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Background: Heart rate recovery (HRR) is an established prognostic predictor. However, a number of methodological issues have not been fully explored, including differences in HRR 1 versus 2 min after exercise termination, absolute versus relative HRR, and the impact of beta-blockers., Design: Cross-sectional study., Methods: Predictors of impaired absolute and relative HRR 1 (HRR-1, HRR-1%) and 2 min after exercise termination (HRR-2, HRR-2%), defined as their lowest quartiles, were assessed in 1667 patients undergoing cycle exercise myocardial perfusion single photon emission computed tomography, and measures of HRR were compared between patients undergoing myocardial perfusion single photon emission computed tomography with continued, discontinued, and without beta-blockers., Results: Higher resting heart rate was an independent predictor of all measures of impaired HRR (P<0.001 for all). Lower peak heart rate was independently associated with impaired HRR-1, HRR-2, and HRR-2% (P<0.001 for all) but not HRR-1%. Higher summed rest score as a marker of scar and in part left ventricular dysfunction was an independent predictor of impaired HRR-1 (P = 0.010) and HRR-1% (P = 0.025) but not HRR-2 and HRR-2%, whereas lower stroke volume index was an independent predictor of slow HRR-2 (P = 0.004) and HRR-2% (P = 0.02) but not HRR-1 and HRR-1%. HRR-1 (P = 0.98) and HRR-2 (P = 0.86) were similar in patients with continued, discontinued, and without beta-blocker therapy. In contrast, HRR-1% (P = 0.01) and HRR-2% (P = 0.001) were faster in patients on beta-blockers than in the other groups., Conclusion: HRR-1 and HRR-2 as well as HRR-1% and HRR-2% reflect different pathophysiological processes. Relative but not absolute measures of HRR seem to be enhanced under beta-blockers.

Background: In Human African Trypanosomiasis, neurological symptoms dominate and cardiac involvement has been suggested. Because of increasing resistance to the available drugs for HAT, new compounds are desperately needed. Evaluation of cardiotoxicity is one parameter of drug safety, but without knowledge of the baseline heart involvement in HAT, cardiologic findings and drug-induced alterations will be difficult to interpret. The aims of the study were to assess the frequency and characteristics of electrocardiographic findings in the first stage of HAT, to compare these findings to those of second stage patients and healthy controls and to assess any potential effects of different therapeutic antiparasitic compounds with respect to ECG changes after treatment., Methods: Four hundred and six patients with first stage HAT were recruited in the Democratic Republic of Congo, Angola and Sudan between 2002 and 2007 in a series of clinical trials comparing the efficacy and safety of the experimental treatment DB289 to the standard first stage treatment, pentamidine. These ECGs were compared to the ECGs of healthy volunteers (n = 61) and to those of second stage HAT patients (n = 56)., Results: In first and second stage HAT, a prolonged QTc interval, repolarization changes and low voltage were significantly more frequent than in healthy controls. Treatment in first stage was associated with repolarization changes in both the DB289 and the pentamidine group to a similar extent. The QTc interval did not change during treatment., Conclusions: Cardiac involvement in HAT, as demonstrated by ECG alterations, appears early in the evolution of the disease. The prolongation of the QTC interval comprises a risk of fatal arrhythmias if new drugs with an additional potential of QTC prolongation will be used. During treatment ECG abnormalities such as repolarization changes consistent with peri-myocarditis occur frequently and appear to be associated with the disease stage, but not with a specific drug.

American trypanosomiasis (Chagas disease) and human African trypanosomiasis (HAT; sleeping sickness) are both caused by single-celled flagellates that are transmitted by arthropods. Cardiac problems are the main cause of morbidity in chronic Chagas disease, but neurological problems dominate in HAT. Physicians need to be aware of Chagas disease and HAT in patients living in or returning from endemic regions, even if they left those regions long ago. Chagas heart disease has to be taken into account in the differential diagnosis of cardiomyopathy, primarily in patients with pathological electrocardiographic (ECG) findings, such as right bundle branch block or left anterior hemiblock, with segmental wall motion abnormalities or aneurysms on echocardiography, and in young patients with stroke in the absence of arterial hypertension. In HAT patients, cardiac involvement as seen by ECG alterations, such as repolarisation changes and low voltage, is frequent. HAT cardiopathy in general is benign and does not cause relevant congestive heart failure and subsides with treatment. We review the differences between the American and African trypanosomiasis with the main focus on the heart.

Objectives: To estimate the frequency and evolution of heart involvement in human African trypanosomiasis (HAT) using electrocardiogram (ECG) findings; to describe these findings and to assess the frequency and clinical relevance of symptoms and signs before and after treatment., Methods: In a prospective cohort study ECG findings, signs and symptoms consistent with heart failure and cardiac laboratory parameters were studied at baseline, 2 days after the end of treatment and 3 months later., Results: Major ECG alterations were significantly more frequent in HAT patients than in healthy controls (71%vs. 18%; P < 0.001); 31% were low voltage changes, 34% were repolarization changes. ECG signs of necrosis and conduction problems were rare. Symptoms consistent with heart failure such as exertional dyspnoea (19%vs. 1.7%; P = 0.002) or palpitations (18%vs. 5%; P = 0.28) occurred more frequently in patients than in controls. The median NT-proBNP was significantly higher in HAT patients than in controls (85.2 vs. 28 pg/ml; P < 0.001). Troponin levels were normal. At the end of treatment repolarization changes appeared or worsened in 33.4%. Such changes improved or disappeared at follow-up in 33.1% of the patients., Conclusions: Cardiac involvement documented by ECG alterations is common in HAT patients, but cardiopathy rarely causes severe congestive heart failure and subsides after treatment. ECG alterations immediately after treatment and their improvement 3 months later may be the result of a treatment-induced inflammatory reaction.

Hypertensive heart disease (HHD) develops in response to the chronic exposure of the left ventricle and left atrium to elevated systemic blood pressure. Left ventricular structural changes include hypertrophy and interstitial fibrosis that in turn lead to functional changes including diastolic dysfunction and impaired left atrial and LV mechanical function. Ultimately, these changes can lead to heart failure with a preserved (HFpEF) or reduced (HFrEF) ejection fraction. This review will outline the clinical evaluation of a patient with hypertension and/or suspected HHD, with a particular emphasis on the role and recent advances of multimodality imaging in both diagnosis and differential diagnosis. [ABSTRACT FROM AUTHOR]

The Swiss Society of Cardiology (SSC) and the Swiss Society of Cardiac and ThoracicVascular Surgery (SSCTVS) have formulated their mutual intent of a close, patient-oriented, and expertise-based collaboration in the Heart Team Paper. The interdisciplinary dialogue between the SSC and SSCTVS reflects an attitude in decision making, which guarantees the best possible therapy for the individual patient. At the same time, it is a cornerstone of optimized process quality, placing individual interests into the background. Evaluation of the correct indication for a treatment is indeed very challenging and almost impossible to verify retrospectively. Quality in this very important health policy process can therefore only be assured by the use of mutually recognized indications, agreed upon by all involved physicians and medical specialties, whereby the capacity of those involved in the process is not important but rather their competence. These two medical societies recognize their responsibility and have incorporated international guidelines as well as specified regulations for Switzerland. Former competitors now form an integrative consulting team able to deliver a comprehensive evaluation for patients. Naturally, implementation rests with the individual caregiver. The Heart Team Paperof the SGK and SGHC, has defined guide boards within which the involved specialists maintain sufficient room to maneuver, and patients have certainty of receiving the best possible therapy they require. [ABSTRACT FROM AUTHOR]

Background: Post-stress ejection fraction (EF), end-diastolic (EDV) and end-systolic (ESV) volumes by gated myocardial perfusion SPECT (MPS) are well validated, reproducible and of prognostic significance. However, little is known about the impact of percutaneous coronary intervention (PCI) on left ventricular volumes and remodeling. Methods: Thirty-eight patients who underwent MPS before and 6 months after PCI were evaluated. MPS were interpreted deriving summed stress (SSS), rest (SRS) and difference (SDS=SSS-SRS; extent of ischemia) scores. EF, EDV and ESV were generated by QGS™. Pre-PCI MPS were compared to post-PCI MPS. Results: Single vessel disease was present in 63% of patients. PCI of one vessel was performed in 82% of patients. After 6 months, SSS (10.6±6.3 vs. 2.8±4.3, p<0.001) and SDS (8.2±5.6 vs. 1.4±2.3, p<0.001) had improved; however, EF did not change significantly (55±10 vs. 57±13, p=ns). Still, EDV (105±25 ml vs. 96±25 ml, p=0.006) and ESV (49±19 ml vs. 41±18 ml, p=0.001) were significantly reduced. Conclusion: Results of MPS documented the beneficial effect of PCI on symptoms and extent of ischemia. In addition, the findings showed a significant decrease in ESV and EDV after PCI as compared to pre-PCI findings which points to a positive effect on left ventricular remodeling even in the absence of significant changes in EF. [Copyright &y& Elsevier]

Abstract: Background: The value of an implantable cardioverter defibrillator (ICD) for primary prevention in dilated cardiomyopathy (DCM) is unclear, as randomized trials could not show a survival benefit compared to drug therapy. It has not been investigated if patients with a very poor left ventricular function (LVEF) could profit from an ICD. Methods: Consecutive patients with DCM who received an ICD between December 1996 and November 2003 were included in this analysis. Patients were divided in group A (secondary prevention) and group B (primary prevention). Both groups were stratified in subgroups with left ventricular ejection fraction (LVEF) below and above 20%. Results: Fifty eight patients were included (male 50, age 56.4±12.7 years). Follow-up was 34±19 months. There was no difference regarding death (18% vs. 11%), but significant differences (p value <0.05) regarding any adverse events (55% vs. 22%), any ICD intervention (48% vs. 17%) and ICD interventions for life-threatening arrhythmias (27% vs. 0%) between group A and B. LVEF was not predictive for events in group A, whereas in group B only patients with a LVEF <20% had events (p value 0.02). Over time there was an increase of the LVEF of more than 15% determined by echocardiography in 36% of patients, significantly more often in group B. Conclusions: Indication for primary prevention with an ICD in DCM should be made with caution. Larger studies are needed to determine if patients with LVEF of <20% might benefit from an ICD. [Copyright &y& Elsevier]

Summary Background No prospective trial-based data are available for incremental cost-effectiveness of drug-eluting stents (DES) compared with bare-metal stents (BMS) in unselected patients, as treated in everyday practice. Methods The Basel stent cost-effectiveness trial (BASKET) included 826 consecutive patients treated with angioplasty and stenting for 1281 de-novo lesions, irrespective of indication for angioplasty. Patients were randomised to one of two DES (Cypher, n=264; Taxus, n=281) or to a cobalt-chromium-based BMS (Vision, n=281) and followed up for 6 months for occurrence of major adverse cardiac events and costs. Analysis was by intention-to-treat. The primary endpoint was cost-effectiveness after 6 months, with effectiveness defined as reduction of major adverse cardiac events. Findings Cardiac death, myocardial infarction, or target vessel revascularisation occurred in 39 of 544 (7·2%) patients with DES and 34 of 280 (12·1%) with BMS (odds ratio 0·56, 95% CI 0·35-0·91; p=0·02), without significant differences between the two DES. Total costs at 6 months were higher with DES (mean &z.euro;10 544, SD 6849) than with BMS (&z.euro;9639, 9067; p<0·0001); higher stent costs of DES were not compensated for by lower follow-up costs. Incremental cost-effectiveness ratio of DES compared with BMS to avoid one major event was &z.euro;18 311, and costs per quality-adjusted life-year gained were more than &z.euro;50 000. Subgroup analyses showed that DES were more cost-effective for elderly patients in specific high-risk groups. Interpretation In a real-world setting, use of DES in all patients is less cost effective than in studies with selected patients. Use of these stents could be restricted to patients in high-risk groups. [ABSTRACT FROM AUTHOR]