Soluble CD146 in the detection and grading of intravascular and tissue congestion in patients with acute dyspnoea: analysis of the prospective observational Lithuanian Echocardiography Study of Dyspnoea in Acute Settings (LEDA) cohort.

OBJECTIVES: To evaluate the potential of soluble cluster of differentiation 146 (sCD146) in the detection and grading of congestion in patients with acute dyspnoea. DESIGN: Subanalysis of the prospective observational Lithuanian Echocardiography Study of Dyspnoea in Acute Settings (LEDA) cohort. SETTING: Two Lithuanian university centres. PARTICIPANTS: Adult patients with acute dyspnoea admitted to the emergency department. METHODS: Congestion was assessed using clinical and sonographic parameters. All patients underwent sCD146 and N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing. RESULTS: The median value of sCD146 concentration in the study cohort (n=437) was 405 (IQR 315-509) ng/mL. sCD146 was higher in patients with peripheral oedema than in those without (median (IQR) 472 (373-535) vs 400 (304-501) ng/mL, p=0.009) and with pulmonary rales than in those without (439 (335-528) vs 394 (296-484) ng/mL, p=0.001). We found a parallel increase of estimated right atrial pressure (eRAP) and sCD146 concentration: sCD146 was 337 (300-425), 404 (290-489) and 477 (363-572) ng/mL in patients with normal, moderately elevated and high eRAP, respectively (p=0.001). In patients with low NT-proBNP, high sCD146 distinguished a subgroup with a higher prevalence of oedema as compared with patients with low levels of both biomarkers (76.0% vs 41.0%, p=0.010). Moreover, high sCD146 indicated a higher prevalence of elevated eRAP, irrespective of NT-proBNP concentration (p<0.05). CONCLUSION: sCD146 concentration reflects the degree of intravascular and tissue congestion assessed by clinical and echocardiographic indices, with this association maintained in patients with low NT-proBNP. Our data support the notion that NT-proBNP might represent heart stretch while sCD146 rather represents peripheral venous congestion.

Risk Factors of Early Atrial Fibrillation Recurrence Following Electrical Cardioversion When Left Ventricular Ejection Fraction Is Preserved.

Background and objectives: To identify clinical, echocardiographic, and laboratory parameters that affect the early recurrence of atrial fibrillation (AF) after restoring sinus rhythm (SR) by electrical cardioversion (ECV), and to determine whether left atrial (LA) strain, as a noninvasive indicator reflecting fibrosis, is associated with laboratory indicators affecting the development of fibrosis, interleukin 6 (IL-6) or tumor necrosis factor α (TNF-α). Materials and Methods: The study included 92 persistent AF patients who underwent elective ECV. The effective maintenance of SR was evaluated after 40 ± 10 days of ECV. Echocardiography, inflammatory markers (high-sensitivity c-reactive protein (hs-CRP), IL-6, and TNF-α), and natriuretic peptides (N-terminal pro b-type natriuretic peptide (NT-proBNP) and N-terminal pro a-type natriuretic peptide (NT-proANP)) were assessed. Results: After a 40 ± 10 days observation period, 51 patients (55.4%) were in SR. Patients with AF recurrence had a significantly longer duration of AF (p = 0.008) and of arterial hypertension (p = 0.035), lower LA ejection fraction (p = 0.009), lower LA strain (p < 0.0001), higher left ventricular global longitudinal strain (p = 0.001), and a higher E/e' ratio (p < 0.0001). LA strain was an independent predictor of early AF recurrence (OR: 0.65; 95% Cl 0.5−0.9, p = 0.004). LA strain < 11.85% predicted AF recurrence with 70% sensitivity and 88% specificity (AUC 0.855, 95% CI 0.77−0.94, p < 0.0001). LA strain demonstrated the association with NT-proBNP (r = −0.489, p < 0.0001) and NT-proANP (r = −0.378, p = 0.002), as well as with hs-CRP (r = −0.243, p = 0.04). Conclusions: LA strain appeared to be the most accurate predictor of early AF recurrence after ECV in patients with persistent AF. LA strain inversely correlated with NT-proBNP and NT-proANP, but no significant association with any of the inflammatory markers was identified.

Biologically Active Adrenomedullin (bio-ADM) is of Potential Value in Identifying Congestion and Selecting Patients for Neurohormonal Blockade in Acute Dyspnea.

PURPOSE: This study was designed to evaluate the role of biologically active adrenomedullin (bio-ADM) in congestion assessment and risk stratification in acute dyspnea. METHODS: This is a sub-analysis of the Lithuanian Echocardiography Study of Dyspnea in Acute Settings. Congestion was assessed by means of clinical (peripheral edema, rales) and sonographic (estimated right atrial pressure) parameters. Ninety-day mortality was chosen for outcome analysis. RESULTS: There were 1188 patients included. Bio-ADM concentration was higher in patients with peripheral edema at admission (48.2 [28.2-92.6] vs 35.4 [20.9-59.2] ng/L, P < .001). There was a stepwise increase in bio-ADM concentration with increasing prevalence of rales: 29.8 [18.8-51.1], 38.5 [27.5-67.1], and 51.1 [33.1-103.2] ng/L in patients with no rales, rales covering less than one-half, and greater than or equal to one-half of the pulmonary area, respectively (P < 0.001). Bio-ADM concentration demonstrated gradual elevation in patients with normal, moderately, and severely increased estimated right atrial pressure: 25.1 [17.6-42.4] ng/L, 36.1 [23.1-50.2], and 47.1 [30.7-86.7] ng/L, respectively (P < .05). Patients with bio-ADM concentration >35.5 ng/L were at more than twofold increased risk of dying (P < .001). Survival in those with high bio-ADM was significantly modified by neurohormonal blockade at admission (P < .05), especially if NT-proBNP levels were lower than the median (P = .002 for interaction). CONCLUSION: Bio-ADM reflects the presence and the degree of pulmonary, peripheral, and intravascular volume overload and is strongly related to 90-day mortality in acute dyspnea. Patients with high bio-ADM levels demonstrated survival benefit from neurohormonal blockade.

The association of biological sex and long-term outcomes in patients with acute dyspnea at the emergency department.

BACKGROUND AND IMPORTANCE: Marked differences have been described between women and men in disease prevalence, clinical presentation, response to treatment and outcomes. However, such data are scarce in the acutely ill. An awareness of differences related to biological sex is essential for the success of clinical care and outcomes in patients presenting with acute dyspnea, the most frequent cause of emergency department (ED) admission. OBJECTIVES: The aim of the present study was to assess the effect of biological sex on 1-year all-cause mortality in patients presenting with acute dyspnea to the ED. DESIGN, SETTINGS AND PARTICIPANTS: Consecutive adult patients presenting with acute dyspnea in two Lithuanian EDs were included. Clinical characteristics, laboratory data and medication use at discharge were collected. Follow-up at 1 year was performed via national data registries. OUTCOMES MEASURE AND ANALYSIS: The primary outcome of the study was 1-year all-cause mortality. Hazard ratios (HRs) for 1-year mortality according to biological sex were calculated using a Cox proportional hazards regression model, with and without adjustment for the following confounders: age, systolic blood pressure, creatinine, sodium and hemoglobin. MAIN RESULTS: A total of 1455 patients were included. Women represented 43% of the study population. Compared to men, women were older [median (interquartile range [IQR]) age 74 (65-80) vs. 68 (59-77) years, P < 0.0001]. The duration of clinical signs before admission was shorter for women [median (IQR) duration 4 (1-14) vs. 7(2-14) days, P = 0.006]. Unadjusted 1-year all-cause mortality was significantly lower in women (21 vs. 28%, P = 0.001). Adjusted HR of 1-year all-cause mortality was lower in women when compared to men [HR 0.68 (0.53-0.88), P = 0.0028]. Additional sensitivity analyses confirmed the survival benefit for women in subgroups including age greater and lower than 75 years, the presence of comorbidities and causes of dyspnea (cardiac or noncardiac). CONCLUSION: Women have better 1-year survival than men after the initial ED presentation for acute dyspnea. Understanding the biological sex-related differences should lead toward precision medicine, and improve clinical decision-making to promote gender equality in health.

Readmission following both cardiac and non-cardiac acute dyspnoea is associated with a striking risk of death.

AIMS: Readmission and mortality are the most common and often combined endpoints in acute heart failure (AHF) trials, but an association between these two outcomes is poorly investigated. The aim of this study was to determine whether unplanned readmission is associated with a greater subsequent risk of death in patients with acute dyspnoea due to cardiac and non-cardiac causes. METHODS AND RESULTS: Derivation cohort (1371 patients from the LEDA study) and validation cohort (1986 patients from the BASEL V study) included acute dyspnoea patients admitted to the emergency department. Cox regression analysis was used to determine the association of 6 month readmission and the risk of 1 year all-cause mortality in AHF and non-AHF patients and those readmitted due to cardiovascular and non-cardiovascular causes. In the derivation cohort, 666 (49%) of patients were readmitted at 6 months and 282 (21%) died within 1 year. Six month readmission was associated with an increased 1 year mortality risk in both the derivation cohort [adjusted hazard ratio (aHR) 3.0 (95% confidence interval, CI 2.2-4.0), P < 0.001] and the validation cohort (aHR 1.8, 95% CI 1.4-2.2, P < 0.001). The significant association was similarly observed in AHF (aHR 3.2, 95% CI 2.1-4.9, P < 0.001) and other causes of acute dyspnoea (aHR 2.9, 95% CI 1.9-4.5, P < 0.001), and it did not depend on the aetiology [aHR 2.2, 95% CI 1.6-3.1 for cardiovascular readmissions; aHR 4.1, 95% CI 2.9-5.7 for non-cardiovascular readmissions (P < 0.001 for both)] or timing of readmission. CONCLUSION​S: Our study demonstrated a long-lasting detrimental association between readmission and death in AHF and non-AHF patients with acute dyspnoea. These patients should be considered 'vulnerable patients' that require personalized follow-up for an extended period.

Differences between familial and sporadic dilated cardiomyopathy: ESC EORP Cardiomyopathy & Myocarditis registry.

AIMS: Dilated cardiomyopathy (DCM) is a complex disease where genetics interplay with extrinsic factors. This study aims to compare the phenotype, management, and outcome of familial DCM (FDCM) and non-familial (sporadic) DCM (SDCM) across Europe. METHODS AND RESULTS: Patients with DCM that were enrolled in the prospective ESC EORP Cardiomyopathy & Myocarditis Registry were included. Baseline characteristics, genetic testing, genetic yield, and outcome were analysed comparing FDCM and SDCM; 1260 adult patients were studied (238 FDCM, 707 SDCM, and 315 not disclosed). Patients with FDCM were younger (P < 0.01), had less severe disease phenotype at presentation (P < 0.02), more favourable baseline cardiovascular risk profiles (P ≤ 0.007), and less medication use (P ≤ 0.042). Outcome at 1 year was similar and predicted by NYHA class (HR 0.45; 95% CI [0.25-0.81]) and LVEF per % decrease (HR 1.05; 95% CI [1.02-1.08]. Throughout Europe, patients with FDCM received more genetic testing (47% vs. 8%, P < 0.01) and had higher genetic yield (55% vs. 22%, P < 0.01). CONCLUSIONS: We observed that FDCM and SDCM have significant differences at baseline but similar short-term prognosis. Whether modification of associated cardiovascular risk factors provide opportunities for treatment remains to be investigated. Our results also show a prevalent role of genetics in FDCM and a non-marginal yield in SDCM although genetic testing is largely neglected in SDCM. Limited genetic testing and heterogeneity in panels provides a scaffold for improvement of guideline adherence.

The Predictive Value of Tissue Doppler Indices for Early Recurrence of Atrial Fibrillation After Electrical Cardioversion.

PURPOSE: Spectral tissue Doppler-derived E/e' ratio has been proposed as the best parameter for prediction of atrial fibrillation (AF). Relaxation and contraction are equivalent parts of a continuous cardiac cycle, where systolic and diastolic abnormalities have a variable contribution to the left ventricle (LV) failure. The aim of this study was to investigate whether the E/(e'xs') ratio is a better index than E/e' to predict AF recurrence and to determine the changes of spectral tissue Doppler indices 1 month after the electrical cardioversion (ECV). PATIENTS AND METHODS: The study included 77 persistent AF patients with restored sinus rhythm (SR) after ECV. Only patients with normal LV ejection fraction (EF) were included. Echocardiography and NT-proBNP laboratory findings were performed. A primary outcome was the early (within 1 month) recurrence of AF. RESULTS: After a 1 month follow-up period, 39 patients (50.6%) were in SR. E/e' (HR=1.74, P=0.001) and E/(e'×s') ratios (HR=8.17, P=0.01) were significant predictors of AF recurrence. E/(e'×s') in combination with LV end-diastolic diameter >49.3 mm and NT-proBNP >2000 ng/L demonstrated a higher contribution in the model to predict AF recurrence compared to the E/e' ratio (18.94, P=0.005 vs 1.95, P=0.001). On ROC analysis, E/(e'×s') and E/e' showed similar diagnostic accuracy (E/(e'×s'), AUC=0.71, P=0.002 and E/e', AUC=0.75, P<0.0001). Average e' value significantly decreased after 1 month in SR (from 10.76±1.24 to 8.96±1.47 cm/s, P=0.01), E wave did not change significantly and E/e' ratio tended to improve. A decrease of average e' and an increase of average s' values led to significant improvement of E/(e'xs') ratio. CONCLUSION: E/(e'xs') and E/e' ratios are comparable to predict early AF recurrence after ECV in patients with persistent AF. The e' value decreased significantly after 1 month follow-up period after ECV for persistent AF patients.

Safety of diuretic administration during the early management of dyspnea patients who are not finally diagnosed with acute heart failure.

OBJECTIVES: Investigating whether it is safe or not to administrate diuretics to patients arriving at emergency departments in a stage of acute dyspnea but without a final diagnosis of acute heart failure. METHODS: We analyzed an unselected multinational sample of patients with dyspnea without a final diagnosis of acute heart failure from Global Research on Acute Conditions Team (France, Lithuania, Tunisia) and Basics in Acute Shortness of Breath Evaluation (Switzerland) registries. Thirty-day all-cause mortality and 30-day postdischarge all-cause readmission rate of treated patients with diuretics at emergency departments were compared with untreated patients by unadjusted and adjusted hazard and odds ratios. Interaction and stratified analyses were performed. RESULTS: We included 2505 patients. Among them, 365 (14.6%) received diuretics in emergency departments. Thirty-day mortality was 4.5% (treated/untreated = 5.2%/4.3%, hazard ratio: 1.22; 95% confidence interval, 0.75-2.00) and 30-day readmission rate was 11.3% (14.7%/10.8%, odds ratio: 1.41; 95% confidence interval, 0.95-2.11). After adjustment, no differences were found between two groups in mortality (hazard ratio: 0.86; 95% confidence interval, 0.51-1.44) and readmission (odds ratio: 1.15; 95% confidence interval, 0.72-1.82). Age significantly interacted with the use of diuretics and readmission (P = 0.03), with better prognosis when used in patients >80 years (odds ratio: 0.27; 95% confidence interval, 0.07-1.03) than in patients ≤80 years (odds ratio: 1.56; 95% confidence interval, 0.94-2.63). CONCLUSIONS: Diuretic administration to patients presenting to emergency departments with dyspnea while they were undiagnosed and in whom acute heart failure was finally excluded was not associated with 30-day all-cause mortality and 30-day postdischarge all-cause readmission rate.

The association of long-term outcome and biological sex in patients with acute heart failure from different geographic regions.

AIMS: Recent data from national registries suggest that acute heart failure (AHF) outcomes might vary in men and women, however, it is not known whether this observation is universal. The aim of this study was to evaluate the association of biological sex and 1-year all-cause mortality in patients with AHF in various regions of the world. METHODS AND RESULTS: We analysed several AHF cohorts including GREAT registry (22 523 patients, mostly from Europe and Asia) and OPTIMIZE-HF (26 376 patients from the USA). Clinical characteristics and medication use at discharge were collected. Hazard ratios (HRs) for 1-year mortality according to biological sex were calculated using a Cox proportional hazards regression model with adjustment for baseline characteristics (e.g. age, comorbidities, clinical and laboratory parameters at admission, left ventricular ejection fraction). In the GREAT registry, women had a lower risk of death in the year following AHF [HR 0.86 (0.79-0.94), P < 0.001 after adjustment]. This was mostly driven by northeast Asia [n = 9135, HR 0.76 (0.67-0.87), P < 0.001], while no significant differences were seen in other countries. In the OPTIMIZE-HF registry, women also had a lower risk of 1-year death [HR 0.93 (0.89-0.97), P < 0.001]. In the GREAT registry, women were less often prescribed with a combination of angiotensin-converting enzyme inhibitors and beta-blockers at discharge (50% vs. 57%, P = 0.001). CONCLUSION: Globally women with AHF have a lower 1-year mortality and less evidenced-based treatment than men. Differences among countries need further investigation. Our findings merit consideration when designing future global clinical trials in AHF.

Multidisciplinary approach to rare primary cardiac sarcoma: a case report and review.

BACKGROUND: Undifferentiated pleomorphic sarcoma is a very rare and aggressive type of primary cardiac tumors. Most cardiac sarcomas result in rapid growth and quick death. According to different sources the median survival is typically 6 to 12 months. We are presenting a case of primary cardiac sarcoma with 26 months disease free survival following cytoreductive surgery and chemotherapy. CASE PRESENTATION: A 48-year-old woman with progressing symptoms of dyspnea and palpitations for over 2 months was referred to a cardiologist. With the help of echocardiography and cardiovascular magnetic resonance cardiac sarcoma was suspected. Open biopsy and cytoreductive surgery were performed, complete resection of the tumor was not possible. Histology revealed undifferentiated pleomorphic sarcoma. Seven cycles of chemotherapy with Doxorubicine and Ifosfamide were completed. Cardiovascular magnetic resonance revealed a complete response - only signs of fibrosis without any signs of tumor were visible. Follow ups with echocardiography, cardiovascular magnetic resonance and chest, abdomen and pelvic computed tomography is performed every 3 months. Twenty-six months from initial diagnosis the patient is still free of recurrence of tumor with no compromises of the quality of life. CONCLUSION: Standard chemotherapy together with cytoreductive surgery can have a complete response effect in undifferentiated pleomorphic sarcoma with unusual long-term survival.

Relationship of Natriuretic Peptides with Left Atrial Structure and Function within 1 Month after Electrical Cardioversion in Patients with Persistent Atrial Fibrillation.

Atrial fibrillation (AF) despite the absence of heart failure is related to increased levels of natriuretic peptides (NPs). NPs have not been widely investigated in relation to left atrium (LA) function after sinus rhythm (SR) restoration and duration of AF. The aim of the study was to determine the changes of NPs levels and to define their relation with LA phasic function after electrical cardioversion (ECV). Methods. The study included 48 persistent AF patients with restored SR after ECV. NT-proANP and NT-proBNP were measured for all patients before the ECV. LA phasic function (reservoir, conduit, and pump phases) was assessed using echocardiographic volumetric analysis within the first 24 hours after ECV. Patients were repeatedly tested after 1 month in case of SR maintenance. Results. After 1 month, SR was maintained in 26 (54%) patients. For those patients, NT-proBNP decreased significantly (p=0.0001), whereas NT-proANP tended to decrease (p=0.13). Following 1 month after SR restoration, LA indexed volume decreased (p=0.0001) and all phases of LA function improved (p=<0.01). Patients with AF duration < 3 months had lower NT-proANP compared to patients with AF duration from 6 to 12 months (p = 0.005). Higher NT-proANP concentration before ECV was associated with lower LA reservoir function during the first day after SR restoration (R=-0.456, p=0.005), whereas higher NT-proBNP concentration after 1 month in SR was significantly related to lower LA reservoir function (R=-0.429, p=0.047). Conclusions. LA indexed volume, all phases of LA function, and NT-proBNP levels improved significantly following 1 month of SR restoration. Preliminary results suggest that higher baseline NT-proANP levels and higher NT-proBNP for patients with maintained SR for 1 month are related to lower LA reservoir function. The longer duration of persistent AF is associated with higher NT-proANP concentration.

The Cardiomyopathy Registry of the EURObservational Research Programme of the European Society of Cardiology: baseline data and contemporary management of adult patients with cardiomyopathies.

Aims: The Cardiomyopathy Registry of the EURObservational Research Programme is a prospective, observational, and multinational registry of consecutive patients with four cardiomyopathy subtypes: hypertrophic cardiomyopathy (HCM), dilated cardiomyopathy (DCM), arrhythmogenic right ventricular cardiomyopathy (ARVC), and restrictive cardiomyopathy (RCM). We report the baseline characteristics and management of adults enrolled in the registry. Methods and results: A total of 3208 patients were enrolled by 69 centres in 18 countries [HCM (n = 1739); DCM (n = 1260); ARVC (n = 143); and RCM (n = 66)]. Differences between cardiomyopathy subtypes (P < 0.001) were observed for age at diagnosis, history of familial disease, history of sustained ventricular arrhythmia, use of magnetic resonance imaging or genetic testing, and implantation of defibrillators. When compared with probands, relatives had a lower age at diagnosis (P < 0.001), but a similar rate of symptoms and defibrillators. When compared with the Long-Term phase, patients of the Pilot phase (enrolled in more expert centres) had a more frequent rate of familial disease (P < 0.001), were more frequently diagnosed with a rare underlying disease (P < 0.001), and more frequently implanted with a defibrillator (P = 0.023). Comparing four geographical areas, patients from Southern Europe had a familial disease more frequently (P < 0.001), were more frequently diagnosed in the context of a family screening (P < 0.001), and more frequently diagnosed with a rare underlying disease (P < 0.001). Conclusion: By providing contemporary observational data on characteristics and management of patients with cardiomyopathies, the registry provides a platform for the evaluation of guideline implementation. Potential gaps with existing recommendations are discussed as well as some suggestions for improvement of health care provision in Europe.

European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1-year follow-up outcomes and differences across regions.

AIMS: The European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT-R) was set up with the aim of describing the clinical epidemiology and the 1-year outcomes of patients with heart failure (HF) with the added intention of comparing differences between participating countries. METHODS AND RESULTS: The ESC-HF-LT-R is a prospective, observational registry contributed to by 211 cardiology centres in 21 European and/or Mediterranean countries, all being member countries of the ESC. Between May 2011 and April 2013 it collected data on 12 440 patients, 40.5% of them hospitalized with acute HF (AHF) and 59.5% outpatients with chronic HF (CHF). The all-cause 1-year mortality rate was 23.6% for AHF and 6.4% for CHF. The combined endpoint of mortality or HF hospitalization within 1 year had a rate of 36% for AHF and 14.5% for CHF. All-cause mortality rates in the different regions ranged from 21.6% to 36.5% in patients with AHF, and from 6.9% to 15.6% in those with CHF. These differences in mortality between regions are thought reflect differences in the characteristics and/or management of these patients. CONCLUSION: The ESC-HF-LT-R shows that 1-year all-cause mortality of patients with AHF is still high while the mortality of CHF is lower. This registry provides the opportunity to evaluate the management and outcomes of patients with HF and identify areas for improvement.

What does the lay public know about heart failure? Findings from the Heart Failure Awareness Day Initiative.

AIM & METHODS: One critical factor enhancing the implementation of successful diagnostic and therapeutic strategies into clinical practice is awareness among the lay public. We describe awareness in a contemporary, multinational convenience sample of subjects attending the Heart Failure Awareness (HFA) Day Initiatives in 2013. RESULTS: We analysed 2,438 subjects (Germany 33%, Lithuania 42%, Romania 8%, Slovenia 17%) : 53% were female, 58% were aged >60 years, 11% (had) worked in the medical sector, 82% heard about HF before. Shortness of breath and tiredness were correctly identified as symptoms of heart failure in 71% and 61%, but only 52% recognized swelling of feet and legs as a clinical sign; 31% considered heart failure a normal symptom of old age, and only 38% realized the particularly poor prognosis after a heart failure related hospitalization. Subjects who had heard about heart failure before had a lower prevalence of common misbeliefs about HF. CONCLUSION: In subjects participating in the HFA Day initiative 2013, the level of awareness was unsatisfactory, and important misconceptions remain. The educational and awareness activities for both the population at large and also for decision makers should be broadened and intensified.

Are hospitalized or ambulatory patients with heart failure treated in accordance with European Society of Cardiology guidelines? Evidence from 12,440 patients of the ESC Heart Failure Long-Term Registry.

AIMS: To evaluate how recommendations of European guidelines regarding pharmacological and non-pharmacological treatments for heart failure (HF) are adopted in clinical practice. METHODS AND RESULTS: The ESC-HF Long-Term Registry is a prospective, observational study conducted in 211 Cardiology Centres of 21 European and Mediterranean countries, members of the European Society of Cardiology (ESC). From May 2011 to April 2013, a total of 12,440 patients were enrolled, 40.5% with acute HF and 59.5% with chronic HF. Intravenous treatments for acute HF were heterogeneously administered, irrespective of guideline recommendations. In chronic HF, with reduced EF, renin-angiotensin system (RAS) blockers, beta-blockers, and mineralocorticoid antagonists (MRAs) were used in 92.2, 92.7, and 67.0% of patients, respectively. When reasons for non-adherence were considered, the real rate of undertreatment accounted for 3.2, 2.3, and 5.4% of the cases, respectively. About 30% of patients received the target dosage of these drugs, but a documented reason for not achieving the target dosage was reported in almost two-thirds of them. The more relevant reasons for non-implantation of a device, when clinically indicated, were related to doctor uncertainties on the indication, patient refusal, or logistical/cost issues. CONCLUSION: This pan-European registry shows that, while in patients with acute HF, a large heterogeneity of treatments exists, drug treatment of chronic HF can be considered largely adherent to recommendations of current guidelines, when the reasons for non-adherence are taken into account. Observations regarding the real possibility to adhere fully to current guidelines in daily clinical practice should be seriously considered when clinical practice guidelines have to be written.

Organization of heart failure management in European Society of Cardiology member countries: survey of the Heart Failure Association of the European Society of Cardiology in collaboration with the Heart Failure National Societies/Working Groups.

AIMS: The aim of this document was to obtain a real-life contemporary analysis of the demographics and heart failure (HF) statistics, as well as the organization and major activities of the Heart Failure National Societies (HFNS) in European Society of Cardiology (ESC) member countries. METHODS AND RESULTS: Data from 33 countries were collected from HFNS presidents/representatives during the first Heart Failure Association HFNS Summit (Belgrade, Serbia, 29 October 2011). Data on incidence and/or prevalence of HF were available for 22 countries, and the prevalence of HF ranged between 1% and 3%. In five European and one non-European ESC country, heart transplantation was reported as not available. Natriuretic peptides and echocardiography are routinely applied in the management of acute HF in the median of 80% and 90% of centres, respectively. Eastern European and Mediterranean countries have lower availability of natriuretic peptide testing for acute HF patients, compared with other European countries. Almost all countries have organizations dealing specifically with HF. HFNS societies for HF patients exist in only 12, while in 16 countries HF patient education programmes are active. Most HFNS reported that no national HF registry exists in their country. Fifteen HFNS produced national HF guidelines, while 19 have translated the ESC HF guidelines. Most HFNS (n = 23) participated in the organization of the European HF Awareness Day. CONCLUSION: This document demonstrated significant heterogeneity in the organization of HF management, and activities of the national HF working groups/associations. High availability of natriuretic peptide and echocardiographic measurements was revealed, with differences between developed countries and countries in transition.

Congestive hepatopathy and hypoxic hepatitis in heart failure: a cardiologist's point of view.

In the setting of long-standing severe chronic heart failure, other organ systems are also involved. The liver is one of the organs that are very sensitive to haemodynamic changes. Differential diagnosis of the liver injury is extremely important in the cardiologist's clinical practice and calls for cardiologist's and hepatologist's collaboration because there are many other diseases that can affect the liver and mimic haemodynamic injury. In this article, liver injuries depending on cardiocirculatory dysfunction such as hypoxic hepatitis and congestive hepatopathy are analysed. The material in the article is presented in two aspects: the evaluation and treatment of heart failure in order to prevent pathologic processes in the liver, and the recognition of the liver injury, including diagnostic tests which are essential for differential diagnosis of different liver pathologies.

Determinants of reduced tricuspid annular plane systolic excursion in patients with severe systolic left ventricular dysfunction.

OBJECTIVE: Right ventricular (RV) dysfunction is associated with poor exercise tolerance and prognosis, regardless of left ventricular (LV) function. Tricuspid annular plane systolic excursion (TAPSE) is a non-invasive parameter of RV longitudinal function which can predict outcome in heart failure (HF) patients (pts). Our aim was to investigate the relation of TAPSE to clinical and echocardiographic parameters in severe LV dysfunction. METHODS AND RESULTS: The study included 119 pts with non-ischaemic dilated cardiomyopathy (n = 46) and ischaemic heart disease (n = 73) in stable HF with severe LV systolic dysfunction (LV ejection fraction (EF) < 30%). In pts with different LV dysfunction severity the higher NYHA class correlated with lower TAPSE dimensions: NYHA class IV 12.7 +/- 2.9 mm vs. NYHA class III 15.9 +/- 4.2 mm and NYHA class II 18.8 +/- 4.2 mm, P < 0.001. The presence of atrial arrhythmias in 16% of pts was related to lower values of TAPSE (12.9 +/- 3.6 mm vs. 15.4 +/- 4.2 mm, P < 0.05). Pts with non-ischaemic HF aetiology were found to have lower values of TAPSE compared to ischaemic aetiology (12.5 +/- 2.8 mm vs. 16.6 +/- 4.1 mm, P = 0.001) and increased odds of low TAPSE (< or = 14 mm)--odds ratio (OR) [95% confidence interval] = 9.8 [3.8-25.6], P < 0.001. Multivariate analysis revealed that LVEF, deceleration time (DT) of early mitral inflow E wave and the RV end-diastolic diameter are independent determinants of reduced TAPSE (< or = 14 mm) in pts with severe LV systolic dysfunction. CONCLUSION: The lower TAPSE values are related to higher NYHA functional class, presence of atrial arrhythmias and non-ischaemic aetiology in HF pts. The LVEF, DT of LV filling and RV end-diastolic diameter are independent predictors of reduced TAPSE (< or = 14 mm) in pts with severe systolic LV dysfunction.

The value of 99mTc-MIBI myocardial perfusion imaging in differentiation of heart failure conditioned by global left ventricular systolic impairment.

OBJECTIVE: The global left ventricular systolic impairment with left ventricular dilatation can manifest due to idiopathic dilated cardiomyopathy or ischemic heart disease and can present a similar clinical picture of severe heart failure. The aim of our investigation was to assess a differential diagnostic value of resting (99m)Tc-MIBI myocardial perfusion defects in evaluation of the etiology of heart failure. MATERIAL AND METHODS: The data of 2D echocardiography, coronary angiography, and myocardial gated single photon emission computed tomography with (99m)Tc-MIBI investigation were evaluated in 43 patients with global left ventricular systolic impairment, characterized by left ventricular end-diastolic diameter of > or =65 mm and ejection fraction of < or =40%. The idiopathic dilative cardiomyopathy was diagnosed in 26 patients (Group 1) and ischemic heart failure in 17 patients (Group 2). The area and the degree (severity) of myocardial perfusion defects (AMPD and DMPD) at rest in regions supplied by three coronary arteries were evaluated in all the patients. RESULTS: The area of perfusion defects in the left anterior descending (LAD) and right coronary artery (RCA) regions in dilative cardiomyopathy patients was smaller than in ischemic heart failure patients (1.43+/-0.9 vs 2.53+/-0.53, P=0.001, and 2.19+/-0.6 vs 2.82+/-0.56, P=0.02). The degree of perfusion defects was also less severe in the same circulation regions (1.39+/-0.93 vs 2.59+/-0.6, P=0.01, and 1.6+/-0.46 vs 2.71+/-0.15, P=0.001). We have designed a logistic regression model expressed by formula x=2.52AMPD(rca)+2.47AMPD(lad)+2.21DMPD(rca). Idiopathic dilative cardiomyopathy was predicted when x was < or =16 and ischemic heart failure when x was >16. The sensitivity in predicting idiopathic dilative cardiomyopathy was 94.44%, and the specificity was 88.24%. CONCLUSION: The difference in the area and degree of (99m)Tc-MIBI myocardial perfusion defects at rest in patients with heart failure caused by idiopathic dilative cardiomyopathy or ischemic heart failure is measurable and has a predictive value for differentiation of the etiology of global left ventricular systolic impairment.

Characteristics and management of acute heart failure patients in a single university hospital center.

OBJECTIVE: To evaluate the causes of acute heart failure, complications, management, and outcomes. MATERIAL AND METHODS: A total of 200 patients with diagnosed de novo acute heart failure (27.5%) or worsening chronic heart failure (72.5%) were treated at the Department of Cardiology, Hospital of Kaunas University of Medicine, which was participating in the Euro Heart Failure Survey-II (EHFS-II). The patients were divided into five groups: 1) chronic decompensated heart failure (66.0%); 2) pulmonary edema (13.0%); 3) hypertensive heart failure (7.5%); 4) cardiogenic shock (11.0%); and 5) right heart failure (2.5%). RESULTS: Hypertensive and coronary heart diseases were the most common underlying conditions of acute heart failure. Noncompliance with the prescribed medications was present as the most frequent precipitating factor in more than half of the cases. Left ventricular ejection fraction of >45% was found in 28.64% of cases. Intravenous diuretics (74.5%), nitrates (44.0%), and heparin (71.0%) were the most widely used in the acute phase. At discharge from hospital, 96.69% of patients were given diuretics; 80.11%, angiotensin-converting enzyme inhibitors; and 62.43%, beta-blockers. The mean duration of inhospital stay was 13 days; death rate was 9.5%: after 3 months and 12 months, it was 7.5% and 11.5%, respectively. CONCLUSION: Preserved systolic function, multiple concomitant diseases, and high mortality rates were observed in a substantial proportion of the patients hospitalized due to acute heart failure. The management of the patients in a university hospital center was performed in accordance with the international guidelines.