Showing papers in "Heart in 2005"

JBS 2: Joint British Societies' guidelines on prevention of cardiovascular disease in clinical practice

Abstract: The Joint British Societies’ guidelines (JBS 2) on cardiovascular disease prevention in clinical practice were developed by a Working Party (see table) with nominated representatives from six professional societies. All members contributed to the text and those from the specialist societies of hypertension, lipids, and diabetes were specifically responsible for developing the sections on blood pressure, lipids, and glucose. All sections of the document represent an evidence based consensus by all professional societies involved. The scientific literature which informs the recommendations is referenced throughout the text and Dr Kornelia Kotseva is thanked for all her help in searches for systematic reviews and meta-analyses, and checking the referencing of all sections. We are grateful to both Mr Harry Heyes of the Department of Medical Illustration, University of Manchester, for the cardiovascular risk prediction charts artwork, and Mr Daniel Prais of Crawford’s Business Services, Salford, for the computer programming. Dr Paola Primatesta is thanked for providing prevalence estimates of total CVD risk in the adult population from the Health Survey for England. Mr Tim Collier (Statistician, London School of Hygiene and Tropical Medicine) is also thanked for preparing the figures on lipid trials. Despoina Xenikaki provided the Working Party with invaluable administrative support. This guideline was reviewed and approved by the boards of all the professional societies. View this table: JBS 2 Working Party ### SUMMARY The aim of these new Joint British Societies’ guidelines (JBS 2) developed by the British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular Society, and The Stroke Association is to promote a consistent multidisciplinary approach to the management of people with established atherosclerotic cardiovascular disease (CVD) and those at high risk of developing symptomatic atherosclerotic disease. We recommend that CVD prevention in clinical practice should focus equally on (i) people with established atherosclerotic CVD, (ii) people with …

Adding social deprivation and family history to cardiovascular risk assessment: the ASSIGN score from the Scottish Heart Health Extended Cohort (SHHEC)

Abstract: Objective: To improve equity in cardiovascular disease prevention by developing a cardiovascular risk score including social deprivation and family history. Design: The ASSIGN score was derived from cardiovascular outcomes in the Scottish Heart Health Extended Cohort (SHHEC). It was tested against the Framingham cardiovascular risk score in the same database. Setting: Random-sample, risk-factor population surveys across Scotland 1984–87 and North Glasgow 1989, 1992 and 1995. Participants: 6540 men and 6757 women aged 30–74, initially free of cardiovascular disease, ranked for social deprivation by residence postcode using the Scottish Index of Multiple Deprivation (SIMD) and followed for cardiovascular mortality and morbidity through 2005. Results: Classic risk factors, including cigarette dosage, plus deprivation and family history but not obesity, were significant factors in constructing ASSIGN scores for each sex. ASSIGN scores, lower on average, correlated closely with Framingham values for 10-year cardiovascular risk. Discrimination of risk in the SHHEC population was significantly, but marginally, improved overall by ASSIGN. However, the social gradient in cardiovascular event rates was inadequately reflected by the Framingham score, leaving a large social disparity in future victims not identified as high risk. ASSIGN classified more people with social deprivation and positive family history as high risk, anticipated more of their events, and abolished this gradient. Conclusion: Conventional cardiovascular scores fail to target social gradients in disease. By including unattributed risk from deprivation, ASSIGN shifts preventive treatment towards the socially deprived. Family history is valuable not least as an approach to ethnic susceptibility. ASSIGN merits further evaluation for clinical use.

Cardiovascular, cerebrovascular, and respiratory changes induced by different types of music in musicians and non-musicians: the importance of silence

Abstract: Objective: To assess the potential clinical use, particularly in modulating stress, of changes in the cardiovascular and respiratory systems induced by music, specifically tempo, rhythm, melodic structure, pause, individual preference, habituation, order effect of presentation, and previous musical training. Design: Measurement of cardiovascular and respiratory variables while patients listened to music. Setting: University research laboratory for the study of cardiorespiratory autonomic function. Patients: 12 practising musicians and 12 age matched controls. Interventions: After a five minute baseline, presentation in random order of six different music styles (first for a two minute, then for a four minute track), with a randomly inserted two minute pause, in either sequence. Main outcome measures: Breathing rate, ventilation, carbon dioxide, RR interval, blood pressure, mid-cerebral artery flow velocity, and baroreflex. Results: Ventilation, blood pressure, and heart rate increased and mid-cerebral artery flow velocity and baroreflex decreased with faster tempi and simpler rhythmic structures compared with baseline. No habituation effect was seen. The pause reduced heart rate, blood pressure, and minute ventilation, even below baseline. An order effect independent of style was evident for mid-cerebral artery flow velocity, indicating a progressive reduction with exposure to music, independent of style. Musicians had greater respiratory sensitivity to the music tempo than did non-musicians. Conclusions: Music induces an arousal effect, predominantly related to the tempo. Slow or meditative music can induce a relaxing effect; relaxation is particularly evident during a pause. Music, especially in trained subjects, may first concentrate attention during faster rhythms, then induce relaxation during pauses or slower rhythms.

The health care burden of acute chest pain

Abstract: Each year, over 15 million people attend an emergency department in England and Wales.1 It has been estimated that 2.4% of attendances are because of chest pain,2 representing 360 000 emergency department attendances. Despite this, surprisingly little data have been published describing this problem. Studies typically report selected groups of patients, or retrospective audits of routinely collected data. Both approaches may lead to biased results. Accurate estimates of the size and nature of the problem are required to allow rational planning of services and to put the findings of research into context. The ESCAPE (effectiveness and safety of chest pain assessment to prevent emergency admissions) randomised controlled trial of chest pain observation unit versus routine care3 required prospective identification of all patients attending with acute chest pain; it thus provided an ideal opportunity for a descriptive study of the health care burden created by this problem. We aimed to describe the clinical epidemiology of acute chest pain, the incidence of emergency department presentation and hospital admission, the proportion with ECG evidence of acute coronary syndrome (ACS), clinically diagnosed ACS, non-ACS, or undifferentiated chest pain, and variations in these parameters by hour of day and day of week. The Northern General Hospital emergency department is the only adult department for the 530 000 population …

Role of B-type natriuretic peptide (BNP) and NT-PROBNP in clinical routine

Abstract: In recent years biomarkers have emerged as important tools for diagnosis, risk stratification and therapeutic decision making in cardiovascular diseases Cardiac troponins in particular have become the cornerstone for diagnostic work up of patients with acute coronary syndromes Currently, several promising new biomarkers are under scientific investigation Most of these new biomarkers, however, are not yet suitable for clinical application, with the exception of B-type natriuretic peptide (BNP) and its N-terminal fragment (NT-proBNP) Both markers have proven their diagnostic usefulness in a great number of studies and thus have progressed from bench to clinical application This article aims to summarise existing data concerning BNP and NT-proBNP measurement in cardiovascular disorders and to outline how these markers can be integrated into clinical routine Furthermore, future perspectives of these markers will be discussed B-type natriuretic peptide, which is also called brain-type natriuretic peptide (BNP), was first described in 1988 after isolation from porcine brain However, it was soon found to originate mainly from the heart, representing a cardiac hormone BNP belongs to the natriuretic peptide family together with other structurally similar peptides, namely atrial natriuretic peptide (ANP), C-type natriuretic peptide (CNP), and urodilatin The natriuretic peptides have in common a characteristic biochemical structure which consists of a 17 amino-acid ring and a disulfide bridge between two cysteine molecules The major source of BNP synthesis and secretion is the ventricular myocardium Whereas ANP is stored in granules and can be released immediately after stimulation, only small amounts of BNP are stored in granules and rapid gene expression with de novo synthesis of the peptide is the underlying mechanism for the regulation of BNP secretion BNP is synthesised as a prehormone (proBNP) comprising 108 amino acids Upon release into the circulation it is cleaved in equal proportions into the biologically active 32 amino acid …

Systematic review of multidisciplinary interventions in heart failure

Abstract: Objective: To determine the impact of multidisciplinary interventions on hospital admission and mortality in heart failure. Design: Systematic review. Thirteen databases were searched and reference lists from included trials and related reviews were checked. Trial authors were contacted if further information was required. Setting: Randomised controlled trials conducted in both hospital and community settings. Patients: Trials were included if all, or a defined subgroup of patients, had a diagnosis of heart failure. Interventions: Multidisciplinary interventions were defined as those in which heart failure management was the responsibility of a multidisciplinary team including medical input plus one or more of the following: specialist nurse, pharmacist, dietician, or social worker. Interventions were separated into four mutually exclusive groups: provision of home visits; home physiological monitoring or televideo link; telephone follow up but no home visits; and hospital or clinic interventions alone. Pharmaceutical and exercise based interventions were excluded. Main outcome measures: All cause hospital admission, all cause mortality, and heart failure hospital admission. Results: 74 trials were identified, of which 30 contained relevant data for inclusion in meta-analyses. Multidisciplinary interventions reduced all cause admission (relative risk (RR) 0.87, 95% confidence interval (CI) 0.79 to 0.95, p = 0.002), although significant heterogeneity was found (p = 0.002). All cause mortality was also reduced (RR 0.79, 95% CI 0.69 to 0.92, p = 0.002) as was heart failure admission (RR 0.70, 95% CI 0.61 to 0.81, p Conclusion: Multidisciplinary interventions for heart failure reduce both hospital admission and all cause mortality. The most effective interventions were delivered at least partly in the home.

Getting the most out of cardiac rehabilitation: a review of referral and adherence predictors

Abstract: Comprehensive cardiac rehabilitation reduces mortality and morbidity but is utilised by only a fraction of eligible cardiac patients, with the participation rate of women being only about half that of men. This quantitative review assesses 32 studies meeting inclusion criteria, describing 16 804 patients, 5882 of whom were female. It was found that the main predictor of referral to a cardiac rehabilitation programme was the physician’s endorsement of the effectiveness of such a programme. Patients were more likely to participate in rehabilitation programmes when they were actively referred, educated, married, possessed high self efficacy, and when the programmes were easily accessible. Patients were less likely to participate when they had to travel long distances to participate in a cardiac rehabilitation programme, or experienced guilt over family obligations. Women were less often referred and participated less often even after referral. In conclusion, many of the observed predictors, including those particular to women, are potentially modifiable with the help of health professionals.

Infective endocarditis in Europe: lessons from the Euro heart survey

Abstract: Objectives: To describe the characteristics, treatment, and outcomes of active infective endocarditis (IE) in Europe. Design: Prospective survey of medical practices in Europe. Setting: 92 centres from 25 countries. Patients: The EHS (Euro heart survey) on valvar heart disease (VHD) enrolled 5001 adult patients between April and July 2001. Of those, 159 had active IE. Results: 118 patients (74%) had native IE and 41 (26%) had prosthetic IE. Mean (SD) age was 57 (16) years. Blood cultures were obtained for 113 patients (71%) before antibiotic treatment was started. Surgery was performed in 52% of patients. Reasons for surgery were heart failure in 60%, persistent sepsis in 40%, vegetation size in 48%, or embolism in 18%. Surgery was for implantation of mechanical prosthesis in 63%, bioprosthesis in 21%, aortic homograft in 5%, and valve repair in 11%. In-hospital mortality was 12.6%, being 10.4% in the medical group and 15.6% in the surgical group. Among the total population of 5001 patients, only 50% of those with native VHD had been educated on endocarditis prophylaxis and only 33% regularly attended dental follow up. Of patients with IE who had had a procedure at risk during the preceding year only 50% had received adequate prophylaxis. Conclusions: The EHS on VHD shows that patients with active IE have a high risk profile and often undergo surgery. However, there are deficiencies in obtaining blood cultures and applying prophylaxis. Mortality remains high, which is a justification for the improvement of patient management through education and the implementation of guidelines.

The fontan circulation

Abstract: A normal mammal cardiovascular system consists postnatally of a double—pulmonary and systemic—circuit, connected in series, powered by a double pump—the “right” and “left” heart. Many complex cardiac malformations are characterised by the existence of only one functional ventricle. This “single” ventricle then has to maintain both the systemic and the pulmonary blood circulation, which are not connected in series but in parallel (fig 1A, B). Such a circuit has two major disadvantages: arterial desaturation, both at rest and increasing during exercise, and a chronic volume overload to the single ventricle. Chronic volume overload will in time impair ventricular function, causing from the third decade on a gradual attrition due to congestive heart failure, with few survivors beyond the fourth decade. Figure 1 (A) The normal cardiovascular circulation. The pulmonary circulation (P) is connected in series with the systemic circulation (S). The right ventricle maintains the right atrial pressure lower than the left atrial pressure, and provides enough energy to the blood to pass the pulmonary resistance. (B) The patient with a univentricular heart. The systemic and pulmonary circuits are connected in parallel, with a considerable volume overload to the single ventricle (V). The width of the line reflects the degree of volume load. There is complete admixture of systemic and pulmonary venous blood, causing arterial oxygen desaturation. (C) The Fontan circulation. The systemic and pulmonary circulations are connected in series. The right atrium (RA) or systemic veins are connected to the pulmonary artery (PA). The volume overload to the single ventricle is now less than expected for body surface area. In the absence of fenestration, there is no more admixture of systemic and pulmonary venous blood, but the systemic venous pressure is notably elevated. Ao; aorta; LA, left atrium; LV, left ventricle, RV, right ventricle. In 1971 Francis Fontan1 from Bordeaux, …

Evaluation of the pattern of treatment, level of anticoagulation control, and outcome of treatment with warfarin in patients with non-valvar atrial fibrillation: a record linkage study in a large British population

Abstract: Objective: To evaluate how well patients with non-valvar atrial fibrillation (NVAF) were maintained within the recommended international normalised ratio (INR) target of 2.0–3.0 and to explore the relation between achieved INR control and clinical outcomes. Design: Record linkage study of routine activity records and INR measurements. Setting: Cardiff and the Vale of Glamorgan, South Wales, UK. Participants: 2223 patients with NVAF, no history of heart valve replacement, and with at least five INR measurements. Main outcome measures: Mortality, ischaemic stroke, all thromboembolic events, bleeding events, hospitalisation, and patterns of INR monitoring. Results: Patients treated with warfarin were outside the INR target range 32.1% of the time, with 15.4% INR values > 3.0 and 16.7% INR values < 2.0. However, the quartile with worst control spent 71.6% of their time out of target range compared with only 16.3% out of range in the best controlled quartile. The median period between INR tests was 16 days. Time spent outside the target range decreased as the duration of INR monitoring increased, from 52% in the first three months of monitoring to 30% after two years. A multivariate logistic regression model showed that a 10% increase in time out of range was associated with an increased risk of mortality (odds ratio (OR) 1.29, p < 0.001) and of an ischaemic stroke (OR 1.10, p = 0.006) and other thromboembolic events (OR 1.12, p < 0.001). The rate of hospitalisation was higher when INR was outside the target range. Conclusions: Suboptimal anticoagulation was associated with poor clinical outcomes, even in a well controlled population. However, good control was difficult to achieve and maintain. New measures are needed to improve maintenance anticoagulation in patients with NVAF.

Intervention in acute coronary syndromes: do patients undergo intervention on the basis of their risk characteristics? The Global Registry of Acute Coronary Events (GRACE)

Abstract: Objective: To determine whether revascularisation is more likely to be performed in higher-risk patients and whether the findings are influenced by hospitals adopting more or less aggressive revascularisation strategies. Methods: GRACE (Global Registry of Acute Coronary Events) is a multinational, observational cohort study. This study involved 24 189 patients enrolled at 73 hospitals with on-site angiographic facilities. Results: Overall, 32.5% of patients with a non-ST elevation acute coronary syndrome (ACS) underwent percutaneous coronary intervention (PCI; 53.7% in ST segment elevation myocardial infarction (STEMI)) and 7.2% underwent coronary artery bypass grafting (CABG; 4.0% in STEMI). The cumulative rate of in-hospital death rose correspondingly with the GRACE risk score (variables: age, Killip class, systolic blood pressure, ST segment deviation, cardiac arrest at admission, serum creatinine, raised cardiac markers, heart rate), from 1.2% in low-risk to 3.3% in medium-risk and 13.0% in high-risk patients (c statistic = 0.83). PCI procedures were more likely to be performed in low- (40% non-STEMI, 60% STEMI) than medium- (35%, 54%) or high-risk patients (25%, 41%). No such gradient was apparent for patients undergoing CABG. These findings were seen in STEMI and non-ST elevation ACS, in all geographical regions and irrespective of whether hospitals adopted low (4.2−33.7%, n = 7210 observations), medium (35.7−51.4%, n = 7913 observations) or high rates (52.6−77.0%, n = 8942 observations) of intervention. Conclusions: A risk-averse strategy to angiography appears to be widely adopted. Proceeding to PCI relates to referral practice and angiographic findings rather than the patient’s risk status. Systematic and accurate risk stratification may allow higher-risk patients to be selected for revascularisation procedures, in contrast to current international practice.

Compliance with and effectiveness of adaptive servoventilation versus continuous positive airway pressure in the treatment of Cheyne-Stokes respiration in heart failure over a six month period

Abstract: Objective: To compare compliance with and effectiveness of adaptive servoventilation (ASV) versus continuous positive airway pressure (CPAP) in patients with the central sleep apnoea syndrome (CSA) with Cheyne-Stokes respiration (CSR) and with congestive heart failure in terms of the apnoea–hypopnoea index (AHI), quality of life, and left ventricular ejection fraction (LVEF) over six months. Methods: 25 patients (age 28–80 years, New York Heart Association (NYHA) class II–IV) with stable congestive heart failure and CSA-CSR were randomly assigned to either CPAP or ASV. At inclusion, both groups were comparable for NYHA class, LVEF, medical treatment, body mass index, and CSA-CSR. Results: Both ASV and CPAP decreased the AHI but, noticeably, only ASV completely corrected CSA-CSR, with AHI below 10/h. At three months, compliance was comparable between ASV and CPAP; however, at six months compliance with CPAP was significantly less than with ASV. At six months, the improvement in quality of life was higher with ASV and only ASV induced a significant increase in LVEF. Conclusion: These results suggest that patients with CSA-CSR may receive greater benefit from treatment with ASV than with CPAP.

Heart failure with a normal ejection fraction

Abstract: Nearly half of patients with symptoms of heart failure are found to have a normal left ventricular (LV) ejection fraction. This has variously been labelled as diastolic heart failure, heart failure with preserved LV function or heart failure with a normal ejection fraction (HFNEF). As recent studies have shown that systolic function is not entirely normal in these patients, HFNEF is the preferred term. The epidemiology, aetiology and possible pathophysiology of this contentious condition are reviewed. The importance of the remodelling process in determining whether a patient presents with systolic heart failure or HFNEF is emphasised and this can be used to classify patients in a more rational manner.

Acute vasodilator effects of a Rho-kinase inhibitor, fasudil, in patients with severe pulmonary hypertension

Abstract: Pulmonary hypertension (PH) is characterised by progressive elevation of pulmonary artery pressure and pulmonary vascular resistance. Pathohistological findings have demonstrated that PH is associated with abnormal vascular structures, including medial and/or intimal hypertrophy, concentric or eccentric intimal fibrosis, obstruction in the arterial lumen, and aneurysmal dilatation.1 Patients with PH are currently treated with anticoagulant agents, vasodilators including continuous intravenous prostacyclin (prostaglandin I2) and oral sildenafil or bosentan, and in end stage, with lung transplantation,1 when applicable. Endothelial dysfunction of pulmonary arteries and enhanced pulmonary vasoconstriction contribute to the development of PH.1 Endothelial nitric oxide synthase (eNOS) expression is reduced in patients with PH and therefore nitric oxide inhalation and sildenafil are useful for those patients. However, more effective treatments remain to be developed.1 We have recently demonstrated that Rho-kinase is substantially involved in the pathogenesis of a wide range of cardiovascular disease.2,3 Rho-kinase suppresses myosin phosphatase activity by phosphorylating the myosin binding …

Sudden adult death syndrome and other non-ischaemic causes of sudden cardiac death

Abstract: Objective: To evaluate non-atherosclerotic cardiac deaths in the UK population aged over 15 years including elderly patients and to highlight the concept of the structurally normal heart in sudden death. Methods: Pathological data were collected prospectively for sudden adult deaths referred by UK coroners. Results: 453 cases of sudden death from 1994 to 2003 (278 men (61.4%) and 175 women (38.6%), age range 15–81 years) were reviewed. Males predominated in both age groups (⩽ 35 years, > 35 years). More than half of the hearts (n = 269, 59.3%) were structurally normal. In the other 40.7%, cardiac abnormalities were noted, which included: (1) cardiomyopathies (23%) such as idiopathic fibrosis, left ventricular hypertrophy, hypertrophic cardiomyopathy, dilated cardiomyopathy, and arrhythmogenic right ventricular dysplasia; (2) inflammatory disorders (8.6%) including lymphocytic myocarditis and cardiac sarcoidosis; (3) non-atheromatous abnormalities of coronary arteries (4.6%); (4) valve diseases; and (5) miscellaneous and rare causes. Conclusion: The concept of the structurally normal heart in sudden death and the need for histological examination to detect underlying disease is highlighted. Relatives need to be referred for cardiological and genetic screening in cases of normal hearts found at necropsy.

Late outcome of Senning and Mustard procedures for correction of transposition of the great arteries

Abstract: Objectives: To evaluate late mortality and morbidity after an atrial switch procedure for correction of transposition of the great arteries (TGA) and to assess predictive factors for adverse outcome. Setting: Tertiary referral centre. Design and patients: Retrospective follow up study of 137 patients surviving hospitalisation for TGA atrial switch procedure (Mustard or Senning) in a single institution and divided into two groups (simple and complex) depending on presurgical anatomy. Several surgical and follow up factors were evaluated during 16.7 (5.6) years’ follow up. Results: Late mortality was 5.1% (95% confidence interval 1.37% to 8.84%) with sudden death as the most common cause. No significant difference was found between Mustard and Senning procedures and between the complex and simple groups in terms of mortality. Independent predictive factors for late mortality were a history of supraventricular tachyarrhythmias and advanced New York Heart Association (NYHA) functional class during follow up. A very common finding was development of sinus node dysfunction (47.6%), which had no influence on mortality. There was little need for reintervention (5.1%) and relatively few cases of right ventricular systolic dysfunction (14.6%). During follow up, most patients (96.2%) were in NYHA functional class I–II. Conclusions: Overall long term outcomes of patients with atrial repair of TGA in the present era are encouraging in terms of late mortality and quality of life. Nevertheless, better outcomes may be offered through improved diagnostic methods for right ventricular function and better management of supraventricular tachyarrhythmias.

Historical trends in reported survival rates in patients with hypertrophic cardiomyopathy

Abstract: Objective: To determine the range of survival rates of patients with hypertrophic cardiomyopathy (HCM) by comparing and contrasting the natural history of a cohort of patients seen between 1988 and 2002 with that of other published series. Methods: 956 adult (⩾ 16 years old) patients with HCM (572 men, mean (SD) age 42 (15) years, range 16–88) were evaluated by ECG, Holter, exercise testing, and echocardiography. Patient characteristics and survival data were compared with those in natural history studies from referral and non-referral centres published between 1960 and January 2003. Results: The duration of follow up was 69 (45) months. 120 (12.6%) patients died or underwent cardiac transplantation. Sudden cardiac death (n = 48) was the most common mode of death. The annual rate of sudden death or implantable cardioverter-defibrillator discharge was 1.02 (95% confidence interval (CI) 0.76 to 1.26). Annual rates for heart failure death or transplantation and stroke related death were 0.55% (95% CI 0.37% to 0.78%) and 0.07% (95% CI 0.02% to 0.19%), respectively. When studies published within the last 10 years of the study period were compared with earlier reports, the size of individual study cohorts was larger (309 (240.6) v 136.5 (98.8), p = 0.058) and the proportion with severe functional limitation NYHA class III/IV lower (12.4% v 24.8%, p v 18.7%, p v 2.0% (0–3.5)). Conclusion: Published survival rates in HCM cohorts have improved progressively over the past 40 years. In the modern era the prevalence of disease related complications is similar in all reporting centres.

Relation of arterial stiffness to diastolic dysfunction in hypertensive heart disease

Abstract: Objectives: To examine the relation of arterial compliance to diastolic dysfunction in hypertensive patients with suspected diastolic heart failure (HF). Patients: 70 medically treated hypertensive patients with exertional dyspnoea (40 women, mean (SD) age 58 (8) years) and 15 normotensive controls. Main outcome measures: Mitral annular early diastolic velocity with tissue Doppler imaging and flow propagation velocity were used as linear measures of diastolic function. Arterial compliance was determined by the pulse pressure method. Results: According to conventional Doppler echocardiography of transmitral and pulmonary venous flow, diastolic function was classified as normal in 33 patients and abnormal in 37 patients. Of those with diastolic dysfunction, 28 had mild (impaired relaxation) and nine had advanced (pseudonormal filling) dysfunction. Arterial compliance was highest in controls (mean (SD) 1.32 (0.58) ml/mm Hg) and became progressively lower in patients with hypertension and normal function (1.04 (0.37) ml/mm Hg), impaired relaxation (0.89 (0.42) ml/mm Hg), and pseudonormal filling (0.80 (0.45) ml/mm Hg, p = 0.011). In patients with diastolic dysfunction, arterial compliance was inversely related to age (p = 0.02), blood pressure (p Conclusions: In hypertensive patients with exertional dyspnoea, progressively abnormal diastolic function is associated with reduced arterial compliance. Arterial compliance is an independent predictor of diastolic dysfunction in patients with hypertensive heart disease and should be considered a potential target for intervention in diastolic HF.

Assessment of diastolic function: what the general cardiologist needs to know

Abstract: Diastolic dysfunction has a major impact on symptom status, functional capacity, medical treatment, and prognosis in both systolic and diastolic heart failure (HF), irrespective of the cause.w1 w2 When systolic dysfunction is clearly present, the central clinical question concerns the presence or absence of elevated filling pressure; a restrictive filling pattern is highly specific for elevated pulmonary wedge pressure in this setting.1w3 The transmitral flow pattern is also predictive of outcome; non-reversibility of restrictive filling with treatment portends a very poor prognosis.2 Thus, diastolic evaluation is an important component of the evaluation of the patient with systolic left ventricular (LV) impairment.

Tako-tsubo transient left ventricular apical ballooning: is intravascular ultrasound the key to resolve the enigma?

Abstract: A new cardiac syndrome exhibiting transient left ventricular (LV) apical ballooning has been widely described in Japan. Conversely, there are few series outside Japan.1,2 This syndrome usually affects elderly women, frequently preceded by emotional/physical stress.1,2 These patients present with chest pain, ECG abnormalities, and minimal enzymatic release, mimicking an anterior wall acute coronary syndrome (ACS). LV contractility recovers in several days. Today, the aetiology remains unknown. Systematically, coronary artery disease (CAD) has been ruled out because of the wide akinetic area and absence of significant coronary artery stenosis on angiography. Recently we have published that tako-tsubo patients have a well developed left anterior descending (LAD) coronary artery, suggesting that the akinetic area could be supplied by LAD alone.1 To test the hypothesis that a ruptured coronary plaque could be the underlying aetiology of this syndrome we prospectively performed intravascular ultrasound (IVUS) examination in five consecutive tako-tsubo patients. From May 2003 to February 2004 we identified five patients fulfilling the following criteria: suspected ACS based on chest pain, ECG changes, and enzymatic release; transient LV apical ballooning; absence of stenosis > 50% in all major coronary arteries. All five patients underwent a LV angiographic and coronariographic examination. Mean (SD) time to angiography was 20.2 (12.0) hours (range 5–36 hours) after the onset of symptoms. We measured the length of the LAD in the left lateral projection, from left coronary ostium to its end, by tracing the actual course of the artery. We have termed the most distant spot of the vessel in relation to the left coronary ostium …

Diagnostic accuracy of B type natriuretic peptide and amino terminal proBNP in the emergency diagnosis of heart failure.

Abstract: Objective: To compare head to head the diagnostic accuracy of B type natriuretic peptide (BNP) and the amino terminal fragment of its precursor hormone (NT-proBNP) for congestive heart failure (CHF) in an emergency setting Methods: 251 consecutive patients presenting to the emergency department with dyspnoea as a chief complaint were prospectively studied Patients with acute coronary syndromes were excluded The diagnosis of CHF was based on the Framingham score for CHF plus echocardiographic evidence of systolic or diastolic dysfunction Blood concentrations of BNP and NT-proBNP were measured by two commercially available assays (Abbott and Roche methods) The diagnostic accuracies of BNP and NT-proBNP were assessed by receiver operating characteristic curve analysis Results: Areas under the curve for BNP and NT-proBNP in patients with dyspnoea caused by CHF (n = 137) and in patients with dyspnoea attributable to other reasons (n = 114) did not differ significantly (area under the curve 0916 v 0903, p = 0277, statistical power 94%) Cut off concentrations with the highest diagnostic accuracy were 295 ng/l for BNP (sensitivity 80%, specificity 86%, diagnostic accuracy 83%) and 825 ng/l for NT-proBNP (sensitivity 87%, specificity 81%, diagnostic accuracy 84%) Evaluation of discordant false classifications at these cut off concentrations showed no advantage for either BNP nor NT-proBNP in the biochemical diagnosis of CHF (17 misclassifications by BNP and 14 by NT-proBNP, p = 0720) In the population studied, age, sex, and renal function had no impact on the diagnostic utility of both tests when compared by logistic regression models Conclusions: BNP and NT-proBNP may be equally useful as an aid in the diagnosis of CHF in short of breath patients presenting to the emergency department

Statins for heart failure: at the crossroads between cholesterol reduction and pleiotropism?

Abstract: Statins are being hailed as the new aspirin—but are they beneficial for patients with heart failure?

Socioeconomic status and ischaemic heart disease mortality in 10 western European populations during the 1990s

Abstract: Objective: To assess the association between socioeconomic status and ischaemic heart disease (IHD) mortality in 10 western European populations during the 1990s. Design: Longitudinal study. Setting: 10 European populations (95 009 822 person years). Methods: Longitudinal data on IHD mortality by educational level were obtained from registries in Finland, Norway, Denmark, England/Wales, Belgium, Switzerland, Austria, Turin (Italy), Barcelona (Spain), and Madrid (Spain). Age standardised rates and rate ratios (RRs) of IHD mortality by educational level were calculated by using Poisson regression. Results: IHD mortality was higher in those with a lower socioeconomic status than in those with a higher socioeconomic status among men aged 30–59 (RR 1.55, 95% confidence interval (CI) 1.51 to 1.60) and 60 years and over (RR 1.22, 95% CI 1.21 to 1.24), and among women aged 30–59 (RR 2.13, 95% CI 1.98 to 2.29) and 60 years and over (RR 1.36, 95% CI 1.33 to 1.38). Socioeconomic disparities in IHD mortality were larger in the Scandinavian countries and England/Wales, of moderate size in Belgium, Switzerland, and Austria, and smaller in southern European populations among men and younger women (p Conclusions: Socioeconomic disparities in IHD mortality were larger in northern than in southern European populations during the 1990s. This partly reflects the pattern of socioeconomic disparities in cardiovascular risk factors in Europe. Population wide strategies to reduce risk factor prevalence combined with interventions targeted at the lower socioeconomic groups can contribute to reduce IHD mortality in Europe.

Diet in childhood and adult cardiovascular and all cause mortality: the Boyd Orr cohort

Abstract: Objective: To examine the association between childhood diet and cardiovascular mortality. Design: Historical cohort study. Setting: 16 centres in England and Scotland. Participants: 4028 people (from 1234 families) who took part in Boyd Orr’s survey of family diet and health in Britain between 1937 and 1939 followed up through the National Health Service central register. Exposures studied: Childhood intake of fruit, vegetables, fish, oily fish, total fat, saturated fat, carotene, vitamin C, and vitamin E estimated from household dietary intake. Main outcome measures: Deaths from all causes and deaths attributed to coronary heart disease and stroke. Results: Higher childhood intake of vegetables was associated with lower risk of stroke. After controlling for age, sex, energy intake, and a range of socioeconomic and other confounders the rate ratio between the highest and lowest quartiles of intake was 0.40 (95% confidence interval 0.19 to 0.83, p for trend 0.01). Higher intake of fish was associated with higher risk of stroke. The fully adjusted rate ratio between the highest and lowest quartile of fish intake was 2.01 (95% confidence interval 1.09 to 3.69, p for trend 0.01). Intake of any of the foods and constituents considered was not associated with coronary mortality. Conclusions: Aspects of childhood diet, but not antioxidant intake, may affect adult cardiovascular risk.

Is the severity of congenital heart disease associated with the quality of life and perceived health of adult patients

Abstract: Objective: To explore whether the severity of congenital heart disease is associated with the quality of life and perceived health status of adult patients. Design: Descriptive, cross sectional study. Setting: Adult congenital heart disease programme in one tertiary care centre in Belgium. Patients: 629 patients (378 men, 251 women) with a median age of 24 years. Main outcome measures: Disease severity was operationalised in terms of initial diagnosis (classification of Task Force 1 of the 32nd Bethesda Conference), illness course (disease severity index), and current functional status (New York Heart Association (NYHA) class, ability index, congenital heart disease functional index, and left ventricular ejection fraction). Quality of life was measured by a linear analogue scale, the satisfaction with life scale, and the schedule for evaluation of individual quality of life. Perceived health status was also assessed with a linear analogue scale. Results: Scores derived from the disease severity classification systems were weakly negatively associated with quality of life and health status, ranging from −0.05 to −0.27. The NYHA functional class and ability index were consistently associated with quality of life and perceived health. Conclusions: This study showed that the severity of congenital heart disease is marginally associated with patients’ quality of life and perceived health. Functional status was more related to patients’ assessment of their quality of life than was the initial diagnosis or illness course.

Staphylococcus lugdunensis infective endocarditis: description of 10 cases and analysis of native valve, prosthetic valve, and pacemaker lead endocarditis clinical profiles

Abstract: Objective: To evaluate the incidence and the clinical and echocardiographic features of infective endocarditis (IE) caused by Staphylococcus lugdunensis and to identify the prognostic factors of surgery and mortality in this disease. Design: Prospective cohort study. Setting: Study at two centres (a tertiary care centre and a community hospital). Patients: 10 patients with IE caused by S lugdunensis in 912 consecutive patients with IE between 1990 and 2003. Methods: Prospective study of consecutive patients carried out by the multidisciplinary team for diagnosis and treatment of IE from the study institutions. English, French, and Spanish literature was searched by computer under the terms “endocarditis” and “Staphylococcus lugdunensis” published between 1989 and December 2003. Main outcome measures: Patient characteristics, echocardiographic findings, required surgery, and prognostic factors of mortality in left sided cases of IE. Results: 10 cases of IE caused by S lugdunensis were identified at our institutions, representing 0.8% (four of 467), 1.5% (two of 135), and 7.8% (four of 51) of cases of native valve, prosthetic valve, and pacemaker lead endocarditis in the non-drug misusers. Native valve IE was present in four patients (two aortic, one mitral, and one pulmonary), prosthetic valve aortic IE in two patients, and pacemaker lead IE in the other four patients. All patients with left sided IE had serious complications (heart failure, periannular abscess formation, or shock) requiring surgery in 60% (three of five patients) of cases with an overall mortality rate of 80% (four of five patients). All patients with pacemaker IE underwent combined medical treatment and surgery, and mortality was 25% (one patient). In total 59 cases of IE caused by S lugdunensis were identified in a review of the literature. The combined analysis of these 69 cases showed that native valve IE (53 patients, 77%) is characterised by mitral valve involvement and frequent complications such as heart failure, abscess formation, and embolism. Surgery was needed in 51% of cases and mortality was 42%. Prosthetic valve endocarditis (nine of 60, 13%) predominated in the aortic position and was associated with abscess formation, required surgery, and high mortality (78%). Pacemaker lead IE (seven of 69, 10%) is associated with a better prognosis when antibiotic treatment is combined with surgery. Conclusions: S lugdunensis IE is an uncommon cause of IE, involving mainly native left sided valves, and it is characterised by an aggressive clinical course. Mortality in left sided native valve IE is high but the prognosis has improved in recent years. Surgery has improved survival in left sided IE and, therefore, early surgery should always be considered. Prosthetic valve S lugdunensis IE carries an ominous prognosis.

Atorvastatin inhibits calcification and enhances nitric oxide synthase production in the hypercholesterolaemic aortic valve

Abstract: Objective: To study in a rabbit model the expression of endothelial nitric oxide synthase (eNOS) in association with the development of calcification of the aortic valve, and to assess the effects of atorvastatin on eNOS expression, nitrite concentration, and aortic valve calcification. Methods: Rabbits (n = 48) were treated for three months: 16, forming a control group, were fed a normal diet; 16 were fed a 0.5% (wt/wt) high cholesterol diet; and 16 were fed a 0.5% (wt/wt) cholesterol diet plus atorvastatin (2.5 mg/kg/day). The aortic valves were examined with eNOS immunostains and western blotting. Cholesterol and high sensitivity C reactive protein (hsCRP) concentrations were determined by standard assays. Serum nitrite concentrations were measured with a nitric oxide analyser. eNOS was localised by electron microscopy and immunogold labelling. Calcification in the aortic valve was evaluated by micro-computed tomography (CT). Results: Cholesterol, hsCRP, and aortic valve calcification were increased in the cholesterol fed compared with control animals. Atorvastatin inhibited calcification in the aortic valve as assessed by micro-CT. eNOS protein concentrations were unchanged in the control and cholesterol groups but increased in the atorvastatin treated group. Serum nitrite concentrations were decreased in the hypercholesterolaemic animals and increased in the group treated with atorvastatin. Conclusion: These data provide evidence that chronic experimental hypercholesterolaemia produces bone mineralisation in the aortic valve, which is inhibited by atorvastatin.

Trends in mortality from coronary heart and cerebrovascular diseases in the Americas: 1970–2000

Abstract: Objective: To describe trends in mortality from coronary heart disease (CHD) and cerebrovascular accidents (CVAs) over the period 1970 to 2000 in the Americas. Methods: Age standardised mortality rates were derived from the World Health Organization database and grouped according to the International classification of diseases , ninth revision. Joinpoint analysis was used to identify changes in trends. Results: In the USA and Canada, CHD mortality rates declined by about 60% in both sexes. In Latin America, falls in CHD mortality were observed for Argentina, Brazil, Chile, Cuba, and Puerto Rico. In 2000, mortality rates among men were highest in Venezuela (137.3/100 000) and lowest (apart from Ecuador) in Argentina (63.5/100 000). For women, the rates were highest in Cuba (79.4/100 000) and lowest in Argentina (26.5/100 000). For CVA mortality, a decline by about 60% was observed in the USA and Canada for both sexes. The falls were smaller (about −25% to −40% among men and −20% to −50% among women) in Puerto Rico, Argentina, Chile, and Costa Rica and only minor in Ecuador, Mexico, and Venezuela. Around 2000, CVA mortality in Latin America was highest in Brazil (85.5/100 000 among men and 61.7/100 000 among women) and lowest in Puerto Rico (29.3/100 000 among men and 24.1/100 000 among women). Conclusions: Recent falls in CHD and CVA were less favourable in Latin America than in the USA and Canada. This may reflect unfavourable changes in nutrition (including obesity), physical activity, and smoking in most Latin American countries, together with less effective control of hypertension and management of the diseases.