Assessment of frailty and related outcomes in older patients with heart failure: A cohort study.

OBJECTIVE: Heart failure (HF) is a common cause of morbidity and mortality in older patients. Frailty is prevalent and complicates the course of HF. We sought to investigate the impact of frailty on HF outcomes. METHODS: Patients over 65 years old hospitalized with acute decompensated HF and mildly reduced or preserved EF, between September 2017 and September 2019 were enrolled in the study. Before hospital discharge at euvolemic state, patients underwent six-minute walk test (6MWT) and frailty assessment using FRIED and modified SOF scores. Predictors of death, readmissions, and increase in diuretic dose were analyzed by multivariable logistic regression models. RESULTS: We enrolled 193 consecutive patients (mean age 78.6 ± 8.4 years, 29.5% males, 59.6% with HF and preserved EF). All patients had at least one comorbidity (40.9% coronary artery disease, 71% diabetes, and 86% hypertension). The mean 6MWT distance was 316.2 meters. According to FRIED score, 4.7% were normal and 17.6% were categorized as pre-frail and 77.7% as frail, while according to SOF index 9.8% were normal, 15% were categorized as pre-frail and 75.1% as frail. Frail patients according to both indices had a higher risk of 90-day readmissions, uptitration of diuretics within 90 days (p < 0.001 for both) and numerically but not significantly higher risk of death. Frailty status was independently associated with higher risk of 90-day readmissions, uptitration of diuretics, and higher BNP at 90 days. CONCLUSIONS: Frailty in older patients with HF is common and associated with worse prognosis. Pre-discharge frailty assessment may aid in identification of patients at high-risk for short-term complications.

A functional supervised learning approach to the study of blood pressure data.

In this work, a functional supervised learning scheme is proposed for the classification of subjects into normotensive and hypertensive groups, using solely the 24-hour blood pressure data, relying on the concepts of Fréchet mean and Fréchet variance for appropriate deformable functional models for the blood pressure data. The schemes are trained on real clinical data, and their performance was assessed and found to be very satisfactory.

Effect of left ventricular pacing mode and site on hemodynamic, torsional and strain indices.

INTRODUCTION: Several reports have indicated that left ventricular (LV) lead placement at an optimal pacing site is an important determinant of short- and long-term outcome. This study investigated the effect of pacing mode (atrioventricular [AV] or ventricular) and site (LV apical or lateral) outside the ischemic region on the LV hemodynamic, torsional and strain indices in the ischemic myocardium. METHODS: Experiments were conducted in anesthetized open-chest pigs (n = 15) 30 min after LAD ligation to investigate the hemodynamic effects of temporary epicardial AV and ventricular LV pacing at the LV apical (outside the ischemic region) or lateral wall. LV hemodynamic data were recorded (ejection fraction, stroke volume, dP/dtmax, systolic pressure, cardiac output and e/e΄ ratio) and torsional (twist, rotation), as well as deformation (radial and circumferential strain), indices of LV function were assessed using two-dimensional speckle tracking imaging. RESULTS: The LV function was highly dependent on the pacing mode and site. LV dP/dtmax, systolic pressure and twist decreased significantly during LV pacing in comparison to sinus rhythm (p = 0.004, p<0.001, p = 0.002, respectively). Torsion in sinus rhythm decreased significantly during AV-pacing at the lateral wall (0.11±0.04°/mm vs. 0.06±0.02°/mm, p = 0.005) but did not change significantly during AV-pacing at the apex (0.07±0.05°/mm). CONCLUSIONS: LV pacing at the apical or lateral wall, in the ischemic myocardium, leads to a suboptimal response in comparison to sinus rhythm. LV pacing at the apex outside the ischemic area exhibits a better response than pacing at the lateral wall, possibly because pacing from this site leads to a more physiological propagation of electrical conduction.

Ambulatory cardiology network in Greece: Clinical and therapeutic implications in the outpatient setting. The TEVE-SSF study.

BACKGROUND: Community based registries are particularly valuable tools to Preventive Cardiology as they summarize epidemiological data of ischemic heart disease risk factors, medications and lifestyle characteristics. METHODS: We enrolled 1191 patients, from an outpatient community based cardiology network, dedicated to cover medically, office based professionals. We recorded demographic and lifestyle characteristics, risk factors for ischemic heart disease, all clinical entities diagnosed and therapies which were prescribed for hypertension and lipid disorders specifically. RESULTS: Our population consisted of 659 males (55%) and 532 females (45%), (mean age 46±14). A sedentary lifestyle was almost universal (92%), followed by smoking (44%) and overweight body composition (38%). Unhealthy lifestyle increased significantly during the third decade of life, while multimorbidity ascended during the fifth. Cardiovascular morbidity was present in 611 patients (51%), while 289 patients (24%) were found negative for cardiovascular disease and positive for a different system diagnosis. Lipid disorders (32%) and hypertension (31%) were the most frequent cardiovascular entities. ß-Blockers and statins were the most frequently prescribed medications for hypertension and lipid disorders respectively. CONCLUSION: Cardiovascular morbidity was frequent in this ambulatory middle aged population, whereas multimorbidity (mainly from gastrointestinal and endocrine system) was a significant coexisting problem, even for a cardiology oriented outpatient population. Unhealthy lifestyle is of major importance because it was present in the majority of our patients early in their life and because it was statistically related to hyperlipidemia and hypertension. Preventive Cardiology must introduce special interventions to deescalate the presence of unhealthy lifestyle in young populations.

Late-onset right ventricular dysfunction after mechanical support by a continuous-flow left ventricular assist device.

BACKGROUND: Right heart failure (RHF) is a serious post-operative complication of left ventricular assist device (LVAD) implantation, with significant morbidity and mortality. Many clinical, hemodynamic and laboratory variables have been shown to have prognostic value for appearance of RHF. We sought to investigate the incidence of new-onset right ventricular dysfunction (RVD) complicating the long-term use of LVADs. METHODS: We retrospectively examined all patients supported with a continuous-flow LVAD for >1 year at our center. RESULTS: Twenty patients (mean age 54 ± 10 years, 95% men, 60% with ischemic cardiomyopathy, left ventricular ejection fraction 22 ± 6%, pulmonary capillary wedge pressure 23.5 ± 7.5 mm Hg, brain natriuretic peptide [BNP] 1,566 ± 1,536 pg/ml, serum creatinine 1.6 ± 0.64 mg/dl, furosemide dose 643 ± 410 mg/day) underwent long-term mechanical support as destination therapy support with a continuous-flow LVAD (HeartMate II) at our center. During follow-up (1,219 ± 692 days), 9 patients (45%) manifested symptoms and signs of RVD (increase in right atrial pressure [RAP], BNP and daily furosemide dose compared with the early post-operative period). In these patients, RAP was increased by 6.6 ± 2.6 mm Hg and BNP by 526 ± 477 pg/ml, whereas furosemide dose increased by 145 ± 119 mg. The mean and median times of RVD onset were 2.3 ± 1.5 and 2.1 years, respectively, after LVAD implantation (range 0.4 to 4.8 years). Four of these patients (44.4%) demonstrated further deterioration of RV function and died 73 ± 106 days (median 25 days, range 9 to 231 days) after first manifestation of RVD. Comparisons of baseline variables regarding medical history and clinical status did not demonstrate significant differences between the patients with or without RVD, including parameters related to RV function at the time of implantation. CONCLUSIONS: Late-onset RVD is a complication of LVAD support, which can manifest several months to years from device implantation. This complication has significant adverse implications with regard to patient outcome. Prognostic factors need to be identified to follow and treat high-risk patients more efficiently.

The impact of nocturnal hypertension and nondipping status on left ventricular mass: a cohort study.

OBJECTIVE: Ambulatory blood pressure monitoring provides a unique tool in the evaluation of night-time blood pressure (BP), having a critical role in the detection of a blunted nocturnal fall and of elevated night-time BP. Both nondipping status and nocturnal hypertension are associated with increased cardiovascular risk and target organ damage. The aim of our study was to investigate the impact of both nondipping status and nocturnal hypertension on left ventricular mass (LVM), assessed by means of echocardiography in a consecutive cohort of untreated participants. METHODS: A total of 937 individuals were assessed by means of ambulatory blood pressure monitoring and echocardiography. Participants were divided into dippers and nondippers with or without systolic nocturnal hypertension (SNH). SNH was defined as night-time systolic blood pressure of 120 mmHg or more, and nondipping status was defined as an average reduction in systolic blood pressure at night less than 10% compared with the daytime BP. RESULTS: Dippers and nondippers with SNH presented significantly higher values of left ventricular mass index compared with dippers and nondippers without SNH, respectively. Multiple regression analysis revealed that age (ß=0.182, P<0.001), male gender (ß=0.168, P<0.001), body mass index (ß=0.080, P=0.011), and nocturnal SBP (ß=0.174, P=0.037) were significant and independent determinants of LVM. Nondipping status was not found as an independent factor associated with LVM (P=0.136). CONCLUSION: Nocturnal hypertension rather than nondipping status seems to be an independent factor associated with left ventricular mass index. The concomitant presence of both nondipping status and nocturnal hypertension is associated with higher LVM, indicating an enhanced cardiovascular risk.

Long-term outcomes of primary systemic light chain (AL) amyloidosis in patients treated upfront with bortezomib or lenalidomide and the importance of risk adapted strategies.

Bortezomib and lenalidomide are increasingly used in patients with AL amyloidosis, but long term data on their use as primary therapy in AL amyloidosis are lacking while early mortality remains significant. Thus, we analyzed the long term outcomes of 85 consecutive unselected patients, which received primary therapy with bortezomib or lenalidomide and we prospectively evaluated a risk adapted strategy based on bortezomib/dexamethasone to reduce early mortality. Twenty-six patients received full-dose bortezomib/dexamethasone, 36 patients lenalidomide with oral cyclophosphamide and low-dose dexamethasone and 23 patients received bortezomib/dexamethasone at a dose and schedule adjusted to the risk of early death. On intent to treat, 67% of patients achieved a hematologic response (24% hemCRs) and 34% an organ response; both were more frequent with bortezomib. An early death occurred in 20%: in 36% of those treated with full-dose bortezomib/dexamethasone, in 22% of lenalidomide-treated patients but only in 4.5% of patients treated with risk-adapted bortezomib/dexamethasone. Activity of full vs. adjusted dose bortezomib/dexamethasone was similar; twice weekly vs. weekly administration of bortezomib also had similar activity. After a median follow up of 57 months, median survival is 47 months and is similar for patients treated with bortezomib vs. lenalidomide-based regimens. However, risk adjusted-bortezomib/dexamethasone was associated with improved 1-year survival vs. full-dose bortezomib/dexamethasone or lenalidomide-based therapy (81% vs. 56% vs. 53%, respectively). In conclusion, risk-adapted bortezomib/dexamethasone may reduce early mortality and preserve activity while long term follow up indicates that remissions obtained with lenalidomide or bortezomib may be durable, even without consolidation with alkylators.

Effect of pacing mode and pacing site on torsional and strain parameters and on coronary flow.

BACKGROUND: Right ventricular apical pacing may induce detrimental effects on left ventricular function and coronary flow. In this study, the effects of pacing site and mode on cardiac mechanics and coronary blood flow were evaluated. METHODS: This prospective study included 25 patients who received dual-chamber pacemakers with the ventricular lead placed in the right ventricular apex and presented in sinus rhythm (SR) at their regularly scheduled visits at the pacemaker clinic. Patients underwent complete transthoracic echocardiographic examinations while in SR, followed by noninvasive Doppler assessment of coronary flow in the left anterior descending coronary artery (LAD) and speckle-tracking echocardiography of short-axis planes in SR, atrial pacing (AAI-P), atrioventricular (dual-chamber) pacing (DDD-P), and ventricular pacing (VVI-P). RESULTS: Rotation of the base was significantly decreased with VVI-P compared with AAI-P. Left ventricular twist decreased significantly with DDD-P compared with AAI-P. Circumferential strain of the base significantly decreased with DDD-P and VVI-P compared with SR. The velocity-time integral of diastolic flow in the LAD decreased significantly with DDD-P compared with SR (10.7 ± 2.2 vs 10.2 ± 2.2 vs 8.9 ± 1.6 vs 8.7 ± 2.6 cm in SR and with AAI-P, DDD-P, and VVI-P, respectively, P = .003). Basal rotation and time from onset of the QRS complex to peak basal rotation as a percentage of systole were independently associated with the velocity-time integral of diastolic flow in the LAD during SR and the three pacing modes. CONCLUSIONS: Acute right ventricular apical pacing showed a detrimental effect on left ventricular twist and basal mechanics, with the latter being independently associated with decreased LAD diastolic flow velocity parameters.

Red blood cell distribution width is a significant prognostic marker in advanced heart failure, independent of hemoglobin levels.

INTRODUCTION: Advanced heart failure (HF) is associated with increased morbidity and mortality; traditionally used prognostic factors often fail to predict the outcome. Increased red blood cell distribution width (RDW) has recently been recognized as an important unfavorable prognostic factor in HF, independent of anemia; however, the role of RDW in patients with advanced HF has not yet been investigated. METHODS: Eighty consecutive patients with stage D heart failure, recently hospitalized for HF decompensation, were enrolled. A Cox proportional-hazard model was used to determine whether RDW was independently associated with outcome. RESULTS: At study entry, ejection fraction (EF), pulmonary capillary wedge pressure (PCWP), hemoglobin (Hb) and RDW were 25 ± 8.6%, 27.5 ± 8 mmHg, 12.5 ± 1.9 mg/dL and 18 ± 3.5% (normal <14.5%) respectively. At 6 months, 44 patients (55%) had died. In this patient population, EF (p=0.45), PCWP (p=0.106), age (p=0.54), albumin (0.678), iron (p=0.37), creatinine (p=0.432), iron deficiency defined by bone marrow aspiration (p=0.37), bilirubin (p=0.422), peak VO2 (p=0.057) and Hb (p=0.95) were not significant predictors of a worse outcome. However, RDW was a significant marker for adverse prognosis (p=0.007, HR: 1.14, CI: 1.04-1.24) and retained its prognostic significance even when corrected for Hb values (HR: 1.15, CI: 1.05-1.27, p=0.003). CONCLUSIONS: RDW is a significant prognostic factor for an adverse outcome in patients with advanced stage heart failure who have experienced recent decompensation, independent of the presence of anemia or malnutrition, and is superior to more traditionally used indices. RDW may be associated with severe disease by reflecting subtle metabolic and proinflammatory abnormalities in HF.

Value of apical circumferential strain in the early post-myocardial infarction period for prediction of left ventricular remodeling.

BACKGROUND: Left ventricular (LV) remodeling after acute myocardial infarction (AMI) is related to increased morbidity and mortality. The aim of the present study was to examine whether LV deformational and torsional parameters can predict LV remodeling in patients with AMI. METHODS: Forty-two patients (age 57 ± 14 years) presenting with an anterior ST-elevation AMI and treated with primary percutaneous transluminal coronary angioplasty (PTCA) were included in the study. Four days post MI, LV ejection fraction (EF), LV torsion, longitudinal (4-, 3- & 2-chamber) and circumferential strain of the LV apex were evaluated by conventional and speckle-tracking echocardiography. The echocardiographic study was repeated at 3 months post-AMI and patients with LV remodeling, i.e. an increase >15% in LV end-systolic volume (LVESV), were identified. RESULTS: The 13 patients with LV remodeling had significantly more impaired apical circumferential strain (-7.3 ± 2.2% vs. -18.9 ± 5.2%, p=0.001), EF (42 ± 7% vs. 48.9 ± 6%, p=0.005), LV apical rotation (6.8 ± 4.8° vs. 11.1 ± 4.0°, p=0.027), and LV global longitudinal strain (-9.7 ± 1.9% vs. -12.9 ± 2.9%, p=0.03) on the 4th day post-AMI, in comparison to those without LV remodeling. Apical circumferential strain on the 4th day post-AMI showed the strongest correlation with the LVESV 3 months post-AMI (r=0.76, p=0.001), compared to EF (r=-0.60, p=0.001), global longitudinal strain (r=0.56, p=0.001), and LV apical rotation (r=-0.53, p=0.001). Furthermore, apical circumferential strain demonstrated the highest diagnostic accuracy: area under the receiver operating characteristic (ROC) curve 0.98, with sensitivity 100% and specificity 96% for prediction of LV remodeling, using a cutoff value <-11.0%. CONCLUSION: In patients with anterior AMI, LV apical circumferential strain in the early post-MI period constitutes a significant prognostic factor for LV remodeling at 3 months. Assessment of this parameter may identify patients at high risk for heart failure development.

Atrioventricular left ventricular apical pacing improves haemodynamic, rotational, and deformation variables in comparison to pacing at the lateral wall in intact myocardium: experimental study.

Aim. To assess the effect on left ventricular (LV) function of atrioventricular (AV) and ventricular pacing at the LV apical or lateral wall and to compare the normal torsional and deformation pattern of the intact LV myocardium with those created by the aforementioned LV pacing modes and sites. Methods. Experiments were conducted in pigs (n = 21) with normal LV function to investigate the acute hemodynamic effects of epicardial AV and ventricular LV pacing at the LV apical or lateral wall. Torsional and deformation indices of LV function were assessed using speckle tracking echocardiography. Results. AV pacing at the apex revealed a significant reduction in the radial strain of the base (P < 0.03), without affecting significantly the ejection fraction and the LV torsion or twist. In contrast, AV pacing at the lateral wall produced, in addition to the reduction of the radial strain of the base (P < 0.01), significant reduction of the circumferential and the radial strain of the apex (both P < 0.01) as well as of the ejection fraction (P < 0.002) and twist (P < 0.05). Conclusions. In pig hearts with intact myocardium, LV function is maintained at sinus rhythm level when AV pacing is performed at the LV apex.

Factors Influencing the twisting and untwisting properties of the left ventricle during normal pregnancy.

AIMS: During pregnancy, important hemodynamic changes occur, consistent with an increase in preload and decrease in afterload and systemic vascular resistance. The aim of the present study was to investigate the changes in left ventricular (LV) strain and rotational properties during the 3 trimesters of normal pregnancy and to examine the factors that drive these changes. METHODS AND RESULTS: Twenty-seven pregnant women (29.7 ± 6.9 years) and 11 age-matched nonpregnant controls (29.9 ± 5.4 years) were evaluated. Conventional echocardiography and two-dimensional speckle tracking imaging were performed at 8-12 (1st trimester), 21-28 (2nd trimester), and 33-36 (3rd trimester) weeks of pregnancy. LV rotation, twist, untwisting rate, and circumferential strain were measured using the parasternal short-axis views at basal and apical levels. Global longitudinal strain was calculated from the LV apical views. Peak LV twist and peak untwisting rate increased significantly in the 3rd trimester of normal pregnancy (13.48 ± 2.90°, 13.12 ± 3.30°, 16.83 ± 3.61°, P < 0.001; and -111.52 ± 23.54°/sec, -107.40 ± 26.58°/sec, -144.30 ± 45.14°/sec, P < 0.001; in the 1st, 2nd, and 3rd trimester, respectively). Global longitudinal and circumferential strain of the apex decreased significantly from the 2nd trimester. An independent association was found between the change in LV twist and the change in LV end-systolic volume between the 1st and 3rd trimester. Peak untwisting rate at the 3rd trimester correlated significantly with peak twist and LV end-diastolic volume. CONCLUSIONS: During normal pregnancy, LV twist and peak untwisting rate increase in the 3rd trimester and correlate with end-systolic and end-diastolic volume, respectively. Circumferential strain of the apex and global longitudinal strain decrease from the 2nd trimester.

Apical rotation as an early indicator of left ventricular systolic dysfunction in acute anterior myocardial infarction: experimental study.

INTRODUCTION: The aim of this study was to determine whether left ventricular (LV) apical rotation assessed by speckle tracking echocardiography (STE) can predict global LV systolic dysfunction after acute anterior myocardial infarction (AMI). METHODS: STE analysis was applied to LV short-axis images at the basal and apical levels in 21 open-chest pigs, before and after left anterior descending coronary artery ligation. LV radial and circumferential strain and strain rate, apical and basal rotation, and LV torsion were recorded. RESULTS: LV apical rotation (3.68 ± 1.73° pre-AMI vs. 2.19 ± 1.64° post-AMI, p<0.009), peak systolic rotation rate, and radial and circumferential strain as well as strain rate decreased significantly 30 min postAMI. The LV global torsion decreased significantly. Strain and rotational changes of the LV apex were primarily correlated with ejection fraction (EF), but those of the LV base were not. EF had a significant correlation with the global LV twist (r=0.31, p<0.05). On multivariate linear regression analysis, fractional shortening of the long-axis (FSL) (b=0.58, p<0.001), rotation of the LV apex (b=0.32, p<0.006) and LV dp/dtmax (b=0.26, p<0.02) were independently related with EF. On analysis, of the receiver operating characteristic curve, the area under the curve for apical rotation was 0.765, p<0.006; the best cutoff value of 2.92° had sensitivity 80% and specificity 71% in predicting EF<40%. CONCLUSION: Apical rotation assessed by STE is a potential noninvasive early indicator of global LV systolic dysfunction in AMI and has a satisfactory association with LVEF. Its assessment could be valuable in clinical and research cardiology.

Brain edema formation is associated with the time rate of blood pressure variation in acute stroke patients.

OBJECTIVES: Both brain edema and increased blood pressure (BP) variability are associated with poor outcome after stroke. The aim of the present study was to evaluate a possible association between edema formation and a relatively new index of BP variability defined as time rate (TR) of BP variation. PATIENTS AND METHODS: A total of 128 first-ever acute stroke patients underwent 24-h ambulatory BP monitoring within 24 h from onset of stroke. All patients were imaged with computed tomography scan on admission and after 5 days to determine the presence of brain edema. The TR of BP variation was defined as the first derivative of the BP values against time. Known risk factors and neurological severity on admission were documented. RESULTS: The 24-h TR of systolic BP variation was significantly higher (P<0.001) in stroke patients with brain edema (0.69±0.15 mmHg/min) compared with those without edema (0.57±0.12 mmHg/min). The multivariate logistic regression model showed that a 0.1 mmHg/min increase in the TR of 24-h systolic BP variation was associated with a 13.9% increased probability of the presence of brain edema (odds ratio=1.139, 95% confidence interval: 1.058-1.225, P<0.001), after adjusting for history of diabetes mellitus, hypercholesterolemia, type of stroke, neurological deficit, and 24-h systolic BP. CONCLUSION: Increased values of 24-h TR of systolic BP variation are associated independently with formation of edema in acute stroke patients.

Bartonella quintana endocarditis as a cause of severe aortic insufficiency and heart failure.

We describe the case of a 26-year-old man who developed severe aortic valve insufficiency due to a culturenegative endocarditis, leading to severe heart failure. The diagnosis of Bartonella quintana endocarditis was suspected from the clinical presentation and serological immunofluorescence assay, and was confirmed by polymerase chain reaction analysis of excised valve tissue after aortic valve replacement. The aim of this report is to illustrate B. quintana endocarditis as an important cause of culture-negative endocarditis that presents challenges in its clinical, diagnostic and therapeutic management.

The impact of ultrasound contrast medium administration on the right ventricle in patients with heart failure.

BACKGROUND: The purpose of the present study was to examine the effect of SonoVue™ on right ventricular (RV) dimensions and contractility in patients with heart failure. PATIENTS AND METHODS: Twenty-four patients were divided into two groups. Group A consisted of 15 patients with heart failure and group B (control) of nine patients without heart disease. SonoVue was administered at low (2 ml) and high (4 ml) doses in both groups separately, in a random order. RV dimensions, contractility, peak systolic pressure gradient from tricuspid regurgitation (TRPG) and the time to maximal RV end-diastolic dimension (EDD), as well as the time for RV-EDD to return to the baseline value (recovery), were calculated in every cardiac cycle starting before the administration of SonoVue (baseline) until the recovery of RV-EDD. RESULTS: Low-(group A, p<0.001 and group B, p<0.05) and high-dose (group A, p<0.0001 and group B, p<0.01) contrast infusion increased the RV-EDD compared to baseline values. TRPG increased significantly (p<0.05) in both groups, under low-as well as high-dose. In group A, high-dose compared to low-dose produced a significant delay in the time duration to max RV-EDD (p<0.05) and in the time to RV-EDD recovery (p<0.0001). CONCLUSION: The administration of SonoVue in patients with heart failure was followed by an acute, transient, dose-dependent increase in RV-EDD and TRPG, without any effect on RV contractility.

Baroreceptor reflex sensitivity is associated with arterial stiffness in a population of normotensive and hypertensive patients.

OBJECTIVES: Baroreceptor reflex sensitivity (BRS) is an important factor in the homeostatic regulation of the cardiovascular system. Arterial stiffening also provides direct evidence of target organ damage in hypertensive patients. The aim of the present study was to evaluate a possible association between BRS and pulse wave velocity (PWV) in a population of normotensive and hypertensive patients. PATIENTS AND METHODS: A consecutive series of 160 patients underwent office blood pressure (BP) measurements, 24-h ambulatory BP monitoring, a 15-min electrocardiographic and noninvasive BP monitoring, and carotid-femoral PWV measurements. Power spectral analysis was carried out to calculate cardiac BRS, expressed as the alpha-index. The study population was divided into two groups according to the office BP values: patients with systolic and diastolic BP<140/90 mmHg were defined as normotensives, whereas patients with systolic BP≥140 mmHg and/or diastolic BP≥90 mmHg were defined as hypertensives. RESULTS: Hypertensive patients (79%) had significantly higher PWV values (P=0.004) and a lower alpha-index (P<0.001) than the normotensive patients (21%). Multivariate linear regression analyses showed significant and independent associations of PWV with the following factors: age [0.510, 95% confidence interval (CI): 0.260-0.760; P<0.001], 24-h systolic BP (0.320, 95% CI: 0.120-0.520; P=0.002), and log(alpha-index) (-1.465, 95% CI: -2.686 to -0.244; P=0.019). A 1 ms/mmHg decrease in the log(alpha-index) correlated to an increment of 1.465 m/s (95% CI: 0.244-2.686) in the PWV of the study population. CONCLUSION: Increased arterial stiffness is significantly and independently associated with impaired BRS in normotensive and hypertensive patients.

Comparison of three different regimens of intermittent inotrope infusions for end stage heart failure.

AIMS: Inotrope treatment is often necessary in refractory to optimal management end stage heart failure, when signs of end-organ hypoperfusion appear. The effect of specific inotropes on patient outcome remains controversial. The aim of the study was to compare the effect of levosimendan versus dobutamine, alone or in combination with levosimendan, on the outcome of end-stage heart failure patients, requiring inotropic therapy. METHODS AND RESULTS: We studied 63 patients in NYHA class IV, refractory to optimal medical therapy, recently hospitalized for cardiac decompensation and stabilized by an intravenous inotrope. They were randomly assigned to intermittent infusions of either a) dobutamine, 10mg/kg/min, versus b) levosimendan, 0.3mg/kg/min, versus c) dobutamine, 10mg/kg/min+levosimendan 0.2 mg/kg/min, each administered weekly, for 6h, over a 6-month period. All patients received amiodarone, 400 mg/day, to suppress the proarrhythmic effects of the inotropes. Baseline characteristics of the 3 groups were similar. At 6 months, survival free from death or urgent left ventricular device implantation was 80% in the levosimendan, 48% in the dobutamine (P=0.037 versus levosimendan), and 43% in the levosimendan+dobutamine (P=0.009 versus levosimendan) group. At 3months, NYHA class improved significantly in all 3 groups, whereas pulmonary capillary wedge pressure decreased (27 ± 4 to 19 ± 8 mmHg, P=0.008) and cardiac index increased (1.5 ± 0.3 to 2.1 ± 0.3 l/min/m(2), P=0.002) significantly only in patients assigned to levosimendan. CONCLUSIONS: In patients with refractory end-stage heart failure, intermittent administration of levosimendan conferred survival and hemodynamic benefits in comparison to a regimen of intermittent infusions of dobutamine, alone or in combination with levosimendan.