Inappropriate implantable cardioverter defibrillator shocks due to atrial far-field on the tip-to-ring channel for lead dislodgement.

We reported a case of inappropriate implantable cardioverter defibrillator shocks, due to atrial far-field on the tip-to-ring channel of the fast electrical activity during atrial fibrillation, caused by lead dislocation in the right ventricle outflow tract. During these episodes the can-to-right ventricle coil signal correctly recorded the ventricular activity. The shock storm stopped when an antitachycardia pacing restored sinus rhythm.

Prognostic value of plasma brain natriuretic peptide, urea nitrogen, and creatinine in outpatients >70 years of age with heart failure.

This study analyzed the relevance of plasma brain natriuretic peptide (BNP) and echocardiography in predicting cardiovascular events in a large population >70 years old with heart failure (HF). Three hundred four outpatients with HF (51.6% men, mean age 78.6) underwent transthoracic echocardiography and plasma BNP testing shortly before hospital discharge. Echocardiography was intended to reveal systolic dysfunction (left ventricular [LV] ejection fraction [EF] <50%) or diastolic dysfunction (EF > or =50% and abnormalities of ventricular relaxation). During 6-month follow-up, all-cause death and readmission were assessed. One hundred seventeen patients had diastolic dysfunction with preserved systolic LV function, and 187 had systolic dysfunction. At 6-month clinical follow-up, 33 subjects (10.9%) had died, and 62 (20.4%) needed readmission for cardiac decompensation. In all patients, univariate logistic regression demonstrated significant correlations between age (r = 0.14, p = 0.01), plasma BNP (r = 0.36, p = 0.0001), the EF (r = 0.16, p = 0.003), urea nitrogen (r = 0.35, p = 0.0001), serum creatinine (r = 0.27, p = 0.0001), and New York Heart Association (NYHA) class (r = 0.35, p = 0.0001) and the occurrence of cardiovascular events. In patients with HF in NYHA class III or IV, a BNP cut-off level of 200 pg/ml identified different outcomes (BNP <200 pg/ml in 1 of 20 events vs BNP >200 pg/ml in 55 of 85 events, p = 0.0001). In patients with HF who were >70 years old, BNP, NYHA class, and renal function predicted adverse outcome. In patients with severe HF, BNP was better than NYHA class in predicting future events.

The NT-proBNP assay identifies very elderly nursing home residents suffering from pre-clinical heart failure.

BACKGROUND: Little is known about the prevalence of heart failure among very old people, although hospitalisation rates for chronic heart failure are very high. Recently, brain natriuretic peptides have emerged as important diagnostic and prognostic serum markers for congestive heart failure. AIMS: The main purpose of our study was to determine whether there is a cut-off for NT-proBNP for detecting the echocardiographic features of left ventricular systolic and/or diastolic dysfunction and clinical heart failure among old people living in nursing homes. Secondarily, we investigated the medium-term prognostic power of the neurohormone levels. METHODS: We screened 101 old people (80% females, aged 84+/-9 years) from two nursing homes. We prospectively evaluated whether we could effectively stratify patients using a combination of (1) restrictive clinical criteria, (2) NT-proBNP measurements (Elecsys System, Roche Diagnostics) and (3) echocardiography for all patients. RESULTS: Forty-two percent of the subjects had left ventricular dysfunction: 11% systolic, 23% diastolic and 8% both systolic and diastolic. The mean NT-proBNP concentration was 2806+/-7028 pg/ml in the 42 patients with left ventricular systolic and/or diastolic dysfunction, compared with 365+/-456 pg/ml in the 59 patients with normal left ventricular function (p<0.01, Z=-4.8 Mann-Whitney U test). The neurohormone proved to be a good predictor of events within 6 months [area under the receiver-operated curve (ROC)=0.79]. CONCLUSIONS: Blood NT-proBNP concentrations can play an important role in stratifying old people into left ventricular dysfunction risk groups. The neurohormone is an independent marker for death or admission for heart failure in the medium term.

[Is early discharge possible in patients with uncomplicated heart failure? Cost-efficacy analysis]. / E possibile dimettere precocemente il paziente con scompenso cardiaco non complicato? Un'analisi costo-efficacia.

BACKGROUND: Heart failure is a common indication for admission to the hospital among old adults. The hospital stay for uncomplicated heart failure is often too long. We hypothesized that a rapid optimization of care and a guideline-based approach would allow an early discharge of patients, still maintaining a greater quality and efficiency of care. METHODS: We conducted a randomized trial of the effect of a guideline-based intervention on rates of readmission within 90 days of hospital discharge and costs of care for patients who were hospitalized for heart failure and discharged after 4 days of stay. The intervention consisted of early echocardiography, aggressive diuretic therapy, comprehensive education of the patient and family, a prescribed diet, and intensive application of the guidelines' recommendations on pharmacological therapy. Fifty early-discharged patients were compared to 50 concurrent normally-discharged patients. RESULTS: Average length of stays during baseline admissions was shorter for early-discharged patients respect to controls (3.9 +/- 0.8 vs 7.0 +/- 1.9 days, p < 0.001). At discharge, when compared with control patients, early-discharged patients were similarly prescribed and/or were taking similar dosages of ACE-inhibitors (84 vs 80% and 17 vs 15 mg/die, p = NS), beta-blockers (64 vs 56% and 14 vs 16 mg/die, p = NS), spironolactone (86 vs 70% and 36 vs 32 mg/die, p = NS), digoxin (74 vs 70% and 0.18 vs 0.15 mg/die, p = NS), and losartan (8 vs 6% and 50 mg/die for both groups, p = NS). Hospital readmission rates and days of stay were similar between groups (6 vs 8% and 18 vs 26 days, respectively for study and control patients), whilst the overall costs of care were lower for early-discharged patients (289 vs 449 [symbol: see text] per patient per month), due to the shorter length of stay at baseline. Survival for 90 days was achieved in 47 patients both in the study and control groups (p = NS). CONCLUSIONS: Our study showed that patients admitted for heart failure may be safely discharged 4 days after admission. An in-hospital guideline-based management of patients allows relevant cost savings, reducing hospital readmission for heart failure.

B-type natriuretic peptide can predict the medium-term risk in patients with acute heart failure and preserved systolic function.

BACKGROUND: Half of patients with heart failure (HF) have preserved left ventricular ejection fraction (LVEF). Neurohormonal activation characterizes the disease and measurement of plasma B-type natriuretic peptide (BNP) indicates the severity of left ventricular dysfunction. The purpose of this study was to test the hypothesis that measurement of BNP levels in ambulatory patients with HF and preserved LVEF can predict the occurrence of cardiovascular events in the next 6 months. METHODS AND RESULTS: We enrolled 233 consecutive patients admitted to the Outpatient Heart Failure Clinic (OHFC), on stabilization after an episode of acute HF, with a LVEF > 50%. Standard echocardiography was performed and left ventricular systolic/diastolic function was assessed. Plasma BNP levels were measured on admission to OHFC. Patients were followed for 6 months; the main endpoint combined cardiovascular death or readmission for HF. Among the 233 patients discharged, 48 endpoints occurred (death: n = 15; readmission: n = 33). Receiver operated curve analysis shows that BNP levels are strong predictors of subsequent events (area under the curve = 0.84; CI = 0.78-0.88). Multivariate Cox regression showed that the cutoff values identified by receiver operated curve analysis (200-500 pg/mL) of the neurohormone are the most accurate predictors of events: HR = 2.2 (P < .04) and HR = 5.8 (P < .001), respectively, for 201-499 pg/mL and > or = 500 pg/mL ranges. CONCLUSION: BNP level is a strong predictor for cardiovascular mortality and early readmission in patients with diastolic HF. The results suggest that BNP levels might be used successfully to guide the intensity of follow-up after a decompensation, because increased BNP levels were associated with a progressively bad prognosis.