Search

Device-Measured Rapid Shallow Breathing With Exertion Worsens Prior to Heart Failure Decompensation Seth Rials, Bela Merkely, Roy Gardner, Viktoria Averina, Robert Sweeney, Yi Zhang, Qi An, John Boehmer; Grant Medical Center, OhioHealth, Columbus, OH; Semmelweis University Heart Center, Budapest, Hungary; Golden Jubilee National Hospital, Glasgow, United Kingdom; Boston Scientific, St. Paul, MN; Penn State Milton S. Hershey Medical Center, Hershey, PA

Cardiac transplantation is an important treatment option for those patients with end stage heart failure who have failed to respond to disease modifying treatment. However, cardiac transplantation is not without risk, with the one year mortality around 19%,1 and identifying patients at the highest risk of death is notoriously difficult. Brain natriuretic peptide (BNP) and the N-terminal portion of pro-brain natriuretic peptide (NT-proBNP) are now well established diagnostic and adverse prognostic markers in all stages of congestive heart failure. Indeed, we have shown that NT-proBNP is predictive of death before cardiac transplantation.2 Studies have also shown that increasing BNP concentrations precede cardiac allograft rejection and are associated with poor survival late after transplantation.3 However, the prognostic ability of NT-proBNP immediately after cardiac transplantation has not been evaluated. The goal of this study was therefore to assess the short term prognostic ability of NT-proBNP in patients after cardiac transplantation. We prospectively studied 26 consecutive patients undergoing orthotopic cardiac transplantation in the Scottish Cardiopulmonary Transplant Unit between September 2001 and September 2003. The primary end point was all cause mortality. The median follow up was 477 days (range 20–922 days). No patients were lost to follow up. Blood for NT-proBNP was collected in EDTA containing tubes before each routine right ventricular endomyocardial biopsy. The samples were then spun at 3000 rpm for 10 minutes at 0°C. Plasma was extracted and frozen in aliquots at −70°C until analysis. NT-proBNP …

Chronic heart failure is increasing in incidence and prevalence. Recent advances in medical therapy have improved prognosis such that, even in patients with chronic heart failure who are New York Heart Association Classes III and IV, annual mortality can be as low as 11.4%. Nevertheless, some patients remain at risk, despite optimal disease-modifying medical therapy, and it would seem appropriate that these patients are considered first for appropriate device therapy or for the scarce resource of cardiac transplantation. Many parameters have been assessed for their prognostic potential in patients with chronic heart failure. In this review, pertinent studies investigating anemia, right-heart hemodynamics and neurohormones as prognostic markers are discussed.

Background: The prognosis of chronic heart failure has improved with modern medical therapy. However, identifying those patients who fail to respond to such therapy and therefore those who remain at high risk is notoriously difficult. The B-type natriuretic peptides are established independent predictors of prognosis in CHF. However, the relevance of a change in NT-proBNP concentration over time in advanced heart failure is unknown. Methods: We prospectively studied 133 patients with advanced CHF referred for consideration of cardiac transplantation. Plasma for NT-proBNP analysis was sampled at baseline and a median of 4months later in the 112 patients surviving without cardiac transplantation. Patients were followed up for a median of 1003days. Results: The primary endpoint of all-cause mortality occurred in 30 (26.8%) patients. Those subjects who had the highest NT-proBNP concentration at 4months were at the greatest risk of death (log rank statistic=10.4, p=0.001). On Cox regression analysis, both a NT-proBNP concentration above the median and an absolute increase in NT-proBNP were independent predictors of mortality (χ2=53, p

Anemia is prevalent in patients with chronic heart failure, the proportion of which increases with deteriorating New York Heart Association functional class. Anemia is also associated with increased symptoms, more frequent hospitalizations, and, in some studies, with an increased mortality rate. We have demonstrated that N-terminal brain natriuretic peptide (NT-proBNP) is a powerful predictor of death in advanced heart failure and is superior to the traditional markers of chronic heart failure (CHF) severity. However, to date, there are no published data that compare the prognostic ability of NT-proBNP with that of hemoglobin and hematocrit in patients with advanced heart failure who are referred for consideration of cardiac transplantation at a time when erythropoietin is under investigation as a treatment option in such a population.We prospectively studied 182 consecutive patients with advanced CHF who had been referred for consideration of cardiac transplantation. Blood samples were taken at recruitment for routine investigation and for NT-proBNP analysis; the patients' condition was followed for a median of 554 days. The primary end point of all-cause death was reached in 30 patients, and the secondary end point of all-cause death or urgent cardiac transplantation was reached in 34 patients. The mean hemoglobin level was 13.9 +/- 2.2 g/dL, and the median concentration of NT-proBNP was 1505 pg/mL (interquartile range, 517-4015). The only multivariate predictor of all-cause death (chi 2 = 14.2; P.001) or the secondary end point of all-cause death or urgent transplantation (chi 2 = 21.8; P.001) was an NT-proBNP concentration above the median value.A single measurement of NT-proBNP in patients with advanced CHF can help to identify patients who are at a higher risk of death and is a better prognostic marker than anemia.

Background: Apelin, the novel endogenous ligand for the G-protein-coupled receptor APJ, has shown positive inotropic, vasodilatory and diuretic properties in animal studies. Differential expression and synthesis of apelin and APJ receptors have been observed in normal and failing human hearts, suggesting a possible role in cardiovascular homeostasis. Changes in plasma apelin concentrations in relation to heart failure have been described in small studies with conflicting results. Our aim was to evaluate plasma apelin concentrations in a large cohort of patients with chronic heart failure (CHF) across a broad spectrum of disease severity. Method and results: Plasma apelin concentrations were measured in 202 patients with CHF secondary to left ventricular systolic dysfunction and 22 age-matched controls. Plasma apelin concentrations were significantly lower in patients with CHF, irrespective of NYHA class, ejection fraction or aetiology when compared to age-matched controls (0.85 [0.53–2.04] versus 3.76 [0.85–5.13] ng/ml, p

Background: Glomerular filtration rate (GFR) has major prognostic implications in heart failure. Our objective was to validate the MDRD prediction equations for GFR in patients with advanced heart failure, and to compare their predictive performance to that of the Cockcroft–Gault (CG) equation. Methods: We analysed GFR in 45 patients referred for heart transplantation evaluation. 51Cr–EDTA-measured GFR was compared to GFR estimates obtained by MDRD1 and MDRD2 equations, CG equation using actual body weight, and ideal body weight. Regression analyses and Pearson correlations were performed, and Bland and Altman plots were drawn. ROC curves were obtained to illustrate each equation's ability to predict a GFR less than 60 ml/min/1.73 m2 (moderate renal impairment). Results: Patients had a mean age of 52 years, and 69% were in NYHA class III. The mean EDTA-measured GFR was 46.9±17.2 ml/min/1.73 m2. The MDRD1 equation provided the best predictive model (narrowest limits of agreement; r=0.766, p

Sir, A 59-year-old male was admitted following an episode of chest pain and a ventricular fibrillation (VF) arrest in the community from which he was successfully resuscitated. He had a past medical history of moderate rheumatic mitral stenosis and atrial fibrillation and 12 months previously had uneventfully undergone 6 pulses of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-CHOP) chemotherapy for high-grade diffuse B-cell gastric lymphoma. Electrocardiogram (ECG) following restoration of sinus rhythm revealed antero-septal T-wave inversion and Troponin I (TnI) was raised at 4.5 ng/ml indicating acute myocardial infarction (MI). Coronary angiography revealed normal epicardial coronary arteries and echocardiography showed no progression of his mitral stenosis but now demonstrated a left ventricular …

A 69-year-old female with a previous hemisternectomy for recurrent phyllodes tumour was referred for echocardiography because of progressive dyspnoea, orthopnea, and a diastolic mitral rumble on auscultation. Transthoracic echocardiography revealed a large left atrial mass. Although a diagnosis of myxoma was likely, there was concern that this was a cardiac metastasis. A tissue diagnosis was mandatory before further thoracic surgery could be considered. This was obtained via a trans-septal puncture using transoesophageal echocardiographic guidance. Histology confirmed a diagnosis of myxoma, and our patient underwent successful surgery. This case highlights the importance of obtaining accurate tissue diagnosis and of excluding metastatic disease in patients with a cardiac mass and a history of tumour, prior to deciding whether surgical excision is warranted.

Arroll and colleagues’ review of the management of congestive heart failure1 disregards much of the progress made since the previous BMJ review of this topic in 2002.2 They concentrated on established pharmacotherapy …

Six dogs were subjected to arterialization of the left anterior descending vein (LADV). Tests showed that the predominant flow through these vessels did perfuse the myocardium: Lowering of oxygen content of the perfusing blood and myocardial uptake of macroaggregate albumin 131I were noted. The possibility of small atrioventricular (A-V) shunts was not excluded.

ObjectivesThe aim of this study was to investigate whether late gadolinium enhancement (LGE) magnetic resonance imaging or N-terminal pro–B-type natriuretic peptide (NT-proBNP) could identify patients with a low risk of death or use of implantable cardioverter-defibrillator (ICD) in patients receiving a primary prevention ICD.BackgroundICDs reduce mortality in patients with heart failure (HF), although two-thirds may never use their device. Current risk stratification, based on New York Heart Association functional class and left ventricular ejection fraction, still leads to implantation of ICDs in patients who may never need their device.MethodsWe examined 157 patients with HF (61 with ischemic cardiomyopathy and 96 with dilated cardiomyopathy; mean age 50.5 years; 78% male) who underwent primary prevention defibrillator implantation. Presence and volume of LGE was measured before device implantation, and serum NT-proBNP level was measured before ICD implantation. The combined primary endpoint was cardiovascular death or appropriate ICD therapy (either appropriate shock or antitachycardia pacing).ResultsThe primary outcome occurred in 32 patients (20.4%) over a median follow-up period of 915 days. Percentage of LGE (hazard ratio [HR]: per 1% increase: 1.06; 95% confidence interval [CI]: 1.04 to 1.09; p < 0.001) and (ln) NT-proBNP (HR: 1.44; 95% CI: 1.04 to 1.98; p = 0.027) were predictors of death or appropriate ICD activation and remained significant when entered into multivariable analysis. When the cohort was stratified into tertiles based on LGE percentage and NT-proBNP, we were able to identify a low-risk group (event rate 3% per year, compared with the intermediate- and high-risk groups [6% and 10% per year, respectively]).ConclusionsBoth percentage of LGE and NT-proBNP were associated with higher risk of death or appropriate ICD activation. The use of these markers in combination may be useful in identifying individuals most likely to benefit from this costly intervention, and more specifically, in the identification of a group at lower risk in whom ICD implantation may be deferred.

Heart failure (HF), defined in its broadest sense as a syndromecharacterized by symptoms and signs of ventricular dysfunction inthe presence of structural and or functional abnormalities of heartfunction, affects millions of people worldwide; in addition, a substantialnumber of individuals have asymptomatic abnormalitiesof heart function that predispose them to symptomatic HF in laterlife. Coronary artery disease and hypertension are by far the most common causes of HF, but a substantial minority of cases arecaused by a heterogeneous group of heart muscle diseases, the cardiomyopathies.These disorders differ in several important respectsfrom other causes of HF in that they are often familial and presentthroughout life. With recent advances in the understanding of themolecular genetics of cardiomyopathies, cardiologists are havingto adapt diagnostic and treatment protocols in order to optimizemanagement of individual patients and their families. In thischapter we review the clinical presentation and pathophysiology ofthe most common monogenic cardiomyopathies and the cardiovascularmanifestations of mutations in the genes controlling therespiratory chain (mitochondrial diseases).