Prognostic value of echocardiography and ECG in heart failure with preserved ejection fraction.

OBJECTIVE: The aim of this study was to evaluate characteristics of patients with heart failure (HF) with preserved ejection fraction (HFPEF) and to assess prognostic predictors in 2-year follow-up. METHODS: We included prospectively 109 patients admitted to the internal department for HF, grouped into HFPEF (EF>40 %, n = 63) and HF with reduced EF (HFREF) (EF≤40 %, n=46). Preserved right ventricular systolic function (PRV) was defined as the peak systolic tricuspid annular velocity (S') >10.8 cm/s. RESULTS: HFPEF and HFREF patients had non-significantly different 2-year all-cause and CV mortality (28.6 % vs 37.0 %, 17.5 % vs 21.7 %). Patients with HFPEF and PRV vs dysfunctional RV had a better survival (76.6  % vs 56.3 %, p=0.045). In HFPEF, the patients who survived had a trend to better S' (13.6±3.1 cm/s vs 11.9±3.4 cm/s, p=0.055), shorter QTc (427±42ms vs 454±42ms, p=0.058), and all-cause mortality was lowered only by anticoagulants (12.0 % vs 39.5 %, p=0.02). QTc interval and PRV emerged as predictors of all-cause mortality (HR 1.7 per 40 ms change, 95  % CI 1.1-2.6, p = 0.02, HR 0.38, 95 % CI 0.15-0.93, p=0.03). CONCLUSIONS: In HFPEF, we observed a trend to lower all-cause and CV mortality compared to HFREF and anticoagulants were the only therapy that significantly lowered mortality. PRV and QTc interval emerged as independent predictors of survival (Tab. 6, Fig. 2, Ref. 26).

[Blood pressure changes in chronically haemodialysed patients]. / Zmeny krvného tlaku u chronicky hemodialyzovaných pacientov.

BACKGROUND: Poor blood pressure control in chronically haemodialysed patients leads to increased cardiovascular morbidity and mortality. Information on valid values of blood pressure during haemodialysis and out of office is very important in order to set up adequate treatment. AIM: To measure blood pressure during the haemodialysis and the subsequent 24-hour period using an ambulatory blood pressure monitoring (ABPM) in patients with normal blood pressure (BP) and patients with high normal BP and hypertension. Relationship between time-dependent blood pressure changes, ultrafiltration (UF) and interdialytic weight gain (IDWG) was analysed. PATIENTS AND METHODS: Fifty chronically haemodialysed (> 3 months) patients (males/females 33/18) aged 57.5 (53-63; median, interquartile interval) years were studied. Systolic and diastolic pressures (SP, DP) were measured during haemodialysis every hour (H0-H4) and over following 24 hours using Spacelab 90217 monitor. Pulse pressure (PP) values were calculated as a difference between SP and DP. The patients were stratified into two groups based on the cut-off-point calculated as the mean of two mean arterial pressure (MAP) values obtained at the beginning and after the first hour of HD: Group A (n = 25), MAP < 100 mm Hg; Group B (n = 25), MAP 100 mm Hg. Interdialytic weight gain was measured before HD (IDWG1) and after the ABPM (IDWG2); also ultrafiltration (UF) was obtained. The post-dialysis 24-h ABPM period was divided into eight 3-hour intervals (M1-8). RESULTS: During HD no significant change in SP, DP or PP was found in both group, but there was a significant difference (p = 0.01) between both groups in SP, DP and PP. Values of BP at the end of dialysis were in group A: SP 125 (120-130) mm Hg, DP 75 (60-80) mm Hg and PP 50 (40-60) mm Hg in group B: SP 150 (140-160) mm Hg, DP 80 (80-90) mm Hg a PP 60 (60-70) mm Hg. We did not find any influence of IDWG1 or IDWG2 on SP or DP in both groups. Relationship between UF 3 000 (2 500-4 300) ml and SP (Δ sTK -5 mm Hg) was confirmed only in group A (p = 0.04). In group A, we found a decrease in SP during the third and sixth 3-hour interval (p = 0.01; p = 0.02) including sleeping period, all compared to the end of HD (H4). In group B, such a decrease in SP was found only in the second sleep interval (p = 0.01) and in the sixth 3-hour interval (p = 0.03), all compared to the end of HD (H4). As to DP at the end of dialysis (H4) in group A, it differed only in the third 3-hour interval (p = 0.02), but not during the sleeping period. In group B, the decrease of DP compared to the end HD (H4) was recorded during the two sleep intervals (p = 0.01), and also in the sixth and seventh 3-hour intervals (p = 0.01; p = 0.03). In group A, PP was compared to the end of HD (PPH4) significantly decreased in the first 3-hour interval (p = 0.02) and in seventh and eight 3-hour interval (p = 0.03; p = 0.04). In group B, PP did not significant change from the end of HD. Difference in SP between both groups was maintained over the entire course of ABPM (p = 0.01). However, DP values in both groups were different in the first and third 3-hour intervals (p = 0.01) but in following intervals DP in group B decreased to the level of that in group A. There was no significant difference in the proportion of non-dippers and reverse dippers in both groups. CONCLUSION: Systolic, diastolic, mean arterial and pulse pressure pressures were not significantly changed during the haemodialysis in both groups. Relationship between ultrafiltration and systolic pressure was confirmed only in group A. No influence of interdialytic weight gain on blood pressure during 24 hours was seen in either group. Systolic pressure decreased in both groups during the nighttime compared to post-HD values, but diastolic pressure decreased only in group B. PP did not decrease during the night in any group. There was no significant difference in the proportion of non-dippers and reverse dippers in both groups.

[Changes in NT-proBNP levels in patients with atrial fibrillation related to heart failure]. / Zmeny hladín NT-proBNP u pacientov s fibriláciou predsiení v iávislosti od srdcového zlyhávania.

INTRODUCTION: NT-proBNP, a well-established diagnostic and prognostic marker in clinical practice, is significantly elevated in individuals with atrial fibrillation (AF), even in absence of heart failure or major structural heart disease. OBJECTIVES: The aim of this study was to determine the cut-off value of NT-proBNP for diagnosis of heart failure in individuals with atrial fibrillation. METHODS: We compared 44 patients (25 male/19 female) with AF and concomitant overt heart failure [age 76 (62-82) years; median (interquartile range - IQR)] versus 29 patients (16 male/13 female) with AF with no signs of heart failure [age 59 (50-67) years; median (IQR)]. We considered the underlying causes of heart failure and its severity, comorbidities, echocardiographic and selected laboratory parameters, the body mass index as well as the treatment at discharge. We determined the cut-off value for heart failure and major structural heart disease using ROC curve analysis. RESULTS: Median NT-proBNP in the group of patients with AF and concomitant heart failure was 3 218 ng/l (IQR 1 758-7 480 ng/l) vs 981 ng/l (IQR 431-1 685 ng/l) in the group of patients with AF with no signs of heart failure; this difference was statistically significant (p < 0.001). The level of NT-proBNP higher than 1 524 ng/l in patients with AF was diagnostic of major structural heart disease and pointed towards a possible heart failure (sensitivity 80%, specificity of 76%, accuracy 78%, positive predictive value 83%, negative predictive value 71%). The NT-proBNP levels significantly correlated with age (p < 0.001), left atrial diameter (p < 0.01) and furosemide dose at discharge (p < 0.05). The NT-proBNP levels significantly negatively correlated with left ventricular ejection fraction (p < 0.001) and body mass index (p < 0.05). CONCLUSION: We found out that NT-proBNP is significantly elevated in patients with AF with preserved left ventricular function and in absence of heart failure and significantly correlates with age, left ventricular ejection fraction, left atrial diameter, body mass index and the furosemide dose necessary to achieve cardiac compensation. Furthermore, we determined the NT-proBNP cut-offvalue predictive of a possible heart failure in patients with AF.

Blood pressure prior to cardioversion predicts a conversion to sinus rhythm in patients with atrial fibrillation.

BACKGROUND: The effect of BP measured prior to the cardioversion has not been studied. METHODS: Eighty patients (mean age 62 +/- 11 yrs, 44 men) with atrial fibrillation (AF), who underwent 92 cardioversions, were included. Non-invasive BP was measured. We performed a retrospective review of clinical data. The variables included into logistic regression analysis were: BP, age, gender, arterial hypertension, coronary artery disease, heart failure, obesity, left atrial diameter, duration of AF, antiarrhythmic and antihypertensive therapy. RESULTS: A success rate of cardioversion was 60.9%. BP was lower in the group of patients with a successful cardioversion (mean BP 97 +/- 15 vs 104 +/- 10 mmHg, p = 0.02; systolic BP 130 +/- 21 vs 140 +/- 18 mmHg, p=0.02; diastolic BP 81 +/- 14 vs 86 +/- 8 mmHg, p = 0.07). Mean, systolic and diastolic BP cut-off levels with the highest sum of sensitivity and specificity were 103, 138 and 75 mmHg, respectively. CONCLUSIONS: Subjects with a successful cardioversion had lower BP measured immediately prior to the procedure. BP and concurrent antiarrhythmic treatment were the only predictors of a successful cardioversion (Tab. 1, Ref. 29). Full Text (Free, PDF) www.bmj.sk.

[Late recurrences of atrial fibrillation in patients after direct-current cardioversion]. / Neskoré recidívy fibrilácie predsiení u patientov po elektrickej kardioverzii.

AIM: To analyze factors after successful direct-current cardioversion in patients with atrial fibrillation and to explore late recurrences of the arrhythmia. METHODS: Forty-three patients with atrial fibrillation without associated valvular heart disease, who underwent non-emergent cardioversion within the years 2002-2006, were included. We retrospectively analyzed clinical data from the medical records. Late reccurence of the arrhythmia was defined as arrhythmia in patients discharged with sinus rhythm. RESULTS: Median follow-up of the patients was 33 (17, 48) months. We found 20 late recurrences of atrial fibrillation in the total group of 43 patients after successful direct-current cardioversion (46.5%). In a 6-month period after direct-current cardioversion the recurrence of arrhythmia was found in two patients, in a one-year period in 6 patients and in a period longer than one year in 12 patients. Median time to recurrence was 15 (6, 33) months. Females relapsed more frequently than males (p < 0.02), what could be explained by higher age, incidence of hypertension and thyreopathy in females. Patients with a history of thyropathy had more frequent occurrence of arrhythmia, despite normal values of TSH, as compared to patients without a history of thyropathy (p < 0.04). Patients with recurrence of the atrial fibrillation had higher systolic pressure (130 vs 120 mm Hg, p < 0.05) and pulse arterial pressure (50 vs 40 mm Hg, p < 0.01) after cardioversion. No significant difference between the two groups in age, left atrium diameter, left ventricle ejection fraction and cardiovascular, or non-cardiovascular risk factors was found. CONCLUSION: Despite successful direct-current cardioversion, the risk of late recurrence of the atrial fibrillation in a following period is at least 46.5%. Females, patients with a history of thyropathy and those with higher systolic and pulse arterial pressures are at higher risk of late recurrences.

Management and two-year prognosis of patients with acute myocardial infarction in a community hospital toward the end of thrombolytic era.

OBJECTIVES: To analyze management, early and long-term prognoses of patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Until now, in Slovakia there have been no relevant data published on prognoses of patients who were treated due to STEMI one or more years ago. We also checked for the adherence to STEMI guidelines at a community hospital. PATIENTS AND METHODS: All 112 patients admitted within 24 hours of STEMI to the Faculty Hospital in Bratislava-Petrzalka in 2000-2001 were involved. Data on acute course of STEMI were acquired from medical records. Two years after STEMI patients were asked to complete a questionnaire. Standard statistic methods were used. RESULTS: Average age of patients was 59.9 +/- 13.3 (mean +/- SD) years. Main prevalent risk factors included smoking (51.8%), diabetes (22.3%), hypercholesterolaemia (54.5%), arterial hypertension (51.8%). Thrombolytic treatment was given to 64.3% of patients; other 25.0% of patients were contraindicated because of their late presentation. Potentially serious complications occurred in 50.9% of patients. Coronarography was performed during the hospitalization in 11.6% of patients and within next 2 years in 19.2% of patients. In-hospital mortality was 11.6%, two-year mortality was 6.1%. CONCLUSION: High prevalence of risk factors, late presentation of patients together with low accessibility to early PCI were responsible for the high amount of patients with complicated STEMI course despite good adherence to clinical guidelines. We expect much better prognoses in patients treated with primary PCI since the management has changed in Slovakia. Long-term prognoses of patients discharged after uncomplicated STEMI and treated with early thrombolysis were optimistic (Tab. 5, Fig. 1, Ref. 17).