Changes in cardiac output, rhythm regularity, and symptom severity after electrical cardioversion of atrial fibrillation.

OBJECTIVES: Symptoms in atrial fibrillation (AF) range from none to disabling. The physiological correlates of AF symptoms are not well characterized. This study investigated the association between physiological parameters and symptom severity before and after electrical cardioversion (EC) of AF. DESIGN: We studied 44 patients with persistent AF (age 66.2 ± 7.9 years, 16% females) 4 ± 2 days before and 5 ± 2 days after EC. Physiological parameters included cardiac output (CO; non-invasive inert gas rebreathing), heart rate (HR), RR variability and resting and ambulatory blood pressure (BP). Symptoms and quality of life (QoL) were assessed by the modified European Heart Rhythm Association score (mEHRA), the Atrial Fibrillation Effect on Quality of Life (AFEQT) and the Symptom Checklist for frequency and severity of symptoms (SCL). RESULTS: 28 of 44 patients were still in sinus rhythm (SR) at post EC evaluation. Those in SR had a decreased HR (-15.4 ± 13.1 bpm, p < 0.001), and an increased CO (+0.8 ± 0.7 L/min, p < 0.001) as compared to those with recurrent AF. Changes in CO after EC correlated with symptom improvement as scored by AFEQT (r = 0.36; p < 0.05), AFEQT symptoms subscore (r = 0.46; p < 0.01), SCL for frequency (r = 0.62; p < 0.01) and severity (r = 0.33; p < 0.05) of symptoms, and the mEHRA score (r = 0.50; p < 0.01). A decrease in RR variability showed similar correlations with these measures of symptom improvement. CONCLUSIONS: Improvements in symptoms and quality of life experienced by patients after electrical conversion of atrial fibrillation are correlated with an increase in CO and a decreased RR variability.

Associations Between Crowding and Ten-Day Mortality Among Patients Allocated Lower Triage Acuity Levels Without Need of Acute Hospital Care on Departure From the Emergency Department.

STUDY OBJECTIVE: We describe the association between emergency department (ED) crowding and 10-day mortality for patients triaged to lower acuity levels at ED arrival and without need of acute hospital care on ED departure. METHODS: This was a registry study based on ED visits with all patients aged 18 years or older, with triage acuity levels 3 to 5, and without need of acute hospital care on ED departure during 2009 to 2016 (n=705,699). The sample was divided into patients surviving (n=705,076) or dying (n=623) within 10 days. Variables concerning patient characteristics and measures of ED crowding (mean length of stay and ED occupancy ratio) were extracted from the hospital's electronic health records. ED length of stay per ED visit was estimated by the average length of stay for all patients who presented to the ED during the same day and shift and with the same acuity level. The 10-day mortality after ED discharge was used as the outcome measure. Multivariable logistic regression analyses were conducted. RESULTS: The 10-day mortality rate was 0.09% (n=623). The event group had larger proportions of patients aged 80 years or older (51.4% versus 7.7%) and triaged with acuity level 3 (63.3% versus 35.6%), and greater comorbidity (age-combined Charlson comorbidity index median interquartile range 6 versus 0). We observed an increased 10-day mortality for patients with a mean ED length of stay greater than or equal to 8 hours versus less than 2 hours (adjusted odds ratio 5.86; 95% confidence interval [CI] 2.15 to 15.94) and for elevated ED occupancy ratio. Adjusted odds ratios for ED occupancy ratio quartiles 2, 3, and 4 versus quartile 1 were 1.48 (95% CI 1.14 to 1.92), 1.63 (95% CI 1.24 to 2.14), and 1.53 (95% CI 1.15 to 2.03), respectively. CONCLUSION: Patients assigned to lower triage acuity levels when arriving to the ED and without need of acute hospital care on departure from the ED had higher 10-day mortality when the mean ED length of stay exceeded 8 hours and when ED occupancy ratio increased.

High beat-to-beat blood pressure variability in atrial fibrillation compared to sinus rhythm.

PURPOSE: Atrial fibrillation (AF) is associated with an increased risk for cardiovascular morbidity and mortality, not entirely explained by thromboembolism. The underlying mechanisms for this association are largely unknown. Similarly, high blood pressure (BP) increases the risk for cardiovascular events. Despite this the interplay between AF and BP is insufficiently studied. The purpose of this study was to examine and quantify the beat-to-beat blood pressure variability in patients with AF in comparison to a control group of patients with sinus rhythm. MATERIALS AND METHODS: We studied 33 patients - 21 in atrial fibrillation and 12 in sinus rhythm - undergoing routine coronary angiography. Invasive blood pressure was recorded at three locations: radial artery, brachial artery and ascending aorta. Blood pressure variability, defined as average beat-to-beat blood pressure difference, was calculated for systolic and diastolic blood pressure at each site. RESULTS: We observed a significant difference (p < .001) in systolic and diastolic blood pressure variability between the atrial fibrillation and sinus rhythm groups at all locations. Systolic blood pressure variability roughly doubled in the atrial fibrillation group compared to the sinus rhythm group (4.9 and 2.4 mmHg respectively). Diastolic beat-to-beat blood pressure variability was approximately 6 times as high in the atrial fibrillation group compared to the sinus rhythm group (7.5 and 1.2 mmHg respectively). No significant difference in blood pressure variability was seen between measurement locations. CONCLUSIONS: Beat-to-beat blood pressure variability in patients with atrial fibrillation was substantially higher than in patients with sinus rhythm. Hemodynamic effects of this beat-to-beat variation in blood pressure may negatively affect vascular structure and function, which may contribute to the increased cardiovascular morbidity and mortality seen in patients with atrial fibrillation.

Improvement of blood pressure control and physicians' management over time in patients with coronary artery disease.

BACKGROUND: Patients with coronary artery disease (CAD) are at high risk for secondary CV events. Few studies have been performed concerning the physicians' reactions to high BP in patients with manifest CAD. AIMS: To compare the prevalence and management of high BP after percutaneous coronary intervention (PCI) in 2011-2012 with that in 2004. MATERIAL AND METHODS: We identified 300 consecutive patients from 2011-2012 and 167 from 2004 with a follow-up visit after PCI at a University hospital in Sweden. Their medical records were reviewed to collect BP values and physicians' actions in response to an elevated BP at the follow-up visit. RESULTS: The proportion of patients who had their BP documented increased in 2011-2012 (91%) as compared to 2004 (79%). The proportion of patients with a BP ≥140 mmHg systolic and/or ≥90 mmHg diastolic at the follow-up visit decreased from 55% in 2004 to 42% in 2011-2012 (p = 0.014). CONCLUSION: BP documentation and control improved from 2004 to 2011-2012 with more patients reaching target BP levels. One of the reasons for the improvements may be the introduction of a secondary preventive unit with cardiovascular specialised nurses who participate in a national quality registry.

Ambulatory pulse pressure predicts cardiovascular events in patients with peripheral arterial disease.

BACKGROUND: Patients with peripheral arterial disease (PAD) are at high risk of cardiovascular (CV) events and often have hypertension with a high pulse pressure (PP). We studied the prognostic value of ambulatory blood pressure (ABP) in PAD patients with special reference to PP. METHODS: 98 consecutive males with PAD had 24-h ABP measurements. The mean age was 68 years and CV comorbidity was prevalent. The outcome variable was CV events defined as CV mortality or any hospitalization for myocardial infarction, stroke or coronary revascularization. The predictive value of ABP variables was assessed by Cox regression. 90 age-matched men free of CV disease served as controls. RESULTS: During follow-up (median 71 months), 36 patients and seven controls had at least one CV event. In PAD patients, 24-h PP (hazard ratios, HR, 1.48 (95% confidence interval, CI, 1.14-1.92), p <0.01) predicted CV events. Office PP did not predict events in PAD patients (HR 1.15 (0.97-1.38), ns). In multivariate analysis, 24-h PP (HR 1.48 (1.12-1.95), p <0.01) remained a predictor of CV events. CONCLUSIONS: Ambulatory PP predicts CV events in patients with PAD. ABP measurement may be indicated for better risk stratification in PAD patients.

Predictors of systolic BP <140 mmHg and systolic BP level by randomly assigned treatment group (benazepril plus amlodipine or hydrochlorothiazide) in the ACCOMPLISH Study.

BACKGROUND: The ACCOMPLISH Trial investigated intensive antihypertensive combination treatment with benazepril + amlodipine (B+A) or benazepril + hydrochlorothiazide (B+H) on cardiovascular outcomes in patients with systolic hypertension. We analyzed the baseline predictors of achieving a systolic blood pressure (SBP) <140 mmHg and achieved SBP level by the end of 12 months in both treatment groups. METHODS: Baseline and 12-month SBP was available in 10,506 patients, of whom 6250 had diabetes. Univariate and multivariate logistic regression models were used for SBP control at 12 months and multivariable regression models were used for the prediction of SBP at 12 months. A stepwise procedure was used to select significant (p < 0.001) predictors in multivariate analyses. RESULTS: Mean (± SD) BP fell from 145.4/80.1 (± 18.3/10.7) mmHg at randomization to 132.8/74.7 (± 16.0/9.6) mmHg at 12 months. The main baseline predictors of SBP control <140 mmHg were region (USA >Nordic region) and Caucasian ethnicity in both randomization arms. A higher diastolic BP and the use of lipid lowering agents indicated favorable effects in the B+H arm only. The predictors of uncontrolled SBP were: (i) higher baseline SBP values, (ii) higher number of previous antihypertensive medications in both arms, (iii) the previous use of insulin in the B+A arm, and (iv) pre-trial calcium channel blocker (CCB) use in the B+H arm. Additionally, pre-trial use of thiazides and electrocardiogram (ECG)-left ventricular hypertrophy (LVH) at baseline predicted higher, and smoking lower absolute SBP in the B+A arm and the use of thiazides and proteinuria a higher SBP in the B+H arm. CONCLUSION: Irrespective of treatment, patients in the USA and Caucasians achieved better SBP control, whereas higher baseline SBP and more previous antihypertensive medications indicated less control. Concomitant use of lipid lowering treatment indicated a better SBP control in the benazepril + hydrochlorothiazide arm. Lastly, insulin use and ECG-LVH in the benazepril + amlodipine arm and proteinuria in the benazepril + hydrochlorothiazide arm indicated poor control.

Does individual learning styles influence the choice to use a web-based ECG learning programme in a blended learning setting?

BACKGROUND: The compressed curriculum in modern knowledge-intensive medicine demands useful tools to achieve approved learning aims in a limited space of time. Web-based learning can be used in different ways to enhance learning. Little is however known regarding its optimal utilisation. Our aim was to investigate if the individual learning styles of medical students influence the choice to use a web-based ECG learning programme in a blended learning setting. METHODS: The programme, with three types of modules (learning content, self-assessment questions and interactive ECG interpretation training), was offered on a voluntary basis during a face to face ECG learning course for undergraduate medical students. The Index of Learning Styles (ILS) and a general questionnaire including questions about computer and Internet usage, preferred future speciality and prior experience of E-learning were used to explore different factors related to the choice of using the programme or not. RESULTS: 93 (76%) out of 123 students answered the ILS instrument and 91 the general questionnaire. 55 students (59%) were defined as users of the web-based ECG-interpretation programme. Cronbach's alpha was analysed with coefficients above 0.7 in all of the four dimensions of ILS. There were no significant differences with regard to learning styles, as assessed by ILS, between the user and non-user groups; Active/Reflective; Visual/Verbal; Sensing/Intuitive; and Sequential/Global (p = 0.56-0.96). Neither did gender, prior experience of E-learning or preference for future speciality differ between groups. CONCLUSION: Among medical students, neither learning styles according to ILS, nor a number of other characteristics seem to influence the choice to use a web-based ECG programme. This finding was consistent also when the usage of the different modules in the programme were considered. Thus, the findings suggest that web-based learning may attract a broad variety of medical students.

Days alive and out of hospital and the patient journey in patients with heart failure: Insights from the candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) program.

BACKGROUND: Conventional composite outcomes in heart failure (HF) trials, for example, time to cardiovascular death or first HF hospitalization, have recognized limitations. We propose an alternative outcome, days alive and out of hospital (DAOH), which incorporates mortality and all hospitalizations into a single measure. A refinement, the patient journey, also uses functional status (New York Heart Association [NYHA] class) measured during follow-up. The CHARM program is used to illustrate the methodology. METHODS: CHARM randomized 7,599 patients with symptomatic HF to placebo or candesartan, with median follow-up of 38 months. We related DAOH and percent DAOH (ie, percentage of time spent alive and out of hospital) to treatment using linear regression adjusting for follow-up time. RESULTS: Mean increase in DAOH for patients on candesartan versus placebo was 24.1 days (95% CI 9.8-38.3 days, P < .001). The corresponding mean increase in percent DAOH was 2.0% (95% CI 0.8%-3.1%, P < .001). These findings were dominated by reduced mortality (23 days) but enhanced by reduced time in hospital (1 day). Percent time spent in hospital because of HF was reduced by 0.10% (95% CI 0.04%-0.14%, P < .001). The patient journey analysis showed that patients in the candesartan group spent more follow-up time in NYHA classes I and II and less in NYHA class IV. CONCLUSIONS: Days alive and out of hospital, especially percent DAOH, provide a valuable tool for summarizing the overall absolute treatment effect on mortality and morbidity. In future HF trials, percent DAOH can provide a useful alternative perspective on the effects of treatment.

Ambulatory blood pressure monitoring and blood pressure control in patients with coronary artery disease-A randomized controlled trial.

Office blood pressure (OBP) is used for diagnosing and treating hypertension but ambulatory blood pressure measurement (ABPM) associates more accurately with patient outcome. BP control is important in secondary prevention but it is unknown whether the use of APBM improves BP-control in this setting. Our objective was to investigate whether physician awareness of ABP after percutaneous coronary intervention (PCI) improved BP-control. Methods: A total of 200 patients performed ABPM before and after their PCI follow-up visit. Patients were randomized to open (O) or concealed (C) ABPM results for the physician at the follow-up visit. The change in ABP and antihypertensive medication in relation to baseline ABP was compared between the two groups. Results: The average OBP (O and C: 128/76 mmHg) and ABP (O: 123/73 mmHg, C: 127/74 mmHg) was well controlled and did not change between the first and second measurement. A slight increase in systolic ABP during night time was observed in the open arm compared to the concealed arm. Among patients with high ABP (>130/80 mm Hg) at baseline more patients in the C compared to O group remained with a high ABP at the end of study 34/44 (77%) vs 19/34 (56%), p = 0.045. There was a positive correlation between baseline systolic ABP and ABP change in both the O (r = 0.41, p < 0.001) and the C (r = 0.24, p = 0.014) groups but the association was steeper in the open group (p = 0.035). In patients with low ABP an increase and in patients with high ABP a decrease in ABP was observed in the O group where more changes in medication were done. Conclusions: ABPM did not lower blood pressure in patients with CAD apart from in those with elevated ABP but led to more relevant changes in antihypertensive treatments. Further studies are needed to answer whether patient outcome is affected.

Changes in 24-h ambulatory blood pressure following restoration of sinus rhythm in patients with atrial fibrillation.

OBJECTIVE: The interplay between atrial fibrillation and blood pressure (BP) is insufficiently studied. In symptomatic patients with persistent atrial fibrillation, electrical cardioversion (ECV) is often used to restore sinus rhythm. In this prospective study, we investigated how restoration of sinus rhythm affected 24-h ambulatory BP. METHODS: Ninety-eight patients with persistent atrial fibrillation were examined with 24-h ambulatory BP monitoring before and approximately a week after ECV. RESULTS: Sixty-two patients remained in sinus rhythm at the time of the second ambulatory BP monitoring (AF-SR group), whereas 36 patients had relapsed into atrial fibrillation (AF-AF group). In the AF-SR group, there was a significant increase in mean systolic 24-h BP (5.6 mmHg), a significant decrease in mean diastolic 24-h BP (-4.7 mmHg) and accordingly, a significant 25% (10.4 mmHg) increase in mean 24-h pulse pressure. CONCLUSION: These findings may reflect the haemodynamic conditions that are prevalent in atrial fibrillation, ambulatory BP measurement bias in atrial fibrillation or a combination of both factors. From a clinical standpoint, our results suggest that an increased attention to BP is needed when sinus rhythm is restored, as underlying hypertension may be masked by BP changes during atrial fibrillation. From a general standpoint, it may be speculated that BP, as indicated by the relatively large difference in pulse pressure, may be inherently different in atrial fibrillation and may therefore not be interpretable in the equivalent manner as BP in sinus rhythm.

Change in blood pressure during hospitalisation for acute heart failure predicts mortality.

OBJECTIVE: In patients with acute heart failure (HF) there is an inverse relation between blood pressure (BP) and mortality but the prognostic impact of the change in BP between admission and discharge is not known. The primary objective was to study the impact of the change in BP during a hospitalisation for acute HF on prognosis. DESIGN: We studied 208 consecutive patients admitted with acute heart failure and discharged alive, age 77 ± 10 years, 49.5% women. RESULTS: BP at admission was 145 ± 35/85 ± 9 mmHg compared to 132 ± 24/76 ± 13 mmHg at discharge. The average number of BP lowering medications at admission and discharge was 2.1 ± 1.2 and 2.8 ± 1.0 respectively. The average number of BP lowering medications with dose increased at discharge compared to admission was 0.3 ± 0.5. Univariate predictors of all-cause mortality at 12 and/or 40 months were admission SBP and DBP, discharge DBP, decrease in SBP and DBP during hospitalisation, age, eGFR, number of added BP-lowering medications during the hospitalisation and left ventricular ejection fraction (LVEF). Multivariate predictors at 12 and/or 40 month were admission DBP, decrease in DBP, age, eGFR, LVEF and number of new BP-lowering medications added during the hospitalisation. CONCLUSIONS: A decrease in BP during hospitalisation for acute heart failure was a predictor of all cause mortality. A higher admission BP and the tolerability of added medications probably played a role, and our findings need confirmation in larger studies.

Weight loss and mortality risk in patients with chronic heart failure in the candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) programme.

AIMS: The curiosity that leanness is associated with poor survival in patients with chronic heart failure (CHF) needs further insight by investigating the impact of weight loss on prognosis in a large sample of patients across a broad spectrum of both reduced and preserved left ventricular (LV) systolic function. METHODS AND RESULTS: We investigated the change in weight over 6 months in 6933 patients in the Candesartan in Heart failure: Reduction in Mortality and morbidity (CHARM) programme, and its association with subsequent mortality (1435 deaths) over a median 32.9 months follow-up using Cox proportional hazard models to account for the impact of body mass index and other risk predictors. We then used time-updated Cox models to relate each patient's ongoing data on annual weight change to their mortality hazard. The percentage weight loss over 6 months had a highly significant monotonically increasing association with excess mortality, both for cardiovascular and for other causes of death. Patients with 5% or greater weight loss in 6 months had over a 50% increase in hazard compared with those with stable weight. Weight loss carried a particularly high risk in patients who were already lean at study entry. Findings were similar in the presence of dependent oedema, preserved or reduced LV ejection fraction, and treatment with candesartan, although weight loss was significantly less common on candesartan. The time-updated analyses revealed an even stronger link between weight loss and short-term risk of dying, i.e. risk increased more than four-fold for patients whose last recorded annual weight loss exceeded 10%. Weight gain had a more modestly increased short-term mortality risk. Weight loss accelerates in the year prior to death. CONCLUSIONS: Weight loss and leanness are important predictors of poor prognosis in CHF. Being lean and losing weight is particularly bad. The detection of weight change, and particularly weight loss, should be considered as an adverse sign prompting further evaluation.

Impact of diabetes on outcomes in patients with low and preserved ejection fraction heart failure: an analysis of the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme.

AIMS: To determine whether the risk of adverse cardiovascular (CV) outcomes associated with diabetes differs in patients with low and preserved ejection fraction (EF) heart failure (HF). METHODS AND RESULTS: We analysed outcomes in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme which randomized 7599 patients with symptomatic HF and a broad range of EF. The prevalence of diabetes was 28.3% in patients with preserved EF (>40%) and 28.5% in those with low EF (

Why Medical Students Choose to Use or Not to Use a Web-Based Electrocardiogram Learning Resource: Mixed Methods Study.

BACKGROUND: Electrocardiogram (ECG) interpretation is a core competence and can make a significant difference to patient outcomes. However, ECG interpretation is a complex skill to learn, and research has showed that students often lack enough competence. Web-based learning has been shown to be effective. However, little is known regarding why and how students use Web-based learning when offered in a blended learning situation. OBJECTIVE: The aim of this paper was to study students' use of Web-based ECG learning resources which has not previously been studied in relation to study strategies. METHODS: A qualitative explanatory design using mixed methods was adopted to explore how medical students reason around their choice to use or not to use a Web-based ECG learning resource. Overall, 15 of 33 undergraduate medical students attending a course in clinical medicine were interviewed. Data on usage of the resource were obtained via the learning management system for all students. At the final examination, all the students answered a questionnaire on study strategies and questions about internet access and estimated their own skills in ECG interpretation. Furthermore, study strategies and use patterns were correlated with results from an ECG Objective Structured Clinical Examination (OSCE) and a written course examination. RESULTS: In total, 2 themes were central in the students' reasoning about usage of Web-based ECG: assessment of learning needs and planning according to learning goals. Reasons for using the Web resource were to train in skills, regarding it as a valuable complement to books and lectures. The main reasons for not using the resource were believing they already had good enough skills and a lack of awareness of its availability. Usage data showed that 21 students (63%) used the Web resource. Of these, 11 were minimal users and 10 were major users based on usage activity. Large variations were found in the time spent in different functional parts of the resource. No differences were found between users and nonusers regarding the OSCE score, final examination score, self-estimate of knowledge, or favoring self-regulated learning. CONCLUSIONS: To use or not to use a Web-based ECG learning resource is largely based on self-regulated learning aspects. Decisions to use such a resource are based on multifactorial aspects such as experiences during clinical rotations, former study experiences, and perceived learning needs. The students' own judgment of whether there was a need for a Web-based resource to achieve the learning goals and to pass the examination was crucial for their decisions to use it or not. An increased understanding of students' regulation of learning and awareness of variations in their ECG learning needs can contribute to the improvement of course design for blended learning of ECG contexts for medical students.

Significant changes in emergency department length of stay and case mix over eight years at a large Swedish University Hospital.

OBJECTIVE: Describe the longitudinal development of crowding and patient/emergency department (ED) characteristics at a Swedish University Hospital. METHODS: A retrospective longitudinal registry study based on all ED visits with adult patients during 2009-2016 (N = 1,063,806). Patient characteristics and measures of ED crowding (ED occupancy ratio, length-of-stay [LOS], patients/clinician's ratios) were extracted from the hospital's electronic health record. Non-parametric analyses were conducted. RESULTS: The proportion of unstable patients (triage level 1-2) increased while the proportion of admitted patients decreased. All crowding variables were stable, except for LOS, which increased by 9 min/visit/year (95% CI: 8.8-9.1). LOS for visits by patients ≥ 80 years increased more compared to those 18-79 (248 min vs. 190 min, p < 0.001). Unstable patients increased their median LOS compared to stable patients (triage level 3-5). LOS for discharged patients increased with an average of 7.7 min/year (95% CI: 7.5-7.9) compared to 15.5 min/year (95% CI: 15.2-15.8) for those being admitted. CONCLUSION: Fewer admissions, despite an increase of unstable patients, is likely related to lack of in-hospital beds and contributes to ED crowding. The increase in median ED LOS, especially for patients in the subgroups unstable, ≥80 years and admitted to in-hospital care reflects this problem.

Systolic blood pressure increases in patients with atrial fibrillation regaining sinus rhythm after electrical cardioversion.

Direct current (DC) cardioversion is used to convert persistent atrial fibrillation (AF) to sinus rhythm (SR), but there is limited knowledge about how blood pressure (BP) is affected by conversion to SR. We sought to evaluate how BP changed in AF patients who converted to SR, compared to patients still in AF. In this retrospective registry analysis, we included a total of 487 patients, treated with DC cardioversion for persistent AF. We obtained data regarding medical history, medication, BP, and electrocardiogram the day before and 7 days after cardioversion. Systolic BP increased by 9 (±16) mm Hg (P < 0.01) and diastolic BP decreased by 3 (±9) mm Hg (P < 0.01) after conversion to SR. In the group of patients with restored SR, there was a 40% increase in the proportion of patients with a hypertensive BP level (≥140/90 mm Hg) after DC cardioversion compared to before. Patients still in AF had no significant change in BP. Systolic BP increases and diastolic BP slightly decreases when persistent AF is converted to SR. The underlying mechanisms explaining these findings are not known, but may involve either hemodynamic changes that occur when SR is restored, an underestimation of systolic BP in AF, or a combination of both. Our findings suggest that an increased attention to BP levels after a successful cardioversion is warranted.

Sex differences in clinical characteristics and prognosis in a broad spectrum of patients with heart failure: results of the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program.

BACKGROUND: We wished to test previous hypotheses that sex-related differences in mortality and morbidity may be due to differences in the cause of heart failure or in left ventricular ejection fraction (LVEF) by comparing fatal and nonfatal outcomes in women and men with heart failure and a broad spectrum of left ventricular ejection fraction. METHODS AND RESULTS: We compared outcomes in 2400 women and 5199 men randomized in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) program using multivariable regression analyses. A total of 1188 women (50%) had a low LVEF (< or = 0.40), and 1212 had a preserved LVEF (> 0.40). Among the men, 3388 (65%) had a low LVEF, and 1811 had a preserved LVEF. A total of 1216 women (51%) and 3465 men (67%) had an ischemic cause of their heart failure. All-cause mortality was 21.5% in women and 25.3% in men (adjusted hazard ratio [HR], 0.77; 95% CI, 0.69 to 0.86; P<0.001). Fewer women (30.4%) than men (33.3%) experienced cardiovascular death or heart failure hospitalization (adjusted HR, 0.83; 95% CI, 0.76 to 0.91; P<0.001). The risks of sudden death (HR, 0.70; 95% CI, 0.58 to 0.85) and death due to worsening heart failure (HR, 0.72; 95% CI, 0.58 to 0.89) were reduced to a comparable extent. The adjusted risk of cardiovascular hospitalization was also lower in women (HR, 0.88; 95% CI, 0.82 to 0.95), mainly because of a reduced risk of heart failure hospitalization (HR, 0.87; 95% CI, 0.78 to 0.97). Women had a lower risk of death irrespective of cause of heart failure or LVEF. CONCLUSIONS: Among patients with heart failure, women have lower risks of most fatal and nonfatal outcomes that are not explained, as previously suggested, by LVEF or origin of the heart failure.

The Anglo-Scandinavian Cardiac Outcomes Trial: blood pressure-lowering limb: effects in patients with type II diabetes.

OBJECTIVE: To compare the effects of two antihypertensive treatment strategies for the prevention of coronary heart disease and other cardiovascular events in the large subpopulation (n=5137) with diabetes mellitus in the blood pressure-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial. METHODS: Patients had either untreated hypertension or treated hypertension. For those with type II diabetes mellitus, inclusion criteria required at least two additional risk factors. Patients were randomized to amlodipine with addition of perindopril as required (amlodipine-based) or atenolol with addition of thiazide as required (atenolol-based). Therapy was titrated to achieve a target blood pressure of less than 130/80 mmHg. RESULTS: The trial was terminated early due to significant benefits on mortality and stroke associated with the amlodipine-based regimen. In patients with diabetes mellitus, the amlodipine-based treatment reduced the incidence of the composite endpoint--total cardiovascular events and procedures--compared with the atenolol-based regimen (hazard ratio 0.86, confidence interval 0.76-0.98, P=0.026). Fatal and nonfatal strokes were reduced by 25% (P=0.017), peripheral arterial disease by 48% (P=0.004) and noncoronary revascularization procedures by 57% (P<0.001). For the other endpoints included in the composite, the endpoint differences were less clear including coronary heart disease deaths and nonfatal myocardial infarctions (the primary endpoint), which were reduced nonsignificantly by 8% (hazard ratio 0.92, confidence interval 0.74-1.15). CONCLUSION: In the large diabetic subgroup in the blood pressure-lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial, the benefits of amlodipine-based treatment, compared with atenolol-based treatment, on the incidence of total cardiovascular events and procedures was significant (14% reduction) and similar to that observed in the total trial population (16% reduction).

Usefulness of N-terminal pro-brain natriuretic Peptide and brain natriuretic peptide to predict cardiovascular outcomes in patients with heart failure and preserved left ventricular ejection fraction.

More than 40% of patients hospitalized with heart failure have preserved left ventricular ejection fraction (HF-PLVEF) and are at high risk for cardiovascular (CV) events. The purpose of this study was to determine the value of N-terminal pro-brain natriuretic peptide (NT-proBNP) and brain natriuretic peptide (BNP) in predicting CV outcomes in patients with HF-PLVEF. Participants with an ejection fraction >40% in the prospective CHARM Echocardiographic Substudy were included in this analysis. Plasma NT-proBNP levels were measured, and 2 cut-offs were selected prospectively at 300 pg/ml and 600 pg/ml. BNP cut-off was set at 100 pg/ml. Clinical characteristics were recorded, and systolic and diastolic function were evaluated by echocardiography. The primary substudy outcome was the composite of CV mortality, hospitalization for heart failure, and myocardial infarction or stroke. A total of 181 patients were included, and there were 17 primary CV events (9.4%) during a median follow-up time of 524 days. In a model including clinical characteristics, echocardiographic measures, and BNP or NT-proBNP, the composite CV event outcome was best predicted by NT-proBNP >300 pg/ml (hazard ratio 5.8, 95% confidence intervals [CI] 1.3 to 26.4, p = 0.02) and moderate or severe diastolic dysfunction on echocardiography. When NT-proBNP >600 pg/ml was used in the model, it was the sole independent predictor of primary CV events (hazard ratio 8.0, 95% CI 2.6 to 24.8, p = 0.0003) as was BNP >100 pg/ml (hazard ratio 3.1, 95% CI 1.2 to 8.2, p = 0.02) in the BNP model. In conclusion, both elevated NT-proBNP and BNP are strong independent predictors of clinical events in patients with HF-PLVEF.