In search of an efficient strategy to monitor disease status of chronic heart failure outpatients: added value of blood biomarkers to clinical assessment.

INTRODUCTION: Blood biomarkers have the potential to monitor the severity of chronic heart failure (CHF). Studies correlating repeated measurements of blood biomarkers with repeatedly assessed New York Heart Association (NYHA) class over a prolonged follow-up period, and concomitantly investigating their associations with clinical endpoints, have not yet been performed. METHODS: Between 2011-2013, 263 CHF patients were included. At inclusion and subsequently every 3 months, we measured N­terminal pro-B-type natriuretic (NT-proBNP), high-sensitivity troponin T (Hs-TnT) and C­reactive protein (CRP), and assessed NYHA class. The primary endpoint comprised heart failure hospitalisation, cardiovascular mortality, cardiac transplantation or left ventricular assist device implantation. Time-dependent Cox models were used. RESULTS: Mean age was 67 ± 13 years, 72% were men and 27% were in NYHA class III-IV. We obtained 886 repeated measures (median 3 [IQR 2-5] per patient). The primary endpoint was reached in 41 patients during a median follow-up of 1.0 [0.6-1.4] year. Repeatedly measured NT-proBNP and Hs-TnT were significantly associated with repeatedly assessed NYHA class, whereas CRP was not (NT-proBNP: ß [95% CI]: 1.56 [1.17-2.06]ln(ng/l) increase per point increase in NYHA class, p = 0.002; HsTNT: ß [95% CI]: 1.58 [1.21-2.07]). Serially measured NT-proBNP (HR [95% CI]:2.86 [1.73-4.73]), CRP (1.69 [1.21-2.34]) and NYHA class (2.33 [1.51-3.62]) were positively and independently associated with the primary endpoint, whereas Hs-TnT lost statistical significance after multivariable adjustment. A model containing serially measured NYHA class and NT-proBNP displayed a C-index of 0.84, while serially measured NYHA class and CRP showed a C-index of 0.82. CONCLUSION: Temporal NT-proBNP, CRP and NYHA class patterns are independently associated with adverse clinical outcome. Serially measured NT-proBNP and NYHA class are best suited for monitoring CHF outpatients.

Follow-up of implantable cardioverter-defibrillator therapy: comparison of coronary artery disease and dilated cardiomyopathy.

PURPOSE: Since several large trials have proven the effectiveness of implantable cardioverter-defibrillators (ICDs) in patients with left ventricular dysfunction, disadvantages have become more apparent. As the prognosis of patients with cardiovascular diseases is improving, assessment of ICD patients and re-evaluation of the current guidelines is mandatory. We aimed to evaluate differences in mortality and occurrence of (in)appropriate shocks in ICD patients with coronary artery disease (CAD) or dilated cardiomyopathy (DCM). METHODS: In a large teaching hospital, all consecutive patients with systolic dysfunction due to CAD or DCM who received an ICD with and without resynchronisation therapy, were collected in a database. RESULTS: A total of 320 consecutive patients (age 67 ± 10 years) were classified as CAD patients and 178 (63 ± 11 years) as DCM patients. Median follow-up was 40 months (interquartile range [IQR] 23─57 months). All-cause mortality was 14 % (CAD 15 % vs DCM 13 %). Appropriate shocks occurred in 13 % of all patients (CAD 15 % vs DCM 11 %, p = 0.12) and inappropriate shocks occurred in 10 % (CAD 8 % vs DCM 12 %, p = 0.27). Multivariate analysis demonstrated impaired left ventricular ejection fraction, QRS >120, age ≥75 years and low estimated glomerular filtration rate as predictors for all-cause mortality. Predictors for inappropriate shocks were permanent and paroxysmal atrial fibrillation. CONCLUSION: Mortality rates were similar in patients with CAD and DCM who received an ICD. Furthermore, no differences were found in the occurrence of appropriate and inappropriate ICD interventions between these patient groups.

Success of electrocardioversion on the elderly.

BACKGROUND: There are two treatment strategies for medication-resistant atrial fibrillation (AF): rhythm control or rate control. It has been suggested that rate control is a valid strategy in well-tolerated AF because it does not result in increased mortality. We aimed to investigate the 1-year outcome of rhythm control in an elderly population of AF patients. METHOD: The study was retrospective, using the data collected from electrocardioversions (ECV) of elderly patients and the data of their follow-up visits to the outpatient clinic. We looked for recurrence of AF within the first year after ECV. Furthermore, we investigated possible predictors of recurrence. RESULTS: From February 2008 till November 2011, 436 consecutive elderly patients admitted for ECV were included. The 1-year recurrence rate of AF was 51.3 %. We found that being female and a large left atrial diameter were independent predictors of recurrence. CONCLUSION: The AF recurrence rate in our elderly population is comparable with reported AF recurrence rates in a younger population; we conclude that rhythm control can be regarded as the viable strategy in persistent AF in elderly patients.

Association between angiographic culprit lesion and out-of-hospital cardiac arrest in ST-elevation myocardial infarction patients.

BACKGROUND: Factors related to the occurrence of out-of-hospital cardiac arrest (OHCA) in ST-elevation myocardial infarction (STEMI) are still poorly understood. The current study sought to compare STEMI patients presenting with and without OHCA to identify angiographic factors related to OHCA. METHODS: This multicenter registry consisted of consecutive STEMI patients, including OHCA patients with return-of-spontaneous circulation. Patients were treated with primary percutaneous coronary intervention (PCI) and therapeutic hypothermia when indicated. Outcome consisted of in-hospital neurological recovery, scored using the Cerebral Performance Categories (CPC) scale, and 1-year survival. Logistic regression was used to identify factors associated with OHCA and survival was displayed with Kaplan-Meier curves and compared using log rank tests. RESULTS: In total, 224 patients presented with OHCA and 3259 without OHCA. Average age was 63.3 years and 75% of patients were male. OHCA occurred prior to ambulance arrival in 68% of patients and 48% required intubation. Culprit lesion was associated with OHCA: risk was highest for proximal left coronary lesions and lowest for right coronary lesions. Also, culprit lesion determined the risk of cardiogenic shock and sub-optimal reperfusion after PCI, which were strongly related to survival after OHCA. Neurological recovery was acceptable (CPC≤2) in 77.1% of OHCA patients and did not differ between culprit lesions. CONCLUSIONS: In the present STEMI population, coronary culprit lesion was associated with the occurrence of OHCA. Moreover, culprit lesion influenced the risk of cardiogenic shock and success of reperfusion, both of which were related to prognosis of OHCA patients.