A multi-center, randomized, double-blind, placebo-parallel controlled trial for the efficacy and safety of shenfuqiangxin pills in the treatment of chronic heart failure (Heart-Kidney yang deficiency syndrome).

BACKGROUND: Heart failure (HF) is the final stage of various cardiac diseases with poor prognosis. The integrated traditional Chinese medicine (TCM) and western medicine therapy has been considered as a prospective therapeutic strategy for chronic heart failure (CHF). There have been small clinical trials and experimental studies to demonstrate the efficacy of Shenfu Qiangxin Pills (SFQX) for treating CHF, however, there is still a lack of further high-quality trial. This paper describes the protocol for the clinical assessment of SFQX in CHF (heart-kidney Yang deficiency syndrome) patients. METHODS: A randomized, double-blind, parallel-group, placebo-controlled, multi-center trial will assess the efficacy and safety of SFQX in the treatment of CHF. 352 patients with CHF (heart-kidney Yang deficiency syndrome) from 22 hospitals in China will be enrolled. Besides their standardized western medicine, patients will be randomized to receive treatment of either SFQX or placebo for 12 weeks. The primary outcome is the plasma N-terminal pro-B-type natriuretic peptide levels, which will be measured uniformly by the central laboratory. The secondary outcomes include composite endpoint events (hospitalization due to worsening HF, all-cause mortality, other serious cardiovascular events), echocardiography indicators, grades of the New York Heart Association (NYHA) functional classification, the 6-minute walk test (6MWT) results, Minnesota Living With Heart Failure Questionnaire and TCM syndrome scores. DISCUSSION: The integrated TCM and western medicine therapy has developed into a treatment model in China. The rigorous design of the trial will assure an objective and scientific assessment of the efficacy and safety of SFQX in the treatment of CHF. TRIAL REGISTRATION: Chinese Clinical Trial Registry: ChiCTR2000028777 (registered on January 3, 2020).

Diagnóstico ecocardiográfico e tratamento de cardiomiopatia dilatada em tamanduá- bandeira ( Myrmecophaga trydactila ) mantido em cativeiro: relato de caso / Echocardiographic diagnosis and treatment of dilated cardiomyopathy in captive giant anteater (Myrmecophaga trydactila): case report

A cardiomiopatia dilatada é uma doença de caráter crônico, que compromete a função cardíaca, resultando em desequilíbrio da circulação sanguínea e da homeostase corporal do animal. Este relato apresenta a evolução do quadro clínico e o tratamento de cardiomiopatia dilatada em um exemplar cativo de tamanduá-bandeira. O animal apresentou quadro clínico de insuficiência cardíaca e foi submetido a duas baterias de exames laboratoriais e de imagem em um período de três meses. Posteriormente, foi iniciado o tratamento com pimobendan e suplementação de taurina, resultando em resposta positiva e melhora dos sinais clínicos do paciente. Os achados ecocardiográficos do caso foram compatíveis com cardiomiopatia dilatada com sinais evidentes de diminuição progressiva das frações de ejeção, bem como encurtamento e aumento expressivo das câmaras cardíacas, quando se comparou este caso ao de cães de grande porte e animais saudáveis da mesma espécie. O tratamento com inotrópico positivo, suplementação dietética de taurina e diuréticos se mostrou eficiente em controlar os sinais clínicos do animal.(AU)

The dilated cardiomyopathy it is a chronic disease that leads to a cardiac dysfunction, resulting in unstable blood circulation and specimen body homeostasis. This description shows the dilated cardiomyopathy evolution and treatment in a giant anteater captive model. The patient presented cardiac insufficient clinical condition and was submitted to two sets of laboratorial and image exams in three months. Furthermore, the treatment started with pimobendam and taurine supplementation, leading to satisfactory response to treatment and clinical improvement. The echocardiographic findings were compatible with dilated cardiomyopathy, moreover clear evidence of progressive reduction at the ejection portions and shortening and expressive increase of the cardiac chamber when compared to large dogs and healthy animals of the same species. Treatment with positive inotropic and taurine dietary supplement revealed as effective in clinical managementr.(AU)

Fluoroless Catheter Ablation of Cardiac Arrhythmias: A 5-Year Experience.

BACKGROUND: Catheter ablations have been traditionally performed with the use of fluoroscopic guidance, which exposes the patient and staff to the inherent risks of radiation. We have developed techniques to eliminate the use of fluoroscopy during cardiac ablations and have been performing completely fluoroless catheter ablations on our patients for over 5 years. METHODS: We present a retrospective analysis of the safety, efficacy, and feasibility data from 500 consecutive patients who underwent nonfluoroscopic catheter ablation, targeting a total of 639 arrhythmias, including atrioventricular reciprocating tachycardia (AVRT), atrioventricular nodal reentrant tachycardia (AVNRT), atrial tachycardia (AT), atrial fibrillation (AF), premature ventricular contractions (PVCs), and ventricular tachycardia (VT). We perform fluoroless ablations using intracardiac electrograms, electroanatomic mapping, and for most cases intracardiac echocardiography. Our experience includes exclusively endocardial cardiac ablations. RESULTS: The mean follow-up was 20.5 months. Recurrence rate for AVRT was 6.5%, for AVNRT 2.5%, for macro-reentrant AT 6.4%, for focal AT 5.4%, for AF 22.6%, for PVC 6.7%, and for VT 21.4%. Major complications occurred in five patients (1.0%); minor complications occurred in three patients (0.6%). No deaths occurred. Fluoroscopy was used in one instance, for 0.3 minutes, to confirm venous access. CONCLUSIONS: Completely fluoroless catheter ablations may be routinely performed for all endocardial ablations without compromising safety, efficacy, or procedural duration.

Vitamin D Attenuates Left Atrial Volume Changes in African American Males with Obesity and Prediabetes.

Vitamin D deficiency is common among African Americans in the United States and is associated with increased cardiovascular disease risk. In this study, prediabetic African American males who were found to be vitamin D-deficient were randomized to vitamin D supplementation and assessed for changes in left atrial (LA) volume. Prediabetic African American males who were vitamin D-deficient (25(OH)D: 5.0-29 ng/mL) were randomized to high-dose ergocalciferol or placebo. Echocardiography was performed at baseline and at 1 year. Ejection fraction (EF), septal and posterior wall thickness, LA area, LA length, LA volume, E, A, septal and lateral e' and a', deceleration time, and isovolumetric relaxation time were collected. Eighty-one of 158 (51%) subjects received vitamin D2 . Baseline characteristics were similar among both groups. In the placebo group, left atrial volume significantly increased on follow-up (LA volume increased 6.3 mL, P = 0.0025). Compared with placebo group, the treatment group with ergocalciferol had attenuated increases in left atrial volume (LA volume increased 2.6 mL, P = 0.29). Changes in left atrial volume persisted when indexed to body surface area. There was no significant difference in other diastolic parameters and blood pressure between groups. In conclusion, vitamin D-deficient prediabetic African American males who were treated with high-dose vitamin D2 were found to have attenuated increases in left atrial volume compared with controls over 12-month follow-up.

Prognostic value of calcium score and coronary flow velocity reserve in asymptomatic diabetic patients.

BACKGROUND: The risk stratification of patients with diabetes mellitus (DM) is a major objective for the clinicians, and it can be achieved by coronary flow velocity reserve (CFVR) or with coronary artery calcium score (CS). CS evaluates underlying coronary atherosclerotic plaque burden and CFVR estimates both presence of coronary artery stenosis and microvascular function. Consequently, CFVR may provide unique risk information beyond the extent of coronary atherosclerosis. AIM: Our aim is to assess joint prognostic value of CFVR and CS in asymptomatic DM patients. MATERIALS AND METHODS: We prospectively included 200 asymptomatic patients (45,5 % male, mean age 57,35 ± 11,25), out of which, there were 101 asymptomatic patients with DM and 99 asymptomatic patients without DM, but with one or more conventionally risk factors for coronary artery disease. We analyzed clinical, biochemical, metabolic, inflammatory parameters, CS by Agatston method, transthoracic Doppler echocardiography CFVR of left anterior descending artery and echocardiographic parameters. RESULTS: Total CS and CS LAD were significantly higher, while mean CFVR was lower in diabetics compared to the nondiabetics. During 1 year follow-up, 24 patients experienced cardio-vascular events (one cardiovascular death, two strokes, three myocardial infarctions, nine new onsets of unstable angina and nine myocardial revascularizations): 19 patients with DM and five non DM patients, (p = 0,003). Overall event free survival was significantly higher in non DM group, compared to the DM group (94,9 % vs. 81,2 %, p = 0,002 respectively), while the patients with CS ≥200 and CFVR <2 had the worst outcome during 1 year follow up in the whole study population as well as in the DM group. At multivariable analysis CFVR on LAD (HR 12.918, 95 % CI 3.865-43.177, p < 0.001) and total CS (HR 13.393, 95 % CI 1.675-107.119, p = 0.014) were independent prognostic predictors of adverse events in DM group of patients. CONCLUSION: Both CS and CFVR provide independent and complementary prognostic information in asymptomatic DM patients. When two parameters are analyzed together, the risk stratification ability improves, even when DM patients are analyzed together with non DM patients. As a result, DM patients with CS ≥200 and CFVR <2 had the worst outcome. Consequently, the use of two tests identified subset of patients who can derive the most benefit from the intensive prevention measures.

[Choosing wisely: the Top 5 list of the Italian Association of Hospital Cardiologists (ANMCO)]. / "Fare di più non significa fare meglio". Le proposte dell'ANMCO.

In recent years, a progressive increase in the number of medical diagnostic and interventional procedures has been observed, namely in cardiology. A significant proportion of them appear inappropriate, i.e. potentially redundant, harmful, costly, and useless. Recently, the document Medical Professionalism in the New Millennium: A Physician Charter, the American Board of Internal Medicine (ABIM) Foundation Putting the Charter into Practice program, JAMA's Less Is More and BMJ's Too Much Medicine series, and the American College of Physicians' High-Value, Cost-Conscious Care initiatives, have all begun to provide direction for physicians to address pervasive overuse in health care. In 2010, the Brody's proposal to scientific societies to indicate the five medical procedures at high inappropriateness risk inspired the widely publicized ABIM Foundation's Choosing Wisely campaign. As part of Choosing Wisely, each participating specialty society has created lists of Things Physicians and Patients Should Question that provide specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate individual care. In Italy, Slow Medicine launched the analogue campaign Fare di più non significa fare meglio. The Italian Association of Hospital Cardiologists (ANMCO) endorsed the initiative by recognizing the need to optimize available resources, reduce costs and avoid unnecessary cardiovascular assessments, thereby enhancing the more efficient care delivery models. An ad hoc ANMCO Working Group prepared a list of five cardiac procedures that seem inappropriate for routine use in our country and, after an internal revision procedure, these are presented here.

Inequity in primary and secondary preventive care for acute myocardial infarction? Use by socioeconomic status across middle-aged and older patients.

BACKGROUND: There has been limited research exploring socioeconomic inequity in targeted preventive care for acute myocardial infarction (AMI). The objective of this study was to examine socioeconomic disparities in the use of primary and secondary preventive services relevant to the identification and management of heart disease in a cohort of patients with AMI. METHODS: Preventive services used before the AMI event were examined in a cohort of 30,491 patients with first-time AMI in Ontario, Canada from 2010 to 2012. Using logistic regression, socioeconomic differences in lipid testing, glucose testing, stress testing, electrocardiography (ECG), and echocardiography in middle-aged and older patients were examined. RESULTS: For many of the services, there were no differences in the use of primary and secondary preventive services between patients according to socioeconomic status; however, a number of exceptions were found. Controlling for other factors, we found that for primary preventive services, low-income middle-aged patients had 13% (95% confidence interval [CI], 0.790-0.967) and 10% (95% CI, 0.812-0.997) lower odds of receiving lipid and glucose testing, respectively, when compared with high-income middle-aged patients. Controlling for other factors, we found that for secondary preventive services, low-income middle-aged and older patients had 24% (95% CI, 1.087-1.415) and 10% (95% CI, 1.012-1.202) higher odds of receiving echocardiography when compared with their high-income counterparts. CONCLUSIONS: Socioeconomic disparities in primary and secondary preventive services for patients with AMI could not be demonstrated in many instances. However, inequities in primary preventive care were found in middle-aged patients receiving lipid and glucose testing, which may have implications for Canadian health policy to ensure healthy aging across the age spectrum.

Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure.

BACKGROUND: The rapid detection of left ventricular systolic dysfunction (LVSD) is an important step in the clinical management of patients admitted with acute decompensated heart failure, because it allows the initiation of treatment specific to LVSD and avoidance of contraindicated therapies. The aim of this study was to determine whether internal medicine residents with limited ultrasound training could use hand-carried ultrasound (HCU) to identify LVSD. METHODS: Fifty patients admitted with acute decompensated heart failure were imaged from the parasternal window at the bedside with an HCU device by residents blinded to all clinical data, who had undergone limited cardiac ultrasound training (20 practice studies). Ejection fraction (EF) on HCU was graded as >40% or <40%. HCU EF and a number of physical exam findings and electrocardiographic and laboratory variables were compared for their ability to predict to formal echocardiographic left ventricular EF. RESULTS: The average formal EF was 32 ± 16% (range, 7%-70%), with 66% of patients having EFs < 40%. The residents' ability to detect an EF < 40% with HCU was excellent (sensitivity, 94%; specificity, 94%; negative predictive value, 88%; positive predictive value, 97%). Binary logistic regression demonstrated that HCU EF was the most powerful predictor of EF < 40%, with minimal additional value from clinical, exam, lab, and electrocardiographic variables. The time interval between clinical assessment and availability of formal echocardiographic results was 22 ± 17 hours. CONCLUSIONS: Residents with limited training in cardiac ultrasound were able to identify LVSD in patients with acute decompensated heart failure with superior accuracy compared with clinical, physical exam, lab, and electrocardiographic findings and an average of 22 hours before the results of formal echocardiography were available.

[Appropriateness in echocardiography and clinical priority classification criteria: a proposal from the Italian Society of Cardiovascular Echography]. / Appropriatezza dell'esame ecocardiografico e definizione delle classi di priorità: una proposta della Società Italiana di Ecografia Cardiovascolare.

One of the main tasks of a scientific society is to define the theoretical bases and appropriate management strategies with the aim to maintain a high-quality diagnostic and therapeutic standard. As far as echocardiography is concerned, the task of the Italian Society of Cardiovascular Echography is to provide appropriate, complete, and useful echocardiographic tests for clinical application, as well as procedural, technological, organizational and economic indications to be adopted in clinical practice. In addition, there is an increasing need for regulating access to echocardiographic assessment according to clinical priority, because of the huge proportion of patients who should undergo a first or follow-up echocardiographic evaluation. The aim of this document is to implement appropriateness in echocardiography for the study and follow-up of cardiovascular diseases, and to optimize demand on the basis of clinical priority classification criteria outlined by the scientific societies and used by the National Health Service. Besides cardiovascular diseases, this document also addresses other diseases that often require echocardiographic investigation, such as liver diseases, connective tissue diseases, endocrine diseases, peripheral vascular and oncological diseases. Although not included in the previous guidelines, clinical priority and followup criteria are defined also for these groups of diseases according to the available literature. In conclusion, this document aims at guaranteeing access to the diagnostic echocardiographic procedures provided by the National Health Service to the general population, with practical indications on how to solve the problem of waiting lists.

Resource use in decompensated heart failure by disease progression categories.

The purpose of this study was to quantify the total hospital resource use for decompensated heart failure according to disease progression categories. Clinical and cost information was obtained from an electronic data repository and chart review. During the 1-year period from June 2002 to June 2003, qualified patients were categorized based on disease progression as (1) new onset, (2) known heart failure, or (3) readmission. The primary outcome variables were total hospital resource use and resource use by services. Analysis of variance, Scheffé analysis for pairwise comparisons, and chi-square analysis were performed to determine differences among groups. Total hospitalization costs are similar whether it is a new diagnosis of heart failure, known diagnosis, or readmission. Among the 3 categories, 5 services contained statistically significant differences in costs (P<.05): echocardiography, electrophysiology, neurodiagnostic, nuclear cardiology, and pharmacy. Careful analysis of hospital resource use by services for heart failure patients provides opportunities for institutional cost containment.

[Omega-3 polyunsaturated fatty acids in the correction of hemodynamic disorders in patients with chronic cor pulmonale]. / Omeha-3 polinenasycheni zhyrni kysloty v korektsiï hemodynamichnykh porushen' u khvorykh z khronichnym lehenevym sertsem.

Indices were studied for the right and left ventricular performance in 15 patients with chronic cor pulmonale before and after treatment with tekom containing above 43% of omega-3 polyunsaturated fatty acids. A drop in the pulmonary artery pressure was recordable as was a decline in hyperfunction and dilatation the right ventricule of the heart, which fact can be explained by improvement of the pulmonary ventilation and vasodilatational effect of tekom mediated by a change of the eicosanoids spectrum.

A identificaçäo cinecoronariográfica da lesäo do tronco da coronária esquerda é indicaçäo de cirurgia de revascularizaçäo de emergência ou urgência? / Is the identification of a lesion in the left main coronary artery an indication for an emergent or urgent coronary artery bypass surgery?

OBJETIVO: Esse estudo tem por objetivo verificar se a identificaçäo da lesäo do tronco da coronária esquerda (LTCE) igual ou superior à 50 'por cento' coloca seus portadores em risco aumentado de eventos coronarianos e justifica a indicaçäo de cirurgia dentro de 30 dias da identificiaçäo da lesäo. MÉTODOS: Entre novembro de 1993 a agosto de 1996 nós selecionamos todos os pacientes com LTCE e indicaçäo de cirurgia de revascularizaçäo. Nós estudamos o grau de obstruçäo da LTCE, dominância arterial, diâmetros cavitários e fraçäo de encurtamento ventriculr esquerdo ao ecocardiograma bidimensional, o motivo da indicaçäo de coronariografia, o intervalo de tempo entre a coronariografia e a cirurgia de revascularizaçäo e os eventos coronários (insuficiência aguda, arritmia ventricular complexa, infarto agudo do miocárdio, necessidade de cirurgia de emergência ou urgência ou morte cardíaca). Os pacientes foram dividididos em dois grupos de acordo com a indicaçäo de coronariografia: grupo 1, composto por 7 pacientes com angina instável e grupo 2, composto por 49 pacientes com doença isquêmica estável. RESULTADOS: Havia maior número de fumantes (p=0,03) no grupo 1. Näo houve diferença nas dimensöes cavitárias ou na fraçäo de encurtamento ventricular....CONCLUSÄO: Com exceçäo dos pacientes com angina instável, o diagnóstico da LTCE acima de 50 'por cento' näo indica necessidade imediata de cirurgia de revascularizaçäo miocárdica.

Transposición corregida de las grandes arterias en pacientes mayores de 65 años / Corrected transposition of the great arteries in the elderly

Describimos tres enfermos con transpocisión corregida de las grandes arterias, mayores de 65 años. El primero con una sobrevida de 80 años tenía situs inversus atrial, estenosis valvular pulmonar calcificada, pequeña comunicación interventricular y discreta regurgitación tricuspídea. El segundo era portador de situs solitus atrial, con comunicación interatrial e interventricular amplias. El último también tenía situs solitus atrial y disctera regurgitación tricuspídea, diagnosticada por ecocardiografía y angiocardiografía. La evolución clínica de uno de estos enfermos mostró que los defectos septales evolucionan al igual que en los enfermos portadores de conexiones atrioventriculares y ventriculoarteriales concordantes, son pacientes que desarrollan hipertensión arterial pulmonar y posteriormente insuficiencia cardíaca secundaria. El primer sujeto de esta serie tenía como lesión significativa una estenosis pulmonar valvular de cierta importancia, que se calcificó y cuya asociación con cardiopatía isquémica tuvo un papel importante en la génesis de la insuficiencia cardíaca. El tercer sujeto, para fines prácticos sin defectos asociados, tuvo como complicación una enfermedad vascular cerebral. Ninguno desarrolló bloqueo atrioventricular, a pesar de la larga evolución. Estos tres casos ejemplifican una evolución natural poco habitual de la transpiración corregida de las grandes arterias

Pericarditis por coccidioidomicosis: informe de un caso / Pericarditis by coccidioidomycosis. A case report

Se presenta el caso de una niña de once años de edad que cursó con pericarditis por coccidioidomicosis, el cual resulta interesante porque no se ha reportado en la literatura regional y nacional siendo el Estado de Sonora considerada área endémica para coccidioidomicosis. Sobresalen en el cuadro clínico fiebre y manifestaciones cardiovasculares desde el inicio de los síntomas y a lo largo de su evolución. Por el curso prolongado e insidioso hubo necesidad de practicar diversos estudios de laboratorio y gabinete, descartándo etiología no infecciosa. Se llegó al diagnóstico definitivo por punción pericárdica; en el material obtenido se praticaron estudios bacteriológicos y cultivo para hongos, resultando positivo para Coccidioides immitis. En el futuro habremos de considerar esta etiología ante cualquier caso de pericarditis y sería recomendable tomarla en cuenta en las regiones de alta prevalencia en la República Mexicana

Gas-filled liposomes as echocardiographic contrast agents in rabbits with myocardial infarcts.

RATIONALE AND OBJECTIVES: The authors evaluated gas-filled liposomes as echocardiographic contrast agents in rabbits with myocardial infarcts. METHODS: Ten rabbits underwent ligation of the left anterior descending coronary artery. Five animals underwent echocardiography before and after production of myocardial infarct (MI) and four animals had post-MI imaging only. In either case, images were obtained before and after injection of a single dose of 1 mL of gas-filed liposomes. Three radiologists blinded to clinical information reviewed the pre- and postcontrast images and assessed endomyocardial border definition, wall motion, confidence levels for normal versus abnormal wall motion and visualization of papillary muscle and mitral valve. RESULTS: Postcontrast scans showed significant improvement (P < .05) in endomyocardial border definition, visualization of wall motion, papillary muscle and mitral valve as well as increased reader confidence level. CONCLUSIONS: These results are encouraging and suggest that gas-filled liposomes may be a useful contrast agent for echocardiography.

[The effect of nifedipine in hypertensive cardiopathy. An echocardiographic and electrocardiographic study]. / Effetto della nifedipina sulla cardiopatia ipertensiva. Studio ecocardiografico ed elettrocardiografico.

To assess whether antihypertensive therapy by nifedipine can reverse left ventricular (LV) hypertrophy, 15 hypertensive patients, mean age 47 years, were serially studied during 12 months of treatment with nifedipine in slow release (40-60 mg/day), by recordings of blood pressure (BP), ECG and echocardiogram. Blood pressure decreased from 161 +/- 6/104 +/- 3 mmHg to 131 +/- 3/89 +/- 1 mmHg, p < 0.001, and this fall first became statistically significant at 1 month. From the hemodynamic view point, BP decreased for a reduction in total peripheral resistance. The Sokolow-Lyon voltage decreased significantly after 6 months (from 33.5 +/- 2.7 to 28.1 +/- 2.1 mm, p < 0.01) without further changes in the subsequent months. Left ventricular mass, by echocardiography, decreased after 6 months (from 189 +/- 15 to 176 +/- 13 g/m2, p < 0.05) and further after 12 months (169 +/- 13 g/m2, p < 0.001). The reduction in LV mass was secondary to the decrease in wall thickness, particularly in posterior wall thickness. No significant changes were observed in LV fractional shortening throughout the study. Thus, nifedipine was an effective antihypertensive agent and reverted LV hypertrophy secondary to arterial hypertension without impairment of LV systolic function.