Obesity-Related Genetic Determinants of Heart Failure Prognosis.

PURPOSE: Recent advances in genomics offer a smart option for predicting future risk of disease and prognosis. The objective of this study was to examine the prognostic value in heart failure (HF) patients, of a series of single nucleotide polymorphisms (SNPs). METHODS: A selection of 192 SNPs found to be related with obesity, body mass index, circulating lipids or cardiovascular diseases were genotyped in 191 patients with HF. Anthropometrical and clinical variables were collected for each patient, and death and readmission by HF were registered as the primary endpoint. RESULTS: A total of 53 events were registered during a follow-up period of 438 (263-1077) days (median (IQR)). Eight SNPs strongly related to obesity and HF prognosis were selected as possible prognostic variables. From these, rs10189761 and rs737337 variants were independently associated with HF prognosis (HR 2.295 (1.287-4.089, 95% CI); p = 0.005), whereas rs10423928, rs1800437, rs737337 and rs9351814 were related with bad prognosis only in obese patients (HR 2.142 (1.438-3.192, 95% CI); p = 0.00018). Combined scores of the genomic variants were highly predictive of poor prognosis. CONCLUSIONS: SNPs rs10189761 and rs737337 were identified, for the first time, as independent predictors of major clinical outcomes in patients with HF. The data suggests an additive predictive value of these SNPs for a HF prognosis. In particular for obese patients, SNPs rs10423928, rs1800437, rs737337 and rs9351814 were related with a bad prognosis. Combined scores weighting the risk of each genomic variant could effect interesting new tools to stratify the prognostic risk of HF patients.

¿Qué papel ocupan los ARA-II en el tratamiento de la insuficiencia cardiaca? ¿Actuamos por evidencias/recomendaciones o por la presión de la industria farmacéutica? / Which is the role of the angiotensine II receptor blockers (ARBS) for the treatment of heart failure? do we work in order to evidence/recomendations or to the pharmaceutical industry pression?

La insuficiencia cardíaca crónica (ICC) representa la primera causa de ingresos hospitalarios en personas mayores de 60 años en nuestro medio. Además tanto su incidencia como su prevalencia continúan aumentando a pesar de nuevas estrategias terapéuticas. Consideramos las recomendaciones de las guías de práctica clínica (GPC) un instrumento valioso a la hora de tomar decisiones, aunque en algunas ocasiones utilicen un lenguaje numérico poco claro. Tampoco debemos de olvidar que los pacientes que entran a formar parte de los ensayos clínicos en muchas ocasiones no son representativos de la realidad. Finalmente añadir que la industria farmacéutica, invierte grandes cantidades en investigación de principios activos, pero como empresa que es necesita obtener beneficios. Con todo ello, en este artículo intentamos analizar qué papel ocupan los antagonistas del receptor de la angiotensinaII (ARA-II) en la estrategia médica a la hora de planificar un tratamiento en el paciente con ICC (AU)

Chronic heart failure (CHF) represents the first cause of hospitalisation in persons older than 60 years in our environment. Besides its incidence and prevalence is increasing although new therapeutic treatments. We think the recommendations of the guidelines of clinical practise are an important instrument to make decisions, although sometimes it is used a numeric language little clear. We do not have either to forget that sometimes patients selected for the clinical trials aren’t really representative. Finally to add that pharmaceutical industry spends a lot of money on investigating active basics, but as company itself is needs to obtain benefits. With all of this, in this article we try to study the role of angiotensin II receptor blockers (ARBs) occupy in the medic strategy for the planifications of a patient’s treatment with chronic heart failure (AU)

[Which patients with heart failure should be offered cardiac resynchronization?]. / A qué pacientes con insuficiencia cardíaca debemos ofertar la resincronización cardíaca?

Chronic heart failure is a very prevalent disease in developed countries. In recent decades, very important advances in drug therapy have occurred. However, mortality is still very high. One third of patients with a low ejection fraction and New York Heart Association (NYHA) functional class IIII-IV have a wide QRS. This means that there is often resynchronization of contraction and higher mortality. In order to improve the prognosis, the therapy based on cardiac resynchronization device has bee4n shown to be a complementary medical treatment and has contributed to clinical, hemodynamic and mortality improvements. In this article, we aim to show the results of clinical trials and recommendations of the main guidelines regarding this therapy.

¿A qué pacientes con insuficiencia cardíaca debemos ofertar la resincronización cardíaca? / Which patients with heart failure should be offered cardiac resynchronization?

La insuficiencia cardíaca crónica (ICC) es una patología muy prevalente en países desarrollados. En las últimas décadas se han producido avances muy importantes en el tratamiento farmacológico, pero a pesar de ello las cifras de mortalidad siguen siendo muy elevadas. Casi la tercera parte de los pacientes con fracción de eyección (FE) baja y clase funcional III-IV de la New York Heart Association (NYHA) presentan un QRS ancho, lo que se traduce en muchas ocasiones en disincronía en la contracción y una mayor mortalidad. Con el propósito de mejorar el pronóstico ha surgido la terapia basada en el dispositivo de resincronización cardíaca (TRC), que como coadyuvante del tratamiento médico ha demostrado mejoría clínica, hemodinámica y en las cifras de mortalidad. Pretendemos en este artículo dar a conocer el fundamento, resultados de ensayos clínicos y recomendaciones de las principales guías sobre esta terapia (AU)

Chronic heart failure is a very prevalent disease in developed countries. In recent decades, very important advances in drug therapy have occurred. However, mortality is still very high. One third of patients with a low ejection fraction and New York Heart Association (NYHA) functional class IIII-IV have a wide QRS. This means that there is often resynchronization of contraction and higher mortality. In order to improve the prognosis, the therapy based on cardiac resynchronization device has bee4n shown to be a complementary medical treatment and has contributed to clinical, hemodynamic and mortality improvements. In this article, we aim to show the results of clinical trials and recommendations of the main guidelines regarding this therapy (AU)

[Which is the role of the angiotensin II receptor blockers (ARBs) for the treatment of heart failure? Do we work based on evidence/recommendations or pharmaceutical industry pressure?]. / ¿Qué papel ocupan los ARA-II en el tratamiento de la insuficiencia cardiaca? ¿Actuamos por evidencias/recomendaciones o por la presión de la industria farmacéutica?

Chronic heart failure (CHF) represents the first cause of hospitalization in persons older than 6o years in our environment. Beside its incidence and prevalence is increasing although new therapeutic treatments. We think the recommendations of the guidelines of clinical practise are an important instrument to make decisions, although sometimes it is used a numeric language little clear. We do not have either to forget that sometimes patients selected for the clinical trials aren t really representative. Finally to add that pharmaceutical industry spends a lot of money on investigating active basics, but as company itself is needs to obtain benefits. With all of this, in this article we try to study the role of angiotensin II receptor blockers (ARBs) occupy in the medic strategy for the planification of a patient s treatment with chronic heart failure.

Anaemia is associated with higher mortality among patients with heart failure with preserved systolic function.

OBJECTIVE: To investigate the prevalence of anaemia and its influence on mortality among hospitalised patients with congestive heart failure (CHF) with preserved left ventricular systolic function (LVSF). METHOD AND RESULTS: 210 patients with preserved LVSF admitted to the cardiology department of a tertiary hospital for CHF between 1 January 2000 and 31 December 2002 were analysed. Anaemic patients, who constituted 46% of the whole group, were older (75 v 72 years, p = 0.036); were in hospital longer (mean (SD) 13 v 11 days, p = 0.007); had a higher prevalence of ischaemic heart disease (54% v 35%, p = 0.009), left bundle branch block (12% v 4%, p = 0.018), and kidney failure (56% v 34%, p = 0.003); and had faster erythrocyte sedimentation rates (mean (SD) 50 v 26 mm in the first hour, p < 0.001), a tendency to lower serum cholesterol concentration (mean (SD) 4.65 v 5.22 mmol/l, p = 0.073), and smaller body mass index (mean (SD) 27 v 29 kg/m2, p = 0.126) than their non-anaemic counterparts. Kaplan-Meier analysis showed the anaemic group to have significantly poorer survival (p = 0.0001), with a one year survival rate of 72.2% versus 90.5% in the non-anaemic group. Multivariate analysis showed anaemia to be the most powerful independent predictor of mortality, increasing the risk of death by a factor of 2.7 (p = 0.007). CONCLUSION: Anaemia is a very prevalent condition in hospitalised patients with CHF with preserved LVSF and is independently associated with higher mortality. Appropriately designed randomised studies are needed to determine whether the prevention or treatment of anaemia can improve survival of these patients.

Heart failure in patients with preserved and deteriorated left ventricular ejection fraction.

OBJECTIVES: To determine clinical and prognostic differences between preserved and deteriorated systolic function (defined as left ventricular (LV) ejection fractions > or = 50% and < 50%, respectively) in patients with heart failure satisfying modified Framingham criteria. PATIENTS AND METHODS: Records were studied of 1252 patients with congestive heart failure (CHF) (mean (SD) age 69.4 (11.7) years; 485 women, 767 men) who had been admitted to a cardiology service for CHF in the period 1991-2002 and whose LV systolic function had been echocardiographically evaluated within two weeks of admission. Data were collected on the main clinical findings, supplementary examinations, treatment, and duration of hospitalisation. Whether the patient was alive in the spring of 2003 was evaluated by searching the general archives of the hospital and by telephone survey. RESULTS: LV systolic function was preserved in 39.8% of patients. Age, female to male sex ratio, and prevalence of atrial fibrillation, valve disease, and other non-ischaemic, non-dilated cardiopathies were all significantly greater in the group with preserved systolic function. New York Heart Association functional class IV, third heart sound, jugular vein congestion, cardiomegaly, radiological signs of lung oedema, pathological Q waves, left bundle branch block, sinus rhythm, ischaemic cardiopathy, and dilated cardiomyopathy were all significantly more prevalent in the group with deteriorated systolic function, as was treatment with angiotensin converting enzyme inhibitors and most other antihypertensive drugs on discharge from hospital. There was no significant difference in survival between the groups with preserved and deteriorated systolic function (either survival regardless of age at admission or in subgroups aged < 75 and > or = 75 years at admission). In the whole group, survival rates after one, three, and five years were 84.0%, 66.7%, and 50.9%, respectively. CONCLUSION: In view of the poor prognosis of patients with CHF with preserved LV systolic function, who are currently treated empirically, it is to be hoped that relevant controlled clinical trials under way will afford information allowing optimisation of their treatment.

Características clínicas y pronóstico de la insuficiencia cardíaca de origen isquémico e hipertensivo / Clinical characteristics and prognoses of ischemic and hypertensive heart failure

Objetivos. Nos propusimos evaluar las características clínicas y la supervivencia de pacientes con insuficiencia cardíaca de origen isquémico o hipertensivo que requirieron ingreso hospitalario. Métodos. Analizamos las características clínicas de 229 pacientes con insuficiencia cardíaca en clase III-IV debida a cardiopatía isquémica o hipertensión arterial (en este grupo se excluyeron los hipertensos con lesiones coronarias o manifestaciones clínicas de cardiopatía isquémica, así como los casos debidos a otras cardiopatías) que requirieron ingreso hospitalario entre el 1 de enero de 1991 y el 31 de diciembre de 1994. Su situación vital se evaluó mediante consulta o contacto telefónico en los meses de abril y mayo de 1998, con un período medio de seguimiento de 4 años. Se obtuvieron datos de 144 pacientes con insuficiencia cardíaca de origen isquémico y 69 pacientes de etiología hipertensiva. La edad media del grupo total era de 70 ñ 11 años, 70 ñ 9 de los 69 pacientes incluidos en el grupo hipertenso y 69 ñ 11 años en el isquémico. Resultados. El 49 por ciento de los isquémicos era también hipertenso. El 72 por ciento de los hipertensos y el 73 por ciento de los isquémicos se encontraban en clase IV en el ingreso hospitalario. La presencia de edema (periférico y pulmonar) era significativamente más frecuente en los pacientes con insuficiencia cardíaca hipertensiva, 49 por ciento frente al 20 por ciento; p = 0,0001, así como la existencia de cardiomegalia en radiografía de tórax: 97 por ciento frente al 84 por ciento, p = 0,01. También la hipertrofia ventricular izquierda en ECG (58 por ciento frente al 31 por ciento; p = 0,0001) y la fibrilación auricular (47 por ciento frente al 19 por ciento; p = 0,0001) eran significativamente más frecuentes en el grupo hipertenso. La disfunción sistólica de ventrículo izquierdo (FE < 50 por ciento) fue más frecuente, aunque no de forma significativa, en los pacientes que tenían cardiopatía isquémica (82 por ciento frente al 68 por ciento; p = 0,057). No se observaron diferencias en la supervivencia de ambos grupos con una supervivencia a 3 años del 58,5 por ciento y 58,6 por ciento de los pacientes incluidos en el grupo hipertenso e isquémico y a los 5 años del 47,7 por ciento y 45,9 por ciento, respectivamente. Conclusiones. El grupo de pacientes con insuficiencia cardíaca de etiología isquémica ingresados en nuestro hospital presenta, a largo plazo una elevada mortalidad similar a la del grupo hipertensivo, siendo la supervivencia a cinco años menor del 50 por ciento en ambos grupos (AU)

Clinical characteristics and prognosis of hospitalised inpatients with heart failure and preserved or reduced left ventricular ejection fraction.

OBJECTIVE: To determine the clinical and prognostic differences between patients with heart failure who had preserved or deteriorated systolic function, defined as a left ventricular ejection fraction of > 50% or < 50%, respectively, within two weeks of admission to hospital. METHODS: The records of 229 patients with congestive heart failure were studied. There were 95 women and 134 men, mean (SD) age 66.7 (11.7) years, who had been admitted to a cardiology department for congestive heart failure in the period 1991 to 1994, and whose left ventricular systolic function had been evaluated echocardiographically within two weeks of admission. Data were collected on the main clinical findings, supplementary investigations, treatment, and duration of hospital admission. Follow up information was obtained in the spring of 1998 by searching the general archives of the hospital and by a telephone survey. RESULTS: Left ventricular systolic function was preserved in 29% of the patients. The preserved and deteriorated groups differed significantly in the sex ratio (more women in the preserved group) and in the presence of a third heart sound, cardiomegaly, alveolar oedema, ischaemic cardiomyopathy, and treatment with angiotensin converting enzyme (ACE) inhibitors (all more in the deteriorated group). There were no significant differences in age, New York Heart Association functional class, rhythm disturbances, left ventricular hypertrophy, treatment with drugs other than ACE inhibitors, or survival. In the group as a whole, the survival rates after three months, one year, and five years were 92.6%, 80%, and 48.4%, respectively. CONCLUSIONS: In view of the unexpectedly poor prognosis of patients with congestive heart failure and preserved left ventricular systolic function, controlled clinical trials should be carried out to optimise their treatment.

Effects on left ventricular mass and function of low doses of enalapril for systemic hypertension.

After 7 years of treatment with 20 mg of enalapril twice daily, regression of the initial left ventricular hypertrophy in a group of 24 patients with essential arterial hypertension was achieved: gradual reduction in the dosage to 10 or 5 mg twice daily caused no worsening of either blood pressure or ventricular structure or function.

The influence of the design on the medium to long-term hemodynamic behavior of 19 mm pericardial aortic valve prostheses.

BACKGROUND AND AIMS OF THE STUDY: The hemodynamics of five designs of 19 mm pericardial aortic valve bioprosthesis were examined by Doppler echocardiography in 48 resting patients at medium or long term follow up. METHODS: The salient differences among the five designs are that valve leaflets are mounted inside the support frame in one (the Carpentier-Edwards valve, evaluated in five patients) and outside the frame in the other four (the Ionescu-Shiley (14 patients), Mitroflow (six patients), Bioflo (eight patients) and Labcor-Santiago (15 patients)); and that two models have either total (Bioflo) or partial (Labcor-Santiago) protective pericardial sheaths on the stent, while the other three do not. The hemodynamic parameters determined included transvalvular pressure drop, valve area, left ventricular outflow tract diameter, subvalvular/valvular velocity ratio and subvalvular/valvular velocity-time integral ratio. RESULTS: There were no significant differences among the various valves as regards left ventricular outflow tract diameter, subvalvular/valvular velocity ratio or subvalvular/valvular velocity-time integral ratio. Negative correlation between left ventricular outflow tract diameter and subvalvular velocity (r = -0.63, p < 0.001) confirmed the need to correct for prevalvular velocities when using the Bernoulli equation to calculate the pressure drop across small pericardial aortic valve bioprostheses. The Bioflo design caused significantly greater pressure drops (peak 49.6 +/- 11.3 mmHg, mean 28.1 +/- 6.1 mmHg) and provided smaller areas (0.80 +/- 0.16 cm2) than the Ionescu-Shiley (26.7 +/- 6.6 and 15.2 +/- 4.1 mmHg, 1.17 +/- 0.17 cm2) and Labcor-Santiago (24.8 +/- 5.9 and 15.1 +/- 3.7 mmHg, 1.24 +/- 0.12 cm2) valves. CONCLUSIONS: Of the currently available 19 mm bovine pericardium heart valve bioprostheses, the Mitroflow and Labcor-Santiago valves, in both of which the leaflets are mounted outside the stent, have better hemodynamics in the aortic position than the Carpentier-Edwards valve, which has internal leaflet mounting. Sheathing the stent totally in pericardium, as in the withdrawn Bioflo valve, gives rise to relatively poor hemodynamics.