Showing papers in "Heart in 2007"

Clinical epidemiology of heart failure

Abstract: The aim of this paper is to review the clinical epidemiology of heart failure. The last paper comprehensively addressing the epidemiology of heart failure in Heart appeared in 2000. Despite an increase in manuscripts describing epidemiological aspects of heart failure since the 1990s, additional information is still needed, as indicated by various editorials.

Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease

Abstract: The National Institute for Health and Clinical Excellence (NICE) guideline, Lipid modification: Cardiovascular risk assessment and the modification of blood lipids for the primary and secondary prevention of cardiovascular disease 1 is a significant advance over earlier more fragmented approaches to cardiovascular risk. The guideline provides strategies for identification of patients at risk, suggests lipid modification in primary and secondary prevention and unifies treatment approaches to coronary heart disease, stroke and peripheral vascular disease. This guideline does not give recommendations for patients with underlying disorders that increase cardiovascular disease risk, but NICE guidance on diabetes, which includes lipid modification, has also just been published2 and NICE guidance on familial hypercholesterolaemia is due shortly. A 20% cardiovascular disease (CVD) 10-year risk threshold for statin treatment was established by the technology appraisal on statins.3 This is considerably lower than the previously recommended National Service Framework threshold, which is equivalent to a 40% CVD risk. The new 20% CVD risk threshold increases the numbers of people targeted for further clinical assessment and possible statin treatment for primary prevention in England and Wales from around one million to over three million.4 The guideline endorses this threshold and sets out a strategy for the identification of people at high CVD risk and clarifies their management and treatment. The guidance recommends a systematic strategy to identify people …

Global burden of cardiovascular disease

Abstract: It was estimated in 1998 that 85% of the global burden of cardiovascular diseases occurred in low and middle income countries.1,2 Furthermore, about half the deaths in the 1990s attributable to cardiovascular diseases in these countries were in those below the age of 70 years compared with only a quarter in the developed countries.2 Although the mortality rate of cardiovascular diseases and prevalence of major cardiovascular risk factors has generally decreased in economically developed countries, the corresponding mortality rate and risk prevalence has substantially increased in China, other East Asian societies and now India, which have been undergoing rapid demographic, social and economic changes.3,4,5 Dietary and lifestyle changes associated with economic growth and increasing wealth have led to a marked increase in obesity and diabetes in Asia that may further increase the burden of cardiovascular diseases.6,7,8 In sub‐Saharan Africa, where infectious diseases remain the leading cause of death, hypertension and stroke are emerging as an important cause of ill health in the rapidly urbanising population of the region.9 Despite these facts, the vast majority of publications in cardiovascular diseases refer to the populations of North America and Western Europe. Additionally, many of the guidelines derived from these areas are being applied, perhaps inappropriately, to other populations in completely different environments. Heart is attempting to redress this imbalance by publishing a series of invited reviews on different aspects of cardiovascular diseases in India, China, sub‐Saharan Africa and South America. Emphasis is placed on local research data and practices so that these can reach a wider audience; there are many lessons to be learnt for all from practising medicine in a more resource‐poor environment that concentrate the mind on doing what is most cost effective. The first in the series begins with cardiomyopathies and pericarditis in Africa, which are major causes of heart failure (see article on page 1176).10 We thank our many contributors for finding time in their busy clinical schedules to produce these reviews and we hope that our readership will find the articles as interesting and illuminating as we have as editors.

Oxidative stress and redox signalling in cardiac hypertrophy and heart failure

Abstract: Substantial evidence suggests the involvement of oxidative stress in the pathophysiology of congestive heart failure and its antecedent conditions such as cardiac hypertrophy and adverse remodelling after MI. Oxidative stress describes an imbalance between antioxidant defences and the production of reactive oxygen species (ROS), which at high levels cause cell damage but at lower levels induce subtle changes in intracellular signalling pathways (termed redox signalling). ROS are derived from many sources including mitochondria, xanthine oxidase, uncoupled nitric oxide synthases and NADPH oxidases. The latter enzymes are especially important in redox signalling, being implicated in the pathophysiology of hypertension and atherosclerosis, and activated by diverse pathologically relevant stimuli. We review the contribution of ROS to heart failure pathophysiology and discuss potential therapies that may specifically target detrimental redox signalling. Indeed, drugs such as ACE inhibitors and statins may act in part through such mechanisms. A better understanding of redox signalling mechanisms may enable the development of new targeted therapeutic strategies rather than the non-specific antioxidant approaches that have to date been disappointing in clinical trials.

Limitations of the New York Heart Association functional classification system and self-reported walking distances in chronic heart failure

Abstract: Background: Two ways to evaluate the symptoms of heart failure are the New York Heart Association (NYHA) classification and asking patients how far they can walk (walk distance). The NYHA system is commonly used, although it is not clear how individual clinicians apply it. Aim: To investigate how useful these measures are to assess heart failure and whether other questions might be more helpful. Methods: 30 cardiologists were asked what questions they used when assessing patients with heart failure. To assess interoperator variability, two cardiologists assessed a series of 50 patients in classes II and III using the NYHA classification. 45 patients who had undergone cardiopulmonary testing were interviewed using a specially formulated questionnaire. They were also asked how far they could walk before being stopped by symptoms, and then tested on their ability to estimate distance. Results: The survey of cardiologists showed no consistent method for assessing NYHA class and a literature survey showed that 99% of research papers do not reference or describe their methods for assigning NYHA classes. The interoperator variability study showed only 54% concordance between the two cardiologists. 70% of cardiologists asked patients for their walk distance; however, this walk distance correlated poorly with actual exercise capacity measured by cardiopulmonary testing (ρ = 0.04, p = 0.82). Conclusion: No consistent method of assessing NYHA class is in use and the interoperator study on class II and class III patients gave a result little better than chance. Some potential questions are offered for use in assessment. Walking distance, although frequently asked, does not correlate with formally measured exercise capacity, even after correction for patient perception of distance, and has never been found to have prognostic relevance. Its value is therefore doubtful.

Cardiopulmonary exercise testing and its application

Abstract: Cardiopulmonary exercise testing (CPET) has become an important clinical tool to evaluate exercise capacity and predict outcome in patients with heart failure and other cardiac conditions. It provides assessment of the integrative exercise responses involving the pulmonary, cardiovascular and skeletal muscle systems, which are not adequately reflected through the measurement of individual organ system function. CPET is being used increasingly in a wide spectrum of clinical applications for evaluation of undiagnosed exercise intolerance and for objective determination of functional capacity and impairment. This review focuses on the exercise physiology and physiological basis for functional exercise testing and discusses the methodology, indications, contraindications and interpretation of CPET in normal people and in patients with heart failure.

Pulmonary arterial hypertension in adults born with a heart septal defect: the Euro Heart Survey on adult congenital heart disease

Abstract: Aim: To investigate the role of pulmonary arterial hypertension (PAH) in adult patients born with a cardiac septal defect, by assessing its prevalence and its relation with patient characteristics and outcome. Methods and results: From the database of the Euro Heart Survey on adult congenital heart disease (a retrospective cohort study with a 5-year follow-up), the relevant data on all 1877 patients with an atrial septal defect (ASD), a ventricular septal defect (VSD), or a cyanotic defect were analysed. Most patients (83%) attended a specialised centre. There were 896 patients with an ASD (377 closed, 504 open without and 15 with Eisenmenger’s syndrome), 710 with a VSD (275, 352 and 83, respectively), 133 with Eisenmenger’s syndrome owing to another defect and 138 remaining patients with cyanosis. PAH was present in 531 (28%) patients, or in 34% of patients with an open ASD and 28% of patients with an open VSD, and 12% and 13% of patients with a closed defect, respectively. Mortality was highest in patients with Eisenmenger’s syndrome (20.6%). In case of an open defect, PAH entailed an eightfold increased probability of functional limitations (New York Heart Association class >1), with a further sixfold increase when Eisenmenger’s syndrome was present. Also, in patients with persisting PAH despite defect closure, functional limitations were more common. In patients with ASD, the prevalence of right ventricular dysfunction increased with systolic pulmonary artery pressure (OR = 1.073 per mm Hg; p Conclusion: In this selected population of adults with congenital heart disease, PAH was common and predisposed to more symptoms and further clinical deterioration, even among patients with previous defect closure and patients who had not developed Eisenmenger’s physiology.

Thrombosis of prosthetic heart valves: diagnosis and therapeutic considerations

Abstract: Prosthetic valve thrombosis (PVT) is a rare but serious complication of valve replacement, most often encountered with mechanical prostheses. The significant morbidity and mortality associated with this condition warrants rapid diagnostic evaluation. However, diagnosis can be challenging, mainly because of variable clinical presentations and the degree of valvular obstruction. Cinefluoroscopy (for mechanical valves) and transthoracic and transoesophageal echocardiography represent the main diagnostic procedures. Although surgical treatment is usually preferred in cases of obstructive PVT, optimal treatment remains controversial. The different therapeutic modalities available for PVT (heparin treatment, fibrinolysis, surgery) will be largely influenced by the presence of valvular obstruction, by valve location (left- or right-sided), and by clinical status. Hence, treatment of an obstructive left-sided PVT will differ from that of non-obstructive or right-sided PVT. The purpose of this article is to review the physiopathology, diagnosis and treatment of PVT and to provide recommendations for management. ### Mechanical valve thrombosis The incidence of obstructive PVT for mechanical valves varies between 0.3–1.3% patient years.1 Thromboembolic complications, including systemic emboli, are more frequent and occur at a rate of 0.7–6% patient years. Non-obstructive PVT is a relatively frequent finding in the postoperative period,2 with a reported incidence as high as 10% in recent transoesophageal echocardiography (TOE) studies. Although these are usually small non-obstructive thrombi, they underline the necessity of optimal anticoagulation in the postoperative period. According to a series of surgical interventions for PVT, the first postoperative year is marked by a 24% incidence of thrombosis, with a stable incidence between the second to fourth years of approximately 15%, with a subsequent decrease thereafter.3 ### Bioprosthetic valve thrombosis Thrombosis of a bioprosthetic valve4 is a rare occurrence when compared to mechanical prostheses. Bioprosthetic PVT is usually diagnosed in the early postoperative period, when endothelialisation of the suture zone is not yet complete. Hence, this has led …

Anthracycline associated cardiotoxicity in survivors of childhood cancer

Abstract: The development of effective antineoplastic therapies for childhood cancer is a great success in modern medicine. Five year survival rates of children diagnosed with cancer in the USA and Western Europe in excess of 70% make long term survivors of childhood cancer a steadily increasing population. Although there is much to celebrate, new challenges lie ahead in treating the systemic sequelae of chemotherapy.1 Results from the Childhood Cancer Survivor Study (CCSS) showed that 30 years after treatment, the cumulative incidence of chronic health conditions in long term survivors reaches 73%, with a cumulative incidence of 42% for severe, disabling, or life threatening conditions or death.2 Severe conditions, that are significantly more common in childhood cancer survivors than in their siblings, include: major joint replacement (relative risk (RR) 54.0), congestive heart failure (RR 15.1), second malignant neoplasm (RR 14.8), severe cognitive dysfunction (RR 10.5), coronary artery disease (RR 10.4), cerebrovascular accident (RR 9.3), and renal failure (RR 8.9).2 Previous CCSS results found that patients who had survived at least 5 years after diagnosis had 10.8-fold increased rates of all cause mortality.3 The standardised mortality ratio for cardiac causes was 8.2 times higher than expected and the cumulative probability of cardiac death increased 15–25 years after cancer diagnosis. A similar study in a large Nordic cohort documented a standardised mortality ratio of 5.8 for cardiac death and elevated rates of sudden, presumed arrhythmic, deaths.4 Chief among adverse late effects is the cardiovascular toxicity of anthracyclines.5–11 Unfortunately, despite well documented dose related toxicity, the superior disease-free survival rates of regimens including anthracyclines leave limited viable treatment alternatives and the majority of long term paediatric cancer survivors in the Pediatric Oncology Group received an anthracycline during treatment.12 ### Mechanism of cardiotoxicity Several cytotoxic biochemical changes follow anthracycline exposure in …

Hepatic changes in the failing Fontan circulation

Abstract: Background: The failing Fontan circulation is associated with hepatic impairment. The nature of this liver injury is poorly defined. Objective: To establish the gross and histological liver changes of patients with Fontan circulation relative to clinical, biochemical and haemodynamic findings. Methods: Patients were retrospectively assessed for extracardiac Fontan conversion between September 2003 and June 2005, according to an established clinical protocol. Twelve patients, mean age 24.6 (range 15.8–43.4) years were identified. The mean duration since the initial Fontan procedure was 14.1 (range 6.9–26.4) years. Results: Zonal enhancement of the liver (4/12) on CT was more common in patients with lower hepatic vein pressures (p = 0.007), and in those with absent cardiac cirrhosis on histological examination (p = 0.033). Gastro-oesophageal varices (4/12) were more common in patients with higher hepatic vein pressure (21 (6.3) vs 12.2 (2.2) mm Hg, p = 0.013) and associated with more advanced cirrhosis (p = 0.037). The extent of cirrhosis (7/12) was positively correlated with the hepatic vein pressure (r = 0.83, p = 0.003). A significant positive correlation was found between the Fontan duration and the degree of hepatic fibrosis (r = 0.75, p = 0.013), as well as presence of broad scars (r = 0.71, p = 0.021). Protein-losing enteropathy (5/12) occurred more frequently in patients with longer Fontan duration (11.7 (3.2) vs 17.9 (6.1) years, p = 0.038). Conclusions: Liver injury, which can be extensive in this patient group, is related to Fontan duration and hepatic vein pressures. CT scan assists non-invasive assessment. Cardiac cirrhosis with the risk of developing gastro-oesophageal varices and regenerative liver nodules, a precursor to hepatocellular carcinoma, is common in this patient group.

Isolated ventricular non-compaction of the myocardium in adults

Abstract: Isolated ventricular non-compaction (IVNC) in adults is a genetic cardiac disease of emerging importance with a distinct clinical and pathophysiological presentation. The body of evidence for the underlying genetic basis of the disease has also grown. Prognosis remains poor for patients with impaired systolic left ventricular function, as treatment options are very limited. The diagnosis of IVNC, however, is often missed, most often as a consequence of ignorance of the condition. The relevant clinical issues and the emerging concepts of the aetiology of IVNC are summarised.

Gender differences in management and outcomes in patients with acute coronary syndromes: results on 20 290 patients from the AMIS Plus Registry

Abstract: Background: Gender differences in management and outcomes have been reported in acute coronary syndrome (ACS). Objectives: To assess such gender differences in a Swiss national registry. Methods: 20 290 patients with ACS enrolled in the AMIS Plus Registry from January 1997 to March 2006 by 68 hospitals were included in a prospective observational study. Data on patients’ characteristics, diagnoses, procedures, complications and outcomes were recorded. Odds ratios (ORs) of in-hospital mortality were calculated using logistic regression models. Results: 5633 (28%) patients were female and 14 657 (72%) male. Female patients were older than men (mean (SD) age 70.9 (12.1) vs 63.4 (12.9) years; p Conclusions: The analysis showed gender differences in baseline characteristics and in the rate of PCI in patients admitted for ACS in Swiss hospitals between 1997 and 2006. Reasons for the significant underuse of PCI in women, and a slightly higher in-hospital mortality in the 51–60 year age group, need to be investigated further.

Wide spectrum of presentation and variable outcomes of isolated left ventricular non-compaction

Abstract: Objectives: To investigate diagnostic routes, echocardiographic substrates, outcomes and prognostic factors in patients with isolated ventricular non-compaction (IVNC) identified by echocardiographic laboratories with referral from specialists and primary care physicians. Patients and design: Since 1991, all patients with suspected IVNC were flagged and followed up on dedicated databases. Patients were divided into symptom-based and non-symptom-based diagnostic subgroups. Results: 65 eligible patients were followed up for 6–193 months (mean 46 (SD 44). In 53 (82%) patients, IVNC was associated with variable degrees of left ventricular (LV) dilatation and hypokinesia, and in the remaining 12 (18%) LV volumes were normal. Diagnosis was symptom based in 48 (74%) and non-symptom based in 17 (26%) (familial referral in 10). The non-symptom-based subgroup was characterised by younger age, lower prevalence of ECG abnormalities, better systolic function and lower left atrial size, whereas the extent of non-compaction was not different. No major cardiovascular events occurred in the non-symptom-based group, whereas 15 of 48 (31%) symptomatically diagnosed patients experienced cardiovascular death or heart transplantation (p = 0.01, Kaplan–Meier analysis). Independent predictors of cardiovascular death or heart transplantation were New York Heart Association class III–IV, sustained ventricular arrhythmias and left atrial size. Conclusions: IVNC is associated with a broad spectrum of clinical and pathophysiological findings, and the overall natural history and prognosis may be better than previously thought. Adult patients with incidental or familial discovery of IVNC have an encouraging outlook, whereas those who have symptoms of heart failure, a history of sustained ventricular tachycardia or an enlarged left atrium have an unstable course and more severe prognosis.

Contemporary trends in the epidemiology and management of cardiomyopathy and pericarditis in sub-Saharan Africa

Abstract: Heart failure in sub-Saharan Africans is mainly due to non-ischaemic causes, such as hypertension, rheumatic heart disease, cardiomyopathy and pericarditis. The two endemic diseases that are major contributors to the clinical syndrome of heart failure in Africa are cardiomyopathy and pericarditis. The major forms of endemic cardiomyopathy are idiopathic dilated cardiomyopathy, peripartum cardiomyopathy and endomyocardial fibrosis. Endomyocardial fibrosis, which affects children, has the worst prognosis. Other cardiomyopathies have similar epidemiological characteristics to those of other populations in the world. HIV infection is associated with occurrence of HIV-associated cardiomyopathy in patients with advanced immunosuppression, and the rise in the incidence of tuberculous pericarditis. HIV-associated tuberculous pericarditis is characterised by larger pericardial effusion, a greater frequency of myopericarditis, and a higher mortality than in people without AIDS. Population-based studies on the epidemiology of heart failure, cardiomyopathy and pericarditis in Africans, and studies of new interventions to reduce mortality, particularly in endomyocardial fibrosis and tuberculous pericarditis, are needed.

Remote ischaemic postconditioning protects the heart during acute myocardial infarction in pigs

Abstract: Background Ischemic preconditioning results in a reduction in ischemic-reperfusion injury to the heart. This beneficial effect is seen both with direct local preconditioning of the myocardium and with remote preconditioning of easily accessible distant non-vital limb tissue. Ischemic postconditioning with a comparable sequence of brief periods of local ischemia, when applied immediately after the ischemic insult, confers similar benefits to preconditioning. The present study tested the hypothesis that limb ischemia induces remote postconditioning and hence reduces experimental myocardial infarct size in a validated swine model of acute myocardial infarction (AMI). Methods and Results AMI was induced in 24 pigs with 90-minute balloon inflations of the left anterior descending coronary artery. Remote ischemic postconditioning was induced in 12 of the pigs by four 5-minute cycles of blood pressure cuff inflation applied to the lower limb immediately after the balloon deflation. Infarct size was assessed by measuring 72 hour creatinine kinase release, MRI scan and immunohistochemistry. Area under the curve of creatinine kinase release was significantly reduced in the postconditioning compared with the control group with a 26% reduction in infarct size (p<0.05). This was confirmed by MRI scanning and immunohistochemistry that revealed a 22 % (p<0.05) and a 47.52 % (p<0.01) relative reduction in infarct size respectively. Conclusion Remote ischemic postconditioning represents a simple technique to reduce infarct size without the hazards and logistics of multiple coronary artery balloon inflations. Remote ischemic postconditioning promises clear clinical potential.

Human embryonic stem cell transplantation to repair the infarcted myocardium

Abstract: Objective: To test the hypothesis that human embryonic stem cells (hESCs) can be guided to form new myocardium by transplantation into the normal or infarcted heart, and to assess the influence of hESC-derived cardiomyocytes (hESCMs) on cardiac function in a rat model of myocardial infarction (MI). Methods: Undifferentiated hESCs (0.5–1×10 6 ), human embryoid bodies (hEBs) (4–8 days; 0.5–1×10 6 ), 0.1 mm pieces of embryonic stem-derived beating myocardial tissue, and phosphate-buffered saline (control) were injected into the normal or infarcted myocardium of athymic nude rats (n = 58) by direct injection into the muscle or into preimplanted three-dimensional alginate scaffold. By 2–4 weeks after transplantation, heart sections were examined to detect the human cells and differentiation with fluorescent in situ hybridisation, using DNA probes specific for human sex chromosomes and HLA-DR or HLA-ABC immunostaining. Results: Microscopic examination showed transplanted human cells in the normal, and to a lesser extent in the infarcted myocardium (7/7 vs 2/6; p Conclusions: Undifferentiated hESCs and hEBs are not directed to form new myocardium after transplantation into normal or infarcted heart and may create teratoma. Nevertheless, this study shows that hESC-derived cardiomyocyte transplantation can attenuate post-MI scar thinning and left ventricular dysfunction.

Myopericarditis versus viral or idiopathic acute pericarditis

Abstract: Objective: To investigate the relative incidence, clinical presentation and prognosis of myopericarditis among patients with idiopathic or viral acute pericarditis. Design: Prospective observational clinical cohort study. Setting: Two general hospitals from an urban area of 220 000 inhabitants. Patients: 274 consecutive cases of idiopathic or viral acute pericarditis between January 2001 and June 2005. Main outcome measures: Relative prevalence of myopericarditis. Clinical features at presentation including echocardiographic data (ejection fraction (EF), wall motion score index (WMSI)) and follow-up data at 12 months including complications, results of echocardiography, electrocardiography and treadmill testing. Results: Myopericarditis was recorded in 40/274 (14.6%) consecutive patients. At presentation, the following clinical features were independently associated with myopericarditis: arrhythmias (odds ratio (OR) = 17.6, 95% confidence interval (CI) 5.7 to 54.1; p Conclusions: Myopericarditis is relatively common and shows a benign evolution also in spontaneous cases not related to vaccination.

The heart in Anderson-Fabry disease and other lysosomal storage disorders

Abstract: Lysosomal storage disorders (LSD) comprise a group of more than 40 diseases caused by a deficiency of lysosomal enzymes, membrane transporters or other proteins involved in lysosomal biology. The predominant inheritance pattern is autosomal recessive except for Anderson-Fabry disease, glycogen storage disease (GSD) type IIb (Danon disease) and mucopolysaccharidosis (MPS) type II (Hunter disease). While the metabolic defects affect all cells, clinical organ involvement usually occurs only in the presence of substrate excess or metabolic pathway activation. Cardiac disease is particularly important in lysosomal glycogen storage diseases (Pompe and Danon disease), mucopolysaccharidoses and in glycosphingolipidoses (Anderson-Fabry disease). Various disease manifestations may be observed including hypertrophic and dilated cardiomyopathy, coronary artery disease and valvular disease (table 1). View this table: Table 1 Lysosomal storage disease causing cardiac disease Anderson-Fabry disease (AFD, synonyms Fabry disease, α-galactosidase A deficiency, angiokeratoma corporis diffusum) is an X-linked LSD caused by mutations in the gene encoding the lysosomal enzyme α-galactosidase A. The resultant deficiency in α-galactosidase A activity leads to intra-lysosomal accumulation of neutral glycosphingolipids, mainly globotriaosylceramide (Gb3), in various organ systems. The disease is characterised by progressive clinical manifestations and premature death from renal failure, stroke and cardiac disease.1 ### Epidemiology The incidence of AFD has been estimated at 1 in 40 000 to 1 in 117 000 live births for males.1 Recently, studies in high risk patient cohorts suggest that it is much more common. The reported prevalence of AFD in patients with end-stage renal disease on haemodialysis ranges between 0.2–1.2%; in patients with cryptogenic stroke the prevalence may be as high as 4.9% in men and 2.8% in women. The prevalence of AFD in patients with heart disease varies depending on the population studied. In a survey of male patients with unexplained left ventricular hypertrophy (LVH) attending an echocardiography clinic, 3% had biochemical evidence for AFD2 …

Prevalence of exercise-induced left ventricular outflow tract obstruction in symptomatic patients with non-obstructive hypertrophic cardiomyopathy

Abstract: Background: Resting left ventricular outflow tract obstruction (LVOTO) occurs in 25% of patients with hypertrophic cardiomyopathy (HCM) and is an important cause of symptoms and disease progression. The prevalence and clinical significance of exercise induced LVOTO in patients with symptomatic non-obstructive HCM is uncertain. Methods and results: 87 symptomatic patients (43.3 (13.7) years, 67.8% males) with HCM and no previously documented LVOTO (defined as a gradient ⩾30 mm Hg) underwent echocardiography during upright cardiopulmonary exercise testing: 54 patients (62.1%; 95% CI 51.5 to 71.6) developed LVOTO during exercise (latent LVOTO); 33 (37.9%; 95% CI 28.4 to 48.5) had neither resting nor exercise LVOTO (non-obstructive). Patients with latent LVOTO were more likely to have systolic anterior motion of the mitral valve (SAM) at rest (relative risk 2.1, 95% CI 1.2 to 3.8; p = 0.01), and higher peak oxygen consumption (mean difference: 10.3%, 95% CI 2.1 to 18.5; p = 0.02) than patients with non-obstructive HCM. The only independent predictors of Δ gradient during exercise were a history of presyncope/syncope, incomplete/complete SAM at rest and Wigle score (all p Conclusions: Approximately two-thirds of patients with symptomatic non-obstructive HCM have latent LVOTO. This study suggests that all patients with symptomatic non-obstructive HCM should have exercise stress echocardiography.

Incidence, clinical characteristics and outcome of congestive heart failure as the initial presentation in patients with primary hyperthyroidism

Abstract: Background: There are limited systematic data on the incidence, clinical characteristics and outcomes of congestive heart failure (CHF) in patients with hyperthyroidism. The aim of this study was to investigate the incidence, clinical characteristics and outcome of CHF as the initial presentation in patients with primary hyperthyroidism. Methods: The prevalence, clinical characteristics and outcome of CHF was studied in 591 consecutive patients (mean (SD) age 45 (1) years, 140 men) who presented with primary hyperthyroidism. Results: CHF was the presenting condition in 34 patients (5.8%) with hyperthyroidism. The presence of atrial fibrillation at presentation (OR 37.4, 95% CI 9.72 to 144.0, p 0.05). Conclusion: CHF was the initial clinical presentation in approximately 6% of patients with hyperthyroidism, and half of them had left ventricular systolic dysfunction. Symptoms of CHF subsided and LVEF improved after treatment for hyperthyroidism. Nonetheless, one-third of these patients developed persistent dilated cardiomyopathy.

A national survey of the prevalence, incidence, primary care burden and treatment of atrial fibrillation in Scotland

Abstract: Objective: To examine the epidemiology, primary care burden and treatment of atrial fibrillation (AF). Design: Cross-sectional data from primary care practices participating in the Scottish Continuous Morbidity Recording scheme between April 2001 and March 2002. Setting: 55 primary care practices (362 155 patients). Participants: 3135 patients with AF. Results: The prevalence of AF in Scotland was 9.4/1000 in men and 7.9/1000 in women (p 85 years). The prevalence of AF decreased with increasing socioeconomic deprivation (9.2/1000 least deprived and 7.5/1000 most deprived category, p = 0.02 for trend). 71% of patients with AF received rate-controlling medication: β-blocker 28%, rate-limiting calcium-channel blocker 42% and digoxin 43%. 42% of patients received warfarin, 44% received aspirin and 78% receeved more than one of these. Multivariable analysis showed that men and women aged ⩾75 years were more likely (than those aged Conclusions: AF is a common condition, more so in men than in women. Deprived individuals are less likely to have AF, a finding raising concerns about socioeconomic gradients in detection and prognosis. Recommended treatments for AF were underused in women and older people. This is of particular concern, given the current trends in population demographics and the evidence that both groups are at higher risk of stroke.

Improving end-of-life care for patients with chronic heart failure: “Let’s hope it’ll get better, when I know in my heart of hearts it won’t”

Abstract: Objective Although chronic heart failure (CHF) has a high mortality rate and symptom burden, and clinical guidance stipulates palliative care intervention, there is a lack of evidence to guide clinical practice for patients approaching the end of life. This study aimed to formulate guidance and recommendations for improving end of life care in CHF. The objectives were to generate data on patients and carers? preferences regarding future treatment modalities, and to investigate communication between staff, patient and carer on end of life issues. Design Semi-structured qualitative interviews were conducted with 20 CHF patients (New York Heart Association functional classification III-IV); 11 family carers; 6 palliative care clinicians and 6 cardiology clinicians. Setting A tertiary hospital in London, UK. Results Patients and families reported a wide range of end of life care preferences. None had discussed these with their clinicians, and none were aware of choices or alternatives in future care modalities, such as adopting a palliative approach. Patients and carers live with fear and anxiety, and are uninformed about the implications of their diagnosis. Cardiac staff confirmed that they rarely raise such issues with patients. Disease specific and specialism-specific barriers to improving end of life care were identified. Conclusions This novel, integrated data provides three recommendations for improving care in line with policy directives: sensitive provision of information and discussion of end of life issues with patients and families; mutual education of cardiology and palliative care staff; and mutually agreed palliative care referral criteria and care pathways for CHF patients.

Thoracic spinal cord stimulation improves functional status and relieves symptoms in patients with refractory angina pectoris: the first placebo‐controlled randomised study

Abstract: Background: Spinal cord stimulation (SCS) is an alternative treatment option for refractory angina. Controlled trials demonstrate symptom relief and improvement in functional status. Since patients experience retrosternal prickling during active SCS, there is no option for blinding patients to active treatment or for placebo control. Objective: To examine the therapeutic effects of subthreshold SCS in patients with refractory angina in a placebo-controlled study. Methods: 12 responders to treatment who had already been treated with SCS for refractory angina were enrolled. Patients were randomised into four consecutive treatment arms, each for 4 weeks, with various stimulation timing and output parameters: 3×2 h/day (phase A) and 24 h/day with conventional output (phase B); 3×2 h/day with a subthreshold output (phase C); and 24 h/day with 0.1 V output, which served as control (phase D). Functional status, quality of life, Canadian Cardiovascular Society classification and nitrate usage were assessed at the end of each 4-week period. Results: In phase D, patients showed a significant reduction in walking distance compared with phases A and C. Canadian Cardiovascular Society classification worsened in phase D compared with phases A–C. Frequency of angina attacks and the visual analogue scale were significantly worse in phase D than in phases A–C. In three patients, it was necessary to prematurely terminate phase D owing to intolerable angina attacks. Conclusions: In this first placebo-controlled trial to apply SCS in patients with refractory angina, improvement in functional status and symptoms was revealed in phases with conventional or subthreshold stimulation, in comparison to a low-output (placebo) phase.

Has the publication of cardiac surgery outcome data been associated with changes in practice in northwest England: an analysis of 25 730 patients undergoing CABG surgery under 30 surgeons over eight years

Abstract: Objectives: To study changes in coronary artery surgery practice in the years spanning publication of cardiac surgery mortality data in the UK. Methods: A retrospective analysis of prospectively collected data from all National Health Service centres undertaking adult cardiac surgery in northwest England was carried out. Patients undergoing coronary artery surgery for the first time between April 1997 and March 2005 were included. Changes in observed, predicted and risk adjusted mortality (EuroSCORE) were studied. Evidence of risk-averse behaviour was looked for by examining the number of patients at low risk (EuroSCORE 0–5), high risk (6–10), and very high risk (11 or more), before and after public disclosure. Results: 25 730 patients underwent coronary artery surgery during the study period. The observed mortality decreased from 2.4% in 1997–8 to 1.8% in 2004–5 (p = 0.014). The expected mortality (EuroSCORE) increased from 3.0 to 3.5 (p Conclusions: Publication of cardiac surgery mortality data in the UK has been associated with decreased risk adjusted mortality on retrospective analysis of a large patient database. There is no evidence that fewer high risk patients are undergoing surgery because mortality rates are published.

Gender differences in management and outcome in non-ST-elevation acute coronary syndrome

Abstract: Objective: To study gender differences in management and outcome in patients with non-ST-elevation acute coronary syndrome. Design, setting and patients: Cohort study of 53 781 consecutive patients ...

Trends for coronary heart disease and stroke mortality among migrants in England and Wales, 1979–2003: slow declines notable for some groups

Abstract: Objective: To examine trends in coronary heart disease and stroke mortality in migrants to England and Wales. Design: Cross-sectional. Outcome measures: Age-standardised and sex-specific death rates and rate ratios 1979–83, 1989–93 and 1999–2003. Results: Coronary mortality fell among migrants, more so in the second decade than the first. Rate ratios for coronary mortality remained higher for men and women from Scotland, Northern Ireland, Republic of Ireland and South Asia, and lower for men from Jamaica, other Caribbean countries, West Africa, Italy and Spain. Rate ratios increased for men from Jamaica (1979–83: 0.45, 0.40 to 0.50; 1999–2003: 0.81, 0.73 to 0.90), Pakistan (1979–83: 1.14, 1.04 to 1.25; 1999–2003: 1.93, 1.81 to 2.06), Bangladesh (1979–83: 1.36, 1.15 to 1.60; 1999–2003: 2.11, 1.90 to 2.34), Republic of Ireland (1979–1983: 1.18, 1.15 to 1.21; 1999–2003: 1.45, 1.39 to 1.52) and Poland (1979–83: 1.17, 1.09 to 1.25; 1999–2003: 1.97, 1.57 to 2.47), and for women from Jamaica (1979–83: 0.63, 0.52 to 0.77; 1999–2003: 1.23, 1.06 to 1.42) and Pakistan (1979–83: 1.14, 0.88 to 1.47; 1999–2003: 2.45, 2.19 to 2.74), owing to smaller declines in death rates than those born in England and Wales. Rate ratios for stroke mortality remained higher for migrants. As a result of smaller declines, rate ratios increased for men from Pakistan (1979–1983: 0.99, 0.76 to 1.29; 1999–2003: 1.58, 1.35 to 1.85), Scotland (1979–1983: 1.11, 1.04 to 1.19; 1999–2003: 1.30, 1.19 to 1.42) and Republic of Ireland (1979–1983: 1.27, 1.19 to 1.36; 1999–2003: 1.67, 1.52 to 1.84). Conclusion: For groups with higher mortality than people born in England and Wales, mortality remained higher. Smaller declines led to increasing disparities for some groups and to excess coronary mortality for women from Jamaica. Maximising the coverage of prevention and treatment programmes is critical.

Abnormal papillary muscle morphology is independently associated with increased left ventricular outflow tract obstruction in hypertrophic cardiomyopathy

Abstract: Background: Abnormal papillary muscles (PM) are often found in hypertrophic cardiomyopathy (HCM). Objective: To assess the relationship between morphological alterations of PM in patients with HCM and left ventricular outflow tract (LVOT) obstruction, using magnetic resonance imaging (MRI) and echocardiography. Methods: Fifty-six patients with HCM (mean age 42 years (interquartile range 27, 51), 70% male) and 30 controls (mean age (42 (30, 53) years, 80% male) underwent MRI on a 1.5 T scanner (Siemens, Erlangen, Germany). Standard cine images were obtained in short-axis (base to apex), along with two-, three- and four-chamber views. The presence of bifid PM (none, one or both) and anteroapical displacement of anterolateral PM was recorded by MRI and correlated with resting LVOT gradients obtained by echocardiography. Results: Double bifid PM (70% vs 17%) and anteroapical displacement of anterolateral PM (77% vs 17%) were more prevalent in patients with HCM than in controls (p Conclusions: Patients with HCM with abnormal PM have a higher degree of resting LVOT gradient, which is independent of septal thickness.

Syncope and QT prolongation among patients treated with methadone for heroin dependence in the city of Copenhagen

Abstract: Background: Methadone is prescribed to heroin addicts to decrease illicit opioid use. Prolongation of the QT interval in the ECG of patients with torsade de pointes (TdP) has been reported in methadone users. As heroin addicts sometimes faint while using illicit drugs, doctors might attribute too many episodes of syncope to illicit drug use and thereby underestimate the incidence of TdP in this special population, and the high mortality in this population may, in part, be caused by the proarrhythmic effect of methadone. Methods: In this cross-sectional study interview, ECGs and blood samples were collected in a population of adult heroin addicts treated with methadone or buprenorphine on a daily basis. Of the patients at the Drug Addiction Service in the municipal of Copenhagen, 450 (∼52%) were included. The QT interval was estimated from 12 lead ECGs. All participants were interviewed about any experience of syncope. The association between opioid dose and QT, and methadone dose and reporting of syncope was assessed using multivariate linear regression and logistic regression, respectively. Results: Methadone dose was associated with longer QT interval of 0.140 ms/mg (p = 0.002). No association between buprenorphine and QTc was found. Among the subjects treated with methadone, 28% men and 32% women had prolonged QTc interval. None of the subjects treated with buprenorphine had QTc interval >0.440s ½ . A 50 mg higher methadone dose was associated with a 1.2 (95% CI 1.1 to 1.4) times higher odds for syncope. Conclusions: Methadone is associated with QT prolongation and higher reporting of syncope in a population of heroin addicts.

Effects of metoprolol and carvedilol on pre-existing and new onset diabetes in patients with chronic heart failure: data from the Carvedilol Or Metoprolol European Trial (COMET)

Abstract: Background: β Blocker treatment may worsen glucose metabolism. Objective: To study the development of new onset diabetes in a large cohort of patients with heart failure treated with either metoprolol or carvedilol. Design: Prospective and retrospective analysis of a controlled clinical trial. Setting: Multinational multicentre study. Patients: 3029 patients with chronic heart failure. Interventions: Randomly assigned treatment with carvedilol (n = 1511, target dose 50 mg daily) or metoprolol tartrate (n = 1518, target dose 100 mg daily). Results: Diabetic events (diabetic coma, peripheral gangrene, diabetic foot, decreased glucose tolerance or hyperglycaemia) and new onset diabetes (clinical diagnosis, repeated high random glucose level or glucose lowering drugs) were assessed in 2298 patients without diabetes at baseline. Diabetic events occurred in 122/1151 (10.6%) patients in the carvedilol group and 149/1147 (13.0%) patients in the metoprolol group (hazard ratio (HR) = 0.78; 95% confidence interval (CI) 0.61 to 0.99; p = 0.039). New onset diabetes was diagnosed in 119/1151 (10.3%) v 145/1147 (12.6%) cases in the carvedilol and metoprolol treatment groups (HR = 0.78, CI 0.61 to 0.997; p = 0.048), respectively. Patients with diabetes at baseline had an increased mortality compared with non-diabetic subjects (45.3% v 33.9%; HR = 1.45, CI 1.28 to 1.65). Both diabetic and non-diabetic subjects at baseline had a similar reduction in mortality with carvedilol compared with metoprolol (RR = 0.85; CI 0.69 to 1.06 and RR = 0.82; CI 0.71 to 0.94, respectively). Conclusion: A high prevalence and incidence of diabetes is found in patients with heart failure over a course of 5 years. New onset diabetes is more likely to occur during treatment with metoprolol than during treatment with carvedilol.

Added value of a physician-and-nurse-directed heart failure clinic : results from the Deventer-Alkmaar heart failure study

Abstract: Aim: To determine whether an intensive intervention at a heart failure (HF) clinic by a combination of a clinician and a cardiovascular nurse, both trained in HF, reduces the incidence of hospitalisation for worsening HF and/or all-cause mortality (primary end point) and improves functional status (including left ventricular ejection fraction, New York Heart Association (NYHA) class and quality of life) in patients with NYHA class III or IV. Setting: Two regional teaching hospitals in The Netherlands. Methods: 240 patients were randomly allocated to the 1-year intervention (n = 118) or usual care (n = 122). The intervention consisted of 9 scheduled patient contacts—at day 3 by telephone, and at weeks 1, 3, 5, 7 and at months 3, 6, 9 and 12 by a visit—to a combined, intensive physician-and-nurse-directed HF outpatient clinic, starting within a week after hospital discharge from the hospital or referral from the outpatient clinic. Verbal and written comprehensive education, optimisation of treatment, easy access to the clinic, recommendations for exercise and rest, and advice for symptom monitoring and self-care were provided. Usual care included outpatient visits initialised by individual cardiologists in the cardiology departments involved and applying the guidelines of the European Society of Cardiology. Results: During the 12-month study period, the number of admissions for worsening HF and/or all-cause deaths in the intervention group was lower than in the control group (23 vs 47; relative risk (RR) 0.49; 95% confidence interval (CI) 0.30 to 0.81; p = 0.001). There was an improvement in left ventricular ejection fraction (LVEF) in the intervention group (plus 2.6%) compared with the usual care group (minus 3.1%; p = 0.004). Patients in the intervention group were hospitalised for a total of 359 days compared with 644 days for those in the usual care group. Beneficial effects were also observed on NYHA classification, prescription of spironolactone, maximally reached dose of β-blockers, quality of life, self-care behaviour and healthcare costs. Conclusion: A heart failure clinic involving an intensive intervention by both a clinician and a cardiovascular nurse substantially reduces hospitalisations for worsening HF and/or all-cause mortality and improves functional status, while decreasing healthcare costs, even in a country with a primary-care-based healthcare system.