Effect of Hemodialysis on 7-Year Clinical Outcomes After Sirolimus-Eluting Stent Implantation.

BACKGROUND: Hemodialysis (HD) patients are reported to show poor clinical outcomes after percutaneous coronary intervention (PCI) with sirolimus-eluting stent (SES) compared with non-HD patients and their long-term prognosis remains unclear. METHODS AND RESULTS: We prospectively enrolled 489 consecutive patients undergoing PCI with SES and performed a retrospective analysis focusing on HD patients. Median follow-up was 7.0 years (interquartile range, 4.2-7.9) and the follow-up rate was 100%. At the 7-year follow-up, the cumulative incidences of all-cause death, target lesion revascularization (TLR) and major adverse cardiac events (MACE) were significantly higher in HD patients than in non-HD patients (HD vs. non-HD=34.7% vs. 9.6%, 42.6% vs. 10.2% and 75.3% vs. 24.4%, respectively; log-rank P<0.001). Cox-proportional hazard analysis revealed that independent predictors of all-cause death were HD (hazard ratio [HR] 2.88, 95% confidence interval [CI]: 1.39-6.00), insulin-treated diabetes mellitus (HR 2.19, 95% CI: 1.17-4.11), heart failure (HR 2.58, 95% CI: 1.25-5.32) and older age (HR 1.06/1-age, 95% CI: 1.02-1.10). Moreover, HD was an independent predictor of TLR (HR 3.63, 95% CI: 1.85-7.11) and MACE (HR 3.54, 95% CI: 2.19-5.73). CONCLUSIONS: In the present study, Japanese HD patients undergoing PCI with SES showed poorer long-term clinical outcomes than non-HD patients. HD was a strong predictor of long-term adverse events after SES implantation.

Blood Urea Nitrogen/Creatinine Ratio and Response to Tolvaptan in Patients with Decompensated Heart Failure: A Retrospective Analysis.

INTRODUCTION: Arginine vasopressin-stimulated reabsorption of urea occurs in the collecting duct via increased expression of the urea transporter. OBJECTIVE: The aim of this study was to evaluate whether the blood urea nitrogen/creatinine (BUN/Cr) ratio is useful for predicting tolvaptan response in patients with decompensated heart failure (HF). METHODS: Among 71 consecutive patients with HF who received oral tolvaptan between 2010 and 2014, we retrospectively studied 33 patients with decompensated HF without any mechanical circulatory assistance or inotropic support who had already been treated with loop diuretics. A responder to tolvaptan was defined as an individual who experienced a ≥30 % increase in their respective 24-h urine volume. RESULTS: Among the 33 patients, 21 met the criteria of a responder. The area under the receiver operating characteristic curves of BUN/Cr and BUN were 0.790 and 0.714, respectively, and the respective cut-off values for responders to tolvaptan were 23.8 and 49.0. BUN/Cr and BUN retained their significant relationships with the responder status (odds ratio for BUN/Cr >23.8: 20.9; 95 % confidence interval [CI] 2.7-531.1; p = 0.002; odds ratio for BUN ≥49: 7.7; 95 % CI 1.4-65.8; p = 0.02). CONCLUSION: Our results suggest that high BUN/Cr may be a predictor of response to tolvaptan in decompensated HF patients. A prospective study with a large sample size is required to confirm this preliminary finding.

Thyroid function on admission and outcome in patients hospitalized for acute decompensated heart failure.

BACKGROUND: Although thyroid dysfunction is a known prognostic factor for cardiovascular disease, the relationship between thyroid function and prognosis in patients with acute decompensated heart failure (ADHF) is poorly understood. Herein, we investigated the association between thyroid hormone levels and outcome in patients hospitalized for ADHF. METHODS: We evaluated 270 hospitalized ADHF patients with thyroid hormone levels measured at admission between April 2007 and May 2012. RESULTS: The median (interquartile range) thyroid stimulating hormone, free triiodothyronine (fT3), and free thyroxine were 2.79 (1.49-4.96)µU/ml, 2.32 (1.93-2.75)pg/ml, and 14.0 (12.1-15.7)pg/dl, respectively. Receiver operating characteristic (ROC) curve analysis was applied to assess their prognostic value for in-hospital outcome. The fT3 had the most favorable performance, with an area under the ROC curve of 0.791 (optimal cutoff point ≤2.05; sensitivity 85.0%; specificity 72.0%). Although patients in the low fT3 group (≤2.05) had higher age and lower body mass index, there were no significant differences with respect to systolic blood pressure and heart rate between the groups. In multivariate analysis adjusted for various markers of disease severity and amiodarone use, low fT3 level was independently associated with higher in-hospital mortality (odds ratio 14.4; p<0.001). In addition, the probability of 1-year total death among patients with low fT3 was significantly higher than that among patients with normal fT3 (log-rank p<0.001). CONCLUSIONS: Low fT3 level was associated with adverse outcomes in patients hospitalized for ADHF. Thyroid hormone measurements might be useful in the risk stratification of ADHF patients.

Clinical implications of midventricular obstruction in patients with hypertrophic cardiomyopathy.

OBJECTIVES: We investigated the prevalence, clinical characteristics, and prognosis of hypertrophic cardiomyopathy (HCM) patients with midventricular obstruction (MVO). BACKGROUND: Previous descriptions of patients with MVO have been confined to case reports or small patient series, and this subgroup of HCM patients has therefore remained underrecognized. METHODS: The study population included 490 HCM patients. Left ventricular MVO was diagnosed when the peak midcavitary gradient was estimated to be ≥30 mm Hg. RESULTS: MVO was identified in 46 patients (9.4%). Patients with MVO were more likely to be symptomatic than those without. MVO was found to be an independent determinant of HCM-related death in multivariate models (hazard ratio [HR]: 2.23, p = 0.016), and this trend was especially pronounced for the combined endpoint of sudden death and potentially lethal arrhythmic events (HR: 3.19, p < 0.001). Apical aneurysm formation was identified in 28.3% of patients with MVO and strongly predicted HCM-related death (HR: 3.47, p = 0.008) and the combined endpoint of sudden death and potentially lethal arrhythmic events (HR: 5.08, p < 0.001). In addition, MVO without apical aneurysm was also identified as an independent determinant of the combined endpoint of sudden death and potentially lethal arrhythmic events (HR: 2.43, p = 0.045). CONCLUSIONS: This analysis identified MVO as an independent predictor of adverse outcomes, especially the combined endpoint of sudden death and potentially lethal arrhythmic events. Our results suggest that longer periods of exposure to MVO might lead to unfavorable consequences. They also support the principle that the presence of MVO in patients with HCM has important pathophysiological implications.

Long-term prognostic stratification by a combination of (123)I-metaiodobenzylguanidine scintigraphy and ejection fraction in dilated cardiomyopathy.

OBJECTIVE: (123)I-metaiodobenzylguanidine (MIBG) scintigraphy is a useful tool for predicting the prognosis in patients with congestive heart failure; however, little is known regarding long-term prognostic evaluations. The aim of this study was to evaluate long-term prognosis in a roughly 10-year period, in dilated cardiomyopathy (DCM) by MIBG imaging, compared to other conventional functional parameters. METHODS: Eighty-six DCM patients (50 ± 14 years of age, 57 males) underwent MIBG imaging, at 15 min and 4 h after tracer injection, from which the delayed heart to mediastinum ratio (H/M) and washout rate (WR) were obtained. The left ventricular ejection fraction (EF) and end-diastolic diameter (LVDd) were also measured by echocardiogram. All patients were followed up for 8-14 years, and the death event was investigated. RESULTS: Kaplan-Meier curves revealed a poor prognosis only in the group above the third quartile of WR (=50%) (10-year prognosis, 35%); however, there were no statistically significant differences in prognosis among the other 3 groups (10-year prognosis, 75-84%). A Cox hazard univariate analysis selected WR (p = 0.0004), H/M (p < 0.0001), EF (p = 0.0024), and LVDd (p = 0.0189) as significant prognostic indicators. Multivariate analysis revealed the H/M (p = 0.0023) and EF (p = 0.024) to be an independent prognostic predictor. The 10-year prognosis of patients with both WR < 50% and EF > 30%; WR < 50% and EF < 30%; and both WR > 50% and EF < 30% were 89, 71, and 33%, respectively. These three groups were well stratified, significantly (log-rank test: χ (2) = 30.0, p < 0.0001). However, even patients with WR ≥ 50% had few death events after 3 years following MIBG imaging. CONCLUSIONS: The MIBG parameter, delayed H/M or WR combined with the EF is a useful tool for the prediction of a long-term prognosis in DCM, which is superior to MIBG parameters alone. However, patients with WR > 50% but no event in a 3-year follow-up period should undergo an additional MIBG imaging for prognostic prediction.