RESUMO
BACKGROUND: The optimal duration of anticoagulation therapy for isolated distal deep vein thrombosis in patients with cancer is clinically relevant, but the evidence is lacking. The prolonged anticoagulation therapy could have a potential benefit for prevention of thrombotic events; however, it could also increase the risk of bleeding. METHODS: In a multicenter, open-label, adjudicator-blinded, randomized clinical trial at 60 institutions in Japan, we randomly assigned patients with cancer with isolated distal deep vein thrombosis, in a 1-to-1 ratio, to receive either a 12-month or 3-month edoxaban treatment. The primary end point was a composite of a symptomatic recurrent venous thromboembolism (VTE) or VTE-related death at 12 months. The major secondary end point was major bleeding at 12 months, according to the criteria of the International Society on Thrombosis and Haemostasis. The primary hypothesis was that a 12-month edoxaban treatment was superior to a 3-month edoxaban treatment with respect to the primary end point. RESULTS: From April 2019 through June 2022, 604 patients were randomized, and after excluding 3 patients who withdrew consent, 601 patients were included in the intention-to-treat population: 296 patients in the 12-month edoxaban group and 305 patients in the 3-month edoxaban group. The mean age was 70.8 years, 28% of the patients were men, and 20% of the patients had symptoms of deep vein thrombosis at baseline. The primary end point of a symptomatic recurrent VTE event or VTE-related death occurred in 3 of the 296 patients (1.0%) in the 12-month edoxaban group and in 22 of the 305 patients (7.2%) in the 3-month edoxaban group (odds ratio, 0.13; 95% CI, 0.03-0.44). The major secondary end point of major bleeding occurred in 28 of the 296 patients (9.5%) in the 12-month edoxaban group and in 22 of the 305 patients (7.2%) in the 3-month edoxaban group (odds ratio, 1.34; 95% CI, 0.75-2.41). The prespecified subgroups did not affect the estimates on the primary end point. CONCLUSIONS: In patients with cancer with isolated distal deep vein thrombosis, 12 months was superior to 3 months for an edoxaban treatment with respect to the composite outcome of a symptomatic recurrent VTE or VTE-related death. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03895502.
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Neoplasias , Trombose , Tromboembolia Venosa , Trombose Venosa , Masculino , Humanos , Idoso , Feminino , Anticoagulantes/efeitos adversos , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/complicações , Hemorragia/complicações , Trombose/complicações , Trombose Venosa/complicações , Neoplasias/complicações , Neoplasias/tratamento farmacológicoRESUMO
The HeartMate Risk Score (HMRS), a simple clinical prediction rule based on the patients' age, albumin, creatinine, and the international normalized ratio of the prothrombin time (PT-INR), is correlated with mortality in the cohort of left ventricular assist device (LVAD) recipients. However, in an aging society, an LAVD is indicated for only a small proportion of patients with acute heart failure (AHF), and whether the HMRS has prognostic implications for unselected patients with AHF is unknown. This study aimed to assess the prognostic value of HMRS categories on admission in patients with AHF. We analyzed 339 hospitalized patients with AHF who had albumin, creatinine, and the PT-INR recorded on admission. The patients were categorized as follows: the High group (HMRS > 2.48, n = 131), Mid group (HMRS of 1.58-2.48, n = 97) group, and Low group (HMRS < 1.58, n = 111). The endpoints of this study were all-cause death and readmission for heart failure (HF). During a median follow-up of 247 days, 24 (18.3%) patients died in the High group, 7 (7.2%) died in the Mid group, and 8 (7.2%) died in the Low group. In a multivariable analysis adjusted for highly imbalanced baseline variables, a high HMRS was independently associated with survival, with a hazard ratio of 2.90 (95% confidence interval 1.42-5.96, P = 0.004). With regard to the composite endpoint of all-cause death and readmission for HF, the Mid group had a worse prognosis than the Low group, and the High group had the worst prognosis. A high HMRS on admission is associated with all-cause mortality and readmission for HF, and a mid-HMRS is associated with readmission for HF after AHF hospitalization. The HMRS may be a valid clinical tool to stratify the risk of adverse outcomes after hospitalization in unselected patients with AHF.
RESUMO
BACKGROUND: Appropriate implantable cardioverter-defibrillator (ICD) shocks are associated with an increased risk of mortality and heart failure (HF) events. The first appropriate shock may occur late after implantation. However, whether the timing of the first appropriate shock influences prognosis is unknown. This study aimed to evaluate the clinical significance of the timing of the first appropriate shock in patients with ICD. METHODS: This retrospective and observational study enrolled 565 consecutive ICD patients. Patients who received an appropriate shock were divided into the early group (first appropriate shock <1 year after ICD implantation) and late group (first appropriate shock ≥1 year after ICD implantation). All-cause mortality was compared between the two groups. RESULTS: Over a median follow-up of 5.6 years, 112 (19.8%) patients received an appropriate shock, including 32 patients (28.6%) in the early group and 80 patients (71.4%) in the late group. Comparisons of baseline characteristics at ICD implantation revealed that the late group was more likely to receive cardiac resynchronization therapy (66.3% vs. 31.3%, p < 0.001), ICD for primary prevention (60.0% vs. 31.3%, p = 0.001), and angiotensin-converting enzyme inhibitor or angiotensin-receptor blocker treatment (88.8% vs. 71.9%, p = 0.028). Survival after shock was significantly worse in the late group than in the early group (p = 0.027). In multivariable Cox proportional hazards analysis, the late group had an increased risk of all-cause mortality compared with the early group (HR: 2.22; 95% CI 1.01-4.53; p = 0.029). In both groups, the most common cause of death was HF. CONCLUSIONS: Late occurrence of the first appropriate ICD shock was associated with a worse prognosis compared with early occurrence of the first appropriate shock. Cardiac death was the most common cause of death in patients who experienced late occurrence of the first appropriate ICD shock, resulting from HF in most cases.
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Desfibriladores Implantáveis , Insuficiência Cardíaca , Humanos , Desfibriladores Implantáveis/efeitos adversos , Estudos Retrospectivos , Seguimentos , Prognóstico , Morte Súbita Cardíaca/etiologia , Fatores de RiscoRESUMO
Patients with persistent heart failure (HF) with reduced ejection fraction (HFrEF) have a poorer prognosis than those with HF with improved ejection fraction (HFimpEF). However, data on the predictive value of echocardiographic parameters for persistent HFrEF are lacking. We retrospectively studied 443 patients who were diagnosed with HFrEF (EF ≤ 40%) during hospitalization and underwent echocardiography at the 1-year follow-up. We divided them into the 2 groups: HFimpEF (EF > 40%) and persistent HFrEF group at 1-year follow-up, and assessed the predictive value of echocardiographic parameters at discharge for persistent HFrEF. In total, 301/443 patients (68%) were diagnosed with persistent HFrEF and 142/443 (32%) with HFimpEF at the 1-year follow-up. Kaplan-Meier analysis revealed that the persistent HFrEF group had a poorer prognosis than the HFimpEF group (log-rank, P < 0.001). Receiver operating characteristic curve analysis revealed that left ventricular end-systolic diameter (LVESD) had the highest area under the curve (AUC) (0.70; 95% confidence interval [CI]: 0.64-0.75; cutoff value: 55 mm) among various echocardiographic parameters. LVESD was an independent predictor of persistent HFrEF at the 1-year follow-up (odds ratio: 1.07, 95%CI: 1.02-1.12) upon multivariable logistic regression analysis. The incidence of persistent HFrEF was higher in patients with an LVESD ≥ 55 mm than in those with an LVESD < 55 mm (81% versus 55%, Fisher's exact test, P < 0.001). In conclusion, an LVESD (≥ 55 mm) was associated with persistent HFrEF. Focusing on LVESD in daily practice may help clinicians with risk stratification for decision-making regarding management in patients with advanced HF refractory to guideline-directed medical therapy.
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Insuficiência Cardíaca , Disfunção Ventricular Esquerda , Humanos , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/complicações , Volume Sistólico , Estudos Retrospectivos , Prognóstico , Ventrículos do Coração/diagnóstico por imagem , Função Ventricular EsquerdaRESUMO
INTRODUCTION: Guidelines recommend ventricular rate control to <130 bpm during atrial fibrillation (AF) in patients with acute decompensated heart failure (ADHF) to avoid aggravating deteriorations in cardiac outputs. We aimed to evaluate the prognostic impact of landiolol in patients with ADHF and AF. METHODS: This observational study included 60 patients who were urgently hospitalized with ADHF and presented with AF and a heart rate (HR) ≥130 bpm at admission. The patients were assigned to the landiolol group (n = 37) or the reference group (n = 23) based on their intravenous landiolol use within 24 h after admission. The primary endpoint was death from any cause. RESULTS: The groups' baseline characteristics were similar. A significant HR reduction occurred in the landiolol group at 2 h after admission. Compared with the reference group, the HR was significantly lower (111.6 vs. 97.9 bpm, p = 0.02) and the absolute HR reduction was greater (-32.2 vs. -50.0 bpm, p = 0.006) in the landiolol group at 48 h after admission. The landiolol group's mortality rate was significantly lower than that in the reference group (log-rank test, p = 0.032). landiolol use within 24 h after admission was independently associated with lower all-cause mortality (adjusted hazard ratio: 0.15, 95% confidence interval: 0.02-0.92). CONCLUSION: Patients with ADHF and AF who received landiolol for rate control during the acute phase had better prognoses than those who did not receive landiolol.
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Fibrilação Atrial , Insuficiência Cardíaca , Humanos , Fibrilação Atrial/tratamento farmacológico , Prognóstico , Morfolinas/uso terapêutico , Insuficiência Cardíaca/tratamento farmacológicoRESUMO
BACKGROUND: Conventional risk factors for sudden cardiac death (SCD) justify primary prevention through implantable cardioverter-defibrillator (ICD) implantation in hypertrophic cardiomyopathy (HCM) patients. However, the positive predictive values for these conventional SCD risk factors are low. Left ventricular outflow tract obstruction (LVOTO) and midventricular obstruction (MVO) are potential risk modifiers for SCD. The aims of this study were to evaluate whether an elevated intraventricular pressure gradient (IVPG), including LVOTO or MVO, is a potential risk modifier for SCD and ventricular arrhythmias requiring ICD interventions in addition to the conventional risk factors among HCM patients receiving ICDs for primary prevention. METHODS: We retrospectively studied 60 HCM patients who received ICDs for primary prevention. An elevated IVPG was defined as a peak instantaneous gradient ≥ 30 mmHg at rest, as detected by continuous-wave Doppler echocardiography. The main outcome was a composite of SCD and appropriate ICD interventions, which were defined as an antitachycardia pacing or shock therapy for ventricular tachycardia or fibrillation. The Cox proportional hazards model was used to assess the relationships between risk factors and the occurrence of SCD and appropriate ICD interventions. RESULTS: Thirty patients met the criteria of elevated IVPG (50%). During the median follow-up period of 66 months, 2 patients experienced SCD, and 10 patients received appropriate ICD interventions. Kaplan-Meier curves showed that the incidence of the main outcome was higher in patients with an IVPG ≥ 30 mmHg than in those without an IVPG ≥ 30 mmHg (log-rank P = 0.03). There were no differences in the main outcome between patients with LVOTO and patients with MVO. The combination of nonsustained ventricular tachycardia (NSVT) and IVPG ≥ 30 mmHg was found to significantly increase the risk of the main outcome (HR 6.31, 95% CI 1.36-29.25, P = 0.02). Five patients experienced ICD implant-related complications. CONCLUSIONS: Our findings showed that a baseline IVPG ≥ 30 mmHg was associated with an increased risk of experiencing SCD or appropriate ICD interventions among HCM patients who received ICDs for primary prevention. Combined with NSVT, which is a conventional risk factor, a baseline IVPG ≥ 30 mmHg may be a potential modifier of SCD risk in HCM patients.
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Cardiomiopatia Hipertrófica/terapia , Morte Súbita Cardíaca/prevenção & controle , Desfibriladores Implantáveis , Cardioversão Elétrica/instrumentação , Prevenção Primária/instrumentação , Taquicardia Ventricular/prevenção & controle , Fibrilação Ventricular/prevenção & controle , Função Ventricular Esquerda , Pressão Ventricular , Adulto , Idoso , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Cardiomiopatia Hipertrófica/mortalidade , Cardiomiopatia Hipertrófica/fisiopatologia , Ecocardiografia Doppler , Cardioversão Elétrica/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Resultado do Tratamento , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/mortalidade , Fibrilação Ventricular/fisiopatologiaRESUMO
Atrial fibrillation (AF) in hypertrophic cardiomyopathy (HCM) patients is highly associated with deterioration of their clinical condition, such as worsening heart failure symptoms, and an increased thromboembolic stroke risk and cardiac mortality rate. This study aimed to investigate the long-term clinical course after catheter ablation (CA) in HCM patients with AF. Among 566 primary HCM patients at our institution, 94 who underwent rhythm control therapy to manage AF from 2002 to 2016 were retrospectively analyzed. The eligible patients were divided into two groups: those who managed AF with CA (n = 34) and those without CA (n = 60). The endpoints were the incidence of initial clinical events, including HCM-related death or an unplanned heart failure hospitalization, or new-onset thromboembolic strokes. During a mean follow-up of 5.8 years, 6% in the CA group and 28% in the non-CA group had a progression of the AF type into permanent AF (Log-rank: p = 0.012). In the Kaplan-Meyer curve analyses, the incidence of clinical events was significantly lower in the CA group than non-CA group (p = 0.025). The annual rates for the incidence of clinical events were 1.2% in the CA group and 6.7% in the non-CA group. In a Cox multivariate analysis, CA therapy (adjusted hazard ratio 0.22; 95% confidence interval: 0.05-0.97; p = 0.046) was the only independent predictor of the incidence of clinical events. In conclusion, CA may be associated with a favorable long-term clinical course in HCM patients with AF.
Assuntos
Fibrilação Atrial/cirurgia , Cardiomiopatia Hipertrófica/complicações , Ablação por Cateter/métodos , Complicações Pós-Operatórias/epidemiologia , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/etiologia , Cardiomiopatia Hipertrófica/diagnóstico , Cardiomiopatia Hipertrófica/fisiopatologia , Ecocardiografia , Eletrocardiografia , Feminino , Seguimentos , Humanos , Incidência , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Sensory disturbance (SD) is a common consequence of peripheral nerve damage associated with diabetes and severe ischemia. Progression of SD places patients at high risk for lower extremity ulcers and amputations. SD has been thought to be progressive and irreversible, and possibly caused by microvascular dysfunction. The aim of this study was to determine whether endovascular revascularization (EVR) induces quantifiable changes in SD in chronic critical limb ischemia (CLI) patients with neuropathy.MethodsâandâResults:In all, 36 legs from 28 chronic CLI patients who underwent elective EVR were prospectively enrolled in this study (64% with diabetes and 54% on maintenance hemodialysis). The current perception threshold (CPT), an established diagnostic parameter for SD, was measured before and 3 months after EVR. Of the target lesions, 11%, 47%, and 81% were in the aortoiliac, femoropopliteal, and below-the-knee arteries, respectively, and 58% were totally occluded. Overall CPT in the target foot had improved significantly 3 months after EVR (from 53 to 30 µA; P=0.010); however, EVR did not change CPT in the non-target foot (from 44 to 33 µA; P=0.33). Patients with improved SD after EVR had a significantly higher 180-day survival rate (94% vs. 63%; P=0.040). CONCLUSIONS: EVR improved CPT in target limbs of patients with CLI, and may be a promising option to improve SD associated with peripheral ischemic sensory neuropathy.
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Procedimentos Endovasculares/métodos , Extremidades/patologia , Isquemia , Doenças do Sistema Nervoso Periférico/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Humanos , Isquemia/terapia , Pessoa de Meia-Idade , Doenças do Sistema Nervoso Periférico/terapia , Projetos PilotoRESUMO
Thrombosis within the vascular system in relation to inflammation and stasis is potentially associated with poor prognosis in patients with heart failure. The aim of this study was to clarify the association between disseminated intravascular coagulation (DIC) score, a scoring system for microvascular thrombosis and multiple organ dysfunction, and outcome in hospitalized patients with acute heart failure (AHF). We retrospectively evaluated 160 AHF patients referred to a cardiac intensive care unit who had their DIC score measured according to the Japanese Association for Acute Medicine (JAAM) DIC scoring system on admission. Platelet count, prothrombin time ratio, fibrin/fibrinogen degradation products, and the criteria for systemic inflammatory response syndrome were measured. Using the JAAM DIC score, the prevalence of DIC (score ≥4) in AHF patients was 5.0% (8 of 160 patients). The risk of death for patients grouped according to the DIC score was 27.8%, 46.2%, and 87.5% for DIC scores 0-1, 2-3, and ≥4, respectively (median follow-up 460 days). In multivariate analysis adjusted for various markers of disease severity, a DIC score ≥2 was independently associated with a higher all-cause death rate (adjusted hazard ratio 2.45; P = 0.005) and a higher rate of reaching the combined endpoint of all-cause death and readmission for AHF (adjusted hazard ratio 2.10; P = 0.006) after admission for AHF. In an intensive care setting, measurement of DIC score on admission could help risk stratification in hospitalized patients with AHF.
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Biomarcadores/sangue , Coagulação Intravascular Disseminada/fisiopatologia , Insuficiência Cardíaca/complicações , Readmissão do Paciente/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/terapia , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Japão , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Mortalidade , Análise Multivariada , Prognóstico , Modelos de Riscos Proporcionais , Encaminhamento e Consulta , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
BACKGROUND AND PURPOSE: Stroke and systemic embolic events are known to occur as complications of hypertrophic cardiomyopathy (HCM), and these complications are more common in patients with accompanying atrial fibrillation (AF). The diagnosis of AF is sometimes difficult, however, and it is possible that subclinical asymptomatic paroxysmal episodes or a first episode of AF in patients without previously documented AF may lead to embolic events. We investigated the prevalence of embolic events in patients with HCM and evaluated risk factors for these events in patients without documented AF. METHODS: This study enrolled 593 patients with clinically diagnosed HCM (age at diagnosis, 51.0±15.6 years) from 1980 to 2010. RESULTS: During a mean follow-up of 10.7±7.5 years, 68 (11.5%) experienced stroke and embolic events. AF had been documented before the event in 29 (42.6%) of them. AF was documented for the first time at the time of the event in 5 (7.4%) and after the event in 10 (14.7%). Among the 431 patients without previously documented AF (39 with events and 392 without events), older age at diagnosis and left atrial dimension ≥48 mm were identified as the independent determinants of the embolic event after adjusting for sex and classic prognostic markers related to HCM. CONCLUSIONS: The incidence of stroke and embolic events was about 1.0% per year in the HCM cohort. AF had not been previously documented before the event in more than half of patients with events. Older age and enlarged left atrial dimension are possible risk factors for embolic events in patients with HCM without documented AF.
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Fibrilação Atrial/complicações , Cardiomiopatia Hipertrófica/complicações , Embolia/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Adulto , Idoso , Embolia/etiologia , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/etiologiaRESUMO
It remains unclear whether flecainide, a Class I antiarrhythmic drug, improves left ventricular pressure gradient (LVPG) or symptoms in patients with obstructive hypertrophic cardiomyopathy (HCM). Our study evaluated the long-term efficacy of flecainide, compared to disopyramide, when administered orally, on LVPG and symptoms in obstructive HCM patients. Among 164 obstructive HCM patients, 15 were administered oral flecainide therapy and 33 administered oral disopyramide therapy. LVPG declined from 79.8 ± 36.6 to 39.2 ± 36.7 mmHg (p = 0.003) after flecainide therapy and from 74.5 ± 26.4 to 31.4 ± 24.8 mmHg (p < 0.001) after disopyramide therapy. The percent reduction in LVPG was -47.9 ± 43.2 % in patients treated with flecainide, comparable to the results for those treated with disopyramide (-57.1 ± 33.0 %; p = 0.425). We found no significant differences in improvement in NYHA functional class between patients treated with flecainide and those treated with disopyramide (p = 0.331). Patients treated with flecainide exhibited no significant adverse side effects, and there was no need for myectomy or alcohol septal ablation to reduce LVPG and symptoms. Improvements in LVPG and symptoms were similar in patients treated with flecainide and patients treated with disopyramide, suggesting that flecainide is a potentially useful alternative for symptomatic obstructive HCM patients, particularly those with disopyramide-induced vagolytic side effects, narrow angle glaucoma, or prostatic hyperplasia and pre-existing urination difficulties. Our data must be viewed with caution, however, in view of the small number of study patients. Flecainide therapy will require further proof of safety before it can be routinely recommended in patients with symptomatic obstructive HCM.
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Cardiomiopatia Hipertrófica/tratamento farmacológico , Disopiramida/administração & dosagem , Flecainida/administração & dosagem , Ventrículos do Coração/fisiopatologia , Obstrução do Fluxo Ventricular Externo/tratamento farmacológico , Pressão Ventricular/efeitos dos fármacos , Administração Oral , Antiarrítmicos/administração & dosagem , Cardiomiopatia Hipertrófica/etiologia , Cardiomiopatia Hipertrófica/fisiopatologia , Relação Dose-Resposta a Droga , Ecocardiografia , Feminino , Seguimentos , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Obstrução do Fluxo Ventricular Externo/complicações , Obstrução do Fluxo Ventricular Externo/fisiopatologia , Pressão Ventricular/fisiologiaRESUMO
BACKGROUND: Hospitalized heart failure (HHF) is a critical issue in Japan. To improve its management and outcomes, the clinical features, in-hospital management, and outcomes should be analyzed to improve the guidelines for HHF. METHODS AND RESULTS: The acute decompensated heart failure syndromes (ATTEND) registry is the largest study of HHF in Japan. The present report covers the clinical features and in-hospital management of HHF patients. The data from 4,842 enrolled patients have demonstrated that most Japanese HHF patients are elderly, with new onset, and a history of hypertension and orthopnea on admission. During hospitalization, furosemide and carperitide were commonly used and the length of stay was extremely long (mean 30 days), with 6.4% in-hospital mortality. CONCLUSIONS: The findings of the present study suggest the following: (1) the focus for hypertensive elderly and diabetic patients should be on primary prevention of HHF,(2) more intensive management with noninvasive positive pressure ventilation should be performed at the urgent stage, (3) it is necessary to clarify the clinical benefit of carperitide and angiotensin-receptor blockers, because they are commonly used in Japan, and (4) it is necessary to clarify the relationship between in-hospital mortality and length of stay from the viewpoint of both outcome and cost of patient care.
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Antagonistas de Receptores de Angiotensina/administração & dosagem , Fator Natriurético Atrial/administração & dosagem , Furosemida/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar , Tempo de Internação , Sistema de Registros , Inibidores de Simportadores de Cloreto de Sódio e Potássio/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Complicações do Diabetes/tratamento farmacológico , Complicações do Diabetes/mortalidade , Feminino , Humanos , Hipertensão/tratamento farmacológico , Hipertensão/mortalidade , Japão/epidemiologia , Masculino , Estudos ProspectivosRESUMO
While recent guidelines for the treatment of acute heart failure syndromes (AHFS) recommend pharmacotherapy with vasodilators in patients without excessively low blood pressure (BP), few reports have compared the relative efficiency of vasodilators on hemodynamics in AHFS patients. The present study aimed to assess the differences in hemodynamic responses between intravenous carperitide and nicorandil in patients with AHFS. Thirty-eight consecutive patients were assigned to receive 48-h continuous infusion of carperitide (n = 19; 0.0125-0.05 µg/kg/min) or nicorandil (n = 19; 0.05-0.2 mg/kg/h). Hemodynamic parameters were estimated at baseline, and 2, 24, and 48 h after drug administration using echocardiography. After 48 h of infusion, systolic BP was significantly more decreased in the carperitide group compared with that in the nicorandil group (22.1 ± 20.0 % vs 5.3 ± 10.4 %, P = 0.003). While both carperitide and nicorandil significantly improved hemodynamic parameters, improvement of estimated pulmonary capillary wedge pressure was greater in the carperitide group (38.2 ± 14.5 % vs 26.5 ± 18.3 %, P = 0.036), and improvement of estimated cardiac output was superior in the nicorandil group (52.1 ± 33.5 % vs 11.4 ± 36.9 %, P = 0.001). Urine output for 48 h was greater in the carperitide group, but not to a statistically significant degree (4203 ± 1542 vs 3627 ± 1074 ml, P = 0.189). Carperitide and nicorandil were differentially effective in improving hemodynamics in AHFS patients. This knowledge may enable physicians in emergency wards to treat and manage patients with AHFS more effectively and safely.
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Fator Natriurético Atrial/administração & dosagem , Insuficiência Cardíaca/tratamento farmacológico , Hemodinâmica/efeitos dos fármacos , Nicorandil/administração & dosagem , Vasodilatadores/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Distribuição de Qui-Quadrado , Esquema de Medicação , Feminino , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Humanos , Infusões Intravenosas , Japão , Masculino , Pessoa de Meia-Idade , Síndrome , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: Systemic sclerosis (SSc) affects the myocardium, thereby resulting in a poor prognosis. Late gadolinium enhancement (LGE) entropy, derived from routine cardiac magnetic resonance (CMR) LGE images, is an index that reflects the complexity of the left ventricular myocardium. The aim of this study was to investigate whether LGE entropy can serve as a prognostic factor in patients with SSc. METHODS: Twenty-four patients with SSc, who underwent CMR-T1 mapping and LGE to identify myocardial damage, were enrolled, and LGE entropy was measured. Extracellular volume (ECV) values were calculated using the same CMR-LGE images. The endpoint was major adverse cardiac events (MACEs), comprising all-cause death, hospitalization due to heart failure, and the onset of sustained ventricular tachycardia and ventricular fibrillation. The ability to predict MACE was assessed using receiver operating characteristic (ROC) analysis, and the predictability of LGE entropy was analyzed using Kaplan-Meier analysis. RESULTS: The ROC curve analysis demonstrated a cut-off value of 7.39 for MACE with LGE entropy and had a sensitivity and specificity of 80â¯% and 79â¯%, respectively. Patients with LGE entropy ≥7.39 had a significantly higher MACE rate than those with LGE entropy <7.39 (pâ¯=â¯0.010). Moreover, LGE entropy ≥7.39 was a poor prognostic factor in patients without elevated ECV values. CONCLUSIONS: LGE entropy can be used to predict MACE and allows for further risk stratification in addition to ECV determination.
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Meios de Contraste , Escleroderma Sistêmico , Humanos , Prognóstico , Gadolínio , Entropia , Imagem Cinética por Ressonância Magnética/métodos , Imageamento por Ressonância Magnética/métodos , Miocárdio/patologia , Pericárdio , Escleroderma Sistêmico/complicações , Escleroderma Sistêmico/patologia , Valor Preditivo dos Testes , Função Ventricular EsquerdaRESUMO
BACKGROUND: In hypertrophic cardiomyopathy (HCM), one of the main pathophysiological features is diastolic dysfunction. According to the 2016 American Society of Echocardiography (ASE)/European Association of Cardiovascular Imaging (EACVI) recommendations, diastolic function is assessed with echocardiographic variables. However, the association between the ASE/EACVI recommendations and the outcome in patients with HCM remains unclear. We evaluated the prognostic implications of the ASE/EACVI recommendations in patients with HCM. METHODS: This study included 290 patients with HCM. We evaluated four variables for identifying diastolic dysfunction using the following abnormal cutoff values: septal e' < 7 cm/sec, septal E/e' ratio > 15, left atrial volume index > 34 mL/m2, and peak tricuspid regurgitation velocity > 2.8 m/sec. A score was developed in which one point was designated for each abnormal echo parameter of diastolic function. We divided patients into two groups with an ASE/EACVI score of 3 as the cutoff value. The primary endpoint was the combination of HCM-related adverse outcomes (combination of sudden death or potentially lethal arrhythmic events, heart failure-related death, and heart failure hospitalization). RESULTS: The prevalence of an ASE/EACVI score ≥3 was 37.2%. Over a median follow-up of 9.7 (6.9-12.9) years, 26 (24.1%) patients with an ASE/EACVI score ≥3 and 25 (13.7%) patients with an ASE/EACVI score <3 experienced a combination of HCM-related adverse outcomes. Patients with an ASE/EACVI score ≥3 had a significantly higher incidence of the combined endpoint than those with an ASE/EACVI score <3 (log-rank, P = .010). An ASE/EACVI score ≥3 was an independent determinant of the combined endpoint in multivariate analysis (adjusted hazard ratio = 1.92; 95% CI, 1.05-3.49; P = .033). CONCLUSIONS: The score for identifying diastolic dysfunction by following ASE/EACVI recommendations may be associated with an adverse outcome in patients with HCM.
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Cardiomiopatias , Cardiomiopatia Hipertrófica , Insuficiência Cardíaca , Cardiomiopatia Hipertrófica/complicações , Cardiomiopatia Hipertrófica/diagnóstico , Diástole , Ecocardiografia , Humanos , Prognóstico , Estados Unidos/epidemiologia , Função Ventricular Esquerda/fisiologiaRESUMO
The effect of the left ventricular ejection fraction (LVEF) on the prognostic impact of the right atrial pressure (RAP) in patients with heart failure (HF) requires clarification. We aimed to investigate whether LVEF affects the prognostic impact of RAP estimated from inferior vena cava (IVC) measurements in patients hospitalized with HF. Initially, this observational study included 1349 consecutive patients urgently hospitalized with HF. After patient exclusions, 506 and 484 patients with reduced (< 40%) and with non-reduced (≥ 40%) LVEF, respectively, were assigned according to maximum IVC diameter and its collapsibility, to the Normal-RAP (diameter ≤ 2.1 cm; collapsibility ≥ 50%), High-RAP (diameter > 2.1 cm; collapsibility < 50%), and Intermediate-RAP (others) groups. The endpoint comprised cardiovascular death after discharge and hospitalization for HF recurrence. During the observation period, 247 (49%) patients with LVEF < 40% and 178 (37%) patients with LVEF ≥ 40% experienced the endpoint. The patient subgroups with LVEF < 40% had comparable event rates (ptrend = 0.10). The High-RAP subgroup with LVEF ≥40% had a higher event rate than the other subgroups (p < 0.001). The RAP independently predicted the endpoint in patients with LVEF ≥ 40% (hazard ratio: 1.26; 95% confidence interval: 1.01-1.59). The interaction between the RAP groups and LVEF regarding the primary endpoint was significant (pinteraction = 0.007). Stratifying patients with HF according to IVC measurements may predict the post-discharge cardiovascular prognoses of patients with non-reduced LVEF, but not that of patients with reduced LVEF.
Assuntos
Insuficiência Cardíaca , Função Ventricular Esquerda , Humanos , Volume Sistólico , Pressão Atrial , Assistência ao Convalescente , Alta do Paciente , Valor Preditivo dos Testes , Insuficiência Cardíaca/diagnóstico por imagem , Insuficiência Cardíaca/terapiaRESUMO
This study aims to characterize flow, volume, and strain of the left atrium in hypertrophic cardiomyopathy (HC) with atrial fibrillation (AF) using cine cardiovascular magnetic resonance (CMR) imaging. Cine CMR data for 144 patients with HC, including 29 patients with episodes of paroxysmal AF and 13 patients with persistent AF, were retrospectively analyzed. The vortex flow of the left atrial (LA, %) was measured using a vortex flow map and was used as an estimate of flow. The LA end-systolic volume index (ml/m2), LA ejection fraction (%) and global peak longitudinal LA strain (%) derived from a feature-tracking method were used as estimates of volume and strain. Vortex flow of the LA in patients with paroxysmal AF was significantly smaller than in patients without AF (vertical long-axis view; 26.7 ± 10.8% vs 33.2 ± 12.2%, p <0.005). The patients with paroxysmal AF had greater LA end-systolic volume index and global peak longitudinal LA strain and lower LA ejection fraction compared with those without AF. In conclusion, patients with HC with paroxysmal AF are characterized by small vortex flow, large volume, and decreased strain of LA on cine CMR.
Assuntos
Fibrilação Atrial , Cardiomiopatia Hipertrófica , Cardiomiopatia Hipertrófica/complicações , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Cardiomiopatia Hipertrófica/patologia , Átrios do Coração , Humanos , Imagem Cinética por Ressonância Magnética/métodos , Estudos RetrospectivosRESUMO
BACKGROUND: Pulmonary hypertension (PH) may affect right ventricular (RV) function; however, the prognostic implications of RV function in patients with heart failure and PH remain unclear. We aimed to investigate the impact of RV function on the prognosis of hospitalized heart failure patients with and without PH. METHODS: This observational study initially included 1,349 consecutive hospitalized heart failure patients. After excluding patients who died in hospital, whose left ventricular (LV) function was preserved, and whose echocardiography data were incomplete, 573 patients with heart failure and reduced LV ejection fractions (HFrEF) were analyzed. The patients were grouped according to RV dysfunction that was defined as an RV-tissue Doppler imaging systolic velocity (RV-TDI s') of ≤9.5 cm/s. The primary endpoint was a composite of cardiovascular death and rehospitalization as a consequence of heart failure. RESULTS: Overall, the patients with reduced RV function had significantly higher event rates than those with preserved RV function (log-rank test p = 0.01). This prognostic impact was observed in the patients with PH (p = 0.001) and was not evident among the patients without PH (p = 0.39). In the patients with PH, reduced RV function independently predicted the prognosis after adjusting for the covariates (adjusted hazard ratio: 3.12; 95% confidence interval: 1.44 to 6.73). CONCLUSION: RV dysfunction that was estimated during hospitalization using the RV-TDI s', which is a simply determined index, may predict clinical outcomes in hospitalized patients with HFrEF and PH after discharge, but not in those without PH.
Assuntos
Insuficiência Cardíaca , Hipertensão Pulmonar , Disfunção Ventricular Direita , Humanos , Hipertensão Pulmonar/etiologia , Prognóstico , Volume Sistólico , Disfunção Ventricular Direita/diagnóstico por imagem , Disfunção Ventricular Direita/etiologia , Função Ventricular Esquerda , Função Ventricular DireitaRESUMO
There is limited data on whether diastolic dysfunction in patients with heart failure (HF) and recovered ejection fraction (HFrecEF) is associated with worse prognosis. We retrospectively assessed 96 patients diagnosed with HFrecEF and created ROC curve of their diastolic function at the 1-year follow-up for the composite endpoint of cardiovascular death and HF readmission after the follow-up. Eligible patients were divided into two groups according to the cutoff value of E/e' ratio (12.1) with the highest AUC (0.70). Kaplan-Meier analysis showed that HFrecEF with high E/e' group had a significantly poorer prognosis than the low E/e' group (log-rank, p = 0.01). Multivariate Cox regression analysis revealed that the high E/e' group was significantly related to the composite endpoint (hazard ratio 5.45, 95% confidence interval [CI] 1.23-24.1). The independent predictors at discharge for high E/e' ratio at the 1-year follow-up were older age and female sex after adjustment for covariates (odds ratio [OR] 1.07, 95% CI 1.01-1.13 and OR 4.70, 95% CI 1.08-20.5). In conclusion, HFrecEF with high E/e' ratio might be associated with a poor prognosis. Older age and female sex were independent predictors for a sustained high E/e' ratio in patients with HFrecEF.
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Insuficiência Cardíaca , Função Ventricular Esquerda , Feminino , Humanos , Prognóstico , Estudos Retrospectivos , Volume SistólicoRESUMO
Anomalous left coronary artery arising from the noncoronary cusp (LCANCC) is a rare congenital disorder. We herein describe a 17-year-old female patient with sudden cardiac arrest followed by refractory cardiogenic shock. LCANCC-induced acute myocardial infarction with left main coronary artery involvement was subsequently diagnosed, and the patient required a durable left ventricular assist device.