMs, as the typical pattern of hyperenhancement can be classified as 'ischaemic-type' or 'non-ischaemic type' on the basis of pathophysiology of ischaemia. This article reviews the potential of DE-CMR to distinguish between ischaemic and NICM as well as to differentiate non-ischaemic aetiologies. Rather than simply describing various hyperenhancement patterns that may occur in different disease states, our goal will be (i) to provide an overall imaging approach for the diagnosis of CM and (ii) to demonstrate how this approach is based on the underlying relationships between contrast enhancement and myocardial pathophysiology.
TL;DR: The main purpose of the consensus document is to reinforce the principle of the need for pre-participation medical clearance of all young athletes involved in organized sports programmes on the basis of the proven efficacy of systematic screening by 12-lead ECG to identify hypertrophic cardiomyopathy and to prevent athletic field fatalities.
Abstract: The 1996 American Heart Association consensus panel recommendations stated that pre-participation cardiovascular screening for young competitive athletes is justifiable and compelling on ethical, legal, and medical grounds. The present article represents the consensus statement of the Study Group on Sports Cardiology of the Working Group on Cardiac Rehabilitation and Exercise Physiology and the Working Group on Myocardial and Pericardial diseases of the European Society of Cardiology, which comprises cardiovascular specialists and other physicians from different European countries with extensive clinical experience with young competitive athletes, as well as with pathological substrates of sudden death. The document takes note of the 25-year Italian experience on systematic pre-participation screening of competitive athletes and focuses on relevant issues, mostly regarding the relative risk, causes, and prevalence of sudden death in athletes; the efficacy, feasibility, and cost-effectiveness of population-based pre-participation cardiovascular screening; the key role of 12-lead ECG for identification of cardiovascular diseases such as cardiomyopathies and channelopathies at risk of sudden death during sports; and the potential of preventing fatal events. The main purpose of the consensus document is to reinforce the principle of the need for pre-participation medical clearance of all young athletes involved in organized sports programmes, on the basis of (i) the proven efficacy of systematic screening by 12-lead ECG (in addition to history and physical examination) to identify hypertrophic cardiomyopathy—the leading cause of sports-related sudden death—and to prevent athletic field fatalities; (ii) the potential screening ability in detecting other lethal cardiovascular diseases presenting with ECG abnormalities. The consensus document recommends the implementation of a common European screening protocol essentially based on 12-lead ECG.
TL;DR: Onset of new atrial fibrillation in patients on long-term beta-blocker therapy is associated with significant increased subsequent risk of mortality and morbidity, but is not an independent risk factor for mortality after adjusting for other predictors of prognosis.
Abstract: Aims Atrial fibrillation is common in patients with chronic heart failure (CHF) We analysed the risk associated with atrial fibrillation in a large cohort of patients with chronic heart failure all treated with a beta-blocker Methods and results In COMET, 3029 patients with CHF were randomized to carvedilol or metoprolol tartrate and followed for a mean of 58 months We analysed the prognostic relevance on other outcomes of atrial fibrillation on the baseline electrocardiogram compared with no atrial fibrillation and the impact of new onset atrial fibrillation during follow-up A multivariate analysis was performed using a Cox regression model where 10 baseline covariates were entered together with study treatment allocation Six hundred patients (198%) had atrial fibrillation at baseline These patients were older (65 vs 61 years), included more men (88 vs78%), had more severe symptoms [higher New York Heart Association (NYHA) class] and a longer duration of heart failure (all P , 00001) Atrial fibrillation was associated with significantly increased mortality [relative risk (RR) 129: 95% CI 112–148; P , 00001], higher all-cause death or hospitalization (RR 125: CI 113–138), and cardiovascular death or hospitalization for worsening heart failure (RR 134: CI 120–152), both P , 00001 By multivariable analysis, atrial fibrillation no longer independently predicted mortality Beneficial effects on mortality by carvedilol remained significant (RR 0836: CI 074–094; P ¼ 00042) New onset atrial fibrillation during followup (n ¼ 580) was associated with significant increased risk for subsequent death in a time-dependent analysis (RR 190: CI 154–235; P , 00001) regardless of treatment allocation and changes in NYHA class Conclusion In CHF, atrial fibrillation significantly increases the risk for death and heart failure hospitalization, but is not an independent risk factor for mortality after adjusting for other predictors of prognosis Treatment with carvedilol compared with metoprolol offers additional benefits among patients with atrial fibrillation Onset of new atrial fibrillation in patients on long-term beta-blocker therapy is associated with significant increased subsequent risk of mortality and morbidity
TL;DR: It is concluded that ‘6MWT’ is a simple and inexpensive test, which is not robust enough to evaluate treatment effects in clinical trials, but may have a role in clinical practice as a routine part of evaluation.
Abstract: Dr Refsgaard1 and Dr Hager have commented our article regarding ‘Six minute walk test’ (6MWT).2 We concluded that ‘6MWT’ is a simple and inexpensive test, which is not robust enough to evaluate treatment effects in clinical trials. However, it may have a role in clinical practice as a routine part of evaluation (as many patients avoid symptoms by reducing their activity). A recently published trial on 1077 elderly heart …
TL;DR: Ivabradine is as effective as atenolol in patients with stable angina in a double-blinded trial and the number of angina attacks was decreased by two-thirds with both ivab radine and atenOLol.
Abstract: Aims Ivabradine, a new I f inhibitor which acts specifically on the pacemaker activity of the sinoatrial node, is a pure heart rate lowering agent. Ivabradine has shown anti-ischaemic and anti-anginal activity in a placebo-controlled trial. The objective of this study was to compare the anti-anginal and anti-ischaemic effects of ivabradine and the beta-blocker atenolol.
Methods and results In a double-blinded trial, 939 patients with stable angina were randomized to receive ivabradine 5 mg bid for 4 weeks and then either 7.5 or 10 mg bid for 12 weeks or atenolol 50 mg od for 4 weeks and then 100 mg od for 12 weeks. Patients underwent treadmill exercise tests at randomization ( M ) and after 4 ( M 1) and 16 ( M 4) weeks of therapy. Increases in total exercise duration (TED) at trough at M 4 were 86.8±129.0 and 91.7±118.8 s with ivabradine 7.5 and 10 mg, respectively and 78.8±133.4 s with atenolol 100 mg. Mean differences (SE) when compared with atenolol 100 mg were 10.3 (9.4) and 15.7 (9.5) s in favour of ivabradine 7.5 and 10 mg ( P <0.001 for non-inferiority). TED at M 1 improved by 64.2±104.0 s with ivabradine 5 mg and by 60.0±114.4 s with atenolol 50 mg ( P <0.001 for non-inferiority). Non-inferiority of ivabradine was shown at all doses and for all criteria. The number of angina attacks was decreased by two-thirds with both ivabradine and atenolol.
Conclusion Ivabradine is as effective as atenolol in patients with stable angina.
TL;DR: MRI is a highly sensitive and reliable tool to detect morphologic and functional sequelae of AMI providing baseline MRI parameters with relevant predictive power for LV adverse remodelling and occurrence of MACE.
Abstract: Aims Because of its high spatial resolution and tissue contrast, magnetic resonance imaging (MRI) was used to assess cardiac structure and function in a large population of patients with acute myocardial infarction (AMI).
Methods and results One hundred and ten patients were studied by MRI 6.1±2.2 days after AMI. Infarct size (IS), persistent microvascular obstruction (PMO), left and right ventricular (LV/RV) volumes, and functions were measured. The same MRI measurements were repeated in 89 patients after a mean follow-up period of 225±92 days. IS was 11.9±7.3% of total LV muscle mass. PMO was detected in 51/110 (46.4%) patients and comprised 15.6±8.5% of IS and 2.8±2.3% of LV muscle mass. Papillary muscle infarct was seen in 26%, RV infarction in 16%, pericarditis in 40%, and pericardial effusion in 66% of the patients. During follow-up, there were 16 major adverse cardiac events (MACE) including seven deaths. IS, PMO, and amount of transmural infarction were predictive for LV adverse remodelling defined as >20% increase in LV end-diastolic volume. Multivariable analysis revealed LV end-diastolic volume, LV ejection fraction, and PMO as significant predictors for the occurrence of MACE.
Conclusion MRI is a highly sensitive and reliable tool to detect morphologic and functional sequelae of AMI providing baseline MRI parameters with relevant predictive power for LV adverse remodelling and occurrence of MACE.
TL;DR: This study demonstrates that LVNC is associated with a better prognosis than previously reported, and in patients with familial disease, relatives may have features consistent with dilated cardiomyopathy rather than LVNC.
Abstract: Aims Non-compaction of the left ventricle (LVNC) is a disorder of endomyocardial morphogenesis that results in multiple trabeculations in the left ventricular myocardium. The current literature suggests that LVNC in adults is rare and associated with a poor prognosis. Given that the disorder is present at birth and that several studies have reported asymptomatic familial disease in some patients, we hypothesized that there is a long pre-clinical phase of the disease. The aim of this study was to define the prognosis and familial incidence of LVNC.
Methods and results This study cohort comprised 45 patients (mean age at diagnosis 37 years) consecutively identified at a referral centre for cardiomyopathy over a 10-year period. Twenty-eight patients (62%) had dyspnoea at presentation; 41 (91%) an abnormal ECG; and 30 (66%) left ventricular dilatation and impaired systolic function. Nine patients (20%) had non-sustained ventricular tachycardia on 24 h Holter monitoring. Mean survival from death or transplantation was 97% at 46 months. There were three thromboembolic events in two patients (4%). On systematic family screening, 8 of 32 (25%) asymptomatic relatives had a range of echocardiographic abnormalities, including LVNC, LVNC with impaired systolic function, and left ventricular enlargement without LVNC.
Conclusion This study demonstrates that LVNC is associated with a better prognosis than previously reported. In patients with familial disease, relatives may have features consistent with dilated cardiomyopathy rather than LVNC.
TL;DR: The RSs studied demonstrated a good predictive accuracy for death or MI at 1 year and enabled the identification of high-risk subsets of patients who will benefit most from myocardial revascularization performed during initial hospital stay.
Abstract: Aims Regarding prognosis, patients with a non-ST elevation acute coronary syndrome (ACS) are a very heterogeneous population, with varying risks of early and long-term adverse events. Early risk stratification at admission seems to be essential for a tailored therapeutic strategy. We sought to compare the prognostic value of three ACS risk scores (RSs) and their ability to predict benefit from myocardial revascularization performed during initial hospitalization.
Methods and results We studied 460 consecutive patients admitted to our coronary care unit with an ACS [age: 63±11 years, 21.5% female, 55% with myocardial infarction (MI)]. For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Platelet glycoprotein IIb/IIIa in Unstable agina: Receptor Suppression Using Integrilin (PURSUIT), and Global Registry of Acute Coronary Events (GRACE) RSs were calculated using specific variables collected at admission. Their prognostic value was evaluated by the combined endpoint of death or MI at 1 year. The best cut-off value for each RS, calculated with receiver operating characteristic curves, was used to assess the impact of myocardial revascularization on the combined incidence of death or MI. Death or MI at 1 year was 15.4% (32 deaths/49 MIs). The best predictive accuracy for death or MI at 1 year was obtained by the GRACE RS (AUC) [area under the curve: 0.715; confidence interval (CI: 0.672–0.756)] but the performance of the PURSUIT RS (AUC: 0.630; CI: 0.584–0.674), and TIMI RS (AUC: 0.585; CI: 0.539–0.631) was also good. We found a statistically significant interaction between the risk stratified by the best cut-off value for the GRACE and PURSUIT RSs and myocardial revascularization, with a better prognosis for the high-risk patients. The high-risk patients represented 36.7, 28.7, and 57.8% of the population, for the GRACE, PURSUIT, and TIMI RSs, respectively.
Conclusion The RSs studied demonstrated a good predictive accuracy for death or MI at 1 year and enabled the identification of high-risk subsets of patients who will benefit most from myocardial revascularization performed during initial hospital stay.
TL;DR: The severe cardiorenal syndrome is proposed, a pathophysiological condition in which combined cardiac and renal dysfunction amplifies progression of failure of the individual organ, so that cardiovascular morbidity and mortality in this patient group is at least an order of magnitude higher than in the general population.
Abstract: The incidence of cardiac failure and chronic renal failure is increasing and it has now become clear that the co-existence of the two problems has an extremely bad prognosis We propose the severe cardiorenal syndrome (SCRS), a pathophysiological condition in which combined cardiac and renal dysfunction amplifies progression of failure of the individual organ, so that cardiovascular morbidity and mortality in this patient group is at least an order of magnitude higher than in the general population Guyton has provided an excellent framework describing the physiological relationships between cardiac output, extracellular fluid volume control, and blood pressure While this model is also sufficient to understand systemic haemodynamics in combined cardiac and renal failure, not all aspects of the observed accelerated atherosclerosis, structural myocardial changes, and further decline of renal function can be explained Since increased activity of the renin-angiotensin system, oxidative stress, inflammation, and increased activity of the sympathetic nervous system seem to be cornerstones of the pathophysiology in combined chronic renal disease and heart failure, we have explored the potential interactions between these cardiorenal connectors As such, the cardiorenal connection is an interactive network with positive feedback loops, which, in our view, forms the basis for the SCRS
TL;DR: Findings suggest that activation of inflammation and haemostasis may be potential mechanisms by which cigarette and pipe/cigar smoking increase cardiovascular risk.
Abstract: Aims To examine the associations between cigarette smoking, pipe/cigar smoking, and years since quitting smoking, and inflammatory and haemostatic markers.
Methods and results A study in 2920 men aged 60–79 with no history of myocardial infarction, angina, stroke, or diabetes, and who were not on warfarin, from general practices in 24 British towns. After adjustment for other major cardiovascular risk factors, compared with never smokers, current cigarette smokers showed significantly higher levels of C-reactive protein (2.53 vs. 1.35 mg/L), white cell count (7.92 vs. 6.42×109/L), and fibrinogen (3.51 vs. 3.13 g/L). They also showed higher levels of haematocrit, blood and plasma viscosity, tissue plasminogen activator antigen, and fibrin D-dimer, and lower levels of albumin. Primary pipe/cigar smokers showed levels similar to never smokers. Ex-cigarette smokers and secondary pipe/cigar smokers showed intermediate levels although secondary pipe/cigar smokers showed higher odds of having elevated white cell count and fibrinogen than ex-cigarette smokers. Most inflammatory and haemostatic levels improved within 5 years of smoking cessation but took over 20 years to revert to levels of never smokers.
Conclusion These findings suggest that activation of inflammation and haemostasis may be potential mechanisms by which cigarette and pipe/cigar smoking increase cardiovascular risk.
TL;DR: The increase in ACE2 after MI suggests that it plays an important role in the negative modulation of the renin angiotensin system in the generation and degradation of angiotENSin peptides after cardiac injury.
Abstract: Dr Ferrario correctly points out that the findings from Dr Burrell's laboratory differ from those reported by his group. No change in ACE2 gene expression was found in his group's study after myocardial infarction (MI) without drug treatment, whereas Dr Burrell's group1 found that ACE2 gene expression and activity were increased in viable myocardium after MI in the rat. Dr Ferrario suggests that this difference may be attributable to the strain of rat used. It is of interest to note that in both the Sprague–Dawley rat and the Wistar rat cardiac ACE activity was increased post-MI.2,3 Dr Ferrario's finding …
TL;DR: The spectrum of adult CHD in Europe emerging from this survey is one of a predominantly young population with substantial morbidity but relatively low mortality in a 5 year period.
Abstract: Aims To describe clinical and demographic characteristics at baseline of a European cohort of adults with congenital heart disease (CHD) and to assess mortality and morbidity in a 5 year follow-up period. Methods and results Data collected as part of the Euro Heart Survey on adult CHD was analysed. This entailed information transcribed from the files of 4110 patients diagnosed with one of eight congenital heart conditions ('defects'), who consecutively visited the outpatient clinics of one of the participating centres in 1998. The patients were included retrospectively and followed until the end of 2003 for a median follow-up of 5.1 years. Notwithstanding their overall relatively good functional class and low mortality over the follow-up period, a considerable proportion of the patients had a history of endocarditis, arrhythmias, or vascular events. There were major differences between the eight defects, both in morbidity and regarding specific characteristics. Outcomes were worst in cyanotic defects and in the Fontan circulation, but a considerable proportion of the other patients also suffer from cardiac symptoms. In particular, arrhythmias are common. Conclusion The spectrum of adult CHD in Europe emerging from this survey is one of a predominantly young population with substantial morbidity but relatively low mortality in a 5 year period.
TL;DR: What is known about inflammation in genesis and perpetuation of atrial fibrillation, the putative underlying mechanisms, and possible therapeutic implications for the inhibition of inflammation as an evolving treatment modality for AF are reviewed.
Abstract: The prevalence and persistence of atrial fibrillation (AF) and the relative inefficacy of the currently available pharmacotherapy requires development of new treatment strategies. Recent findings have suggested a mechanistic link between inflammatory processes and the development of AF. Epidemiological studies have shown an association between C-reactive protein and both the presence of AF and the risk of developing future AF. In case-control studies, C-reactive protein is significantly elevated in AF patients and is associated with successful cardioversion. Moreover, C-reactive protein elevation is more pronounced in patients with persistent AF than in those with paroxysmal AF. Furthermore, treatment with glucocorticoids, statins, angiotensin converting enzyme inhibitors, and angiotensin II receptor blockers seems to reduce recurrence of AF. Part of this anti-arrhythmic effect may be through anti-inflammatory activity. This article reviews what is known about inflammation in genesis and perpetuation of AF, the putative underlying mechanisms, and possible therapeutic implications for the inhibition of inflammation as an evolving treatment modality for AF.
TL;DR: Unrecognized heart failure is very common in elderly patients with stable chronic obstructive pulmonary disease, and closer co-operation among general practitioners, pulmonologists, and cardiologists is necessary to improve detection and adequate treatment of heart failure in this large patient population.
Abstract: Aims To establish the prevalence of unrecognized heart failure in elderly patients with a diagnosis of chronic obstructive pulmonary disease, in a stable phase of their disease.
Methods and results In a cross-sectional study, patients ≥65 years of age, classified as having chronic obstructive pulmonary disease by their general practitioner and not known with a cardiologist-confirmed diagnosis of heart failure, were invited to our out-patient clinic. Four hundred and five participants underwent an extensive diagnostic work-up, including medical history and physical examination, followed by chest radiography, electrocardiography, echocardiography, and pulmonary function tests. As reference (i.e. ‘gold’) standard the consensus opinion of an expert panel was used. The panel based the diagnosis of heart failure on all available results from the diagnostic assessment, guided by the diagnostic principles of the European Society of Cardiology (ESC) for heart failure (i.e., symptoms and echocardiographic systolic and/or diastolic dysfunction). The diagnosis of chronic obstructive pulmonary disease was based on the diagnostic criteria of the Global Initiative (GOLD) for chronic obstructive pulmonary disease. Of 405 participating patients with a diagnosis of chronic obstructive pulmonary disease, 83 (20.5%, 95% CI 16.7–24.8) had previously unrecognized heart failure (42 patients systolic, 41 ‘isolated’ diastolic, and none right-sided heart failure). In total, 244 (60.2%) patients had chronic obstructive pulmonary disease according to the GOLD criteria and 50 (20.5%, 95% CI 15.6–26.1) patients combined with unrecognized heart failure.
Conclusion Unrecognized heart failure is very common in elderly patients with stable chronic obstructive pulmonary disease. Closer co-operation among general practitioners, pulmonologists, and cardiologists is necessary to improve detection and adequate treatment of heart failure in this large patient population.
TL;DR: It is demonstrated that adherence of physicians to treatment guidelines is a strong predictor of fewer CV hospitalizations in actual practice and there is a need to develop further quality improvement programmes in this condition.
Abstract: Aims The impact on outcome of the implementation of European guidelines for the treatment of chronic heart failure (CHF) has not been evaluated. We investigated the consequences of adherence to care by cardiologists on the rate of CHF and cardiovascular (CV) hospitalizations and time to CV hospitalization. Methods and results We constructed class adherence indicators for angiotensin-converting enzyme (ACE) -inhibitors, beta-blockers, spironotactone, diuretics, and cardiac glycosides and GAls (GAl3 adherence to first three classes of heart failure medication, GAl5 adherence to five classes). In the study, 1410 evaluable patients (mean age 69, 69% mates, New York Heart Association (NYHA) II: 64%, III: 34%, IV: 2%) were enrolled and followed up for 6 months by 150 randomly selected cardiologists/cardiology departments from six European countries (France, Germany, Italy, The Netherlands, Spain, and UK). Overall, adherence to treatment guidelines was 60 (GAl3) and 63% (GAl5) and was better for ACE-] (88%) or diuretics (82%) than for cardiac gtycosides (52%), beta-blockers (58%), and spironolactone (36%). In the three tertites of the population defined by a decreasing mean adherence score value, CHF and CV hospitalization rates were, respectively, 6.7, 9.7, and 14.7% and 11. 2, 15.9, and 20.6% (P <0.002 and P <0.001, respectively). Global adherence indicator GAl3 was an independent predictor of time to CV hospitalization in a multi-variable model together with NYHA Class, history of CHF hospitalization, ischaemic aetiology, diabetes mellitus, and hypertension. Conclusion We demonstrate that adherence of physicians to treatment guidelines is a strong predictor of fewer CV hospitalizations in actual practice. There is a need to develop further quality improvement programmes in this condition.
TL;DR: Successful percutaneous revascularization of a CTO leads to a significantly improved survival rate and a reduction in major adverse events at 5 years, and new technologies must focus on a safe approach to successful recanalization.
Abstract: Aims Chronic total occlusions (CTOs) are commonly found on diagnostic angiography, and there is some evidence from one study that successful percutaneous revascularization leads to an improvement in long-term survival rates. However, this study included patients treated for unstable angina with short-duration occlusion, and stent implantation was utilized in only 7%. We re-evaluated the long-term outcomes of a large consecutive series of patients with a CTO of >1-month duration treated at our centre, with stent implantation utilized in the majority.
Methods and results All patients treated with percutaneous coronary intervention (PCI) between 1992 and 2002 were retrospectively identified from a dedicated database. A total of 874 consecutive patients were treated for 885 CTO lesions. Mean follow-up time was 4.47±2.69 years (median 4.10 years). Patients were evaluated for the occurrence of major adverse cardiac events (MACE) comprising death, acute myocardial infarction, and need for repeat revascularization with either coronary artery bypass surgery or PCI. Successful revascularization was achieved in 576 lesions (65.1%), in which stent implantation was used in 81.0%. At 30 days, the overall MACE rate was significantly lower in those patients with a successful recanalization (5.5 vs. 14.8%, P <0.00001). At 5 years, survival was significantly higher in those patients with a successful revascularization (93.5 vs. 88.0%, P =0.02). In addition, there was a significantly higher survival free of MACE (63.7 vs. 41.7%, P <0.0001), with the majority of events reflecting the need for repeat intervention. Independent predictors for survival were successful revascularization, lower age, and the absence of diabetes mellitus and multivessel disease.
Conclusion Successful percutaneous revascularization of a CTO leads to a significantly improved survival rate and a reduction in major adverse events at 5 years. Most events relate to the need for repeat reintervention, and the introduction of drug-eluting stents, with low-restenosis rates, encourages the development of technologies to improve recanalization success rates. However, failed recanalization may be associated acutely with an adverse event, and new technologies must focus on a safe approach to successful recanalization.
TL;DR: A significant proportion of patients with apparently asymptomatic aortic stenosis experience limiting symptoms on treadmill exercise testing, and the subsequent development of spontaneous symptoms is strongly related to the severity of stenosis and to limited symptoms on exercise testing.
Abstract: Aims The aims of this study were to assess the accuracy of exercise testing in predicting symptom onset within 12 months in patients with asymptomatic aortic stenosis and to establish the criteria that define a positive test.
Methods and results A total of 125 patients with aortic stenosis [effective orifice area (EOA) 0.9±0.2 cm2] were assessed by Specific Activity Scale (SAS) classification, transthoracic echocardiography, and treadmill exercise testing using the modified Bruce protocol. During follow-up, 36 patients (29%) developed spontaneous symptoms within 12 months. Of these, 26 (72%) had had symptoms revealed by exercise testing and 24 (67%) had severe stenosis (EOA≤0.8 cm2). Exercise-limiting symptoms were the only independent predictors of outcome at 12 months, and an abnormal blood pressure response or ST segment depression did not improve the accuracy of the exercise test. The positive predictive accuracy for exercise-induced symptoms was 57% in the whole population and 79% for patients aged <70 in SAS Class I. The negative predictive accuracy was 87% in the whole population and 86% in the subgroup.
Conclusion A significant proportion of patients with apparently asymptomatic aortic stenosis experience limiting symptoms on treadmill exercise testing. The subsequent development of spontaneous symptoms is strongly related to the severity of stenosis and to limiting symptoms on exercise testing, but less so to an abnormal blood pressure response or ST segment depression.
TL;DR: Increased arterial wave reflections are independently associated with an increased risk for severe short- and long-term cardiovascular events in patients undergoing PCI.
Abstract: Aims Increased arterial wave reflections are associated with the presence and extent of coronary atherosclerosis and with cardiovascular mortality in selected populations. We prospectively evaluated their prognostic value in the short- and long-term following percutaneous coronary interventions (PCIs). Methods and results We non-invasively quantified wave reflections [expressed as augmentation index corrected for heart rate of 75 b.p.m. (AIx@75)] using applanation tonometry of the radial artery and a validated transfer function to obtain the corresponding aortic values in 262 patients undergoing PCI. During 2-year follow-up, 61 patients reached the primary endpoint [death, myocardial infarction (MI), and restenosis]. Increasing tertiles of Alx@75 were related to the rate of patients reaching the primary endpoint [15.2, 20 and 35.3%, respectively (P ¼ 0.001)], as well as the secondary endpoints total mortality, myocardial infarction and death plus myocardial infarction (RR for the third vs. the first tertile 4.33, 3.25 and 3.46, respectively, P , 0.05). In a multivariable Cox-regression model, AIx@75 added prognostic value above and beyond clinical risk factors, angiographic variables, and medications (RR 1.8, 95%CI 1.18–2.76 per increasing AIx@75-tertile, P , 0.01). Conclusion Increased arterial wave reflections are independently associated with an increased risk for severe short- and long-term cardiovascular events in patients undergoing PCI.
TL;DR: F-FDG PET has the potential to detect cardiac sarcoidosis that cannot be diagnosed by (67)Ga or (99m)Tc-MIBI scintigraphy.
Abstract: Aims To evaluate the value of 18 F-fluoro-2-deoxyglucose positron emission tomography ( 18 F-FDG PET) in detecting cardiac sarcoidosis. Methods and results Thirty-two patients with sarcoidosis and thirty controls were recruited. All subjects underwent cardiac 18 F-FDG PET after a 6 h fasting period, and subjects with sarcoidosis underwent blood testing, ECG, echocardiography, and 67 Ga and 99m Tc-sestamibi (MIBI) scintigraphy. We classified 18 F-FDG PET images into four patterns ('none', 'diffuse', 'focal', and 'focal on diffuse') and found that all the control subjects exhibited either none (n = 16) or diffuse (n = 14) pattern. In contrast, fifteen subjects with sarcoidosis exhibited none, seven exhibited diffuse, eight exhibited focal, and two exhibited focal on diffuse patterns, with the prevalence of the focal and focal on diffuse patterns being significantly higher in the sarcoidosis group when compared with the control group (P < 0.001). None of the 32 subjects with sarcoidosis exhibited abnormal findings on 67 Ga scintigraphy, and 4 exhibited abnormal findings on 99m Tc-MIBI scintigraphy. Conclusion Focal uptake of the heart on 18 F-FDG PET images is a characteristic feature of patients with sarcoidosis. Furthermore, 18 F-FDG PET has the potential to detect cardiac sarcoidosis that cannot be diagnosed by 67 Ga or 99m Tc-MIBI scintigraphy.