Relationships among norepinephrine levels, exercise capacity, and chronotropic responses in heart failure patients.

In heart failure (HF) patients, the pathophysiological mechanisms of severe exercise intolerance and impaired exercise capacity are related to both central and peripheral abnormalities. The central abnormalities in HF patients include impaired cardiac function and chronotropic incompetence (CI). Indeed, CI, the inability to adequately increase heart rate (HR) from rest to exercise often exhibited by HF patients, is related to activation of the sympathetic nervous system (SNS) yielding a rise in circulating norepinephrine (NE). CI may result from downregulation of ß-adrenergic receptors, ß-blocker usage, high baseline HR, or due to a combination of factors. This paper discusses the role of elevated NE in altering chronotropic responses in HF patients and consequently resulting in impaired exercise capacity. We suggest that future research should focus on the potential treatment of CI with rate-adaptive pacing, using a sensor to measure physical activity, without inducing deleterious hormonal activation of the sympathetic system.

The Prognostic Value of Cardiovascular Risk Factors and Laboratory Biomarkers in Predicting 6-Month Outcomes in High-risk Patients with Non-ST Segment Elevation Myocardial Infarction.

BACKGROUND: Acute coronary syndrome (ACS) represents a spectrum of ischemic myocardial disease including unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Various prognostic scores were developed for patients presenting with NSTEMI-ACS. Among these scores, the GRACE risk score offers the best discriminative performance for prediction of in-hospital and 6-month mortality. However, the GRACE score is limited and cannot be used in several ethnic populations. Moreover, it is not predictive of clinical outcomes other than mortality. OBJECTIVES: To assess the prognostic value of traditional cardiovascular risk factors and laboratory biomarkers in predicting 6-month major adverse cardiac and cerebrovascular events (MACCE), including hospitalization, recurrent percutaneous coronary intervention (PCI), stroke, and cardiovascular mortality in patients with NSTEMI treated with PCI. METHODS: This retrospective study included consecutive patients admitted with an initial diagnosis of NSTEMI to the cardiac intensive care unit (CICU) at the Tzafon Medical Center, Israel, between April 2015 and August 2018 and treated by PCI within 48 hours of admission. RESULTS: A total of 223 consecutive patients with NSTEMI treated by PCI were included in the study. Logarithmebrain natriuretic peptide (LogₑBNP), prior MI, and Hb levels were found to be significant predictors of any first MACCE. Only logₑBNP was found to be an independent predictor of a first MACCE event by multivariate logistic regression analysis. CONCLUSIONS: LogₑBNP is an independent predictor of worse prognosis in patients with NSTEMI. Routine evaluation of BNP levels should be considered in patients admitted with NSTEMI.

Clinical factors and pre-surgical depression scores predict pain intensity in cardiac surgery patients.

BACKGROUND: Severe pain is prevalent in cardiac surgery patients and can increase cardiac complications, morbidity and mortality. The objectives of the study were to assess perioperative pain intensity and to assess predictors of pain post-cardiac surgery, including clinical characteristics and depression. METHODS: A total of 98 cardiac surgery patients were included in the study. Pain intensity was assessed using a Numerical Rating System. Pain was measured one day pre-operatively and recorded daily from Post-operative Day 2 to Day 7. Clinical data were recorded and depression scores were assessed using the Center for Epidemiological Study of Depression (CES-D). RESULTS: Pain intensity increased significantly during hospitalization from pre-operative levels, surging at 2 days post-operatively. Predictors of high pain intensity were high pre-operative CES-D scores, female gender, cardiac function, smoking and high body mass index (BMI). Significantly higher pre-operative CES-D scores were found in patients with severe pain compared to patients with no pain to moderate pain (18.23 ± 1.80 vs 12.84 ± 1.22, p = 0.01 pre-operatively). Patients with severe pain (NRS 7-10) had significantly higher levels of white blood cells (WBC) compared to patients with no pain-moderate pain (NRS 0-6), (p = 0.01). However, CES-D scores were only weakly correlated maximum WBC levels perioperatively. CONCLUSION: Pain intensity significantly increased following surgery, and was associated with depressive symptoms, female sex, cardiac function, BMI, and smoking. These factors may serve as a basis for identification and intervention to help prevent the transition from acute pain to chronic pain.

Bypassing the emergency room to reduce door-to-balloon time and improve outcomes of ST elevation myocardial infarction patients: analysis of data from 2004-2010 ACSIS registry.

OBJECTIVES: Our objective was to assess whether bypassing the emergency room (ER) is associated with meaningful reduction in Major Adverse Cardiac and Cerebrovascular Event (MACCE) or mortality in a large cohort of ST Elevation Myocardial Infarction (STEMI) patients. BACKGROUND: Prior studies suggest that bypassing the emergency room reduces door-to-balloon time (DBT). However, it is not clear whether this translates into reduced mortality. METHODS: We analyzed data of 1,552 consecutive patients with STEMI treated by primary percutaneous coronary intervention (PCI) and enrolled in the Acute Coronary Syndrome Israeli Survey (ACSIS) registry. Thirty percent of patients (n = 459) arrived directly to the Intensive Cardiac Care Unit or catheterization laboratory and 70% (n = 1093) were assessed first in the ER. Our primary end points were DBT, 30-day MACCE, and 30-day and 1-year mortality. Our secondary end points were pre-discharge ejection fraction less than 40%, in-hospital pulmonary edema, in-hospital cardiogenic shock, ST resolution, and duration of hospitalization. RESULTS: Bypassing the ER was associated with signficantly shorter DBT (59 vs. 97 minutes, P = 0.001). There was no difference in 30-day MACCE and 30-day or 1-year mortality between the 2 study groups. The findings were consistent in multiple subgroups, including women, anterior STEMI, off hours PCI, and patients with pain-to-door (PDT) time of less than 120 minutes. CONCLUSION: Bypassing the ER is associated with significant shortening of DBT. This reduction, however, is not associated with any change in 30-day MACCE and 30-day or 1-year mortality.

Bypassing the emergency room to reduce door-to-balloon time and improve outcomes of patients with ST elevation myocardial infarction: the Acute Coronary Syndrome Israeli Survey experience.

BACKGROUND: Rapid reperfusion of an infarct-related artery is crucial for the successful treatment of ST elevation myocardial infarction. Every effort should be made to shorten door-to-balloon time. OBJECTIVES: To investigate whether bypassing the emergency room (ER) has a positive influence on door-to-balloon time in patients presenting with ST elevation myocardial infarction (STEMI) and whether the reduction in door-to-balloon time improves patients' clinical outcome. METHODS: We analyzed data of 776 patients with STEMI from the 2004 and the 2006 Acute Coronary Syndrome Israeli Survey (ACSIS) registry. The ACSIS is a biennial survey on acute myocardial infarction performed in all 25 intensive cardiac care units in Israel during a 2-month period. Twenty-five percent of patients (193 of 776) arrived directly to the intensive cardiac care unit (ICCU) and 75% (583 of 776) were assessed first in the ER. We compared door-to-balloon time, ejection fraction, 30 days MACE (major adverse cardiac and cerebrovascular events) and 30 days mortality in the two study groups. RESULTS: There was significantly shorter door-to-balloon time in the direct ICCU group as compared with the ER group (45 vs. 79 minutes, P< 0.002). Patients in the direct ICCU group were more likely to have door-to-balloon time of less than 90 minutes in accordance with ACC/AHA guidelines (88.7% vs. 59.2%, P < 0.0001). Moreover, patients in the direct ICCU group were less likely to have left ventricular ejection fraction < 30% (5.4% vs. 12.2%, P= 0.045) and less likely to have symptoms of overt congestive heart failure. Lastly, 30 days MACE was significantly lower in the direct ICCU group (22 vs. 30%, P< 0.004). CONCLUSIONS: There is significant reduction of the door-to-balloon time in the direct ICCU admission strategy. This reduction translates into improvement in clinical outcome of patients. It is reasonable to apply the direct ICCU strategy to patients with STEMI.

Predictors of Mitral Regurgitation Severity Improvement in Patients With Severe Aortic Stenosis Undergoing Transcatheter Aortic Valve Implantation.

BACKGROUND: Mitral regurgitation (MR) is frequently associated with severe aortic stenosis (AS). Significant MR is associated with less favorable prognosis after transcatheter aortic valve implantation (TAVI), including higher early and late mortality rate. The severity of MR is improved in about half of patients undergoing TAVI. However, the predictors of MR improvement after TAVI are unknown. We sought to investigate whether several demographic, clinical, echocardiographic and laboratory parameters and procedure characteristics are predictive of MR severity improvement after TAVI procedure. METHODS: A total of 309 consecutive patients with severe symptomatic AS underwent TAVI procedure in our center from July 1, 2015 till December 31, 2019. The 85 patients had concomitant significant (grade 2 or 3) MR. We performed logistic regression analysis of age, sex, atrial fibrillation, left ventricular ejection fraction, end diastolic diameter, end systolic diameter, left atrial diameter, left atrial area, MR etiology (functional vs. degenerative), CHA2DS2-VASc score, pre-procedure B-type natriuretic peptide (BNP) levels and type of TAVI bioprosthesis as possible predictors of post-TAVI improvement of severity of MR. RESULTS: The 35 patients have at least one grade reduction in the severity of MR in follow-up echo. None of the analyzed parameters were predicting of the MR severity improvement. CONCLUSIONS: In this small single-center cohort study, we were unable to find any feasible demographic, clinical, echocardiographic or laboratory predictors of MR improvement after TAVI. There was no correlation between etiology of MR or type of TAVI bioprosthesis used and MR improvement.