Acute heart failure with accompanying chronic obstructive pulmonary disease: should we focus on beta blockers?

BACKGROUND: Acute heart failure (AHF) with systolic dysfunction is associated with increased morbidity and mortality, and optimal therapy is not well established, despite the findings of evidence-based medicine. Beta blockers provide a mortality and morbidity benefit in patients with chronic systolic HF, and are currently indicated in all stages of patients with systolic HF. We evaluated therapies before discharge, in particular beta blockers, in patients hospitalized with AHF with and without accompanying chronic obstructive pulmonary disease (COPD). METHODS: The hospital discharge records of 959 consecutive de novo AHF patients, hospitalized and treated for systolic HF (ejection fraction < 45%), were retrospectively reviewed in three cardiovascular institutions. RESULTS: The presence of accompanying COPD was associated with significantly lower prescription of beta blockers before discharge (p < 0.001). Furthermore, with regard to the type of beta blocker, patients with accompanying COPD were less frequently prescribed nonselective beta blockers (29% vs. 48%, p < 0.001). The presence of accompanying COPD among AHF patients increased the risk of omitting (not prescribing) beta blockers before discharge by a factor of 1.785. CONCLUSION: Beta blockers, a proven life-saving therapy in the setting of chronic systolic HF, were found to be less frequently prescribed before discharge in the presence of de novo AHF with accompanying COPD.

Modification of Diet in Renal Disease equation in the risk stratification of contrast induced acute kidney injury in hospital inpatients.

BACKGROUND: Several organizations recommend using estimated glomerular filtration rate (eGFR) in kidney function monitoring, preferably calculated with Modification of Diet in Renal Disease (MDRD) formula. The role of this formula is not clear in the risk stratification of contrast induced acute kidney injury (CIAKI) in nonsteady state patients. AIM: Comparative evaluation of the MDRD eGFR in risk stratification of CIAKI. METHOD: GFR was measured twice (pre- and post-examination) by Tc-99m-DTPA, along with serum levels of urea nitrogen and creatinine in 32 patients (mean age+/-SD; 60.1+/-13.2 years) needing hospital care for various reasons and underwent to x-ray examination with contrast media (mean; 90.2+/-16.8 ml). eGFR was calculated by the dedicated formula. Agreement between measured GFR (mGFR) and MDRD eGFR was assessed and patients were scored and stratified for CIAKI by using first mGFR, then eGFR and results were compared. RESULTS: A moderate correlation was obtained between mGFR and eGFR (r=0.47, p < 0.001) and the difference was not significant. However, Bland & Altman analysis revealed large limits of agreement between mGFR and eGFR (-80.3 to 55.2) with a mean difference of -12.5 ml/min/1.73m2. In ROC analysis, when mGFR values were classified as normal (>60ml/min/1.73m2) and decreased (<60ml/min/1.73m2), AUC was 0.80 (95%CI; 0.62-0.92) for eGFR, with a sensitivity of 29% and specificity of 100%. Furthermore, the risk group categorization, using eGFR instead of mGFR was resulted in a group change for four patients (13%); from moderate to low risk group. CONCLUSION: It seems that MDRD eGFR differs from mGFR. In nonsteady state patients CIAKI classification using eGFR should be considered with caution.

Evaluation of risk factors in predicting coronary artery disease in patients with left bundle branch block.

This retrospective study examined whether classical risk factors for coronary artery disease (CAD) could also be used to predict CAD in patients with left bundle branch block (LBBB). Clinical and demographic features were studied in patients with/without CAD who presented with LBBB on their surface electrocardiograms and had undergone coronary angiography. Of the 312 patients with LBBB, 161 (51.6%) had CAD. Patients with CAD were more likely to be older, male, have CAD risk factors and to be taking acetylsalicylic acid or angiotensin-converting enzyme inhibitors. A model with six independent variables (family history, smoking, angina, advanced age, hypertension and total cholesterol levels) was statistically significant in predicting CAD in patients with LBBB, with an ability to predict patients with and without CAD of 87.1% and 90.6%, respectively. Predictors of CAD in patients with LBBB are consistent with classical risk factors and may help the accurate prediction of patients with CAD.

An unusual cause of hemoptysis: ventriculopulmonary fistula.

A 55-year-old man presented with massive hemoptysis following coronary artery bypass grafting and repair of a left ventricular aneurysm. Radiological and bronchoscopic examinations revealed no bronchial cause. The findings of computed tomography (CT) of the chest and echocardiography showed a pseudoaneurysm of the left ventricle. Surgical exploration confirmed that the pseudoaneurysm communicated with the lung parenchyma.

Diurnal variation of QT dispersion in patients with and without coronary artery disease.

QT dispersion defined as interlead QT variability in a 12-lead electrocardiogram was proposed by Day and associates as a simple method to evaluate the repolarization heterogenicity of the ventricular myocardium. The frequency of onset of myocardial infarction and sudden death has been reported to have a circadian variation, with a peak incidence in the early morning hours. The authors investigated whether there is diurnal variation of QT interval and QT interval dispersion in healthy subjects and in patients with coronary artery disease. The study population consisted of two groups. Group I consisted of 62 subjects without coronary artery disease and group II consisted of 82 patients with coronary artery disease. Twelve-lead ECG was recorded for each patient in the morning (between 7 AM and 8 AM), afternoon (between 3 PM and 5 PM) and at night (between 11 PM and 1 AM), on the day after performance of coronary angiography. QTc dispersion was significantly higher in patients with coronary artery disease than in healthy subjects in the morning hours and afternoon (p<0.001). Although the differences were much prominent in group I than group II, both QTc dispersion of morning and afternoon were significantly greater than those at night. There were no statistically significant differences between group I and group II at nighttime with respect to maximum QTc, minimum QTc intervals, and QTc dispersion (p>0.05). In conclusion, QT dispersion shows diurnal variation with an increase in the morning hours in both patients with coronary artery disease and subjects without coronary artery disease. The mechanism of diurnal variation of QT dispersion in patients with coronary artery disease is quite different from that of healthy subjects.

QTc dispersion measurement for risk of syncope in patients with aortic stenosis.

The purposes of this study are to evaluate the clinical usefulness of maximum QTc and QTc dispersion determination in aortic stenosis, and to compare the effects of maximum QTc and QTc dispersion on the risk of syncope in aortic stenosis. The QT interval dispersion has long been known to be a marker of dispersion of ventricular repolarization and, hence, electrical instability. Additionally, it has been shown that these patients have a propensity to ventricular tachyarrhythmic syncope. The study included 86 patients with aortic stenosis who underwent left-heart catheterization and coronary angiography during investigation of syncope and 30 healthy subjects. The patients were characterized with regard to the presence or absence of a history of syncope and the severity of aortic stenosis (the degree of peak transvalvular gradient). In addition, QT max and QT dispersion measurements were corrected for heart rate according to Bazett's formula. The QTc max and QTc dispersion were greater in patients with aortic stenosis than in the healthy subjects (477 +/- 49 ms vs 370 +/- 22 ms, p < 0.001; 60 +/- 13 ms vs 38 +/- 1 ms, p < 0.001). Similarly, the QTc max and QTc dispersion were greater in the patients with a history of syncope than in the patients with no history of syncope (493 +/- 48 ms vs 459 +/- 4 ms, p < 0.001; 68 +/- 12 ms vs 53 +/- 10 ms, p < 0.001). In addition, both parameters were greater in the patients with a high transvalvular gradient than in the patients with a low transvalvular gradient (489 +/- 49 ms vs 451 +/- 39 ms, p < 0.001; 65 +/- 12 ms vs 50 +/- 9 ms, p < 0.001). Multivariate logistic regression analysis showed that only a increased QTc dispersion had significant value for the risk of syncope in aortic stenosis. An increased QTc dispersion caused a 10.4% increase in the occurrence of syncope in aortic stenosis. These results suggest that high values of QTc dispersion are sensitive noninvasive markers to determine the risk for syncope in aortic stenosis.

Diagnosis of coronary artery disease with Tl-201 SPECT in patients with left bundle branch block: importance of alternative interpretation approaches for left anterior descending coronary lesions.

Left bundle branch block (LBBB) is a strong predictor of mortality in the presence of coronary artery disease (CAD). Noninvasive evaluation of CAD in these patients has some difficulties. Exercise-induced electrocardiographic ST segment changes are nondiagnostic, and several scintigraphic studies have reported false-positive anteroseptal and septal perfusion defects up to 80%. The authors aimed to assess the diagnostic accuracy of thallium-201 (Tl-201) exercise myocardial single photon emission computerized tomography (SPECT) in comparison with coronary angiography (CAG) for detection of CAD in patients with LBBB. Seventy-seven consecutive patients suffering from chest pain with complete and permanent LBBB were included in the study. All patients (40 women, 37 men, mean age = 54 +/- 7 years) were studied with Tl-201 exercise SPECT and coronary angiography. Tl-201 exercise SPECT for diagnosis of left anterior descending (LAD) artery lesions was interpreted by using three different approaches: method A (conventional approach), method B (involvement of anterior and septal wall regardless of apical wall), and method C (apical approach: involvement of anterior septal and apical wall). Methods A and B gave a sensitivity of 100% each but a specificity of 47% and 56%, respectively. Although method C gave a higher value of specificity than that of methods A and B (98% vs 47% and 56%, respectively p < 0.05), the sensitivity of method C significantly decreased in respect to methods A and B (33% vs 100% p < 0.01). Isolated septal defects were evaluated separately. Isolated septal defects on exercise Tl-201 SPECT were detected in 11 patients, and none of them had CAD according to CAG results. Isolated septal wall involvement had a sensitivity of 0% and a specificity of 74%. The sensitivity and specificity of Tl-201 SPECT for diagnosis of CAD in the right coronary and left circumflex artery territories were 91% and 89%, respectively. In conclusion, the apical approach increased the specificity and decreased the sensitivity of the test. Isolated septal defects seem to have no value for diagnosis of CAD in patients with left bundle branch block.

The clinical significance of QTc dispersion measurement for risk of syncope in patients with aortic stenosis.

OBJECTIVES: (1) To evaluate the clinical usefulness of QTc dispersion determination in aortic stenosis and (2) to compare the effects of QTc dispersion on the occurrence risk of syncope in aortic stenosis. BACKGROUND: QT interval dispersion has long been known to be a marker of dispersion of ventricular repolarization and, hence, electrical instability. Additionally, it has been shown that these patients have a propensity to ventricular tachyarrhythmic syncope. METHODS: The study included 86 patients with aortic stenosis who underwent left-heart catheterization and coronary angiography during investigation of syncope, as well as 30 control subjects. The patients were characterized with regards to the presence or absence of a history of syncope and the severity of aortic stenosis (the degree of peak transvalvular gradient). In addition, QT dispersion measurements were corrected for heart rate according to Bazett's formula and both were measured. RESULTS: QTc dispersion was greater in patients with aortic stenosis than in the control subjects (60 +/- 13 msec vs 38 +/- 12 msec, P < 0.001). Similarly, QTc dispersion was greater in the patients with a history of syncope than in the patients with no history of syncope (68 +/- 12 msec vs 53 +/- 10 msec, P < 0.001). In addition, QTc dispersion values were greater in the patients with a high transvalvular gradient than in the patients with a low transvalvular gradient (65 +/- 12 msec vs 50 +/- 9 msec, P < 0.001). Multivariate logistic regression analysis showed that only an increased QTc dispersion had significant value for the risk of syncope in aortic stenosis. CONCLUSIONS: An increased QTc dispersion increases the occurrence risk for syncope in aortic stenosis. These results suggest that high values of QTc dispersion are a sensitive noninvasive marker for determining the risk for syncope in aortic stenosis.

Comparison of thallium-201 exercise SPECT and dobutamine stress echocardiography for diagnosis of coronary artery disease in patients with left bundle branch block.

The present study assessed and compared the diagnostic accuracy of thallium-201 (Tl-201) exercise myocardial single photon emission computerised tomography (SPECT) and dobutamine stress echocardiography (DSE) for detection of coronary artery disease (CAD) in patients with left bundle branch block (LBBB). Study population consisted of 26 consecutive patients with permanent LBBB who were suffering from chest pain. Patients (8 women, 18 men mean age = 57+/-8 years) were studied with DSE, Tl-201 SPECT and coronary angiography (CAG). Three different approaches for diagnosis of CAD were used to identify CAD in left arterial descending (LAD) coronary artery territories in scintigraphic studies: (1) Approach A (conventional approach): involvement of septal, and/or anterior, and/or apical wall. (2) Approach B: involvement of anterior and septal wall irrespective of apical wall. (3) Approach C: involvement of septum, anterior and apical wall. DSE gave a sensitivity of 91%, specificity of 92% and accuracy of 92% for diagnosis of CAD in the LAD coronary artery territory. Tl-201 SPECT (conventional approach) gave a sensitivity of 100%, specificity of 42% and diagnostic accuracy of 69% for diagnosis of CAD in the LAD coronary artery territory. Sensitivity, specificity and diagnostic accuracy of approach C were 33, 85 and 57% respectively. The specificity of Tl-201 SPECT significantly increased in approach C when compared with approach A and B (p < 0.02). However sensitivity of the Tl-201 SPECT with approach C showed significant decrease when compared with DSE and approach A and B (p < 0.005). Specificity of DSE for diagnosis of CAD in LAD were significantly higher than those of Tl-201 SPECT regarding the approach A and B (p < 0.01). In conclusion the use of DSE for diagnosis of CAD in patients with LBBB seems to be more suitable than Tl-201 SPECT.

Increased QT interval dispersion after hemodialysis: role of peridialytic electrolyte gradients.

Chronic renal failure patients on maintenance hemodialysis (HD) have a number of ECG abnormalities and cardiac arrhythmias. Clinical and experimental data have shown that increased QT dispersion is associated with severe ventricular arrhythmias and sudden cardiac death. Therefore, the aim of this study was to investigate whether the uremic patients receiving long-term HD have increased QTc interval and/or QTc dispersion compared to normal subjects and to evaluate the effect of electrolyte changes between the predialysis and postdialysis phases on these parameters. Forty patients with end-stage renal failure on long-term HD (22 men, 18 women, mean age 44 years) were included in this study. Serum concentrations of K+, Na+, Ca++, Mg++, Cl-, phosphate, urea, creatinine, HCO3-, and arterial blood gases (PO2, PCO2), together with blood pH, were monitored and QTc intervals and QTc dispersion were measured from 12-lead ECG in predialysis and postdialysis phases. The hemodialyzed patients had an increased predialysis QTc maximum interval and QTc dispersion compared to normal subjects (480 +/- 51 vs 310 +/- 38 msec, p < 0.001 and 61 +/- 17 vs 42 +/- 14 msec, p < 0.001, respectively). Both QTc maximum interval and QTc dispersion increased significantly at the end of the HD (480 +/- 51 vs 505 +/- 49 msec p < 0.001 and 61 +/- 17 vs 86 +/- 18 msec, p < 0.001, respectively). The serum K+ (5.3 +/- 0.56 vs 3.36 +/- 0.41 mEq/L, p < 0.001), phosphate (7.19 +/- 1.62 vs 3.81 +/- 1.02 mg/dL, p < 0.001), magnesium (0.87 +/- 18 vs 0.75 +/- 0.14 mg/dL) and urea concentrations (174 +/- 22 vs 74 +/- 14 mg/dL, p < 0.001) significantly decreased, whereas the Ca++ (2.21 +/- 0.18 vs 2.47 +/- 0.24 mg/dL, p < 0.001), HCO3- (15.5 +/- 3.2 vs 20.1 +/- 3.4 mmol/L, p<0.001) concentrations and pH (7.27 +/- 1.1 vs 7.43 +/- 1.2, p < 0.001) significantly increased after HD compared to predialysis values. There was significant correlation between the QT dispersion increase and serum electrolyte changes (K+, Ca++, and pH levels) (p < 0.05). The association between serum electrolyte changes, acid-base status and QT measurements might provide new insights into the evaluation of the ionic bases involved in inhomogeneous ventricular repolarization.

Influence of thrombolytic therapy on the incidence of left ventricular thrombi after acute anterior myocardial infarction: role of successful reperfusion.

BACKGROUND: Previous studies have reported controversial results regarding the effectiveness of systemic thrombolysis in preventing left ventricular (LV) thrombus after acute myocardial infarction (MI). HYPOTHESIS: This study was performed to evaluate the influences of thrombolysis, and particularly successful reperfusion, on the incidence of LV thrombus formation after acute anterior MI. METHODS: In all, 191 patients suffering from a first attack of acute anterior MI were prospectively evaluated by two-dimensional echocardiography and coronary angiography, performed at the end of the first week and within the first two weeks of MI, respectively. Of these, 98 who presented within 12 h of onset of symptoms received intravenous streptokinase (1.5 million IU), while the remaining 93 patients who, either because of contraindications or late admission, did not receive thrombolytic treatment served as control group. All patients received aspirin and full-dose anticoagulation with intravenous heparin. Successful reperfusion in the streptokinase group was assessed by enzymatic and electrocardiographic evidence. RESULTS: The overall incidence of LV thrombi was 24.6% (47/191). When all patients were evaluated, no statistically significant difference was found between the frequency of LV thrombi in the patients who had thrombolysis (22.4%) and those who did not (26.8%), despite a trend toward the formation of fewer thrombi in the initial group (p > 0.05). However, the patients who had successful reperfusion with streptokinase (n = 64) had significantly reduced incidence of LV thrombi compared with those who did not receive thrombolytic therapy (20 vs. 26.8%, p < 0.05). Stepwise multivariate analysis suggested that LV abnormal wall motion score (p = 0.01) and presence of LV aneurysm were independent predictors of LV thrombus formation in patients with acute anterior MI. CONCLUSION: Not all patients who received streptokinase for acute anterior MI, but only those with successful reperfusion had reduced incidence of LV thrombi. The favorable effects of thrombolysis on LV thrombus formation are probably due to the preservation of global LV systolic function.