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1.
JAMA Netw Open ; 4(1): e2035470, 2021 01 04.
Artigo em Inglês | MEDLINE | ID: mdl-33496796

RESUMO

Importance: Frequent right ventricular (RV) pacing can cause and exacerbate heart failure. Cardiac resynchronization therapy (CRT) has been shown to be associated with improved outcomes among patients with reduced left ventricular ejection fraction who need frequent RV pacing, but the patterns of use of CRT vs dual chamber (DC) devices and the associated outcomes among these patients in clinical practice is not known. Objective: To assess outcomes, variability in use of device type, and trends in use of device type over time among patients undergoing implantable cardioverter defibrillator (ICD) implantation who were likely to require frequent RV pacing but who did not have a class I indication for CRT. Design, Setting, and Participants: This retrospective cohort study used the National Cardiovascular Data Registry (NCDR) ICD Registry. A total of 3100 Medicare beneficiaries undergoing first-time implantation of CRT defibrillator (CRT-D) or DC-ICD from 2010 to 2016 who had a class I or II guideline ventricular bradycardia pacing indication but not a class I indication for CRT were included. Data were analyzed from August 2018 to October 2019. Exposures: Implantation of a CRT-D or DC-ICD. Main Outcomes and Measures: All-cause mortality, heart failure hospitalization, and complications were ascertained from Medicare claims data. Multivariable Cox proportional hazards models and Fine-Gray models were used to evaluate 1-year mortality and heart failure hospitalization, respectively. Multivariable logistic regression was used to evaluate 30-day and 90-day complications. All models accounted for clustering. The median odds ratio (MOR) was used to assess variability and represents the odds that a randomly selected patient receiving CRT-D at a hospital with high implant rates would receive CRT-D if they had been treated at a hospital with low CRT-D implant rates. Results: A total of 3100 individuals were included. The mean (SD) age was 76.3 (6.4) years, and 2500 (80.6%) were men. The 1698 patients (54.7%) receiving CRT-D were more likely than those receiving DC-ICD to have third-degree atrioventricular block (828 [48.8%] vs 432 [30.8%]; P < .001), nonischemic cardiomyopathy (508 [29.9%] vs 255 [18.2%]; P < .001), and prior heart failure hospitalizations (703 [41.4%] vs 421 [30.0%]; P < .001). Following adjustment, CRT-D was associated with lower 1-year mortality (hazard ratio [HR], 0.70; 95% CI, 0.57-0.87; P = .001) and heart failure hospitalization (subdistribution HR, 0.77; 95% CI, 0.61-0.97; P = .02) and no difference in complications compared with DC-ICD. Hospital variation in use of CRT was present (MOR, 2.00), and the use of CRT in this cohort was higher over time (654 of 1351 [48.4%] in 2010 vs 362 of 594 [60.9%] in 2016; P < .001). Conclusions and Relevance: In this cohort study of older patients in contemporary practice undergoing ICD implantation with a bradycardia pacing indication but without a class I indication for CRT, CRT-D was associated with better outcomes compared with DC devices. Variability in use of device type was observed, and the rate of CRT implantation increased over time.


Assuntos
Bradicardia/terapia , Terapia de Ressincronização Cardíaca/métodos , Desfibriladores Implantáveis , Disfunção Ventricular Esquerda/terapia , Idoso , Bradicardia/mortalidade , Feminino , Insuficiência Cardíaca/mortalidade , Hospitalização/estatística & dados numéricos , Humanos , Masculino , Medicare , Sistema de Registros , Estudos Retrospectivos , Estados Unidos/epidemiologia , Disfunção Ventricular Esquerda/mortalidade
2.
Am J Cardiol ; 143: 74-79, 2021 03 15.
Artigo em Inglês | MEDLINE | ID: mdl-33359194

RESUMO

Low systolic blood pressure (SBP) was previously suggested to be a marker for heart failure and mortality in patients with low left ventricular ejection fraction. We aimed to explore the association of SBP on risk of ventricular tachyarrhythmias (VTA) and atrial arrhythmias as well as appropriate and inappropriate Implantable Cardioverter Defibrillator (ICD) therapy. The study population comprised 1,481 of 1,500 (99%) patients enrolled in the Multicenter Automatic Defibrillator Implantation Trial - Reduce Inappropriate Therapy trial. Multivariate Cox proportional hazards regression modeling was used to identify the association of baseline SBP (recorded prior to ICD implantation) with the risk of VTA > 170 beats/min during follow-up (primary end point) and atrial arrhythmia, appropriate and inappropriate ICD therapy, hospitalization and death (secondary end points). SBP was dichotomized at 120 mm Hg (approximate mean and median) and was also assessed as a continuous measure. Multivariate analysis showed that each 10 mm Hg decrement in SBP was associated with corresponding 11% increased risk for VTA (p = 0.008). Low SBP (≤120 mm Hg) was associated with a significant 58% (p = 0.002) increased risk for VTA ≥170 beats/min; 53% (p = 0.019) increased risk for VTA ≥200 beats/min; and 65% (p = 0.001) increased risk for appropriate ICD therapy, as compared with SBP >120 mm Hg. Low SBP was not associated with increased risk of atrial arrhythmias, and inappropriate ICD therapy. In conclusion, in MADIT-RIT, SBP (≤120 mm Hg) predicted higher rates of VTA. These findings suggest that SBP may be utilized for VTA risk stratification in candidates for primary ICD therapy.


Assuntos
Pressão Sanguínea , Morte Súbita Cardíaca/prevenção & controle , Cardioversão Elétrica/estatística & dados numéricos , Insuficiência Cardíaca/terapia , Taquicardia Ventricular/epidemiologia , Disfunção Ventricular Esquerda/terapia , Fibrilação Ventricular/epidemiologia , Idoso , Fibrilação Atrial/epidemiologia , Morte Súbita Cardíaca/etiologia , Desfibriladores Implantáveis , Feminino , Insuficiência Cardíaca/complicações , Insuficiência Cardíaca/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Modelos de Riscos Proporcionais , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Volume Sistólico , Sístole , Taquicardia Supraventricular/epidemiologia , Taquicardia Ventricular/terapia , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/fisiopatologia , Fibrilação Ventricular/terapia
3.
J Card Surg ; 35(10): 2866-2868, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32720320

RESUMO

BACKGROUND AND AIMS: Fracture and retention of a guidewire after cardiac resynchronization therapy device implantation has not been reported in the literature so far, although it is an uncommon but known complication during cardiac interventions like percutaneous coronary interventions and other cardiac catheterization procedures. METHODS: A 53 years old female patient presented with severe pain over the left arm and shoulder for a period of 1 to 2 days. The patient had a history of dilated cardiomyopathy with severe left ventricular dysfunction and underwent cardiac resynchronization therapy device implant 3 years back with subsequent lead replacement 6 months back due to lead dysfunction. On evaluation, a coronary guidewire which might have fractured and been retained inadvertently during previous surgical procedure, was discovered in her deltoid muscle. Her symptoms were attributed to the guide wire which may have been aggravated by the movements of her arm. Emergency surgical exploration was done and the guidewire was removed. RESULTS AND CONCLUSION: We are reporting a case of unlikely and unusual delayed presentation of retained intervention guide-wire post cardiac resynchronization therapy, which was retrieved from the left deltoid muscle.


Assuntos
Dispositivos de Terapia de Ressincronização Cardíaca/efeitos adversos , Cardiomiopatia Dilatada/terapia , Músculo Deltoide/cirurgia , Remoção de Dispositivo/métodos , Falha de Equipamento , Intervenção Coronária Percutânea/efeitos adversos , Disfunção Ventricular Esquerda/terapia , Cardiomiopatia Dilatada/complicações , Emergências , Feminino , Humanos , Pessoa de Meia-Idade , Resultado do Tratamento , Disfunção Ventricular Esquerda/complicações
4.
Cardiovasc Pathol ; 49: 107243, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32629211

RESUMO

Heart failure with preserved ejection fraction (HFpEF) accounts for 50% of cases of heart failure, which is the most common cause of hospitalization in US patients over the age of 65. HFpEF pathogenesis is increasingly believed to be due to pathological hypertrophy and fibrosis of the myocardium that may be a result of systemic inflammation from comorbid conditions such as hypertension, diabetes mellitus, chronic obstructive pulmonary disease, anemia, chronic kidney disease and others. It is believed that oxidative stress triggers a process of pathological hypertrophy and fibrosis in cardiac endothelial cells, which leads to increased left ventricle filling pressures and, eventually, symptoms of heart failure. Numerous recent major clinical trials that have examined various therapies aimed at improving mortality in HFpEF have emerged empty-handed and thus the search for effective management strategies continues. Over the last several years, there have been many new developments in the field of antisense oligonucleotide-based therapeutics, which involves using noncoding nucleic acid particles such as microRNA and small interfering RNA to repress the expression of specific messenger RNA. In this article, we review the concept of using oligonucleotide-based therapeutics to prevent or treat HFpEF by targeting a specific microRNA that has been implicated in the pathogenesis of myocardial fibrosis and hypertrophy, microRNA-21 (miR-21). We review the various evidence that implicates miR-21 in the process of myocardial fibrosis and discuss recent attempts to use antimiR-21 compounds to prevent fibrosis. We also discuss proposed methods for screening patients at high risk for HFpEF for diastolic dysfunction in order to determine which patients.


Assuntos
Terapia Genética/métodos , Insuficiência Cardíaca/prevenção & controle , Hipertrofia Ventricular Esquerda/terapia , MicroRNAs/antagonistas & inibidores , Oligonucleotídeos Antissenso/uso terapêutico , Volume Sistólico , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda , Animais , Insuficiência Cardíaca/genética , Insuficiência Cardíaca/metabolismo , Insuficiência Cardíaca/fisiopatologia , Humanos , Hipertrofia Ventricular Esquerda/genética , Hipertrofia Ventricular Esquerda/metabolismo , Hipertrofia Ventricular Esquerda/fisiopatologia , MicroRNAs/genética , MicroRNAs/metabolismo , Resultado do Tratamento , Disfunção Ventricular Esquerda/genética , Disfunção Ventricular Esquerda/metabolismo , Disfunção Ventricular Esquerda/fisiopatologia , Remodelação Ventricular
5.
Circ Arrhythm Electrophysiol ; 13(7): e008168, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32538135

RESUMO

BACKGROUND: Dofetilide is one of the only anti-arrhythmic agents approved for atrial fibrillation (AF) in patients with reduced left ventricular ejection fraction (LVEF). However, postapproval data and safety outcomes are limited. In this study, we assessed the incidence and predictors of LVEF improvement, safety, and outcomes in patients with AF with LVEF ≤35% without prior implantable cardioverter defibrillator, cardiac resynchronization therapy, or AF ablation. METHODS: An analysis of 168 consecutive patients from 2007 to 2016 was performed. Incidences of adverse events, drug continuation, implantable cardioverter defibrillator and cardiac resynchronization therapy implantation, LVEF improvement (>35%) and recovery (≥50%), AF recurrence, and AF ablation were determined. Multivariable regression analysis to identify predictors of LVEF improvement/recovery was performed. RESULTS: The mean age was 64±12 years. Dofetilide was discontinued before hospital discharge in 46 (27%) because of QT prolongation (14%), torsades de pointe or polymorphic ventricular tachycardia/fibrillation (6% [sustained 3%, nonsustained 3%]), ineffectiveness (5%), or other causes (3%). At 1 year, 43% remained on dofetilide. Freedom from AF was 42% at 1 year, and 40% underwent future AF ablation. LVEF recovered (≥50%) in 45% and improved to >35% in 73%. Predictors of LVEF improvement included presence of AF during echocardiogram (odds ratio, 4.22 [95% CI, 1.71-10.4], P=0.002), coronary artery disease (odds ratio, 0.35 [95% CI, 0.16-0.79], P=0.01), left atrial diameter (odds ratio, 0.52 per 1 cm increase [95% CI, 0.30-0.90], P=0.01), and LVEF (odds ratio, per 1% increase, 1.09 [95% CI, 1.02-1.16], P=0.006). The C statistic was 0.78. CONCLUSIONS: In patients with LVEF ≤35%, who are potential implantable cardioverter defibrillator candidates, treated with dofetilide as an initial anti-arrhythmic strategy for AF, drug discontinuation rates were high, and many underwent future AF ablation. However, most patients had improvement in LVEF, obviating the need for primary prevention implantable cardioverter defibrillator.


Assuntos
Antiarrítmicos/uso terapêutico , Fibrilação Atrial/tratamento farmacológico , Frequência Cardíaca/efeitos dos fármacos , Fenetilaminas/uso terapêutico , Volume Sistólico/efeitos dos fármacos , Sulfonamidas/uso terapêutico , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda/efeitos dos fármacos , Idoso , Antiarrítmicos/efeitos adversos , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Bases de Dados Factuais , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fenetilaminas/efeitos adversos , Recuperação de Função Fisiológica , Recidiva , Estudos Retrospectivos , Sulfonamidas/efeitos adversos , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologia
6.
Heart Fail Clin ; 16(3): 295-303, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32503753

RESUMO

Continuous-flow left ventricular assist devices are frequently used for management of patients with advanced heart failure with reduced ejection fraction. Although technologic advancements have contributed to improved outcomes, several complications arise over time. These complications result from several factors, including medication effects, physiologic responses to chronic exposure to circulatory support that is minimally/entirely nonpulsatile, and dysfunction of the device itself. Clinical presentation can range from chronic and indolent to acute, life-threatening emergencies. Several areas of uncertainty exist regarding best practices for managing complications; however, growing awareness has led to development of new guidelines to reduce risk and improve outcomes.


Assuntos
Tratamento de Emergência/métodos , Insuficiência Cardíaca , Coração Auxiliar , Choque Cardiogênico , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapia , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia
7.
J Card Surg ; 35(7): 1514-1524, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32485030

RESUMO

INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a life-saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO-induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking. MATERIALS & METHODS: We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n = 30) versus immediate (Group 2, n = 33) LV unloading and then compared patients unloaded with an Impella CP (n = 19) versus an intra-aortic balloon pump (IABP, n = 16), analyzing survival and ECMO-related complications. RESULTS: Survival was similar between Groups 1 and 2 (33 vs 42%, P = .426) with Group 2 experiencing more clinically-significant hemorrhage (40 vs. 67%, P = .034). Survival and ECMO-related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%). DISCUSSION: Based on this analysis, reactive unloading appears to be a viable strategy while venting with the Impella CP provides better than anticipated survival. Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design.


Assuntos
Oxigenação por Membrana Extracorpórea/efeitos adversos , Coração Auxiliar , Balão Intra-Aórtico , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/terapia , Idoso , Feminino , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia
8.
Cardiovasc Diabetol ; 19(1): 38, 2020 03 23.
Artigo em Inglês | MEDLINE | ID: mdl-32293458

RESUMO

BACKGROUND: Left ventricular ejection fraction (LVEF) trajectories and functional recovery with current heart failure (HF) management is increasingly recognized. Type 2 diabetes mellitus (T2D) leads to a worse prognosis in HF patients. However, it is unknown whether T2D interferes with LVEF trajectories. The aim of this study was to prospectively assess very long-term (up to 15 years) LVEF trajectories in patients with and without T2D and underlying HF. METHODS: Ambulatory patients admitted to a multidisciplinary HF clinic were prospectively evaluated by scheduled two-dimensional echocardiography at baseline, 1 year, and then every 2 years afterwards, up to 15 years. Statistical analyses of LVEF change with time were performed using the linear mixed effects (LME) models, and locally weighted error sum of squares (Loess) curves were plotted. RESULTS: Of the 1921 patients, 461 diabetic and 699 non-diabetic patients with LVEF < 50% were included in the study. The mean number of echocardiography measurements performed in diabetic patients was 3.3 ± 1.6. Early LVEF recovery was similar in diabetic and non-diabetic patients, but Loess curves showed a more pronounced inverted U shape in diabetics with a more pronounced decline after 9 years. LME analysis showed a statistical interaction between T2D and LVEF trajectory over time (p = 0.009), which was statistically significant in patients with ischemic etiologies (p < 0.001). Other variables that showed an interaction between LVEF trajectories and T2D were male sex (p = 0.04) and HF duration (p = 0.008). CONCLUSIONS: LVEF trajectories in T2D patients with depressed systolic function showed a pronounced inverted U shape with a marked decline after 9 years. Diabetic cardiomyopathy may underlie the functional decline observed.


Assuntos
Diabetes Mellitus Tipo 2/complicações , Cardiomiopatias Diabéticas/etiologia , Insuficiência Cardíaca/etiologia , Volume Sistólico , Disfunção Ventricular Esquerda/etiologia , Função Ventricular Esquerda , Idoso , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/fisiopatologia , Diabetes Mellitus Tipo 2/terapia , Cardiomiopatias Diabéticas/diagnóstico por imagem , Cardiomiopatias Diabéticas/fisiopatologia , Cardiomiopatias Diabéticas/terapia , Progressão da Doença , Feminino , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Intervalo Livre de Progressão , Estudos Prospectivos , Fatores de Risco , Fatores de Tempo , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia
9.
Int J Cardiovasc Imaging ; 36(8): 1445-1454, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32297100

RESUMO

Previous studies have focused on only 1 or 2 echocardiographic parameters as prognostic markers in patients with acute ischemic stroke (AIS). A total of 900 patients with AIS who underwent transthoracic echocardiography (72.6 ± 12.0 years and 60% males) were retrospectively reviewed. Composite clinical events, including all-cause mortality, non-fatal stroke, non-fatal myocardial infarction, and coronary revascularization, were assessed during clinical follow-ups. During a median follow-up of 3.3 years (interquartile range 0.6-5.1 years), there were 151 (16.8%) composite events. In the multivariable analyses after controlling for potential confounders, left ventricular ejection fraction (LVEF) < 62% (hazard ratio [HR] 1.62; 95% confidence interval [CI] 1.14-2.30; p = 0.007) and AV sclerosis (AVs) (HR 1.56; 95% CI 1.10-2.21; p = 0.013) were independent prognostic factors associated with composite events. Multivariable analyses showed that HR for composite events gradually increased according to LVEF and AVs: HR was 2.6-fold higher in the highest-risk group than in the lowest group (p < 0.001). Compared with a clinical model (global chi-square = 69.6), LVEF, AVs, and both of them were significantly improved outcome prediction in sequential Cox model analysis (global chi-square = 75.6, 75.7, and 78.8, respectively; p < 0.05 for each) for each. In patients with AIS, LVEF < 62%, and the presence of AV sclerosis can predict future vascular events. Patients with AIS exhibiting reduced LVEF and AV sclerosis may benefit from aggressive secondary prevention.


Assuntos
Valva Aórtica/diagnóstico por imagem , Isquemia Encefálica/terapia , Ecocardiografia Doppler em Cores , Doenças das Valvas Cardíacas/diagnóstico por imagem , Acidente Vascular Cerebral/terapia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Valva Aórtica/fisiopatologia , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/mortalidade , Causas de Morte , Feminino , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/fisiopatologia , Doenças das Valvas Cardíacas/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Esclerose , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/mortalidade , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda
12.
JAMA Cardiol ; 5(7): 819-824, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32219357

RESUMO

Importance: Virus infection has been widely described as one of the most common causes of myocarditis. However, less is known about the cardiac involvement as a complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Objective: To describe the presentation of acute myocardial inflammation in a patient with coronavirus disease 2019 (COVID-19) who recovered from the influenzalike syndrome and developed fatigue and signs and symptoms of heart failure a week after upper respiratory tract symptoms. Design, Setting, and Participant: This case report describes an otherwise healthy 53-year-old woman who tested positive for COVID-19 and was admitted to the cardiac care unit in March 2020 for acute myopericarditis with systolic dysfunction, confirmed on cardiac magnetic resonance imaging, the week after onset of fever and dry cough due to COVID-19. The patient did not show any respiratory involvement during the clinical course. Exposure: Cardiac involvement with COVID-19. Main Outcomes and Measures: Detection of cardiac involvement with an increase in levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T, echocardiography changes, and diffuse biventricular myocardial edema and late gadolinium enhancement on cardiac magnetic resonance imaging. Results: An otherwise healthy 53-year-old white woman presented to the emergency department with severe fatigue. She described fever and dry cough the week before. She was afebrile but hypotensive; electrocardiography showed diffuse ST elevation, and elevated high-sensitivity troponin T and NT-proBNP levels were detected. Findings on chest radiography were normal. There was no evidence of obstructive coronary disease on coronary angiography. Based on the COVID-19 outbreak, a nasopharyngeal swab was performed, with a positive result for SARS-CoV-2 on real-time reverse transcriptase-polymerase chain reaction assay. Cardiac magnetic resonance imaging showed increased wall thickness with diffuse biventricular hypokinesis, especially in the apical segments, and severe left ventricular dysfunction (left ventricular ejection fraction of 35%). Short tau inversion recovery and T2-mapping sequences showed marked biventricular myocardial interstitial edema, and there was also diffuse late gadolinium enhancement involving the entire biventricular wall. There was a circumferential pericardial effusion that was most notable around the right cardiac chambers. These findings were all consistent with acute myopericarditis. She was treated with dobutamine, antiviral drugs (lopinavir/ritonavir), steroids, chloroquine, and medical treatment for heart failure, with progressive clinical and instrumental stabilization. Conclusions and Relevance: This case highlights cardiac involvement as a complication associated with COVID-19, even without symptoms and signs of interstitial pneumonia.


Assuntos
Betacoronavirus , Infecções por Coronavirus/complicações , Miocardite/virologia , Pericardite/virologia , Pneumonia Viral/complicações , Disfunção Ventricular Esquerda/virologia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Feminino , Humanos , Pessoa de Meia-Idade , Miocardite/diagnóstico por imagem , Miocardite/terapia , Pandemias , Pericardite/diagnóstico por imagem , Pericardite/terapia , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Disfunção Ventricular Esquerda/diagnóstico por imagem , Disfunção Ventricular Esquerda/terapia
13.
Am J Cardiol ; 125(8): 1270-1275, 2020 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-32087998

RESUMO

Prolonged trastuzumab therapy is the standard of care for women with metastatic HER2 positive (HER2+) breast cancer. There are limited data on the incidence of cardiotoxicity, its treatment implication, and cardiac care in these patients. We retrospectively identified consecutive women who received >12 months of trastuzumab treatment at Princess Margaret Cancer Centre (Toronto, ON) from 2007 to 2012 for metastatic HER2 positive breast cancer and followed them until death or August 2018. Patients were included if a pretherapy multigated acquisition scan and ≥2 subsequent follow-up scans were available. The Cardiac Review and Evaluation Committee Criteria were used to identify cardiotoxicity. Baseline characteristics and outcomes (final left ventricular ejection fraction, change in LVEF, trastuzumab interruption) were compared in patients with and without cardiotoxicity. Cardiac care and treatment received were recorded. Sixty patients (mean age 52 ± 10.4 years) were included. The median trastuzumab exposure was 37 cycles (interquartile range 23 to 56) over 28 months (interquartile range 19 to 49) and 48% received previous anthracycline therapy. The cumulative incidence of cardiotoxicity was 35% (95% CI 23 to 48) at 3 years. Patients who developed cardiotoxicity were more likely to receive third-line cancer treatments and had lower final LVEF than patients without (54.9% ± 6.3% vs 64% ± 4.9%, p <0.001). Of the 23 patients with cardiotoxicity, 10 (43%) had trastuzumab interrupted for at least 1 cycle, only 7 (30%) patients were seen by a cardiologist and 4 (17%) received cardiac medications. In conclusion, patients with metastatic breast cancer receiving prolonged trastuzumab therapy appear to have high rates of cardiotoxicity. This was associated with high rates of trastuzumab interruption, but low rates of cardiology referral and cardiac treatment, reflecting a potential cardiac care gap.


Assuntos
Antineoplásicos Imunológicos/efeitos adversos , Neoplasias Ósseas/tratamento farmacológico , Neoplasias Encefálicas/tratamento farmacológico , Neoplasias da Mama/tratamento farmacológico , Neoplasias Hepáticas/tratamento farmacológico , Neoplasias Pulmonares/tratamento farmacológico , Trastuzumab/efeitos adversos , Disfunção Ventricular Esquerda/induzido quimicamente , Adulto , Antraciclinas/uso terapêutico , Antineoplásicos Hormonais/uso terapêutico , Neoplasias Ósseas/metabolismo , Neoplasias Ósseas/secundário , Neoplasias Encefálicas/metabolismo , Neoplasias Encefálicas/secundário , Neoplasias da Mama/metabolismo , Neoplasias da Mama/patologia , Cardiologia , Cardiotoxicidade , Estudos de Coortes , Feminino , Humanos , Incidência , Neoplasias Hepáticas/metabolismo , Neoplasias Hepáticas/secundário , Neoplasias Pulmonares/metabolismo , Neoplasias Pulmonares/secundário , Pessoa de Meia-Idade , Metástase Neoplásica , Receptor ErbB-2/metabolismo , Encaminhamento e Consulta , Estudos Retrospectivos , Volume Sistólico , Taxoides/uso terapêutico , Disfunção Ventricular Esquerda/epidemiologia , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia
14.
Am J Cardiol ; 125(8): 1180-1186, 2020 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-32088000

RESUMO

Married patients have been shown to have a lower risk for adverse cardiovascular outcomes. However, the risk of heart failure (HF) or death in married versus unmarried patients with left ventricular (LV) dysfunction and an implantable cardioverter defibrillator (ICD), and the effect of cardiac resynchronization therapy with defibrillator (CRT-D) are unknown. In Multicenter Automatic Defibrillator Implantation Trial-Cardiac Resynchronization Therapy (MADIT-CRT), in patients with left bundle branch block, we evaluated long-term clinical outcomes of all-cause mortality or HF events in married (including common law status) compared with unmarried (single/divorced/widowed) patients with CRT-D versus an ICD-only. There were 937 married patients and 344 unmarried patients with left bundle branch block. Multivariate analysis showed that married patients had a 54% lower risk of all-cause mortality (hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.30 to 0.71, p <0.001) compared with the unmarried. However, the survival benefit associated with marital status was pronounced in ICD patients (HR 0.40, 95% CI 0.23 to 0.69, p <0.001) and attenuated in CRT-D patients (HR 0.74, 95% CI 0.51 to 1.06, p = 0.10), interaction (p = 0.07). Consistently, during the median follow-up of 5.6 years, in patients with ICD, married patients had a significantly lower incidence of death (24%) compared with unmarried patients (42%; p = 0.004), whereas the corresponding mortality rates in CRT-D patients were not significantly different (p = 0.814). In conclusion, during long-term follow-up of mild HF patients with LV dysfunction, married patients were at a significantly lower risk for death compared with those not married. The survival benefit associated with marital status was pronounced in patients implanted with an ICD and is attenuated in those implanted with a CRT-D device.


Assuntos
Bloqueio de Ramo/terapia , Dispositivos de Terapia de Ressincronização Cardíaca , Terapia de Ressincronização Cardíaca , Desfibriladores Implantáveis , Insuficiência Cardíaca/terapia , Estado Civil/estatística & dados numéricos , Mortalidade , Disfunção Ventricular Esquerda/terapia , Idoso , Causas de Morte , Progressão da Doença , Feminino , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais
16.
Sci Rep ; 10(1): 1736, 2020 02 03.
Artigo em Inglês | MEDLINE | ID: mdl-32015449

RESUMO

To compare in-hospital outcomes between left ventricular myocardial infarction (LVMI) patients with and without right ventricular myocardial infarction (RVMI). Patients with acute ST-segment elevation MI (STEMI) undergoing primary percutaneous coronary intervention (PCI) were enrolled and divided into LVMI with and without RVMI groups. Between-group differences and in-hospital outcomes were compared. Compared to patients without RVMI, patients with RVMI were more likely to be male, have higher body mass index, serum levels of C-reactive protein (8.9 ± 2.4 vs 6.2 ± 2.1 mg/dL), B-type natriuretic peptide (1295 ± 340 vs 872 ± 166 pg/mL) and cardiac troponin-I (8.6 ± 2.9 vs 5.2 ± 2.1 ng/mL), and have diabetes (36.3% vs 3.4%) and dyslipidemia (53.4% vs 48.1%). Patients with RVMI had lower left and right ventricular ejection fraction (50.5 ± 5.6% vs 53.4 ± 3.8% and 33.6 ± 2.9% vs 45.7 ± 2.0%), but had higher mean pulmonary artery pressure (30.6 ± 3.3 vs 23.8 ± 3.1 mm Hg). Compared to patients without RVMI, patients with RVMI had higher odds of in-hospital all-cause mortality (4.1% vs 1.0%) and new onset acute heart failure (3.4% vs 1.0%). After adjusted for confounding factors, LVMI with RVMI remained independently associated with composite outcomes, with odds ratio 1.66 (95% confidence interval 1.39-2.04). Compared to isolated LVMI patients, those with concomitant RVMI have higher odds of in-hospital complications, particularly all-cause mortality and new onset acute heart failure.


Assuntos
Infarto do Miocárdio/terapia , Intervenção Coronária Percutânea , Disfunção Ventricular Esquerda/terapia , Disfunção Ventricular Direita/terapia , Adulto , Idoso , Índice de Massa Corporal , Proteína C-Reativa/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Peptídeo Natriurético Encefálico/sangue , Análise de Sobrevida , Resultado do Tratamento , Disfunção Ventricular Esquerda/complicações , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Direita/complicações , Disfunção Ventricular Direita/mortalidade
17.
J Cardiovasc Electrophysiol ; 31(2): 494-502, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31908084

RESUMO

INTRODUCTION: We investigated whether pacing-induced electrical dyssynchrony at the time of cardiac resynchronization therapy (CRT) device implantation was associated with chronic CRT response. METHODS AND RESULTS: We included a total of 69 consecutive heart failure patients who received a CRT device. Left (LVp-RVs) and right (RVp-LVs) pacing-induced interlead delays were measured intraoperatively and used to determine if there was paced left ventricular (LV) dyssynchrony, defined as present when LVp-RVs is larger than RVp-LVs. CRT response was defined as a reduction in LV end-systolic volume ≥15%, 6 months after implantation. Paced left ventricular dyssynchrony (PLVD) was associated with ischemic cardiomyopathy (ICM) (χ2 : 8; P = .005) but not with QRS morphology nor with pacing lead positions. In a univariate analysis, PLVD (odds ratio [OR], 6.53; 95% confidence interval [CI], 2.2-18.9; P = .001), atypical left bundle branch block (LBBB) (OR, 3.3; 95% CI, 1.2-9.4; P = .022), and ICM (OR, 5.2; 95% CI, 1.6-17; P = .006) were associated with nonresponse. In a multivariate analysis, both PLVD (OR, 9.74; 95% CI, 2.8-33.9; P < .0001) and atypical LBBB (OR, 5.6; 95% CI, 1.5-20.3; P = .009) were independently associated with nonresponse. Adding PLVD to a model based on QRS morphology provided a significant and meaningful incremental value to predict LV reverse remodeling after CRT (χ2 to enter: 8; P < .005). Computer simulations corroborate these findings by showing that, while intrinsic electrical dyssynchrony is a prerequisite, the level of pacing-induced dyssynchrony modulates acute CRT response. CONCLUSION: In addition to the intrinsic electrical substrate, PLVD is strongly associated with less LV reverse remodeling, demonstrating that measuring the electrical substrate during pacing has additional value for prediction of CRT response in an already well-selected patient population.


Assuntos
Terapia de Ressincronização Cardíaca , Insuficiência Cardíaca/terapia , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda , Remodelação Ventricular , Adulto , Idoso , Idoso de 80 Anos ou mais , Simulação por Computador , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Hemodinâmica , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Cardiovasculares , Estudos Prospectivos , Recuperação de Função Fisiológica , Fatores de Tempo , Resultado do Tratamento , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/fisiopatologia
18.
JACC Cardiovasc Imaging ; 13(1 Pt 2): 310-326, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31918900

RESUMO

By assessing nonhospitalized asymptomatic patients, community-based studies inform the prevalence, key clinical characteristics, and outcomes associated with diastolic dysfunction. As the number of parameters to define and grade diastolic function continues to increase, there has been a shift to a focus on readily obtainable measurements with minimal interobserver variability. In this regard, mitral inflow and annular tissue Doppler velocities, as well as measurement of left atrial volume index, are the most feasible and reproducible. Within communities, variations in definitions have limited generalizability regarding the prevalence and risks associated with diastolic dysfunction. Nevertheless, community-based studies have established important associations with hypertension, obesity, and diabetes. Randomized controlled trials of treatment in heart failure with preserved ejection fraction have been disappointing. Importantly, diastolic dysfunction is consistently associated with higher mortality, which emphasizes the importance of early recognition and initiation of appropriate preventative treatments.


Assuntos
Ecocardiografia Doppler , Insuficiência Cardíaca/diagnóstico por imagem , Disfunção Ventricular Esquerda/diagnóstico por imagem , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Diástole , Medicina Baseada em Evidências , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Disfunção Ventricular Esquerda/mortalidade , Disfunção Ventricular Esquerda/fisiopatologia , Disfunção Ventricular Esquerda/terapia , Função Ventricular Esquerda , Adulto Jovem
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