RESUMO
PURPOSE: Heart failure (HF) is a major public health issue. This study conducted a real-life analysis of the impact of clinical characteristics and medical management of HF on its prognosis. METHODS: Analysis was based on the EGB ("Echantillon Généraliste des Bénéficiaires") database. A cohort comprising 1825 adult patients with a first admission for HF between 2009 and 2011 was created and followed until June 2013 (median 22.3 [7.7-34.5] months) for survival analysis. RESULTS: Mean age was 77.3 ± 13.2 years (53 % ≥80 years). The overall incidence of HF admission was 117 [112-122] per 100,000 population with a marked increase in patients >80 years (1297 [1217-1348]). At discharge, only 8 % of patients received recommended combination of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta-blockers (BB) and mineralocorticoid receptor antagonists (MRA). Only prescription levels of BB and vitamin K antagonists, at discharge, increased during the study period. In-hospital mortality was 9 % and survival was 71.6 %[69.5-73.6] and 52.0 %[49.4-54.6] at 12 and 36 months, respectively. In multivariate analysis, female gender [HR:0.78 (0.67-0.91), p = 0.001], ACEi/ARB + BB + MRA [0.41 (0.28-0.60), p < 0.001] and ACEi/ARB + BB [0.47 (0.39-0.57) p < 0.001] treatments were associated with improved survival, conversely to age 70-79 [1.90 (1.20-3.00), p = 0.003] and ≥80 [3.50 (2.30-5.40), p < 0.001], cardiogenic shock [3.00 (2.10-4.40), p < 0.001], acute pulmonary edema [1.70 (1.10-2.50), p = 0.01], denutrition [1.80 (1.45-2.24), p < 0.001], dilated cardiomyopathy [1.20 (1.00-1.40), p = 0.02] and in-hospital acute renal failure [1.36 (1.05-1.78), p = 0.002]. CONCLUSIONS: These real-life HF data provide insight into prognostic factors and "real-world" pharmacological management in this unselected HF population, confirming the benefit of ACEi/ARB + BB ± MRAs on patient survival.
Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Antagonistas Adrenérgicos beta/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Bloqueadores do Receptor Tipo 1 de Angiotensina II/uso terapêutico , Inibidores da Enzima Conversora de Angiotensina/uso terapêutico , Estudos de Coortes , Feminino , França/epidemiologia , Insuficiência Cardíaca/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Antagonistas de Receptores de Mineralocorticoides/uso terapêutico , PrognósticoRESUMO
PURPOSE: The aim of the study was to assess the impact of clinical characteristics and management on the mid- to long-term follow-up prognosis of unselected over-80-year-old patients hospitalized for a first heart failure (HF) episode in a real-life setting. Despite the increasing proportion of HF patients over 80 years of age, the latter remain a poorly studied population. METHODS: Analysis was based on the EGB ("Echantillon Généraliste des Bénéficiaires") database. A cohort comprising 1825 adult patients with a first admission for HF between 2009 and 2011 was created and followed until June 2013 for survival analysis. RESULTS: Over-80-year-old patients represented 53 % of this cohort, with a median follow-up of 18.6 (3.3-29.5) months. Only 5 % of patients over 80 years received an optimal treatment at discharge [combination of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), beta-blockers (BB), and mineralocorticoid receptor antagonists (MRA)]. During the follow-up period, only BB prescription levels (p = 0.02) increased. In over-80-year-olds, in-hospital mortality was 12 % (range, 10-14) and survival was 62.8 % (59.6-65.7) and 48.7 % (45.4-51.9) at 12 and 24 months, respectively. On multivariate analysis, dyslipidemia [0.74 (0.58-0.94), p = 0.02], vitamin K antagonists [0.55 (0.44-0.69), p < 0.001], ACEi/ARB + BB + MRA [0.56 (0.32-0.96), p = 0.04], and ACEi/ARB + BB [0.57 (0.45-0.72), p < 0.001] were associated with improved survival, conversely to cardiogenic shock [3.37 (1.90-5.98), p < 0.001], denutrition [1.61 (1.24-2.09), p < 0.001], and age over 90 [1.35 (1.09-1.67), p = 0.01]. CONCLUSIONS: These real-life HF data provide insight into prognostic factors and demonstrate that over-80-year-old HF patients displaying several comorbidities are poorly managed, despite the confirmed clinical benefit of HF drugs.
Assuntos
Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Feminino , França/epidemiologia , Hospitalização/estatística & dados numéricos , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND & AIMS: There is an increase in the number of patients worldwide with cardiac implantable electronic devices (CIEDs). Current medical practice guidelines warn against performing bioimpedance analysis (BIA) in this group of patients in order to avoid any electromagnetic interference. These recommendations restrict using the BIA in patients undergoing heart failure or with nutrition disorders in whom BIA could be of major interest in detecting peripheral congestion and to help guide treatment. The present study was conducted to evaluate whether BIA caused electromagnetic interference in patients having CIEDs. METHODS: Patient enrollment was conducted during routine face-to-face consultations for scheduled CIEDs interrogations. Device battery voltage, lead impedance, pacing thresholds and device electrograms were recorded before and after each BIA measurement to detect any electromagnetic interference or oversensing. RESULTS: A total of 200 patients were enrolled. During BIA, no significant changes in battery voltage, lead impedance or pacing thresholds were detected, nor were there any inappropriate over- or undersensing observed in intracardiac electrograms. Furthermore, 6- and 12-month follow-up did not reveal any changes in CIEDs. CONCLUSIONS: This study shows no interference in patients equipped with CIEDs and suggests that BIA can be securely performed in these patients. Trial registered under the identifier NCT03045822.
Assuntos
Desfibriladores Implantáveis/efeitos adversos , Impedância Elétrica , Marca-Passo Artificial/efeitos adversos , Idoso , Idoso de 80 Anos ou mais , Composição Corporal/fisiologia , Impedância Elétrica/efeitos adversos , Impedância Elétrica/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Segurança do Paciente , Estudos ProspectivosRESUMO
BACKGROUND: Transcatheter aortic valve implantation (TAVI) has revolutionized the management of severe aortic stenosis. The development of a new-onset complete left bundle branch block (LBBB) is, however, a frequent complication. The objective of the present study was to assess the impact of a new-onset LBBB after TAVI on the evolution of left ventricular ejection fraction (LVEF). METHODS: Forty consecutive patients were included after the development of a new-onset LBBB after TAVI and were matched for age and LVEF with 40 patients implanted during the same period who did not develop an LBBB. The primary endpoint was evolution of the LVEF measured by echocardiography before implantation and between 6 and 12 months after TAVI. RESULTS: The development of an LBBB was associated with a 5-point decrease in LVEF [-12.5; 2.5], contrary to the non-LBBB group (1.5 [-6.5; 9.5], P = 0.007) at 8 months, with the persistence of the LBBB (n = 23) exacerbating this decrease (-7 [-13; 2], P = 0.009). When left ventricular dysfunction (LVEF < 50%) was present before TAVI, the appearance of an LBBB was associated with a reduction in LVEF (-2 [-8; 2]) contrary to the non-LBBB group (20 [9; 22], P = 0.02). CONCLUSIONS: The appearance of a new-onset LBBB after TAVI has a pejorative impact on left ventricular systolic function, particularly in patients with an initial LVEF < 50%, due to a lack of recovery of the latter, thereby potentially affecting their prognosis.
Assuntos
Estenose da Valva Aórtica/cirurgia , Bloqueio de Ramo/fisiopatologia , Complicações Pós-Operatórias/fisiopatologia , Sístole , Substituição da Valva Aórtica Transcateter , Função Ventricular Esquerda , Idoso , Idoso de 80 Anos ou mais , Feminino , Seguimentos , Humanos , Masculino , Estudos ProspectivosRESUMO
Cardiac fibrosis is associated with heart failure and poor prognosis. Fibrosis biomarkers have been poorly evaluated as a tool to predict cardiac resynchronization therapy (CRT) response generating conflicting results. The present study assessed the predictive value of cardiac fibrosis biomarkers on CRT response. Patients underwent clinical examination, echocardiography and blood fibrosis biomarker evaluation prior to CRT implantation. At six months, a positive response to CRT was defined by a composite endpoint of no death or hospitalization for heart failure, and presence of left ventricular (LV) reverse remodeling (decrease in LV end-systolic volume ≥15%). Sixty patients were included in a multicenter study. At 6 months, 38 were positive responders to CRT and reached the response criteria (63%). Compared to non-responders, CRT responders displayed lower concentration levels of the fibrosis biomarkers procollagen type I C-terminal propeptide [PICP 135[99-166] ng/ml vs. 179[142-226]ng/ml, p = 0.001)] and procollagen type III N-terminal propeptide [PIIINP 5.50[3.66-8.96] ng/ml vs. 8.01[5.01-11.86]ng/ml, p = 0.014)] at baseline. In multivariate analysis, a PICP ≤ 163 ng/ml was associated with a positive CRT response [OR = 7.8(1.3-46.7), p = 0.023] independently of the presence of LBBB, QRS duration, LV lead position or non-ischemic cardiomyopathy. Altogether, the present findings show that a lower degree of cardiac fibrosis is associated with a positive response after CRT implantation. PICP evaluation before CRT implantation could help improve patient selection.
Assuntos
Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca/terapia , Fragmentos de Peptídeos/sangue , Pró-Colágeno/sangue , Idoso , Biomarcadores/sangue , Feminino , Fibrose , Insuficiência Cardíaca/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Remodelação VentricularRESUMO
AIMS: Spontaneous coronary artery dissection (SCAD) is an underdiagnosed entity of acute coronary syndrome (ACS). Its prevalence remains unclear due to a challenging diagnosis, particularly in instances of intramural haematoma without intimal rupture. In the present study, we aimed to: 1) estimate the prevalence of SCAD among acute coronary syndrome (ACS) patients managed in a French coronary care centre, 2) demonstrate the value of specific angiographic signs for diagnosing SCAD, and 3) confirm the incremental value of intracoronary imaging in ambiguous cases. METHODS AND RESULTS: From 1999 to 2014, 55 cases of SCAD (all women, mean age 50.1 years) were diagnosed. Ignoring age, 51 (92.7%) had ≤2 cardiovascular risk factors. Thirty-six were diagnosed prospectively during the latter period (2012-2014). Among these, SCAD accounted for 35.7% of ACS (20/56) in women <60 years with ≤1 cardiovascular risk factor. Upon close investigation, five angiographic features commonly observed with SCAD were identified: 1) absence of atheroma on other coronary arteries, 2) radiolucent flap(s), 3) contrast dye staining of the arterial wall, 4) starting and/or ending of the angiographic ambiguity on a side branch, 5) long narrowing of lumen calibre: smooth and linear, or stenosis of varying severity mimicking a "stick insect" or "radish" aspect. Three of the above five signs were present in 51 (92.7%) cases. Optical computed tomography (OCT) was performed in 19 cases with no complication. All explored arteries had evidence of intramural haematoma and/or intimomedial membrane separation. An intimal rupture was observed in 10 (52.6%) patients. The diseased segment initiated or ended on a side branch in 14 (73.7%) patients. CONCLUSIONS: SCAD accounts for approximately one third of ACS in young women with ≤1 CRF. The combination of specific angiographic signs and OCT imaging facilitates the diagnosis of ambiguous cases without intimal rupture.
Assuntos
Angiografia Coronária , Anomalias dos Vasos Coronários/epidemiologia , Doenças Vasculares/congênito , Adulto , Doença da Artéria Coronariana/etiologia , Anomalias dos Vasos Coronários/diagnóstico por imagem , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Doenças Vasculares/diagnóstico por imagem , Doenças Vasculares/epidemiologiaRESUMO
Reintroduction of amiodarone in patients with a history of amiodarone-induced thyrotoxicosis (AIT) is rarely used. To date, the risk of AIT recurrence after amiodarone reintroduction is unpredicted. The aim of the study was to evaluate the risk of AIT recurrence. Retrospectively, from 2000 to 2011, all euthyroid patients with a history of AIT with amiodarone reintroduction were included. Type and severity of the first AIT, amiodarone chronology, and thyroid function evolution after reintroduction of amiodarone were investigated: 46 of 172 patients with AIT history needed amiodarone reintroduction. At first AIT episode, the mean age was 62.2 ± 16 years with male gender predominance; 65% of patients were classified as type 1 AIT. AIT recurred in 14 patients (30%), 12 patients developed hypothyroidism (26%), and 20 patients remained euthyroid (44%). Characteristics of type 1 AIT during the first episode, namely briefer exposure period to amiodarone and longer duration of treatment to normalize thyroid hormones, were predictive of AIT recurrence; 73% of patients (8 of 11) with previous episode of type 1 AIT, who did not receive a preventive thioamide treatment, developed a second episode of AIT. Thioamide preventive treatment could be useful to prevent type 1 AIT recurrence. In conclusion, AIT recurrence after amiodarone reintroduction is 4 times more frequent in patients with type 1 AIT history. Thyroid ablation before amiodarone reintroduction in patients with a history of type 1 AIT is preferred. Preventive thioamide treatment could be suggested in patients with type 1 AIT history pending for surgery.
Assuntos
Amiodarona/efeitos adversos , Antiarrítmicos/efeitos adversos , Arritmias Cardíacas/tratamento farmacológico , Tireotoxicose/induzido quimicamente , Adulto , Idoso , Amiodarona/administração & dosagem , Antiarrítmicos/administração & dosagem , Arritmias Cardíacas/complicações , Arritmias Cardíacas/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Recidiva , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Tireotoxicose/diagnóstico , Tireotoxicose/epidemiologiaRESUMO
BACKGROUND: The prevalence and incidence of heart failure (HF) in elderly patients are increasing worldwide. Management of HF with reduced ejection fraction (HF-REF) in patients aged 80 years or more follows international guidelines, despite the lack of a dedicated study in this frail population. AIMS: To determine whether optimized management of HF-REF in patients aged 80 years or more can improve quality of life at 6 months. METHODS: Patients aged 80 years or more hospitalized for acute HF-REF were randomized prospectively into an optimized group or a control group (usual care). All patients benefitted from the same in-hospital management. Optimized group patients were also managed at 3, 6 and 9 weeks, and 3, 6, 9 and 12 months after initial hospitalization, to optimize HF-REF treatment. The primary endpoint was quality of life at 6 months. RESULTS: The trial was stopped prematurely, according to prespecified rules and an independent data monitoring board, after 34 patients were included (n=17 in each group). There was no difference in quality of life at baseline and at 6 months between the two groups (P=0.14 and 0.64, respectively), although a significant improvement was observed between baseline and 6 months in the optimized group compared with the control group: -20.2±25.2 (P=0.01) versus -9.9±19.0 (P=0.19). Mortality at 12 months was lower in the optimized group (17.7% vs 47.1%; P=0.03). There was no increase in acute renal failure, hyperkalaemia or falls in the optimized group (P=0.49, 1 and 1, respectively). CONCLUSIONS: Optimizing the management of HF-REF in patients aged 80 years or more, according to the modalities of the HF80 study, seems to be both effective and safe.
Assuntos
Gerenciamento Clínico , Insuficiência Cardíaca/terapia , Hospitalização , Qualidade de Vida , Medição de Risco/métodos , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Idoso de 80 Anos ou mais , Causas de Morte/tendências , Feminino , Seguimentos , França/epidemiologia , Insuficiência Cardíaca/epidemiologia , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Morbidade/tendências , Prognóstico , Estudos Prospectivos , Taxa de Sobrevida/tendências , Fatores de TempoRESUMO
New-onset left bundle branch block (LBBB) is a specific concern of transcutaneous aortic valve implantation (TAVI) given its estimated incidence ranging from 5% to 65%. This high rate of occurrence is dependent on the type of device used (size and shape), implantation methods, and patient co-morbidities. The appearance of an LBBB after TAVI reflects a very proximal lesion of the left bundle branch as it exits the bundle of His. At times transient, its persistence can lead to permanent pacemaker implantation in 15% to 20% of cases, most often for high-degree atrioventricular block. The management of LBBB after TAVI is currently not defined by international societies resulting in individual centers developing their own management strategy. The potential consequences of LBBB are dysrhythmias (atrioventricular block, syncope, and sudden death) and functional (heart failure) complications. Prompt postprocedural recognition and management (permanent pacemaker implantation) of patients prevents the occurrence of potential complications and may constitute the preferred approach in this frail and elderly population despite additional costs and complications of cardiac pacing. Moreover, the expansion of future indications for TAVI necessitates better identification of the predictive factors for the development of LBBB. Indeed, long-term right ventricular pacing may potentially increase the risk of developing heart failure in this population. In conclusion, it is thus imperative to not only develop new aortic prostheses with a less-deleterious impact on the conduction system but also to prescribe appropriate pacing modes in this frail population.
Assuntos
Estenose da Valva Aórtica/cirurgia , Bloqueio de Ramo , Complicações Pós-Operatórias , Substituição da Valva Aórtica Transcateter/efeitos adversos , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/epidemiologia , Bloqueio de Ramo/etiologia , Saúde Global , Humanos , IncidênciaRESUMO
BACKGROUND: Multicentre registries of myocardial infarction management show a steady improvement in prognosis and greater access to myocardial revascularization in a more timely manner. While French registries are the standard references, the question arises: are data stemming solely from the activity of French cardiac intensive care units (ICUs) a true reflection of the entire French population with ST-segment elevation myocardial infarction (STEMI)? AIM: To compare data on patients hospitalized for STEMI from two French registries: the French registry of acute ST-elevation or non-ST-elevation myocardial infarction (FAST-MI) and the Échantillon généraliste des bénéficiaires (EGB) database. METHODS: We compared patients treated for STEMI listed in the FAST-MI 2010 registry (n=1716) with those listed in the EGB database, which comprises a sample of 1/97th of the French population, also from 2010 (n=403). RESULTS: Compared with the FAST-MI 2010 registry, the EGB database population were older (67.2±15.3 vs 63.3±14.5 years; P<0.001), had a higher percentage of women (36.0% vs 24.7%; P<0.001), were less likely to undergo emergency coronary angiography (75.2% vs 96.3%; P<0.001) and were less often treated in university hospitals (27.1% vs 37.0%; P=0.001). There were no significant differences between the two registries in terms of cardiovascular risk factors, comorbidities and drug treatment at admission. Thirty-day mortality was higher in the EGB database (10.2% vs 4.4%; P<0.001). CONCLUSIONS: Registries such as FAST-MI are indispensable, not only for assessing epidemiological changes over time, but also for evaluating the prognostic effect of modern STEMI management. Meanwhile, exploitation of data from general databases, such as EGB, provides additional relevant information, as they include a broader population not routinely admitted to cardiac ICUs.
Assuntos
Gerenciamento Clínico , Infarto do Miocárdio/epidemiologia , Vigilância da População , Saúde Pública , Sistema de Registros , Angiografia Coronária , Feminino , Seguimentos , França/epidemiologia , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/terapia , Prognóstico , Estudos Retrospectivos , Fatores de TempoRESUMO
Pheochromocytoma and paraganglioma (PPG) are rare and late-diagnosed catecholamine secreting tumors, which may be associated with unrecognized and/or severe cardiomyopathies. We performed a computer-assisted systematic search of the electronic Medline databases using the MESH terms "myocarditis," "myocardial infarction," "Takotsubo," "stress cardiomyopathy," "cardiogenic shock", or "dilated cardiomyopathy," and "pheochromocytoma" or "paraganglioma" from 1961 to August 2012. All detailed case reports of cardiomyopathy due to a PPG, without coronary stenosis, and revealed by acute symptoms were included and analyzed. A total of 145 cases reports were collected (49 Takotsubo Cardiomyopathies [TTC] and 96 other Catecholamine Cardiomyopathies [CC]). At initial presentation, prevalence of high blood pressure (87.7%), chest pain (49.0%), headaches (47.6%), palpitations (46.9%), sweating (39.3%), and shock (51.0%) were comparable between CC and TTC. Acute pulmonary edema (58.3% vs 38.8%, Pâ=â0.03) was more frequent in CC. There was no difference in proportion of patients with severe left ventricular systolic dysfunction (LV Ejection Fraction [LVEF]â<â30%) at initial presentation between both groups (Pâ=â0.15). LVEF recovery before (64.9% vs 40.8%, Pâ=â0.005) and after surgical resection (97.7% vs 73.3%, Pâ=â0.001) was higher in the TTC group. Death occurred in 11 cases (7.6%). In multivariate analysis, only TTC was associated with a better LV recovery (0.15 [0.03-0.67], Pâ=â0.03). Pheochromocytoma and paraganglioma can lead to different cardiomyopathies with the same brutal and life-threatening initial clinical presentation but with a different recovery rate. Diagnosis of unexplained dilated cardiomyopathy or TTC should lead clinicians to a specific search for PPG.
Assuntos
Neoplasias das Glândulas Suprarrenais/complicações , Cardiomiopatias/diagnóstico , Cardiomiopatias/etiologia , Feocromocitoma/complicações , Doença Aguda , Neoplasias das Glândulas Suprarrenais/patologia , Doença Crônica , Humanos , Feocromocitoma/patologia , PrognósticoRESUMO
BACKGROUND: Preliminary trials of direct coronary stenting have demonstrated the benefits of this approach. It lowers procedural cost, time, and radiation exposure compared with predilatation. Nevertheless, the long-term outcome after direct stenting remains less well known. METHODS: Between January and September 1999, 338 patients were randomly assigned to either direct stent implantation (DS+, n = 173) or standard stent implantation with balloon predilatation (DS-, n = 165). Clinical follow-up was performed. RESULTS: Baseline characteristics were similar in the 2 groups. Procedural success was achieved in 98.3% of patients assigned to DS+ and 97.5% of patients assigned to DS- (not significant). Clinical follow-up was obtained in 99% of patients (mean 16.4 +/- 4.6 months). Major adverse cardiac events--defined as whichever of the following occurred first; cardiac death, myocardial infarction, unstable angina, new revascularization--were observed at a higher rate in the DS+ group than in the DS-, but this difference was not significant (11.3% vs 18.2%, P = not significant). The difference in target lesion revascularization rate in the DS+ group (7%) and DS- group (5.2%) was also not significant. Multivariate analysis showed that direct stenting had no influence on long-term major adverse cardiac events rate. Independent relationships were found between long-term major adverse cardiac events rate and final minimal lumen diameter <2.48 mm (relative risk [RR] 0.449, CI 0.239-0.845, P =.013), prior myocardial infarction (RR 2.028, CI 1.114-3.69, P =.02), and hypertension (RR 1.859, CI 1.022-3.383, P =.042). CONCLUSION: The main finding that emerges from this randomized study is that the influence of direct stenting on long-term need for new target lesion revascularization does not differ from that of stenting with balloon predilatation.
Assuntos
Angioplastia Coronária com Balão , Doença das Coronárias/terapia , Stents , Angina Pectoris/etiologia , Angina Pectoris/terapia , Terapia Combinada , Doença das Coronárias/complicações , Morte Súbita Cardíaca/etiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/etiologia , Estatística como Assunto , Resultado do TratamentoRESUMO
BACKGROUND: Takotsubo cardiomyopathy (TTC) continues to be under-diagnosed, due to its varying presentation, with potentially serious consequences if treatment is delayed. AIMS: To demonstrate the consistent involvement of catecholaminergic stress in TTC, regardless of the trigger. METHODS: Between 01 July 2009 and 31 August 2013, patients managed in our centre for thoracic pain syndrome, with or without troponin release, were followed up prospectively. TTC was diagnosed from the apical ballooning seen on left ventricular imaging (angiography or transthoracic echocardiography) in the absence of a significant coronary artery lesion. Triggers (emotional trauma, surgical stress and ß2-mimetic intoxication) were recorded; catecholamine-secreting tumours were screened for with a urinary methoxylate-derivative assay. RESULTS: TTC was diagnosed in 40 out of 2754 (1.5%) patients with thoracic pain syndrome, with or without troponin release. Triggers were emotional trauma (n=29, 72.5%), surgical stress (n=5, 12.5%), adrenergic intoxication (n=3, 7.5%) and catecholaminergic tumour (n=3, 7.5%). Mean left ventricular ejection fraction at admission was 38.0 ± 15.7%. Eight (20%) patients initially showed cardiogenic shock. In-hospital mortality was 7.5%, with no deaths from cardiogenic causes. Thirty-five (94.6%) of the survivors had recovered a normal left ventricular ejection fraction (> 55%) by discharge. CONCLUSION: Whatever the trigger, the common denominator in TTC is catecholaminergic stress. Classically suggested after emotional trauma, TTC may also be induced by surgical stress or endogenous or iatrogenic ß2-mimetic intoxication. The various contexts all have a similarly excellent cardiovascular prognosis if treated early.
Assuntos
Catecolaminas/urina , Ventrículos do Coração/metabolismo , Cardiomiopatia de Takotsubo/urina , Função Ventricular Esquerda , Neoplasias das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/urina , Adulto , Idoso , Biomarcadores/urina , Catecolaminas/efeitos adversos , Emoções , Feminino , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Feocromocitoma/complicações , Feocromocitoma/urina , Estudos Prospectivos , Fatores de Risco , Estresse Fisiológico , Estresse Psicológico/complicações , Estresse Psicológico/urina , Volume Sistólico , Cardiomiopatia de Takotsubo/diagnóstico , Cardiomiopatia de Takotsubo/etiologia , Cardiomiopatia de Takotsubo/fisiopatologiaRESUMO
UNLABELLED: Vasospastic angina is a frequent and well-recognized pathology with a high risk of life-threatening ventricular arrhythmias and sudden cardiac death. The diagnosis of vasospastic angina requires the combination of clinical and electrocardiographic variables and the results of provocation tests, such as ergonovine administration. Smoking cessation is the first step in the management of vasospastic angina. Optimal medical treatment using calcium-channel blockers and/or nitrate derivatives can provide protection, but life-threatening ventricular arrhythmias may occur despite optimal medical treatment and several years after the start of treatment. In this review, we evaluate the role of implantable defibrillators as a complement to optimal medical management in patients with life-threatening ventricular arrhythmias due to vasospastic angina; this role is not well characterized in the literature or guidelines. We discuss the role of implantable defibrillators in secondary prevention in light of three recent cases managed in our departments and a review of the literature. An implantable defibrillator was implanted in two of the three cases of vasospastic angina with ventricular arrhythmias that we managed. We considered secondary prevention by implantable defibrillator to be justified even in the absence of any obvious risk factor. Ventricular arrhythmias recurred during implantable defibrillator follow-up in the two patients implanted. CONCLUSION: In patients with life-threatening ventricular arrhythmias due to vasospastic angina, an implantable defibrillator should be considered because of the risk of recurrence despite optimal medical management.
Assuntos
Angina Pectoris/terapia , Arritmias Cardíacas/prevenção & controle , Vasoespasmo Coronário/terapia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Angina Pectoris/diagnóstico , Angina Pectoris/mortalidade , Angina Pectoris/fisiopatologia , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/mortalidade , Arritmias Cardíacas/fisiopatologia , Angiografia Coronária , Vasoespasmo Coronário/diagnóstico , Vasoespasmo Coronário/mortalidade , Vasoespasmo Coronário/fisiopatologia , Morte Súbita Cardíaca/etiologia , Eletrocardiografia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Valor Preditivo dos Testes , Desenho de Prótese , Medição de Risco , Fatores de Risco , Fumar/efeitos adversos , Abandono do Hábito de Fumar , Prevenção do Hábito de Fumar , Tomografia de Coerência Óptica , Resultado do TratamentoRESUMO
BACKGROUND: An aging population and better management of various heart diseases explain the exponential growth in incidence and prevalence of chronic heart failure, with poor prognosis and heavy health costs. Medical management is codified in international guidelines. The management of heart failure in over-80 year-old patients follows these guidelines, but no clinical trials have been able to confirm benefit. Moreover, registries show down-prescription of heart failure treatments in the elderly and over-80s. METHODS/DESIGN: We present the design of the HF-80 ("Is there benefit in optimising heart failure treatment in over-80 year-old patients?") study, which is a prospective randomised open-label clinical trial with blinded end-points, designed to evaluate the effect of optimising management by adhering to guidelines in over-80 year-old heart failure patients. Patients over 80 years of age admitted with acute heart failure will be included. The primary endpoint is to assess quality of life at 6 months on the Minnesota questionnaire. The secondary endpoints are to assess the effect of optimised management on quality of life, mortality, readmission for acute heart failure, cardiac fibrosis and economic data at 12 months. 80 patients will be included, divided into 2 groups: group A, with usual heart failure management by general practitioners; and group B, with optimised management based on international guidelines. DISCUSSION: It is necessary to assess the benefit of guidelines in over-80 year-old heart failure patients because of the fragility of this population and the elevated risk of iatrogenic complications. TRIAL REGISTRATION: Clinical trials.gov number: NCT01437371.
Assuntos
Medicina Baseada em Evidências , Fidelidade a Diretrizes , Insuficiência Cardíaca/terapia , Guias de Prática Clínica como Assunto , Padrões de Prática Médica , Projetos de Pesquisa , Fatores Etários , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Medicina Baseada em Evidências/economia , França , Fidelidade a Diretrizes/economia , Custos de Cuidados de Saúde , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/economia , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/psicologia , Humanos , Readmissão do Paciente , Projetos Piloto , Padrões de Prática Médica/economia , Estudos Prospectivos , Qualidade de Vida , Inquéritos e Questionários , Fatores de Tempo , Resultado do TratamentoRESUMO
There is evidence that pulmonary arterial hypertension plays a major role in the occurrence of high altitude pulmonary edema (HAPE). We tested the hypothesis that the pulmonary arterial systolic pressure response to a challenge associated with hypoxia and mild exercise may be considered a predictive factor of HAPE. Pulmonary arterial systolic pressure was measured by Doppler echocardiography in 8 HAPE susceptible (HAPE-S) subjects and 8 HAPE resistant mountaineers (HAPE-R) during a hypoxic exercise challenge established by the French Association for Sport Medicine (Richalet's test). Pulmonary arterial systolic pressure during hypoxic exercise allowed a significant discrimination between the groups, although an overlap of values was observed. When expressed as individual variations from baseline to hypoxic exercise level however, we found a highly significant difference. No overlap was observed between HAPE-R (range: 6.7-18.5 mmHg) and HAPE-S (range: 19.2-30.4 mmHg) groups, with a cut-off value at 19 mmHg. Plasma Vascular Endothelial growth factor (VEGF) and malondialdehyde (MDA) increased in response to hypoxic exercise only in HAPE-S group. Individual increases in pulmonary arterial systolic pressure during hypoxic exercise from basal resting normoxic values seem relevant to estimate HAPE susceptibility when measured during the Richalet's test.
Assuntos
Doença da Altitude/fisiopatologia , Pressão Sanguínea/fisiologia , Hipertensão Pulmonar/fisiopatologia , Artéria Pulmonar/fisiologia , Adulto , Doença da Altitude/metabolismo , Suscetibilidade a Doenças/metabolismo , Suscetibilidade a Doenças/fisiopatologia , Ecocardiografia Doppler , Ensaio de Imunoadsorção Enzimática , Exercício Físico/fisiologia , Feminino , Humanos , Hipertensão Pulmonar/metabolismo , Hipóxia/fisiopatologia , Subunidade alfa do Fator 1 Induzível por Hipóxia/biossíntese , Masculino , Malondialdeído/sangue , Pessoa de Meia-Idade , Nitratos/sangue , Nitritos/sangue , RNA Mensageiro/análise , Fator A de Crescimento do Endotélio Vascular/sangue , Adulto JovemRESUMO
BACKGROUND: Optical coherence tomography is an imaging method that enables cardiologists to study atheromatous plaques, and to check the implantation and evolution of coronary stents. It is an invasive technique, providing high-resolution (10 microm) in vivo images, but with limitations and artefacts that need to be understood before the field of application can be extended. AIM: To determine the feasibility and limitations of optical coherence tomography coronary imaging from a single-centre experience. METHODS: We analysed the first 301 optical coherence tomography (version M2, LightLab Imaging) sequences obtained in our department from examination of 73 patients. RESULTS: Results showed that 92% of sequences for selected lesions were usable, with a mean examination time of 17 min. Only one complication occurred (ventricular fibrillation, reduced by external electroshock). In our registry, sequence quality depended on operator experience (improving after 20 examinations), and was impaired by artefacts, especially in right coronary analysis and in arteries of greater than 3.5 mm calibre. CONCLUSIONS: Proximal coronary occlusion and the distal flush quality currently required for quality imaging should no longer be indispensable with the new generation of optical coherence tomography systems.
Assuntos
Artefatos , Doença da Artéria Coronariana/diagnóstico , Doença da Artéria Coronariana/terapia , Vasos Coronários/patologia , Tomografia de Coerência Óptica , Adulto , Idoso , Angioplastia Coronária com Balão/instrumentação , Competência Clínica , Doença da Artéria Coronariana/patologia , Vasos Coronários/diagnóstico por imagem , Estudos de Viabilidade , Feminino , França , Humanos , Aumento da Imagem , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Sistema de Registros , Stents , Tomografia de Coerência Óptica/efeitos adversos , Resultado do Tratamento , Ultrassonografia de IntervençãoRESUMO
The dramatic occurrence, during haemodialysis sessions, of hemodynamic and cerebral symptoms in a 53-year-old haemodialysed woman with a history of aortocoronary bypass leads to discovery and treatment by percutaneous angioplasty and stenting of a significant stenosis of proximal subclavian artery, ipsilateral to the arteriovenous fistula, with retrograde flow in internal mammary artery graft and vertebral artery. All symptoms resume after interventional radiology. Analysis of literature confirms possibility of coronary artery steal induced by use of the arteriovenous fistula in haemodialysed patients with ipsilateral internal mammary bypass, especially if there is concomitant subclavian artery stenosis, and leading us to discuss the diagnostic and therapeutic implications.
Assuntos
Ponte de Artéria Coronária/efeitos adversos , Artéria Torácica Interna , Diálise Renal , Doenças Vasculares/etiologia , Feminino , Humanos , Pessoa de Meia-IdadeRESUMO
The prevalence of coronary artery abnormalities, in particular the single vessel form, is low among the general population. We report a case of a transluminal angioplasty of the left anterior descending artery arising from the right coronary artery during the acute phase of myocardial infarction.