Proposal for a clinical and an echocardiographic score for prediction of left atrial thrombosis in atrial fibrillation patients undergoing early electrical cardioversion.

AIMS: Left atrial thrombosis (LAT) is usually detected by transesophageal echocardiography (TEE). The aim of the present study was to identify clinical and echocardiographic factors associated with left atrial thrombosis in atrial fibrillation (AF) patients undergoing early electrical cardioversion (ECV) in order to create scores that can predict LAT, in a non-invasive way. METHODS: A consecutive cohort of patients with persistent AF scheduled for ECV was evaluated by transthoracic echocardiography and TEE. By a logistic regression model, variables significantly associated with LAT were assessed and introduced in predictive models to develop both a clinical and an echocardiographic prediction score for the presence of LAT. RESULTS: In total, 125 patients [median 71 (range 49-88) years, 60.0% males] were enrolled. Transesophageal echocardiography showed LAT in 35 patients (28%). The clinical variables significantly associated with LAT were previous stroke (OR = 4.17), higher CHA2 DS2 -VASc score (OR = 1.93), lower estimated glomerular filtration rate (OR = 0.80), and higher brain natriuretic peptide levels (OR = 1.44). Among echocardiographic parameters, E/e' ratio was directly associated with LAT (OR = 2.25), while an inverse correlation was detected with left ventricular ejection fraction (OR = 0.43) and total global left atrial strain (OR = 0.59). Two prediction scores (clinical and echocardiographic) were developed. The positive predictive values of the clinical and the echocardiographic score were 80% and 100%, respectively, while the negative predictive values were 98% and 94%, respectively. Combined use of the scores reached a positive and negative predictive value of 100%. CONCLUSIONS: When providing concordant information the two scores are able to correctly identify patients with or without LAT. An external validation is necessary to demonstrate their usefulness in the clinical practice.

Acute effect of a peritoneal dialysis exchange on electrolyte concentration and QT interval in uraemic patients.

BACKGROUND: Hemodialysis (HD) sessions induce changes in plasma electrolytes that lead to modifications of QT interval, virtually associated with dangerous arrhythmias. It is not known whether such a phenomenon occurs even during peritoneal dialysis (PD). The aim of the study is to analyze the relationship between dialysate and plasma electrolyte modifications and QT interval during a PD exchange. METHODS: In 15 patients, two manual PD 4-h exchanges were performed, using two isotonic solutions with different calcium concentration (Ca++1.25 and Ca1.75++ mmol/L). Dialysate and plasma electrolyte concentration and QT interval (ECG Holter recording) were monitored hourly. A computational model simulating the ventricular action potential during the exchange was also performed. RESULTS: Dialysis exchange induced a significant plasma alkalizing effect (p < 0.001). Plasma K+ significantly decreased at the third hour (p < 0.05). Plasma Na+ significantly decreased (p < 0.001), while plasma Ca++ slightly increased only when using the Ca 1.75++ mmol/L solution (p < 0.01). The PD exchange did not induce modifications of clinical relevance in the QT interval, while a significant decrease in heart rate (p < 0.001) was observed. The changes in plasma K+ values were significantly inversely correlated to QT interval modifications (p < 0.001), indicating that even small decreases of K+ were consistently paralleled by small QT prolongations. These results were perfectly confirmed by the computational model. CONCLUSIONS: The PD exchange guarantees a greater cardiac electrical stability compared to the HD session and should be preferred in patients with a higher arrhythmic risk. Moreover, our study shows that ventricular repolarization is extremely sensitive to plasma K+ changes, also in normal range.

AnatoMy and physIopathoLogy of the heArt in a ceNtenarian cOhort (MILANO study).

Background: Centenarians are increasingly being encountered in clinical practice. The aim of the study was to characterize centenarians' clinical features and cardiovascular system. Methods: A prospective, observational, cross-sectional, case-control study included 118 hospitalized >100-year-old patients compared to 50 octogenarians, selected in Milan (Italy) from December 2010 to December 2017, to assess their clinical and echocardiographic characteristics. Results: Centenarians were mostly women with small body surface area; long history of hypertension; chronic renal failure; and low incidence of smoking, diabetes, dyslipidemia, hyperuricemia, coronary artery disease, atrial fibrillation, and cerebrovascular disease. They showed high prevalence of severe cognitive impairment and disability. Almost half of patients (46%) were hospitalized for congestive heart failure (HF), mostly diastolic (80% of cases). Centenarians' hearts had reduced left ventricular end-diastolic dimensions (25.3 ± 3.8 mm/m^2), increased septal thickness (13.3 ± 1.9 mm), and higher relative wall thickness (0.58 ± 0.1). The ejection fraction was usually normal and rarely depressed (57.1% ± 11.7%), whereas the E/e' ratio was considerably increased (17.0 ± 6.0). Noninvasive evaluation of ventricular-arterial coupling parameters revealed significantly higher values of LV end-diastolic elastance in all centenarians versus octogenarians (0.4 ± 01 mm Hg/mL/m^2 vs 0.18 ± 0.2 mm Hg/mL/m^2, P < .0001) and in centenarians with HF versus those without HF (0.5 ± 0.1 mm Hg/mL/m^2 vs 0.34 ± 0.1 mm Hg/mL/m^2, P < .0001). Conclusions: The centenarians' cardiovascular system manifested a significant increase in LV diastolic stiffness with consequent susceptibility to diastolic HF. A progressive afterload increase and a passive load independent mechanism could have contributed to such changes.

Sudden Death in End Stage Renal Disease: Comparing Hemodialysis versus Peritoneal Dialysis.

BACKGROUND/AIMS: This study aimed to evaluate total and sudden death (SD) in a cohort of dialysis patients, comparing hemodialysis (HD) vs. peritoneal dialysis (PD). METHODS: This is a multicenter retrospective cohort study. RESULTS: Deaths were 626 out of 1,823 in HD and 62 of 249 in PD patients. HD patients had a greater number of comorbidities (p < 0.05). PD patients had a lower risk of death than HD patients (p < 0.001); however, the advantage decreased with time (p < 0.001). Mortality predictors were left ventricular ejection fraction (LVEF) ≤35%, older age, ischemic heart disease, diabetes mellitus, previous stroke, and atrial fibrillation (p < 0.03). SDs were 84:71 in HD and 13 in PD population (12.1 and 22.8% of all causes of death, respectively). A non-significant risk of SD among PD compared to HD patients was detected. SD predictors were older age, ischemic heart disease, and LVEF ≤35% (p < 0.05). CONCLUSIONS: HD patients showed a greater presence of comorbidities and reduced survival compared to PD patients; however, the incidence of SD does not differ in the 2 populations. Video Journal Club "Cappuccino with Claudio Ronco" at http://www.karger.com/?doi=464347.

Recurrent intradialytic paroxysmal atrial fibrillation: hypotheses on onset mechanisms based on clinical data and computational analysis.

Atrial fibrillation (AF) incidence is high in end-stage renal disease (ESRD) patients, and haemodialysis (HD) session may induce paroxysmal AF episodes. Structural atrium remodelling is common in ESRD patients, moreover, HD session induces rapid plasma electrolytes and blood volume changes, possibly favouring arrhythmia onset. Therefore, HD session represents a unique model to study in vivo the mechanisms potentially inducing paroxysmal AF episodes. Here, we present the case report of a patient in which HD regularly induced paroxysmal AF. In four consecutive sessions, heart rate variability analysis showed a progressive reduction of low/high frequency ratio before the AF onset, suggesting a relative increase in vagal activity. Moreover, all AF episodes were preceded by a great increase of supraventricular ectopic beats. We applied computational modelling of cardiac cellular electrophysiology to these clinical findings, using plasma electrolyte concentrations and heart rate to simulate patient conditions at the beginning of HD session (pre-HD) and right before the AF onset (pre-AF), in a human atrial action potential model. Simulation results provided evidence of a slower depolarization and a shortened refractory period in pre-AF vs. pre-HD, and these effects were enhanced when adding acetylcholine effect. Paroxysmal AF episodes are induced by the presence of a trigger that acts upon a favourable substrate on the background of autonomic nervous system changes and in the described case report all these three elements were present. Starting from these findings, here we review the possible mechanisms leading to intradialytic AF onset.

Rationale and design of the health economics evaluation registry for remote follow-up: TARIFF.

AIMS: The aims of the study are to develop a cost-minimization analysis from the hospital perspective and a cost-effectiveness analysis from the third payer standpoint, based on direct estimates of costs and QOL associated with remote follow-ups, using Merlin@home and Merlin.net, compared with standard ambulatory follow-ups, in the management of ICD and CRT-D recipients. METHODS AND RESULTS: Remote monitoring systems can replace ambulatory follow-ups, sparing human and economic resources, and increasing patient safety. TARIFF is a prospective, controlled, observational study aimed at measuring the direct and indirect costs and quality of life (QOL) of all participants by a 1-year economic evaluation. A detailed set of hospitalized and ambulatory healthcare costs and losses of productivity that could be directly influenced by the different means of follow-ups will be collected. The study consists of two phases, each including 100 patients, to measure the economic resources consumed during the first phase, associated with standard ambulatory follow-ups, vs. the second phase, associated with remote follow-ups. CONCLUSION: Remote monitoring systems enable caregivers to better ensure patient safety and the healthcare to limit costs. TARIFF will allow defining the economic value of remote ICD follow-ups for Italian hospitals, third payers, and patients. The TARIFF study, based on a cost-minimization analysis, directly comparing remote follow-up with standard ambulatory visits, will validate the cost effectiveness of the Merlin.net technology, and define a proper reimbursement schedule applicable for the Italian healthcare system. TRIAL REGISTRATION: NCT01075516.

A noninvasive index of atrial remodeling in patients with paroxysmal and persistent atrial fibrillation: a pilot study.

PURPOSE: This study aims to develop a noninvasive atrial remodeling index (RI) to separate patients presenting paroxysmal atrial fibrillation (ParAF) from those with sustained persistent atrial fibrillation (PerAF), that is, AF episodes interrupted 7 days or more after the onset. METHODS: Signal-averaged P-wave duration (SAPWd) and left atrial anteroposterior diameter (LADd) were measured in 33 ParAF patients, in 26 sustained PerAF patients, and in 18 control subjects. By using SAPWd and LADd, a dichotomous (0/1) RI was created. A logistic regression model on the probability of having a sustained PerAF vs a ParAF episode was estimated, including the RI, sex, age, and cardiac comorbidities as covariates. RESULTS: Signal-averaged P-wave duration was significantly longer in sustained PerAF (153 ± 15 milliseconds) than in ParAF patients (142 ± 13 milliseconds, P < .001) and in both ParAF and sustained PerAF groups vs control group (123 ± 7 milliseconds, P < .001). Left atrial anteroposterior diameter was larger both in sustained PerAF (43 ± 6 mm) vs ParAF patients (38 ± 5 mm, P = .002) and in sustained PerAF group vs control group (38 ± 2 mm, P = .004), but no differences were observed between ParAF patients and controls (P = .6). A 12-fold increase (odds ratio, 11.8; 95% confidence interval, 2.2-63.5) in the odds of having a sustained PerAF vs a ParAF episode was observed in patients with RI equal to 1. CONCLUSIONS: P-wave duration and left atrium diameter enabled to define a noninvasive atrial RI to separate patients with ParAF from those with sustained PerAF. This could be a useful tool to select a suitable strategy for AF treatment.

Alterations of atrial electrophysiology related to hemodialysis session: insights from a multiscale computer model.

BACKGROUND: The prevalence of atrial fibrillation is increased in patients with end-stage renal disease. Previous studies suggested that extracellular electrolyte alterations caused by hemodialysis (HD) therapy could be proarrhythmic. METHODS: Multiscale models were used for a consequent analysis of the effects of extracellular ion concentration changes on atrial electrophysiology. Simulations were based on measured electrolyte concentrations from patients with end-stage renal disease. RESULTS: Simulated conduction velocity and effective refractory period are decreased at the end of an HD session, with potassium having the strongest influence. P-wave is prolonged in patients undergoing HD therapy in the simulation as in measurements. CONCLUSIONS: Electrolyte concentration alterations impact atrial electrophysiology from the action potential level to the P-wave and can be proarrhythmic, especially because of induced hypokalemia. Analysis of blood electrolytes enables patient-specific electrophysiology modeling. We are providing a tool to investigate atrial arrhythmias associated with HD therapy, which, in the future, can be used to prevent such complications.

Baroreceptor sensitivity and baroreceptor effectiveness index in cirrhosis: the relevance of hepatic venous pressure gradient.

BACKGROUND: Autonomic dysfunction has been reported as one of the complications of cirrhosis. AIMS: The aim of this study was to test autonomic dysfunction in cirrhotic patients by analysing the baroreflex sensitivity and the baroreceptor effectiveness index (BEI), in order to determine its correlation with the severity and the aetiology of liver disease. Moreover, we explored the relationship between baroreceptor function and mortality in our cohort of patients. METHODS: Clinical and laboratory evaluation, hepatic venous pressure gradient (HVPG) and haemodynamic setting and baroreceptor function were assessed in 45 cirrhotic patients (median age 55, range 38-72 years) divided in groups according to the severity of their disease (26 patients Child A, 13 patients Child B and six patients Child C). RESULTS: Baroreceptor sensitivity and BEI were impaired in more advanced cirrhotic patients compared with subjects with milder disease (P<0.001). HVPG was significantly, independently and inversely correlated with baroreceptor sensitivity (P=0.003). More severe impairment of baroreceptor function was associated with a higher mortality (P=0.04) and subjects with alcohol-related cirrhosis presented worse baroreceptor function (P=0.032) and poorer survival (P=0.003) compared with subjects with post-viral liver disease. CONCLUSIONS: These data support the hypothesis that liver disease severity and particularly portal hypertension have an important role in the derangement of baroreceptor function. The aetiology of cirrhosis seems to be related to baroreceptor impairment as well. Mortality rate is higher in subjects with a more damaged autonomic system, strengthening the idea of a worse prognosis in cirrhotic patients with autonomic neuropathy.

Alterations of atrial electrophysiology induced by electrolyte variations: combined computational and P-wave analysis.

AIMS: Haemodialysis (HD) therapy represents a unique model to test in vivo, in humans, the effects of changes in plasma ionic concentrations. Episodes of paroxysmal atrial fibrillation (AF) often occur during the treatment. We investigated the effects of HD-induced electrolyte variations on atrial electrophysiology by analysing ECG P-wave duration (PWd), which reflects atrial conduction velocity (CV), and simulated atrial action potential (AP). METHODS AND RESULTS: In 20 end-stage renal disease patients PWd (signal-averaged ECG), heart rate (HR), blood pressure, Na(+), K(+), Ca(2+), and Mg(2+) plasma concentrations were measured before and after HD session. The Courtemanche computational model of human atrial myocyte was used to simulate the atrial AP. AP upstroke duration (AP(ud)), AP duration and atrial cell effective refractory period (ERP) were computed. Extracellular electrolyte concentrations and HR were imposed to the average values measured in vivo. HD decreased K(+) (from 4.9 +/- 0.5 to 3.9 +/- 0.4 mmol/L, P < 0.001) and Mg(2+) (0.92 +/- 0.08 to 0.86 +/- 0.05 mmol/L, P < 0.05), and increased Na(+) (139.8 +/- 3.4 to 141.6 +/- 3.1 mmol/L, P < 0.05) and Ca(2+) (1.18 +/- 0.09 to 1.30 +/- 0.07 mmol/L, P < 0.001) plasma concentrations. PWd systematically increased in all the patients after HD (131 +/- 11 to 140 +/- 12 ms, P < 0.001), indicating an intra-atrial conduction slowing. PWd increments were inversely correlated with K(+) variations (R = 0.73, P < 0.01). Model-based analysis indicated an AP(ud) increase (from 2.58 to 2.94 ms) after HD, coherent with experimental observations on PWd, and a reduction of ERP by 12 ms. CONCLUSION: Changes of plasma ionic concentrations may lead to modifications of atrial electrophysiology that can favour AF onset, namely a decrease of atrial CV and a decrease of atrial ERP.

Left Atrial Cavity Thrombus and Fatal Systemic Embolization in a Stroke Patient with Nonvalvular Atrial Fibrillation: A Caveat against Left Atrial Appendage Closure for Stroke Prevention.

An 88-year-old male with nonvalvular atrial fibrillation (NVAF) and severe congestive heart failure (HF), was admitted to the Neurological Intensive Care Unit because of the acute onset of aphasia and left hemiplegia. Transthoracic echocardiography revealed a left atrial (LA) cavity thrombus. Its "fatal" distal embolization to abdominal aorta occurred in a few days. These observations should lead to a cautious approach in proposing a percutaneous closure of LA appendage in older NVAF patients, with HF and/or left ventricular dysfunction and larger LA volumes, who are not adequately anticoagulated.

QT interval prolongation and decreased heart rate variability in cirrhotic patients: relevance of hepatic venous pressure gradient and serum calcium.

A prolongation of QT interval has been shown in patients with cirrhosis and it is considered as part of the definition of the so-called 'cirrhotic cardiomyopathy'. The aim of the present study was to assess the determinants of QT interval prolongation in cirrhotic patients. Forty-eight male patients with different stages of liver disease were divided into three subgroups according to the Child-Pugh classification. All patients underwent a 24-h ECG Holter recording. The 24-h mean of QT intervals corrected for heart rate (termed QTc) and the slope of the regression line QT/RR were calculated. HRV (heart rate variability), plasma calcium and potassium concentration and HVPG (hepatic venous pressure gradient) were measured. QTc was progressively prolonged from Child A to Child C patients (P=0.001). A significant correlation between QTc and HVPG was found (P=0.003). Patients with alcohol-related cirrhosis presented QTc prolongation more frequently than patients with post-viral cirrhosis (P<0.001). The QT/RR slope was steeper in subjects with alcoholic aetiology as compared with viral aetiology (P=0.02), suggesting that these patients have a further QTc prolongation when heart rate decreases. The plasma calcium concentration was inversely correlated with QTc (P<0.001). The presence of severe portal hypertension was associated with decreased HRV (P<0.001). Cirrhotic patients with a more severe disease, especially of alcoholic aetiology, who have greater HVPG and lower calcium plasma levels, have an altered ventricular repolarization and a reduced vagal activity to the heart, which may predispose to life-threatening arrhythmias.

Sudden death and associated factors in a historical cohort of chronic haemodialysis patients.

BACKGROUND: In haemodialysis patients, deaths due to cardiovascular causes constitute a large proportion of total mortality and sudden cardiac deaths account for approximately 22% of all deaths. The aim of this study was to evaluate the incidence of sudden cardiac death and associated risk factors in a cohort of haemodialysis patients. METHODS AND RESULTS: The 3-year cumulative incidence of death in a cohort of 476 patients on chronic haemodialysis treatment was 34.3% (SE 2.3). Sudden death had a 6.9% (SE 1.2) cumulative incidence, with 32 events representing 19.2% of all deaths, while cardiovascular not sudden death and noncardiovascular death accounted for a 3-year cumulative incidence of 7.3% (SE 1.2) and 20.1% (SE 1.9), respectively. According to Cox multivariate analysis, significant risk factors for sudden death were the presence of atrial fibrillation, diabetes mellitus, predialytic hyperkalaemia, haemodialysis mode and C-reactive protein level, which were associated with a 2.9 (CI(95%) 1.3-6.4), 3.0 (CI(95%) 1.3-7.2), 2.7 (CI(95%) 1.3-5.8), 4.5 (CI(95%) 1.3-15.5) and 3.3 (CI(95%) 1.2-8.8)-fold increase in the risk of sudden death, respectively. Sudden death was significantly more frequent during the first 24 h of the first short interdialytic interval and during the last 24 h of the long interval, i.e. immediately before and immediately after the first weekly haemodialysis session (P = 0.02). CONCLUSIONS: Our data show that the incidence of sudden death in haemodialysis patients is high and that atrial fibrillation, diabetes, hyperkalaemia, haemodialysis mode and C-reactive protein play an important role in developing fatal arrhythmia. Further studies will be necessary to define which interventions could be helpful in reducing this cause of mortality.

Mechanical atrial recovery after cardioversion in persistent atrial fibrillation evaluated by bidimensional speckle tracking echocardiography.

BACKGROUND: Atrial fibrillation induces reversible electrical and mechanical modifications (atrial remodeling). Atrial stunning is a mechanical dysfunction with preserved bioelectrical function, occurring after successful atrial fibrillation electrical cardioversion (ECV). Two-dimensional speckle tracking echocardiography is a new technology for evaluating atrial mechanical function. We assessed atrial mechanical function after ECV with serial two-dimensional speckle tracking echocardiography evaluations. The investigated outcome was left atrium mechanical recovery within 3 months. METHODS: A total of 36 patients [mean age 73 (7.9) years, 23 males] with persistent atrial fibrillation underwent conventional transthoracic and transesophageal echocardiography before ECV. Positive global atrial strain (GSA+) was assessed at 3 h, 1, 2, 3, 4 weeks and 3 months after ECV. Mechanical recovery was defined as the achievement of a GSA+ value of 21%. RESULTS: Independent predictors of GSA+ immediately after ECV (basal GSA+) were E/e' ratio and left atrial appendage anterograde flow velocity. During the follow-up, 25% of patients suffered atrial fibrillation recurrence. In 12/36 patients (33%) left atrium mechanical recovery was detected (mechanical recovery group), while in 15/36 (42%) recovery did not occur (no atrial mechanical recovery group). At univariate analysis, the variables associated with recovery, were basal GSA+ (P = 0.015) and maximal velocity left atrial appendage (P = 0.022). Female sex (P = 0.038), N-terminal pro-B type natriuretic peptide (P = 0.013), E/e' (P = 0.042) and the indexed left atrium volume (P = 0.019) were associated with the lack of left atrium mechanical recovery. CONCLUSION: In almost half of the patients, the left atrium did not resume mechanical activity within the 3 months after ECV, despite sinus rhythm recovery. The left atrium of these patients was larger, stiffer and their E/E' was higher, suggesting a higher endocavitary pressure compared with mechanical recovery patients. These findings might suggest an increased thromboembolic risk.

Prognostic value of global left atrial peak strain in patients with acute ischemic stroke and no evidence of atrial fibrillation.

Prognostic stratification of acute ischemic stroke (AIS) patients without atrial fibrillation (AF) remains a challenge. Two-dimensional speckle tracking echocardiography (2D-STE) has recently been introduced for dynamic evaluation of left atrial function. However only few data are actually available regarding the application of 2D-STE in AIS patients. The aim of our study was to assess the prognostic role of global left atrial peak strain (GLAPS), measured by 2D-STE, in AIS patients without AF history. Eighty-five AIS patients (mean age 74.1 ± 12.1 years, 49 males) with normal sinus rhythm on ECG and without AF history were enrolled in the prospective study. All patients underwent a complete echocardiographic study with 2D-STE. At 1 year follow-up, we evaluated the occurrence of a composite endpoint of all-cause mortality plus cardiovascular re-hospitalizations. GLAPS was markedly reduced in AIS patients (15.71 ± 4.70%), without any statistically significant difference between the stroke subtypes. At 1-year follow-up, 14 deaths and 17 hospital readmissions were detected in AIS subjects. On a multivariate Cox model, variables independently associated with the occurrence of the composite endpoint were the "Rankin in" Scale (HR 1.69, p = 0.001), GFR (HR 0.98, p = 0.03) and the GLAPS value (HR 0.78, p < 0.0001). A GLAPS value ≤ 15.5% predicted the composite endpoint with sensitivity of 100% and specificity of 80%. A GLAPS value ≤ 15.5% reflects a more advanced atrial cardiomyopathy and might provide a reliable and useful prognostic risk stratification of AIS patients without AF history.

Incremental prognostic value of global left atrial peak strain in women with new-onset gestational hypertension.

BACKGROUND: Left atrial strain and strain rate parameters, measured by bidimensional-speckle tracking echocardiography, have been proposed as predictors of atrial fibrillation, stroke, congestive heart failure and cardiovascular death. However, they have not yet been tested in hypertensive disorders of pregnancy. The aim of this study was to assess the prognostic role of global left atrial peak strain (GLAPS) in a population of pregnant women with new-onset hypertension in a medium-term follow-up. METHODS: Twenty-seven consecutive women with new-onset hypertension after 20 weeks pregnancy and 23 age-matched, race-matched and gestational week-matched consecutive normotensive pregnant women were enrolled in this prospective study. All participants underwent a complete echocardiographic study with bidimensional-speckle tracking echocardiography and carotid examination. At 1-year follow-up, we evaluated the occurrence of persistent hypertension. RESULTS: In comparison with normotensive women, those hypertensive had a higher burden of cardiovascular risk factors, similar left atrial volume indexed (P = 0.14), but severely impaired left atrial strain (P < 0.0001) and strain rate values (P < 0.0001). At 1-year follow-up, persistent hypertension was documented in 59.3% of patients. At the univariate Cox analysis, the variables associated with the occurrence of the investigated outcome in all hypertensive pregnancies were SBP (hazard ratio 1.04, P = 0.04), DBP (hazard ratio 1.11, P = 0.01), mean arterial pressure (hazard ratio 1.09, P = 0.01) values and the GLAPS value (hazard ratio 0.85, P = 0.0019). The latter was significantly associated with the investigated outcome both in preeclamptic (hazard ratio 0.84, P = 0.02) and nonpreeclamptic pregnant women (hazard ratio 0.83, P = 0.04). The receiver operating characteristics curve analysis highlighted that a GLAPS value of 23.5% or less predicted persistent hypertension with sensitivity of 100% and specificity of 90.90%. CONCLUSION: In hypertensive pregnant women a GLAPS value of 23.5% or less reveals a greater severity of atrial cardiomyopathy and might predict postpregnancy persistent hypertension.

Electrical storm in patients with biventricular implantable cardioverter defibrillator: incidence, predictors, and prognostic implications.

BACKGROUND: The aim of the present study was to evaluate the incidence, predictors, and related outcomes of patients with heart failure (HF) treated with cardiac resynchronization therapy with an implantable cardioverter defibrillator (CRT-D) who experienced electrical storm (ES). Electrical storm was defined as the occurrence of >or=3 episodes in 24 hours of sustained ventricular tachyarrhythmias. METHODS: A total of 631 patients with HF (90% male, mean 66+/-9 years) consecutively received a CRT-D device. At baseline, the mean left ventricular ejection fraction was 26%+/-7%, the QRS duration was 164+/-33 milliseconds, and the mean New York Heart Association class was 3.3+/-0.3. RESULTS: During a mean follow-up of 19+/-11 months, 2,419 ventricular tachyarrhythmia episodes were appropriately detected in 141 (22%) patients. Electrical storm occurred in 45 (7%) of 631 patients. Kaplan-Meier analysis and multivariable Cox regression showed that ES is more frequent in secondary prevention (hazard ratio 2.3, 95% CI 1.2-4.3, P=.015) and in nonischemic patients (hazard ratio 2.0, 95% CI 1.1-3.8, P=.028). In patients who presented ES, CRT was associated with only marginal nonsignificant improvements of New York Heart Association class and left ventricular ejection fraction. Hospitalizations and death due to HF were more frequent in patients with ES compared with those without ES, amounting to 16.8 (4.3) versus 8.6 (0.9) per 100 patient-years (P = .018) and 7.7 versus 2.7 per 100 patient-years (P=.014), respectively. CONCLUSIONS: Electrical storm affect only 7% of CRT-D recipients and occurred more frequently in nonischemic patients with HF with biventricular implantable cardioverter defibrillators implanted for secondary prevention. Electrical storm was associated with worse HF morbidity and mortality.

Atrial fibrillation and morbidity and mortality in a cohort of long-term hemodialysis patients.

BACKGROUND: Atrial fibrillation is associated with increased mortality and hospitalization in the general population. Data about mortality, morbidity, and hospitalization in hemodialysis patients with atrial fibrillation are limited. SETTING & PARTICIPANTS: All patients (n = 476) in 5 dialysis centers in Lombardia, Italy, as of June 2003 were enrolled and followed up until June 2006 (median age, 69 years; median hemodialysis duration, 45.2 months; and median follow-up, 36 months). 127 patients had atrial fibrillation at enrollment. PREDICTORS & OUTCOME: A Cox model was used to relate: (1) atrial fibrillation, age, hemodialysis therapy duration, and comorbid conditions to all-cause and cardiovascular mortality; (2) angiotensin-converting enzyme (ACE)-inhibitor treatment and comorbid conditions to new onset of atrial fibrillation; and (3) atrial fibrillation and comorbid conditions on hospitalization. RESULTS: There were 167 deaths (39.5% from cardiovascular disease). In multivariable models, atrial fibrillation was independently associated with increased mortality (hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.18 to 2.31). This was more notable for cardiovascular (HR, 2.15; 95% CI, 1.27 to 3.64) than noncardiovascular mortality (HR, 1.39; 95% CI, 0.89 to 2.15). New-onset atrial fibrillation occurred in 35 of 349 individuals (4.1 events/100 person-years); the risk of incident atrial fibrillation was lower in those using ACE-inhibitor therapy (HR, 0.29; 95% CI, 0.10 to 0.82) and higher in those with left ventricular hypertrophy (HR, 2.55; 95% CI, 1.04 to 6.26). There were 539 hospitalizations during 3 years, with 114 hospitalizations in 162 patients with atrial fibrillation and 155 hospitalizations in 314 patients without atrial fibrillation (HR, 1.54; 95% CI, 1.18 to 2.01). Rates of stroke did not significantly differ by atrial fibrillation status (P = 0.4). LIMITATIONS: Because of the observational nature of this study, results for treatment need confirmation in future trials. CONCLUSIONS: Atrial fibrillation is associated with greater total and cardiovascular mortality. Patients with atrial fibrillation were hospitalized more frequently than patients without atrial fibrillation. ACE inhibitors may decrease the risk of new-onset atrial fibrillation.

Persistent atrial fibrillation worsens heart rate variability, activity and heart rate, as shown by a continuous monitoring by implantable biventricular pacemakers in heart failure patients.

BACKGROUND: Atrial fibrillation (AF) induces loss of atrial contribution, heart rate irregularity, and fast ventricular rate. OBJECTIVES: The objectives of the study were to accurately measure AF incidence and to investigate the mutual temporal patterns of AF and heart failure (HF) in patients indicated to cardiac resynchronization therapy. METHODS: Four hundred ten consecutive patients (70% male, age 69 +/- 11) with advanced HF (NYHA = 3.0 +/- 0.6), low ejection fraction (EF = 27 +/- 9%), and ventricular conduction delay (QRS = 165 +/- 29 ms) received a biventricular pacemaker. Enrolled patients were divided into two groups: G1 = 249 patients with no AF history, G2 = 161 patients with history of paroxysmal/persistent AF. RESULTS: In a median follow-up of 13 months, AF episodes longer than 5 minutes occurred in 105 of 249 (42.2%) G1 patients and 76 of 161 (47.2%) G2 patients, while AF episodes longer than one day occurred in 14 of 249 (5.6%) G1 patients and in 36 of 161 (22.4%) G2 patients. Device diagnostics monitored daily values of patient activity, night heart rate (NHR), and heart rate variability (HRV). Comparing 30-day periods before AF onset and during persistent AF, significant (P < 0.0001) changes were observed in patient activity, which decreased from 221 +/- 13 to 162 +/- 12 minutes, and in NHR, which increased from 68 +/- 3 to 94 +/- 7 bpm. HRV significantly decreased (from 75 +/- 5 ms before AF onset to 60 +/- 6 ms after AF termination). NHR during AF was significantly (P < 0.01) and inversely correlated (R(2)= 0.73) with activity, with a significant lower activity associated with NHR >or= 88 bpm. CONCLUSION: AF is frequent in HF patients. Persistent AF is associated with statistically significant decrease in patient activity and HRV and NHR increase.

Heart rate variability monitored by the implanted device predicts response to CRT and long-term clinical outcome in patients with advanced heart failure.

BACKGROUND: Few data exist on the long-term changes and the prognostic value of heart rate variability (HRV) assessed by implanted devices in heart failure (HF) patients treated with resynchronization therapy (CRT). AIMS: To analyze the long-term changes in the standard deviation of 5-minute median atrial-atrial sensed intervals (SDANN), and assess its role in predicting CRT efficacy and major cardiovascular events. METHODS AND RESULTS: We included 509 consecutive patients implanted with CRT devices. At 12-month follow-up, 44 patients had died and 86 patients had at least one HF hospitalisation. A significant increase in SDANN occurred after 4 weeks of CRT (from 69+/-22 ms to 82+/-27 ms, p<0.001). A further increase in SDANN was observed 6 months after implantation. Multivariable analysis identified SDANN as the sole predictor of major cardiovascular events (p=0.03) among several baseline parameters. SDANN< or =65 ms at the first week and SDANN< or =76 ms after 4 weeks of CRT yielded the best prediction of all-cause mortality and urgent heart transplantation on Kaplan-Meier analysis (log-rank test p=0.015 and p=0.011, respectively for week 1 and 4 values). Moreover, relative reduction in LVESV after CRT significantly correlated with SDANN at week 1 (r=-0.596, p=0.012), and week 4 (r=-0.703, p=0.001). CONCLUSIONS: Device-monitored HRV is a useful tool to identify, early after implantation, patients with a low likelihood of long-term benefits from CRT and at high risk for cardiovascular events.