Empagliflozin and Cardiovascular and Kidney Outcomes across KDIGO Risk Categories: Post Hoc Analysis of a Randomized, Double-Blind, Placebo-Controlled, Multinational Trial.

BACKGROUND AND OBJECTIVES: In the Empagliflozin Cardiovascular Outcome Event Trial in Type 2 Diabetes Mellitus Patients (EMPA-REG Outcome), empagliflozin, in addition to standard of care, significantly reduced risk of cardiovascular death by 38%, hospitalization for heart failure by 35%, and incident or worsening nephropathy by 39% compared with placebo in patients with type 2 diabetes and established cardiovascular disease. Using EMPA-REG Outcome data, we assessed whether the Kidney Disease Improving Global Outcomes (KDIGO) CKD classification had an influence on the treatment effect of empagliflozin. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients with type 2 diabetes, established atherosclerotic cardiovascular disease, and eGFR≥30 ml/min per 1.73 m2 at screening were randomized to receive empagliflozin 10 mg, empagliflozin 25 mg, or placebo once daily in addition to standard of care. Post hoc, we analyzed cardiovascular and kidney outcomes, and safety, using the two-dimensional KDIGO classification framework. RESULTS: Of 6952 patients with baseline eGFR and urinary albumin-creatinine ratio values, 47%, 29%, 15%, and 8% were classified into low, moderately increased, high, and very high KDIGO risk categories, respectively. Empagliflozin showed consistent risk reductions across KDIGO categories for cardiovascular outcomes (P values for treatment by subgroup interactions ranged from 0.26 to 0.85) and kidney outcomes (P values for treatment by subgroup interactions ranged from 0.16 to 0.60). In all KDIGO risk categories, placebo and empagliflozin had similar adverse event rates, the notable exception being genital infection events, which were more common with empagliflozin for each category. CONCLUSIONS: The observed effects of empagliflozin versus placebo on cardiovascular and kidney outcomes were consistent across the KDIGO risk categories, indicating that the effect of treatment benefit of empagliflozin was unaffected by baseline CKD status. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: EMPA-REG OUTCOME, NCT01131676.

Hemiblocks revisited.

The trifascicular nature of the intraventricular conduction system and the concept of trifascicular block and hemiblock were described by Rosenbaum and his coworkers in 1968. Since then, anatomic, pathological, electrophysiological, and clinical studies have confirmed the original description and scarce advances have been developed on the subject. In the present study, we attempt to review and redefine reliable criteria for the electrocardiographic and vectorcardiographic diagnosis of left anterior and posterior hemiblock. One of the most important problems related to hemiblocks is that they may simulate or conceal the electrocardiographic signs of myocardial infarction or myocardial ischemia and may mask or simulate ventricular hypertrophy. Illustrative examples of these associations are shown to help the interpretation of electrocardiograms. The incidence and prevalence of the hemiblocks is presented based on studies performed in hospital patients and general populations. One of the most common causes of hemiblocks is coronary artery disease, and there is a particularly frequent association between anteroseptal myocardial infarction and left anterior hemiblock. The second most important cause is arterial hypertension, followed by cardiomyopathies and Lev and Lenègre diseases. The hemiblocks may also occur in aortic heart disease and congenital cardiopathies. Left anterior hemiblock is more common in men and increases in frequency with advancing age. Evidence is presented regarding the relationship of spontaneous closure of ventricular septal defects, which may explain the finding of this and other conduction defects in young populations. Isolated left anterior hemiblock is a relatively frequent finding in subjects devoid of evidence of structural heart disease. Conversely, isolated left posterior hemiblock is a very rare finding; its prognostic significance is unknown and is commonly associated with right bundle-branch block. The most remarkable feature of this association is that the prognosis is much more serious with a great propensity to develop complete atrioventricular block and Adams-Stoke seizures.

Acute nonspecific carditis in adolescents presenting with Stokes-Adams attacks.

Three patients, aged between 12 and 17 years presented with Stokes-Adams attacks as a result of atrioventricular block, atrioventricular silence and ventricular arrhythmias, complicating acute myocarditis. All the patients required temporary pacing for a few days. One patient required hemodialysis for anuria. All the patients made complete recovery.

[Adams-Stokes syncope disclosing a crisis of rheumatic fever. Apropos of a case]. / Syncope d'Adams Stokes révélant une crise de rhumatisme articulaire aigu. A propos d'un cas.

A high degree atrioventricular block (AVB) is an exceptional finding during an acute episode of rheumatic fever (RF). The authors report a case of complete syncopal AVB requiring a temporary pacemaker, representing the first episode of RF.

Common form of Lyme borreliosis carditis--complete heart block with syncope: report on 3 cases.

Third degree atrioventricular (AV) heart block with severe Adams-Stokes attacks in 3 patients with Lyme borreliosis is described. All patients had similar clinical manifestations: previously healthy, they experience syncope as an abrupt onset of the disease. Data on skin changes--erythema migrans--was subsequently obtained, although the patients did not recall being bitten by a tick. Diagnoses were based on clinical manifestations and on positive serologic test results to borrelia. Following AV block returned to sinus rhythm with normal AV conduction in all patients.

[Integrated traditional and Western medicine treatment of severe viral myocarditis].

33 patients divided into 2 groups for treatment. Group A (18 cases) early use of adrenal cortico-steroid treatment in combination with traditional Chinese medicine; group B (15 cases): early use of adrenal cortico-steroid treatment is combination with interferon, then compared the therapeutic effects of these 2 groups. The results showed that, in these 2 groups, the sinus-atrial block, atrial ventricular block, ventricular tachycardia, acute pump failure as well as the EKG changes were relieved and improved to the same degree. In group A, after therapy, the parameters of OKT3 (%) was elevated from 51 +/- 15.22 to 55.23 +/- 8.53; OKT4(%) was elevated from 30.06 +/- 11.47 to 47.32 +/- 10.87; ratio of OKT4/OKT8 was elevated from 1.11 to 1.53; all of their P values were < 0.01. NK cell activity was elevated from 8.36 +/- 3.75 to 13.08 +/- 5.77, P value < 0.05. In group B, the parameters of OKT3 (%) was elevated from 50.91 +/- 8.12 to 56.75 +/- 8.29; OKT4 (%) was elevated from 32. 55 +/- 6.78 to 45.13 +/- 10.85; ratio of OKT4/OKT8 was elevated from 1.00 +/- 0.21 to 1.37 +/- 0.16; P value < 0.05, < 0.05 and < 0.01 respectively. NK cell activity (%) was elevated from 8.20 +/- 3.08 to 14. 0.3 +/- 4.89, P value also < 0.01. Hence, not only in group A but also in group B, after therapy, the parameters of OKT3,4,8, OKT4/OKT8 and NK cell activity (%) were all improved. But there was no significant statistical difference between group A and B.(ABSTRACT TRUNCATED AT 250 WORDS)

[Assessment of third-degree congenital atrioventricular block by ergometric tests]. / Avaliação do bloqueio atrioventricular do 3 degrees. grau congênito pelo teste ergométrico.

PURPOSE: To analyse the use of the exercise testing as the method of initial evaluation, following a prognostic indicative of patients with congenital complete heart block. METHODS: Five patients were analysed (3 men and 2 woman) with ages between 7 and 34 years (mean = 22.8). The patients were submitted to a treadmill exercise testing using the Bruce protocol 1 and symptom limited. RESULTS: In all patients the atrial frequency increased from a median of 74.40 bpm in the basal to 155.20 bpm in the maximum effort; the atrial chronotropism was a little below that calculated based on the age of the patients. The median of the ventricular frequency in the maximum effort was 94.80 bpm, very different from that foreseen and showing a deficit of ventricular chronotropism. The median consumption of oxygen was 35.68ml0(2)/Kg/min. In one patients (20%) there was not any change in the ventricular frequency with the effort, in 3 (60%) complex ventricular arrhythmia arise during the effort and in one (20%) a definitive ventricular pacemaker was implanted. CONCLUSIONS: The exercise testing is a simple method of initial evaluation, providing information as chronotropism, functional capacity and the presence of arrhythmias, that can be very useful in the evaluation of prognostic. The presence of complex ventricular arrhythmias during the exercise is indicative of a more regular follow-up.

Avaliaçäo do bloqueio atrioventricular do 3§ grau congênito pelo teste ergométrico / Study of the congenital complete heart block by the exercise te sting

Objetivo - Analisar o uso do teste ergométrico como método de avaliação inicial, acompanhamento e indicador prognóstico de pacientes portadores de bloqueio atrioventricular (BAV) do 3º grau congênito. Métodos - Cinco pacientes (3 masculinos) com idades variando de 7 a 34 anos (X = 22,8), utilizando-se o teste ergométrico em esteira rolante segundo o protocolo de Bruce, sintoma limitante. Resultados - Em todos os casos houve aumento da freqüência atrial, média de 74,40 bpm no basal atingindo 155,20 bpm no esforço máximo; tendo o cronotropismo atrial ficado pouco abaixo daquele prescrito para a faixa etária. A média da freqüência ventricular (FV) no esforço máximo foi de 94,80 bpm, ficando bem abaixo da prevista e demonstrando déficit cronotrópico ventricular. O consumo médio de oxigênio foi de 35,68ml02 ½Kg½min. Em 1 paciente (20%) não houve variação da FV com o esforço. Em 3 (60%) ocorreu aparecimento de arritmia ventricular complexa e em 1 (20%) foi indicado o implante de marcapasso definitivo...

Purpose - To analyse the use of the exercise testing as the method of initial avaliation, following a prognostic indicative of patients with congenital complete heart block. Methods - Five patients were analysed (3 men and 2 woman) with ages between 7 and 34 years (X = 22.8). The patients were submitted to a threadmill exercise testing using the Bruce protocol 1 and symptom limited. Results - In all patients the atrial frequency increased from a median of 74.40 bpm in the basal to 155.20 bpm in the maximum effort; the atrial chronotropism was a little below that calculated based on the age of the patients. The median of the ventricular frequency in the maximum effort was 94.80 bpm, very different from that foreseen and showing a deficit of ventricular chronotropism. The median consumption of oxygen was 35.68ml02 /Kg/min. In one patients (20%) there was not any change in the ventricular frequency with the effort, in 3 (60%) complex ventricular arrhythmia arise during the effort and in one (20%) a definitive ventricular pacemaker was implanted...

[Recurrent episodes of Morgagni-Adams-Stokes syndrome due to degeneration of atrio-ventricular tachycardias into atrial fibrillation in a patient with Wolf-Parkinson-White syndrome]. / Nawracajacy zespól MAS w nastepstwie przeksztalcania sie czestoskurczu przedsionkowo-komorowego w migotanie przedsionków u chorej z zespolem WPW.

We present clinical problems and the therapy of a 52 year old patient with Wolf-Parkinson-White syndrome and numerous episodes of Morgagni-Adams-Stokes syndrome. In that patient atrio-ventricular tachycardia caused atrial fibrillation. Short refractory period of the accessory pathway and the ventricular muscle allowed for extremely fast ventricular rate with haemodynamic collapse and syncope. Long-term treatment with propafenone or amiodarone did not prevent the arrhythmias. Electrophysiological study pre- and intraoperation including the epicardial mapping were performed several weeks after discontinuation of therapy with amiodarone. The studies revealed left free wall accessory pathway. Dr. A. Biederman and al. performed dissection of the accessory pathway. There were no evidence of conduction through the accessory pathway during the post operation electrophysiologic study. The patient has neither reentrant tachycardias nor atrial fibrillation episodes.

[The natural course of a complete atrioventricular block]. / Estestvennoe techenie polnoi atrioventrikuliarnoi blokady.

The natural disease course is analyzed in 311 patients with atrioventricular blockade admitted for surgical treatment to the Leningrad Center of Arrhythmia Surgery and Cardiac Pacing. It has been discovered that, as a rule, Morgagni-Adams-Stokes (MAS) attacks do not occur for over 2-3 years after their onset, which determines to a considerable measure the patients: life expectancy. The authors hold that the very first Mas attack which may occur in a patient with atrioventricular blockade is an absolute indication for implantation of a permanent cardiac pacemaker. If the permanent cardiac pacemaker was established, 1-, 3-, 5-, 7- and 8-year survival rates were, respectively, 91.1, 85.8, 77.3, 63.2, and 60.8%.

[Malignant lymphoma with Adams-Stokes syndrome as the first manifestation].

A case of malignant lymphoma with Adams-Stokes attack which was the first manifestation was reported. A 56-year-old female admitted our institute because of unconsciousness attack. After implantation of pacemaker she had high fever and abdominal mass. Ga scintigraphy revealed many accumulation on the hepatic hilus and the heart. Abdominal Computed Tomography and echography revealed abnormal mass in the hepatic hilus. The biopsy of this abnormal mass was performed. The histological examination of this specimen showed diffuse middle sized type malignant lymphoma.