Heart failure admissions in adults with congenital heart disease; risk factors and prognosis.

BACKGROUND: Heart failure (HF) is a serious complication and often the cause of death in adults with congenital heart disease (CHD). Therefore, our aims were to determine the frequency of HF-admissions, and to assess risk factors of first HF-admission and of mortality after first HF-admission in adults with CHD. METHODS: The Dutch CONCOR registry was linked to the Hospital Discharge Registry and National Mortality Registry to obtain data on HF-admissions and mortality. Risk factors for both HF-admission and mortality were assessed using Cox regression models. RESULTS: Of 10,808 adult patients (49% male), 274 (2.5%) were admitted for HF during a median follow-up period of 21 years. The incidence of first HF-admission was 1.2 per 1000 patient-years, but the incidence of HF itself will be higher. Main defect, multiple defects, and surgical interventions in childhood were identified as independent risk factors of HF-admission. Patients admitted for HF had a five-fold higher risk of mortality than patients not admitted (hazard ratio (HR)=5.3; 95% confidence interval 4.2-6.9). One- and three-year mortality after first HF-admission were 24% and 35% respectively. Independent risk factors for three-year mortality after first HF-admission were male gender, pacemaker implantation, admission duration, non-cardiac medication use and high serum creatinine. CONCLUSIONS: The incidence of HF-admission in adults with CHD is 1.2 per 1000 patient-years. Mortality risk is substantially increased after HF-admission, which emphasises the importance to identify patients at high risk of HF-admission. These patients might benefit from closer follow-up and earlier medical interventions. The presented risk factors may facilitate surveillance.

Reversal of ventricular premature beat induced cardiomyopathy by radiofrequency catheter ablation.

Frequent monomorphic ventricular premature beats (VPBs) may lead to left ventricular dysfunction. We describe two patients with frequent monomorphic VPBs and dilated cardiomyopathy in whom left ventricular function normalised after elimination of the VPBs by radiofrequency catheter ablation. The recent literature on this topic is summarised and potential candidates for catheter ablation are discussed. (Neth Heart J 2010;18:493-8.).

Campylobacter jejuni: enterocolitis and myopericarditis.

Campylobacter jejuni enteritis is the commonest enteric infection in the developed world. There are only few reported cases in the medical literature of cardiac complications associated with C. jejuni enterocolitis, most of the patients in the reported literature were males and most of the cases followed a benign course. Severe left ventricular dysfunction complicated only two cases of C. jejuni myocarditis. We report here a young male with Campylobacter myopericarditis. We believe that this is the first reported case of Campylobacter associated myopericarditis in The Netherlands. The mechanism by which Campylobacter causes myo(peri)carditis remains uncertain, it may be caused by direct bacterial invasion of cardiac tissue, bacterial toxins, circulating immune complexes, or cytotoxic T-cells. Since the number of C. jejuni infection is increasing worldwide, cardiac complications, although rare, are a remarkable manifestation of this pathogen and should be always kept in mind.

Reversal of pathophysiologic changes with long-term lisinopril treatment in isolated systolic hypertension.

The purpose of this study was to evaluate in a prospective, double-blind, placebo-controlled study the effect of long-term (2-year) lisinopril treatment on cardiovascular end-organ damage in patients with previously untreated isolated systolic hypertension (ISH). All patients with ISH were derived from a population screening program. End-organ damage measurements, done initially and after 6 and 24 months of treatment, included measurements of aortic distensibility and echocardiographic left ventricular mass index (LVMI) and diastolic function. Blood pressure was measured by office and ambulatory measurements. Of the 97 subjects with ISH selected from the screening, 62 (30 lisinopril) completed the study according to protocol. Office blood pressure decreased in both groups, but ambulatory results significantly decreased with lisinopril-treatment only. Aortic distensibility increased significantly with lisinopril, as opposed to a decrease in placebo-treated subjects. The main effect of increased distensibility occurred between 6 and 24 months, whereas ambulatory blood pressure changed mainly in the first 6 months of treatment. LVMI decreased in both treatment groups, with a significantly higher reduction in lisinopril-treated subjects. Left ventricular diastolic function showed no significant changes in either group. The vascular pathophysiologic alterations of ISH-a decreased aortic distensibility-can be improved with long-term lisinopril treatment, whereas values deteriorate further in placebo-treated subjects. These results, in one of the first studies including subjects with previously untreated ISH only, indicate that lisinopril treatment might favorably influence the cardiovascular risk of ISH.

Isolated systolic hypertension from a vascular point of view.

Due to the results of antihypertensive intervention studies, isolated systolic hypertension (ISH) has gained new interest lately. Yet, apart from increased aortic stiffness, the specific pathophysiological features of ISH have remained largely undetermined. Therefore, we investigated the elastic properties of the vascular bed of an upper arm segment in uncomplicated ISH patients and matched normotensive controls using an electrical bioimpedance technique. Compared with the controls, the compliance of the arterial bed as a whole at normotensive blood pressure level was on the average 108.0% higher (p < 0.005) in the hypertensive patients. The blood volume of the arterial bed as a whole at operating blood pressure level and that of the larger arteries were significantly higher (40.5%, p < 0.05, and 40.5%, p < 0.01, respectively). The same held true for the venous blood volume (64.4%, p < 0.05), and for the width of the arterial compliance-pressure relation (34.6%, p < 0.01). We concluded that ISH is a separate pathophysiological entity in which all parts of a peripheral vascular bed are changed and the decreased buffering function of the aorta and large arteries is partly compensated for by an increase in small artery compliance.

A simple nomogram for determination of echocardiographic left ventricular geometry.

Recent data have shown that left ventricular (LV) geometry provides additional information on the simple dichotomy of presence or absence of LV hypertrophy with regard to cardiovascular risk of hypertensive patients. A "new" class of concentric remodeling was created, identifying a rather large group of hypertensive patients who do have increased risk despite no LV hypertrophy. Because determination of LV geometry is not easy, our objective was to develop a nomogram enabling determination of LV geometry in a simple way. The geometric classification is based on the combination of increased relative wall thickness and LV hypertrophy (LV mass index > or = 125 g/m2) both of which are calculated from wall thickness and end-diastolic diameter. In the nomogram the calculated cutoff lines for relative wall thickness and left ventricular hypertrophy are plotted, forming 4 quadrants that represent the geometric classes. Two nomograms are made: 1 based on Penn convention measurement calculations and 1 based on American Society of Echocardiography convention measurements. This nomogram provides a simple way to determine LV geometry, and thus a quick assessment of the additional cardiovascular risk of the hypertensive patient. This is especially important for subjects with concentric remodeling, who would otherwise not be identified as having increased risk for cardiovascular disease.

Effects of amlodipine and lisinopril on left ventricular mass and diastolic function in previously untreated patients with mild to moderate diastolic hypertension.

The aim of the study was to compare the effects of two long-acting antihypertensive agents, the calcium-antagonist amlodipine and the ACE inhibitor lisinopril, on left ventricular mass and diastolic filling in patients with mild to moderate diastolic hypertension from primary care centres. It is a 1-year prospective, double-blind, randomized, parallel group, comparative study. Patients between 25 and 75 years of age with untreated hypertension with elevated diastolic blood pressure (> or = 95 mmHg) on three occasions (twice on the first visit and once only on the second and third visits) were recruited from a population survey. After 4 weeks placebo run-in 71 patients were randomized to dosages of amlodipine 5-10 mg or lisinopril 10-20 mg, which were titrated on the basis of the effects on blood pressure. Fifty-nine patients completed the study period. Primary endpoints were left ventricular mass index and early to atrial peak filling velocity. Office and ambulatory blood pressure and other echocardiographic measurements were considered secondary. Decrease in blood pressure was equal for both treatment regimens. A statistically significant decrease in left ventricular mass index in both treatment groups was observed: -11.0 g/m2 (95% CI: -6.0, -16.1) in the amlodipine group and -12.6 g/m2 (95% CI: -8.2, -17.0) in the lisinopril group. The higher the baseline value of left ventricular mass before treatment, the more the decrease after treatment. Early to atrial peak filling velocity did not change significantly within the treatment groups: +0.07 (95% CI: -0.01, +0.15) in the amlodipine group and +0.01 (95% CI: -0.06, +0.08) in the lisinopril group. However, analysis of time measurements of the early peak showed significant changes for both treatment groups. No significant differences in primary and secondary endpoints between treatment groups were found. Twelve patients did not complete the study, seven in amlodipine and five in lisinopril, basically due to adverse events. The effects of amlodipine and lisinopril on left ventricular mass and early to atrial filling peak velocity after 1 year of treatment in patients with previously untreated mild to moderate hypertension are similar. Further studies are recommended, particularly with a larger sample size and a follow-up of longer duration.

Effect of quinapril and triamterene/hydrochlorothiazide on cardiac and vascular end-organ damage in isolated systolic hypertension.

We compared, in a prospective double-blind randomized study, the effect of the angiotensin-converting enzyme inhibitor quinapril (QUI) with that of triamterene/hydrochlorothiazide (THCT) treatment on cardiovascular end-organ damage in subjects with untreated isolated systolic hypertension (ISH). End-organ damage measurements, performed initially and after 6 and 26 weeks of treatment, included echocardiographic determination of left ventricular mass index (LVMI) and of diastolic function and measurement of aortic distensibility and peripheral vascular resistance. Blood pressure was significantly reduced in the 44 subjects (21 QUI, 23 THCT) completing the study. Both LVMI and aortic distensibility had changed at 6 weeks, with comparable improvements in both groups. LV diastolic function showed overall no significant changes, although patterns of early filling did differ between the two drug groups. Peripheral vascular resistance appeared to increase between 6 and 26 weeks in THCT subjects only, along with a decreased aortic distensibility. Blood pressure and LV mass were rapidly and markedly reduced in both treatment groups of ISH subjects, paralleled by an improvement of aortic distensibility. In interpreting these results, the pathophysiologic alterations in ISH need to be taken into account, because these differ strongly from those in diastolic hypertension. Results of LV diastolic function and peripheral vascular resistance were less clear but appear to show less favorable changes in the THCT subjects treatment group.

High prevalence of concentric remodeling in elderly individuals with isolated systolic hypertension from a population survey.

Echocardiographic determination of left ventricular mass index (LVMI) is shown to be valuable in the assessment of cardiovascular risk. Determination of left ventricular geometry, including concentric remodeling, provides additional prognostic information. In isolated systolic hypertension (ISH), the few echocardiographic studies available show an increased LVMI, but criteria and patient populations differ. No comparison with diastolic hypertension (DH) has been made, nor has left ventricular geometry (with concentric remodeling) been evaluated. We compared both LVMI and left ventricular geometry of newly diagnosed ISH subjects with normotensive and DH subjects, all previously untreated and from the same population. The echocardiographic LVMI of 97 previously untreated ISH subjects (4 x systolic pressure > or = 160 mm Hg, diastolic pressure < 95 mm Hg) was clearly elevated compared with values in age- and sex-matched normotensive subjects (98 and 71 g/m2, respectively; P < .001). The geometric pattern was abnormal in most ISH subjects, with a high prevalence (43%) of concentric remodeling. Both LVMI and left ventricular geometry of ISH subjects did not differ significantly from values in DH subjects (LVMI, 92 g/m2; concentric remodeling, 56%). Sex differences in LV geometry in ISH were present only with the Framingham criteria, not with the Koren criteria. This study shows a high prevalence of concentric remodeling in elderly individuals with previously untreated ISH. The increase of LVMI and abnormality in left ventricular geometry are comparable with those in DH subjects, further defining the place of ISH as a cardiovascular risk factor in the elderly. Whether there are sex differences in cardiac adaptation in ISH and whether the geometric classification can be used to adjust treatment remain to be investigated.

Acceptance and side effects of ambulatory blood pressure monitoring: evaluation of a new technology.

Ambulatory blood pressure (BP) monitoring is probably becoming a clinically useful procedure for the evaluation of hypertensive patients. Previous reports have shown that the devices are safe and serious side effects are rare. Discomfort and inconveniences associated with its use are more frequent. In this study, patient acceptance of ambulatory blood pressure monitoring (ABPM) was compared with acceptance of other diagnostic procedures and their side effects were assessed. Patients were asked to fill in a form and 129 of 166 patients responded. The acceptance was measured with a visual analogue scale which ranged from 'very annoying' on the left to 'not annoying at all' on the right. All forms were collected anonymously. Mean distance (cm) of the visual likert scale was 8.6 to 9.4 for the diagnostic procedures frequently used in routine patient care. Ambulatory BP measurement (ABPM) scored 6.1 cm. Reported side effects (in 27% of patients) were: plan (9%), skin irritation (8%), noisy device (8%), inconvenience with work (3%), haematoma (2%) and other (4%). Reports from the patients on sleep quality were: 23% normal, 61% minor disturbance, 14% had sleep, and 2% did not sleep at all. It can be concluded that ambulatory BP monitoring was the diagnostic procedure with the lowest patient acceptance. Side effects of this new technology were reported by 27% of patients. However, risks are relatively minor. Sleep disturbances were very frequent and was a serious problem for 16% of patients.

Predictive value of ambulatory blood pressure shortly after withdrawal of antihypertensive drugs in primary care patients.

OBJECTIVE: To determine whether ambulatory blood pressure eight weeks after withdrawal of antihypertensive medication is a more sensitive measure than seated blood pressure to predict blood pressure in the long term. DESIGN: Patients with previously untreated diastolic hypertension were treated with antihypertensive drugs for one year; these were withdrawn in patients with well controlled blood pressure, who were then followed for one year. SETTING: Primary care. SUBJECTS: 29 patients fulfilling the criteria for withdrawal of antihypertensive drugs. MAIN OUTCOME MEASURES: Sensitivity, specificity, and positive and negative predictive value of seated and ambulatory blood pressure eight weeks after withdrawal of antihypertensive drugs. RESULTS: Eight weeks after withdrawal of medication, mean diastolic blood pressure returned to the pretreatment level on ambulatory measurements but not on seated measurements. One year after withdrawal of medication, mean diastolic blood pressure had returned to the pretreatment level both for seated and ambulatory blood pressure. For ambulatory blood pressure, the sensitivity and the positive predictive value eight weeks after withdrawal of medication were superior to those for seated blood pressure; specificity and negative predictive value were comparable for both types of measurement. Receiver operating characteristic curves showed that the results were not dependent on the cut off values that were used. CONCLUSION: Ambulatory blood pressure eight weeks after withdrawal of antihypertensive drugs predicts long term blood pressure better than measurements made when the patient is seated.

Prediction of the left ventricular mass from the electrocardiogram in systemic hypertension.

Although echocardiography provides a reliable method to determine left ventricular (LV) mass, it may not be available in all settings. Numerous electrocardiographic (ECG) criteria for the detection of LV hypertrophy have been developed, but few attempts have been made to predict the LV mass itself from the ECG. In a community-based survey program in the general population, 277 subjects were identified with untreated diastolic hypertension (diastolic blood pressure 95 to 115 mm Hg, 3 occasions) or isolated systolic hypertension (diastolic blood pressure <95 mm Hg and systolic blood pressure 160 to 220 mm Hg, 3 occasions). All subjects underwent ECG and echocardiography on the same day. A multiple linear regression analysis was performed using a random training sample of the data set (n = 185). The independent variables included both ECG and non-ECG variables. The resulting model was used to predict the LV mass in the remainder of the data set, the validation sample (n = 92). Using sex, age, body surface area, the S-voltage in V1 and V4, and the duration of the terminal P in V1 as independent variables, the model explained 45% of the variance (r = 0.67) in the training sample and 42% (r = 0.65) in the validation sample. This result exceeded that of 2 existing ECG models for LV mass (r = 0.40 and 0.41). The correlations between LV mass and combinations of ECG variables used for the detection of LV hypertrophy, such as the Sokolow-Lyon Voltage (r = 0.03) and the Cornell Voltage (r = 0.31), were comparatively low. In settings where echocardiography is not available or is too expensive and time-consuming, prediction of the LV mass from the ECG may offer a valuable alternative.