Rationale and Design of Heart Failure Prevalence and Evolution of Heart Failure in Diabetes Mellitus Type II Patients at High Risk (HF-LanDMark Study).

(1) Background: Patients with diabetes mellitus (DM) are at increased risk for heart failure (HF). Accurate data regarding the prevalence of HF stages among diabetics in Greece are scarce. (2) Aim: The present study will examine the prevalence and evolution of HF stages among patients with type II DM (T2DM) diagnosed in the past 10 years, with no previous history of HF and at high CV risk, in Greece, as well as will explore the potential determinants of the development of symptomatic HF in these patients. (3) Methods: Through a non-interventional, epidemiological, single-country, multi-center, prospective cohort study design, a sample of 300 consecutive patients will be enrolled in 11 cardiology departments that are HF centers of excellence. Patients will be either self-referred or referred by primary or secondary care physicians and will be followed for up to 24 months. Demographic, clinical, echocardiography, electrocardiography, cardiac biomarkers (troponin, NT-proBNP) and health-related quality of life questionnaire data will be recorded as well as clinical events, including mortality, HF hospitalizations and HF-related healthcare resource utilization. The primary outcomes are the proportion of patients diagnosed with symptomatic HF (ACC/AHA Stage C) at enrolment in the overall study population and the proportions of patients with HF stages A, B and C, as well as by NYHA functional classification in the overall study population. (4) Conclusions: The HF-LanDMark study is the first epidemiological study that will assess the prevalence of HF among T2DM patients in Greece that could potentially enhance prompt therapeutic interventions shown to delay the development of HF in the T2DM patient population (HF-LanDMark, Clinical Trials.gov number, NCT04482283).

Plasma activity of B-type natriuretic peptide in patients with biventricular heart failure versus those with right heart failure due to chronic obstructive pulmonary disease.

BACKGROUND: Plasma B-type natriuretic peptide (BNP) is an established prognostic indicator in patients with left ventricular systolic heart failure (LHF). However, no efficient data exist regarding the differences in plasma BNP activity between patients with biventricular heart failure and those with right heart failure (RHF) due to chronic obstructive pulmonary disease (COPD). OBJECTIVE: This study investigates BNP in RHF due to COPD in comparison to RHF due to LHF, and estimates the relation of BNP levels with clinical and echocardiographic parameters. METHODS: We evaluated plasma BNP in 88 patients admitted to hospital with acutely decompensated chronic heart failure (31 with RHF due to LHF, 30 with RHF due to COPD without left heart disease, and 27 with LHF without right ventricular involvement). All patients underwent echocardiography examination and blood samples were collected to determine BNP and routine blood chemistry measurements. RESULTS: Plasma BNP levels were significantly higher in RHF due to LHF compared with RHF due to COPD (P <0.001). Plasma BNP did not appear to differ between RHF due to LHF and LHF alone (P = 0.802). In multiple linear regression analysis, tissue Doppler imaging e(LV) (B: -0.053, P = 0.002) and e(RV) (B: -0.079, P = 0.007) had an independent negative association with BNP, whereas logUrea (B: 0.635, P < 0.001) and hematocrit (B: 0.014, P = 0.005) showed an independent positive association with BNP levels in the group of RHF due to COPD. CONCLUSION: BNP levels were significantly lower in RHF due to COPD compared with RHF due to LHF and were independently predicted by indices of left ventricular and right ventricular diastolic function, renal function, and anemia.

Clinical and echocardiographic correlates of serum copper and zinc in acute and chronic heart failure.

AIM: Emerging evidence suggests a pathophysiological role of micronutrient dyshomeostasis in heart failure, including promotion of adverse remodeling and clinical deterioration. We sought to evaluate serum copper (Cu) and zinc (Zn) levels in acute (AHF) and chronic (CHF) heart failure. METHODS: We studied 125 patients, 71 % male, aged 69 ± 11 years, 37 % with preserved left ventricular ejection fraction (LVEF ≥40 %) (HFPEF), including 81 with AHF and 44 with CHF; 21 healthy volunteers served as controls. Serum Cu and Zn levels were determined using air-acetylene flame atomic absorption spectrophotometry. RESULTS: Serum Cu levels were significantly higher in AHF (p = 0.006) and CHF (p = 0.002) patients compared to controls after adjusting for age, gender and comorbidities, whereas they did not differ between AHF and CHF (p = 0.840). Additionally, serum Cu in patients with LVEF <40 % was significantly higher compared to both controls (p < 0.001) and HFPEF patients (p = 0.003). Serum Zn was significantly lower in AHF (p < 0.001) and CHF (p = 0.039) compared to control after adjusting for the above-mentioned variables. Moreover, serum Zn was significantly lower in AHF than in CHF (p = 0.015). In multiple linear regression, LVEF (p = 0.033) and E/e ratio (p = 0.006) were independent predictors of serum Cu in total heart failure population, while NYHA class (p < 0.001) and E/e ratio (p = 0.007) were independent predictors of serum Zn. CONCLUSION: Serum Cu was increased both in AHF and CHF and correlated with LV systolic and diastolic function. Serum Zn, in contrast, was decreased both in AHF and CHF and independently predicted by clinical status and LV diastolic function.

Potential-guided versus anatomic-guided approach for slow pathway ablation of the common type atrioventricular nodal reentry tachycardia: a randomized study.

OBJECTIVE: The present study aimed to compare the effectiveness and safety of the potential- and the anatomic-guided approach for slow pathway ablation in patients with recurrent episodes of symptomatic common type atrioventricular (AV) nodal reentrant tachycardia. METHODS: Two hundred and twenty-eight patients were randomly assigned to undergo either a potential- (n=114, 47% men, mean age 52.85 +/- 14.04 years) or an anatomic-guided approach (n=114, 50% men, mean age 52.45 +/- 14.46 years) for radiofrequency ablation of the slow pathway.The mean duration of the follow-up period was 26.7 +/- 7.9 and 24.8 +/- 7.6 months in the potential- and anatomic- guided approach, respectively (P > 0.05). RESULTS: The success rate for slow pathway ablation was 100% in both ablative methods.The mean duration of atrial electrograms at the successful ablation sites of the potential- and the anatomic-guided approaches was 69 +/- 14 msec and 57 +/- 10 msec, respectively (P = 0.001).There were no significant differences between the potential- and the anatomic-guided approach regarding the duration of the procedure (121.13 +/- 56.83 vs. 109.93 +/- 57.12 min, P = 0.139), the duration of fluoroscopic exposure (6.12 +/- 3.32 vs. 6.64 +/- 3.33 min, P = 0.239) or the mean number of radiofrequency applications delivered (3.96 +/- 2.77 vs. 4.33 +/- 2.73, P = 0.311). Residual dual AV nodal pathway following successful ablation was observed in 9.6% of patients who underwent the potential-guided approach and in 23.7% of patients who underwent the anatomic method (P = 0.004). During followup, arrhythmia recurrence was observed in four patients (1.8%), two in each group (P > 0.05). CONCLUSIONS: The efficacy and safety of the slow pathway ablation is very high using either the potential- or the anatomic-guided approach.

Wide QRS complex supraventricular tachycardia with negative precordial concordance.

The authors describe the case of a 49-year-old man who experienced an episode of palpitations and dizziness. The results of 24-hour Holter monitoring demonstrated an episode of wide QRS complex regular tachycardia. During the electrophysiological study, a wide QRS complex tachycardia with negative precordial concordance was induced. A diagnosis of orthodromic atrioventricular re-entrant tachycardia involving a left lateral accessory pathway with left bundle branch aberration was made. This case represents a rare exception to the rule that negative precordial QRS concordance is diagnostic of ventricular tachycardia.

Predictors of atrial fibrillation recurrence in patients with long-lasting atrial fibrillation.

BACKGROUND: Limited data are available on the predictors of atrial fibrillation (AF) recurrence in patients with chronic AF. OBJECTIVES: To evaluate potential clinical, echocardiographic and electrophysiological predictors of AF recurrence, after internal cardioversion for long-lasting AF. METHODS: A total of 99 consecutive patients (63 men and 36 women, mean age 63.33+/-9.27 years) with long-standing AF (52.42+/-72.02 months) underwent internal cardioversion with a catheter that consisted of two defibrillating coils. Shocks were delivered according to a step-up protocol. Clinical follow-up and electrocardiographic recordings were performed on a monthly basis for a 12-month period or whenever patients experienced symptoms suggestive of recurrent AF. RESULTS: Ninety-three patients (93.94%) underwent a successful uncomplicated cardioversion, with a mean atrial defibrillation threshold of 10.69+/-6.76 J. Immediate reinitiation of AF was observed in 15 patients (15.78%) of whom a repeated cardioversion restored sinus rhythm in 13 cases. Early recurrence of AF (within one week) was observed in 12 of 93 patients (12.90%). At the end of the 12-month follow-up period, during which seven patients were lost, 42 of the 86 remaining patients (48.84%) were still in sinus rhythm. Multivariate regression analysis showed that left atrial diameter (OR 1.126, 95% CI 1.015 to 1.249; P=0.025) and mitral A wave velocity (OR 0.972, 95% CI 0.945 to 0.999; P=0.044) were significant and independent predictors of AF recurrence, whereas age, left ventricular ejection fraction and AF cycle length were not predictive of arrhythmia recurrence. CONCLUSION: The present study showed that the left atrial diameter and mitral A wave velocity are the only variables associated with AF recurrence after successful cardioversion.

Clinical characteristics of patients with drug-induced QT interval prolongation and torsade de pointes: identification of risk factors.

The present study aimed to investigate the causative medications and underlying risk factors that predispose to drug-induced QT interval prolongation. Twenty-one patients with drug-induced long QT (90% females, mean age 64.3 +/- 14.1 years) were included in the study. Transthoracic echocardiography as well as continuous or ambulatory 48-h electrocardiographic monitoring was carried out in all patients during their hospitalization. The mean corrected QT (QTc) interval was 542 +/- 56.8 ms. Known cardiac agents (mainly class III antiarrhythmics) were implicated in 13/21 (62%), antipsychotics in 8/21 (38%), and antibiotics in 5/21 patients (24%). Potential drug-interactions through inhibition of cytochrome P450 isoenzymes were considered responsible in 5/21 cases (24%). The underlying cardiovascular diseases included hypertension (57%) with left ventricular hypertrophy (29%), paroxysmal atrial tachyarrhytmias (48%), heart failure (14%), valvular heart disease (10%), and coronary artery disease (5%). Torsade de pointes (TdP) was recorded in 6/21 of patients, and cardiac arrest necessitating resuscitation occurred in five of them. A significant correlation was observed between administration of cardiac agents and TdP events (P < 0.05). TdP and cardiac arrest events were both associated with a QTc interval >510 ms (P < 0.05). Advanced age (>60 years), female gender, hypertension and paroxysmal atrial tachyarrhytmias were the most common identifiable pre-existing factors for drug-induced long QT in our patient cohort. Marked QTc interval prolongation should be considered of prognostic significance for TdP and cardiac arrest events.

Determinants of plasma NT-pro-BNP levels in patients with atrial fibrillation and preserved left ventricular ejection fraction.

OBJECTIVES: The present study aimed to investigate the clinical and echocardiographic determinants of plasma NT-pro-BNP levels in patients with atrial fibrillation (AF) and preserved left ventricular ejection fraction (LVEF). METHODS: NT-pro-BNP levels were measured in 45 patients with paroxysmal AF, 41 patients with permanent AF and 48 controls. RESULTS: NT-pro-BNP levels were found significantly elevated in patients with paroxysmal (215+/-815 pg/ml) and permanent AF (1,086+/-835 pg/ml) in relation to control population (86.3+/-77.9 pg/ml) (P<0.001). According to the univariate linear regression analysis, age, hypertension, beta-blocker use, left atrial diameter (LAD), LVEF and AF status (paroxysmal or permanent or both) were significantly associated with NT-pro-BNP levels (P<0.05). In multiple linear regression analysis, LVEF (B coefficient: -53.030; CI: -95.738 to -10.322; P: 0.015) and LAD (B coefficient: 285.858; CI: 23.731-547.986; P: 0.033) were significant and independent determinants of NT-pro-BNP levels. CONCLUSIONS: Plasma NT-pro-BNP levels were significantly higher in patients with paroxysmal and permanent AF compared to those with sinus rhythm in the setting of preserved left ventricular systolic function. LVEF and LAD were independent predictors of NT-pro-BNP levels.

Ablation of atrial fibrillation in patients with heart failure: reversal of atrial and ventricular remodelling.

INTRODUCTION: The management of patients with heart failure and atrial fibrillation (AF) is a medical challenge, especially in the case of patients in whom sinus rhythm or rate control cannot be achieved with optimal pharmaceutical treatment. METHODS: Thirteen consecutive patients (11 men and 2 women, 35-70 years old, median age 55 +/- 23 years) with heart failure (NYHA I-IV, median ejection fraction 35 +/- 5%, range 25-40%) and symptomatic persistent (10 patients, 76.9%) or permanent (3 patients, 23.1%) AF, underwent circumferential ablation using a system of electroanatomic mapping with contact. Circumferential ablation, encircling the pulmonary veins in pairs, and linear ablation between the left and right superior pulmonary vein and along the mitral isthmus were performed. Follow up included 24-hour Holter monitoring and transthoracic echocardiogram at 1, 3, 6, 9 and 12 months. RESULTS: Eight patients (62%) remained in sinus rhythm at the end of the follow up and had achieved a statistically significant improvement in ejection fraction (from 37.5 8.75% to 60.0 +/- 3.75%, p = 0.011), reduction of left ventricular end-diastolic diameter (from 63.0 +/- 3.25 mm to 56.5 +/- 1.75 mm, p = 0.011) and reduction of left atrial diameter (from 49.0 +/- 5.5 mm to 44.5 +/- 4.25 mm, p = 0.011). In contrast, patients with relapse of AF had none of the above changes (p > 0.05). Prognostic indexes of AF recurrence appeared to be the failure to improve ejection fraction (p = 0.003), non-reversal of left ventricular (p = 0.002) and left atrial (p = 0.006) remodelling, a shorter energy application time (p = 0.030) and the presence of coronary artery disease (p = 0.035). None of the patients suffered any complication from the procedure. CONCLUSION: AF ablation in selected patients with heart failure and low ejection fraction is a relatively effective method of maintaining sinus rhythm, improving left ventricular systolic function and reversing atrial and ventricular remodelling.

QT interval prolongation and torsade de pointes associated with indapamide.

Direct blockade of the delayed rectifier repolarising potassium current is the major underlying mechanism of drug-induced QT interval prolongation. Indapamide is a well known blocker of the slow component of the delayed rectifier current leading to prolongation of cardiac repolarization. The case of an acquired long QT and torsade de pointes ventricular tachycardia in a woman with systemic lupus erythematosus and hypertension receiving prednisolone and indapamide, respectively, is described in the present report.