CPAP telemonitoring can track Cheyne-Stokes respiration and detect serious cardiac events: The AlertApnée Study.

BACKGROUND AND OBJECTIVE: Case reports have suggested that continuous positive airway pressure (CPAP) telemonitoring can detect the onset of acute cardiac events such as decompensated heart failure (HF) or atrial fibrillation through an increase in the apnoea-hypopnoea index (AHI) and onset of Cheyne-Stokes Respiration (CSR). This study addressed whether long-term remote CPAP treatment telemonitoring revealing CSR can help detect serious cardiac events (SCEs) in obstructive sleep apnoea (OSA) patients. METHODS: This monocentric prospective cohort study included adults receiving CPAP therapy for OSA with daily telemonitoring. Any sudden increase in AHI generated an alert for the home healthcare provider to download CPAP data to identify CSR. A medical consultation was scheduled if CSR was detected. RESULTS: We included 555 adults (412 men; 57% with known cardiovascular comorbidities). During the 1-year follow-up, 78 CSR episodes were detected in 74 patients (CSR+). The main conditions associated with incident CSR were HF (24 patients [30.8%]), ventilatory instability (21, 26.9%), leaks (13, 16.7%), medications inducing central apnoeas (baclofen, ticagrelor, opioids) (7, 9.0%), arrhythmias (6, 7.7%) and renal failure (2, 2.6%). Fifteen (20.3%) CSR+ patients had a confirmed SCE. In univariable analysis, a CSR episode increased the risk of an SCE by 13.8-fold (5.7-35.6) (p < 0.0001), with an adjusted OR of 5.7 (2.0-16.8) in multivariable analysis. CONCLUSION: Long-term telemonitoring of patients on CPAP treatment can alert CSR episodes and allows early detection of SCEs in patients with or without known cardiac comorbidities.

Sites of left and right ventricular lead implantation and response to cardiac resynchronization therapy observations from the REVERSE trial.

OBJECTIVES: The objective of this study is to ascertain the effects of the left (LV) and right (RV) ventricular lead tip position in response to cardiac resynchronization therapy (CRT). BACKGROUND: The REVERSE randomized trial examined the effects of CRT in patients with asymptomatic or mildly symptomatic heart failure (HF). METHODS: We analysed data collected from the active group (CRT-ON) of REVERSE in whom the precise locations of the LV and RV ventricular lead tips were determined from postoperative chest roentgenograms as part of a prespecified sub-study. LV position was classified as lateral or non-lateral, and apical or non-apical. RV position was classified as apical or non-apical. Echocardiographic LV end-systolic volume index (LVESVi), QRS duration, and clinical outcomes at 12-24 months of follow-up were evaluated with respect to the lead tip position. The primary trial endpoint was the proportion of patients with a worsened HF clinical composite response, scored as improved, unchanged, or worsened. RESULTS: Totally 346 patients included in this analysis were followed for a median of 12.6 months (interquartile range: 11.9-23.9 months). The proportion of worsened HF clinical composite response did not correlate with lead position, whereas a significantly greater decrease in the powered secondary endpoint of LVESVi was observed with the non-apical vs. the apical LV lead positions. CRT-paced QRS duration was significantly shorter than at baseline in patients with lateral vs. non-lateral LV position, as well non-apical vs. apical LV position. The incidence of composite endpoint of death and first hospitalization for HF was lower in the LV lateral than in the non-lateral (HR 0.44; 95% CI 0.19-0.99; P= 0.04), and in the LV non-apical than in the apical group (HR 0.27; 95% CI 0.11-0.63; P= 0.001). No significant differences were observed between RV apical and non-apical positions of the lead tip. CONCLUSIONS: A more favourable outcome of CRT with regard to LV reverse remodelling and the composite of time to death or first HF hospitalization was observed when the LV lead tip was implanted in the lateral wall, away from the apex, while the position of the RV lead tip was indifferent. The long-term change in QRS duration was significantly associated with the position of the LV lead tip. ClinicalTrials.gov Identifier: NCT00271154.

Door-to-balloon delays before primary angioplasty in the Regional Acute Myocardial Infarction Registry of Brittany. An analysis of the Observatoire Régional Breton sur l'Infarctus du myocarde (ORBI).

BACKGROUND: Minimizing delays to coronary reperfusion is critical in the management of acute myocardial infarction (AMI). AIMS: To determine delays in in-hospital management and factors associated with delays of over 45min. METHODS: We analysed data from the Observatoire Régional Breton sur l'Infarctus, a registry of AMI patients admitted within 24h of symptom onset (July 2007 to December 2008) to an interventional cardiology centre in Brittany. Prehospital delay was defined as time between first responder arrival at the patient and patient arrival at an interventional cardiovascular centre. In-hospital delay was defined as time between admission to the interventional cardiovascular centre and first balloon inflation. Patients were grouped according to duration of in-hospital delay (>45 vs

Systemic light chain amyloidosis and Sjogren syndrome: an uncommon association.

Sjogren syndrome is associated with lymphoproliferative disease in 7% of cases; however, association with AL amyloidosis is uncommon. We present a patient who presented simultaneously with Sjogren syndrome (supported by dry mouth, positive Schirmer's test, anti-Ro/SSA antibodies, and a lower lip salivary gland biopsy) and AL amyloidosis revealed by heart failure without myeloma. Although is it know that amyloidosis can masquerade as Sjogren syndrome, the occurrence of simultaneous AL amyloidosis and primary Sjogren syndrome has been reported rarely.

Surface electrocardiogram to predict outcome in candidates for cardiac resynchronization therapy: a sub-analysis of the CARE-HF trial.

AIMS: In CARE-HF, cardiac resynchronization therapy (CRT) lowered morbidity and mortality in patients with moderate to severe heart failure. We examined whether baseline and follow-up electrocardiographic characteristics might predict long-term outcome. METHODS AND RESULTS: CARE-HF randomly assigned 409 patients to medical therapy (MT) plus CRT, and 404 patients to MT alone. Electrocardiographic measurements were made at baseline during sinus rhythm, and at 3 months during paced or spontaneous rhythm depending on treatment assignment. Favourable outcome was defined as freedom from death, urgent transplantation, or cardiovascular hospitalization. Among patients assigned to CRT, 39% had unfavourable outcomes including 55 deaths. By single variable analysis, (i) prolonged PR interval, left QRS axis (but not QRS duration), and left bundle branch block (BBB) at baseline, and (ii) heart rate, PR, and QRS duration at 3 months predicted unfavourable outcome. By multiple variable analysis, treatment assignment (P = 0.0001), PR (P = 0.0004), and right BBB (P < 0.00013) at baseline predicted outcome, whereas baseline JTc and QRS duration at 3 months predicted all-cause mortality and heart failure hospitalization (P = 0.0071). CONCLUSION: In CARE-HF, QRS duration at baseline did not predict outcome, but QRS at 3 months was a predictor by single variable analysis. Patients with prolonged PR interval and the 5% of patients with right BBB had a particularly high event rate.

Argument for a Doppler echocardiography during exercise in assessing asymptomatic patients with severe aortic stenosis.

AIMS: Exercise stress testing (EST) is recommended by guidelines to risk-stratify patients with asymptomatic valvular aortic stenosis (AS), though the role of quantitative exercise-Doppler echocardiography has rarely been studied. This prospective study sought to correlate standard EST results with the haemodynamic measurements made during exercise by Doppler echocardiography. METHODS AND RESULTS: We performed rest and semi-supine exercise Doppler echocardiography in 44 consecutive patients (mean age=68+/-12 years) with aortic valve areas

Mitral regurgitation in dilated cardiomyopathy: value of both regional left ventricular contractility and dyssynchrony.

AIMS: Mitral regurgitation (MR) is common and independently predicts mortality in patients with left ventricular (LV) systolic dysfunction. Its management remains challenging because of the complexity and variety of potential mechanisms implicated. We sought to determine which LV functional characteristics are the most important determinants of the severity of the MR associated with dilated cardiomyopathies. METHODS AND RESULTS: We performed echocardiographic studies in 87 consecutive patients with dilated cardiomyopathy. The degree of MR was quantified according to guidelines. LV, left atrial and mitral annulus dimensions, mitral valve tenting, estimated filling pressures, regional myocardial contractility, and dyssynchrony (using regional strain (epsilon) analysis) were recorded too. Determinants of significant MR was thus assessed using multivariate models. Mitral regurgitant volume correlated with mitral annulus diameter (P<0.001), mitral valve tenting height (P<0.001), LV volumes (P=0.004), LV ejection fraction, mid-lateral wall peak of epsilon (P=0.01), and its delay (P<0.001). That inter-relation between the mitral annulus, the ventricle shape, contractility, and dyssynchrony was founded in the multivariate analysis. As a matter of fact, the model predicting the best the MR volume (R=0.78) included: mitral annulus diameter, dyssynchrony, tenting heigh and contractility of the LV mid-lateral wall (measured by epsilon). CONCLUSION: The MR of the dilated cardiomyopathy is multifactorial. Our data suggest that analysing only LV geometry and mitral orifice is insufficient to correctly describe functional MR determinant. LV contractility and dyssynchrony are essential too.

Resting echocardiographic assessments of left atrial function and filling pressure interest in the understanding of exercise capacity in patients with chronic congestive heart failure.

OBJECTIVE: Doppler echocardiography is well recognized as the primary noninvasive imaging technique to assess global and regional cardiac function. Cardiopulmonary exercise testing has become a powerful tool to predict outcome in chronic heart failure (CHF). We looked for cardiac determinants, using resting echocardiographic parameters, of exercise tolerance in patients with CHF. METHODS: Transthoracic echocardiography and standardized cardiopulmonary exercise testing were performed in 75 patients (59 +/- 11 years) with CHF, New York Heart Association functional class II to III. Systolic and diastolic function, filling pressures, and left ventricular, right ventricular, and left atrial (LA) regional function were assessed using Doppler tissue velocities and strain values. RESULTS: Maximal workload (86 +/- 41 W) and peak oxygen (14.6 +/- 3.1 mL/min/kg) correlated with left ventricular filling pressure estimates (E/Ea and E/Vp) but also with end-diastolic pulsed Doppler tissue velocity at the mitral annulus (Aa), LA volume, and regional LA function assessed by strain analysis. In multivariate analysis, maximum workload and peak oxygen were shown to correlate with right ventricular peak strain, although Aa and E/Ea were the best predictors of exercise capacity. CONCLUSION: Capacity to exercise in patients with CHF is understandable by resting echocardiography. Filling pressures, and LA and right ventricular functions, are its cardiac best determinants. Adding Aa peak velocity in resting echocardiographic evaluation of patients with CHF is found useful.