Therapeutic inertia in rhythm control strategies in hospitalized patients with fibrillation: Insights from Hellenic Cardiorenal Morbidity Snapshot (HECMOS) study.

BACKGROUND: Current guidelines recommend a rhythm control strategy in patients with symptomatic atrial fibrillation (AF) while catheter ablation has been shown to be a safer and more efficacious approach than antiarrhythmic medications. METHODS: HECMOS was a nationwide snapshot survey of cardiorenal morbidity in hospitalized cardiology patients. In this sub-study, we included 276 cases who had a history of AF, particularly on the rhythm strategy, and catheter ablation procedures had been performed before the index admission. RESULTS: Among 276 AF patients (mean age: 76.4 ±â€¯11.5 years, 58 % male), 60.9 % (N = 168) had persistent AF and 39.1 % (N = 108) had paroxysmal AF. Heart failure was the main cause of admission in 54.3 % (N = 145) of the patients, while 14.1 % (N = 39) were admitted due to paroxysmal AF, 7.3 % (N = 20) due to bradyarrhythmic reasons, and 6.5 % (N = 18) suffered from acute coronary syndrome. Most importantly, heart failure with reduced ejection fraction was present in 76 (27 %) patients. Only 10 patients out of the total (3 %, mean age 59.7 years) had undergone AF ablation while electrical cardioversion had been attempted in 37 (13.4 %) patients. Interestingly, in this AF population with heart failure, 3.6 % (N = 10) had a defibrillator implanted (4 single-chamber), and only 1.5 % (N = 4) had a cardiac resynchronization therapy defibrillator (CRT-D). CONCLUSION: High prevalence of persistent AF was detected in hospitalized patients, with heart failure being the leading cause of admission and main co-morbidity. Rhythm control strategies are notably underused, along with CRT-D implantation in patients with AF and heart failure.

Serum Uric Acid is Independently Associated with Diastolic Dysfunction in Apparently Healthy Subjects with Essential Hypertension.

OBJECTIVES: Accumulating evidence suggests a direct role of Uric Acid (UA) on Left Ventricular (LV) diastolic function in chronic kidney disease and Heart Failure (HF) patients. Recently, UA has been linked to LV Hypertrophy (LVH) and Diastolic Dysfunction (DD) in women with preserved Ejection Fraction (pEF) but not in corresponding men. We sought to assess if UA could predict indices of DD in hypertensive subjects with pEF independently of gender. METHOD: We consecutively recruited 382 apparently healthy hypertensive subjects (age: 61.7±10.7, women: 61.3%, median EF: 64%). In 318 patients in sinus rhythm, LV mass-indexed to body surface area-was calculated (LVMI). LVH was set as an LVMI >116g/m2 or 96 g/m2 in men and women, respectively. The ratio of early transmitral peak velocity (E) to the mitral annular early diastolic velocity (Em) was used as an approximation of mean left atrial pressure (E/Em). RESULTS: UA [median (interquartile range): 5.4(2) mg/dl] independently predicted E/Em (adjusted coefficient: 1.01, p =0.026) while an interaction term between gender and UA was no significant (p=0.684). An ordinal score of DD was calculated taking into account increased E/Em, left atrium dilatation and LVH. Women with increased UA had 254% increased odds (adjusted OR=2.54, p=0.005) to be classified in the upper range of the DD score. CONCLUSION: In hypertensive subjects without HF, UA is independently associated with the presence of DD in both genders and correlates with its severity in women. Further prospective studies are warranted to evaluate the association of UA with adverse cardiovascular outcomes in high-risk populations such as HF with pEF.

Lack of correlation between coronary flow reserve and vascular remodelling in hypertensive patients without left ventricular hypertrophy: an optical coherence tomography study.

INTRODUCTION: This study aimed to evaluate the relationships between coronary flow reserve (CFR), coronary intima thickness (IT), and intima-media thickness (IMT) in hypertensive patients. METHODS: Thirteen consecutive, never-treated hypertensives (mean age 59.7 years, 6 men), without left ventricular hypertrophy and with angiographically normal coronary arteries, underwent CFR measurement in the left anterior descending artery in response to a bolus intracoronary administration of adenosine, together with an optical coherence tomography (OCT) study for the estimation of IT and IMT. RESULTS: Hypertensive patients with a low CFR (2.5, n=5) compared to those with a normal CFR (>2.5, n=8) exhibited significantly greater aortic pulse pressure (79.2 vs. 59.4 mmHg, p=0.01), while there was no difference with respect to age, sex, or left ventricular mass index (p=NS). Moreover, no difference was found between patients with low and normal CFR as regards maximal IT and IMT, or mean IT and IMT (p=NS for all). In the entire population, CFR exhibited no relationship with IT and IMT (p=NS). Finally, hypertensives with a low CFR compared to those with a normal CFR exhibited a trend towards a smaller left anterior descending area (7.8 vs. 9.5 mm(2), p=0.24). CONCLUSIONS: In hypertensive patients without left ventricular hypertrophy, adverse functional microcirculatory changes assessed by CFR are not accompanied by OCT-estimated alterations in coronary IT and IMT.

In-hospital worsening renal function is an independent predictor of one-year mortality in patients with acute myocardial infarction.

BACKGROUND: We investigated the incidence, clinical predictors and prognostic value of worsening renal function (WRF) regarding 1-year mortality in patients with acute myocardial infarction (AMI). METHODS: We collected in-hospital data from 447 patients hospitalized for AMI in our institute within 12h of symptoms' onset. WRF was defined as a 25% or more decrease in estimated glomerural filtration rate during hospital stay. From blood samples obtained on admission and throughout hospitalization hemoglobin, white blood cell count, C-reactive protein, B-type natriuretic peptide, plasma glucose, troponin I and baseline and peak creatinine levels were measured. Ejection fraction was calculated on admission with 2D echocardiography. All patients underwent coronary arteriography and the revascularization status (complete or not) was also recorded. The end point was all-cause mortality after one-year of follow-up. RESULTS: WRF was detected in 63 pts (16.7%) and age, ejection fraction and white blood cell count emerged as the only independent predictors. The incidence of 1-year mortality was 10.7% (48 deaths). Patients with WRF exhibited higher 1-year mortality (37.5% vs. 6.3%, log rank p<0.001) and were characterized by more severe and less completely treated coronary artery disease, greater degree of myocardial necrosis and marked neurohormonal activation. By applying multivariate Cox regression analysis WRF, B-type natriuretic peptide, ejection fraction and admission diastolic blood pressure were identified as the only independent predictors of death. CONCLUSIONS: WRF is associated with adverse 1-year outcome in patients with AMI. Close monitoring of renal function in the acute phase of MI may substantially contribute to long-term risk stratification.

Distinct role of electrocardiographic criteria in echocardiographic diagnosis of left ventricular hypertrophy according to age, in the general population: the Ikaria Study.

OBJECTIVE: The age-dependent performance of electrocardiographic (ECG) criteria was examined for left ventricular hypertrophy (LVH) prediction. METHODS: During 2009, 570 middle-aged (54  ±â€Š7 years, 45% men) and 507 elderly (75 ±â€Š6 years, 45% men) inhabitants of the Ikaria Island were studied. Seven ECG criteria were calculated (Sokolow-Lyon voltage and product, sex-specific Cornell voltage and product, Gubner-Ungerleider voltage, Lewis voltage and Framingham), whereas LVH was defined as left ventricular mass indexed for body surface area (BSA) at least 125 g/m in men and at least 110 g/m in women or left ventricular mass indexed for height 49 g/m or more in men and 45 g/m or more in women. RESULTS: The Framingham criteria had in hierarchical order the highest, although insignificant, sensitivity among the elderly individuals, either when LVH was indexed for BSA or for height (18.4 and 16.7%, respectively). Cornell voltage and product criteria had hierarchically the highest sensitivity among middle-aged participants, either when LVH was indexed for BSA (19.0 and 23.8%, respectively) or for height (17.2 and 20.3%, respectively). In the multiadjusted analysis applied in elderly participants, Cornell voltage, its product and Framingham criteria were associated with echocardiographic detection of LVH (indexed for BSA); however, when LVH was indexed for height, the Sokolow-Lyon and Framingham criteria were associated with LVH detection. In contrast, among middle-aged individuals, the Cornell product was the only ECG criterion that was associated with LVH detection (irrespective of indexation). CONCLUSION: Age should be taken into consideration in selection of appropriate ECG criteria for LVH detection. Indexation of left ventricular mass differentiates the diagnostic ability of ECG criteria, especially in older patients.