Search

For patients with nonischemic cardiomyopathy (NICM), current guidelines recommend implantable cardioverter defibrillators (ICD) when left ventricular ejection fraction (LVEF) is ≤35%, but the DANISH trial failed to confirm that ICDs reduced all-cause mortality for such patients. Circumstantial evidence suggests that scar on CMR is predictive of sudden and arrhythmic death in this population. The presence of myocardial scar identified by cardiac magnetic resonance imaging (CMR) in patients with NICM and an LVEF ≤35% might identify patients at higher risk of sudden arrhythmic death, for whom an ICD is more likely to reduce all-cause mortality. The BRITISH trial is a prospective, multicenter, randomized controlled trial aiming to enrol 1,252 patients with NICM and an LVEF ≤35%. Patients with a nonischemic scar on CMR will be randomized to either: (1) ICD, with or without cardiac resynchronization (CRT-D), or (2) implantable loop recorder (ILR) or cardiac resynchronization (CRT-P). Patients who are screened for the trial but are found not to be eligible, predominantly due to an absence of scar or those who decline to be randomized will be enrolled in an observational registry. The primary endpoint is all-cause mortality, which we plan to assess at 3 years after the last participant is randomized. Secondary endpoints include clinical outcomes, appropriate and inappropriate device therapies, symptom severity and well-being, device-related complications, and analysis of the primary endpoint by subgroups with other risk markers. The BRITISH trial will assess whether the use of CMR-defined scar to direct ICD implantation in patients with NICM and an LVEF ≤35% is associated with a reduction in mortality. [ABSTRACT FROM AUTHOR]

Ketone bodies (KBs) might increase in response to physiological situations, usually after glycogen stores have been exhausted (fasting, prolonged exercise) or due to pathological causes (cardiac dysfunction or development of congestion); in patients with acute heart failure, diuresis might reduce KBs. Therefore, KBs might be a marker of cardiac and hemodynamic stress in heart failure (left panel). Preliminary experimental and human studies suggest that augmentation of KBs might have beneficial effects on cardiac hemodynamics and function; for instance, KBs might increase heart rate (HR), left ventricular ejection fraction (LVEF) and stroke volume (SV), and atrial contraction, and might cause a fall in systemic (SVR) and pulmonary (PVR) vascular resistance (right panel). SGLT2is, sodium-glucose cotransporter 2 inhibitors. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Pulmonary hypertension (PH) is common in patients with heart failure (HF) but, its relationship to symptoms and prognosis in a broad representative population of patients with HF has rarely been investigated. Methods: We interrogated a large database of consecutive referral to a HF clinic serving a population of 600,000 people. Systolic HF (S-HF) was defined as a LVEF≤45% and Preserved systolic LV HF (PS-HF) was defined as LVEF >45% with an NT-proBNP value >400pg/mL. Right Ventricle Systolic Pressure (RVSP) was assessed by the measurement of the tricuspid regurgitation (TR) peak systolic velocity. Results: Of 2135 patients referred, 1026 had S-HF, 354 had PS-HF and 533 had an accurate TR velocity measurement. Median (IQR) calculated RVSP for HF patients was 25 (18-35mmHg). Amongst these patients, 270 had S-HF and 143 had PS-HF. Mean age, prevalence of ischaemic heart disease and arrhythmia were 74+/-10, 52% and 44%. The maximal follow up was 88 months and the median follow up was 65 months. Amongst 1,380 patients with HF, the 413 with RVSP measurement had a worse prognosis than those who did not (log Rank=0.0001). Patients in the lowest quartile of RVSP (<17.5mmHg) had a similar prognosis to the subgroup of HF patients without TR measurement (16% and 17% at 2 years). Mortality increased as function of the increase in PH (log Rank=0.005). Quartile of RVSP predicted outcome similarly in patients with S-HF and PS-HF. Patients in the highest quartile of RVSP had a 2 year mortality of 38% if S-HF and 35% if PS-HF. On Cox proportional hazards multivariate analysis, COPD, Age, logNTproBNP, mean blood pressure and the highest RVSP quartile were independent predictors of outcome. Conclusion: Patients with heart failure and a TR velocity indicating even mild pulmonary hypertension have a worse prognosis whether or not LV systolic function is impaired. Patients with more severe PH have an even worse outcome. PH is an independent predictor of outcome in HF. [Copyright &y& Elsevier]

Purpose: In healthy individuals, reducing inspired oxygen concentrations to 15% (equivalent to an altitude of ∼2500 metres or usual aircraft cabin pressure) causes an increase in heart rate (HR), left ventricular ejection fraction (LVEF) and pulmonary arterial pressure (PAP). The clinical and haemodynamic responses to hypoxia (15% oxygen) have not been reported in patients with chronic heart failure (CHF). Methods: Patients with CHF were enrolled who met at least one of the following criteria: NYHA≥III, LVEF <40%, or diuretic dose equivalent to furosemide ≥ 80mg. Patients inspired 15% oxygen from a Douglas bag through a mouthpiece whilst lying supine. Clinical and echocardiographic measurements were performed at baseline and after one hour of hypoxia. Results: Thirty two CHF patients (mean age and LVEF were 63±13yrs and 33±9% respectively) were recruited. 70% had ischemic heart disease and 22% had permanent atrial fibrillation. Hypoxia was well tolerated and was not associated with worsening HF-symptoms. Arterial oxygen saturation (SpO2) decreased from 97.2±1.2 to 85.7±5.0%, p<0.0001. Mean systemic blood pressure (MSBP) increased from 84±11mmHg to 92±11mmHg, p<0.0001, whilst HR remained unchanged at 69±14bpm. LVEF and E/A ratio were unchanged. Diastolic LV function tended to improved (E/Ea from 13.6±7.2 to 12.3±7.7 p=0.09). Systolic PAP increased (from 34±9mmHg to 38±9mmHg, p<0.05 in n=16 patients with tricuspid regurgitation) and the right ventricular systolic function assessed by the tricuspid annular systolic excursion was unchanged. Conclusion: Hypoxia caused no symptoms in any patients despite a significant increase in MSBP and a decrease in arterial SpO2. Further investigations in a larger patient group and with longer periods of hypoxia are being conducted. [Copyright &y& Elsevier]