Summary Background Angiotensin receptor blockers (ARB) and angiotensin converting enzyme (ACE) inhibitors are known to reduce proteinuria. Their combination might be more effective than either ...treatment alone, but long-term data for comparative changes in renal function are not available. We investigated the renal effects of ramipril (an ACE inhibitor), telmisartan (an ARB), and their combination in patients aged 55 years or older with established atherosclerotic vascular disease or with diabetes with end-organ damage. Methods The trial ran from 2001 to 2007. After a 3-week run-in period, 25 620 participants were randomly assigned to ramipril 10 mg a day (n=8576), telmisartan 80 mg a day (n=8542), or to a combination of both drugs (n=8502; median follow-up was 56 months), and renal function and proteinuria were measured. The primary renal outcome was a composite of dialysis, doubling of serum creatinine, and death. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov , number NCT00153101. Findings 784 patients permanently discontinued randomised therapy during the trial because of hypotensive symptoms (406 on combination therapy, 149 on ramipril, and 229 on telmisartan). The number of events for the composite primary outcome was similar for telmisartan (n=1147 13·4%) and ramipril (1150 13·5%; hazard ratio HR 1·00, 95% CI 0·92–1·09), but was increased with combination therapy (1233 14.5%; HR 1·09, 1·01–1·18, p=0·037). The secondary renal outcome, dialysis or doubling of serum creatinine, was similar with telmisartan (189 2·21%) and ramipril (174 2·03%; HR 1·09, 0·89–1·34) and more frequent with combination therapy (212 2·49%: HR 1·24, 1·01–1·51, p=0·038). Estimated glomerular filtration rate (eGFR) declined least with ramipril compared with telmisartan (−2·82 SD 17·2 mL/min/1·73 m2 vs −4·12 17·4, p<0·0001) or combination therapy (−6·11 17·9, p<0·0001). The increase in urinary albumin excretion was less with telmisartan (p=0·004) or with combination therapy (p=0·001) than with ramipril. Interpretation In people at high vascular risk, telmisartan's effects on major renal outcomes are similar to ramipril. Although combination therapy reduces proteinuria to a greater extent than monotherapy, overall it worsens major renal outcomes. Funding Boehringer-Ingelheim.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
The neutrophil/lymphocyte ratio (NLR) has recently emerged as better indicator of inflammation and oxidative stress and has been widely studied in several cardiovascular diseases. In the present ...study, we evaluated the role of the preablation NLR in atrial fibrillation (AF) recurrence after cryoballoon-based catheter ablation. A total of 251 patients (47.8% women, age 54.12 ± 10.9 years, 80.1% with paroxysmal AF) with symptomatic AF underwent cryoablation. At a mean follow-up of 19.0 ± 6.6 months, 60 patients (23.9%) had developed AF recurrence. The patients who developed AF recurrence had had a greater preablation NLR (3.53 ± 0.95 vs 2.65 ± 0.23, p <0.001) and a higher white blood cell count, neutrophil count, and high-sensitivity C-reaction protein levels. On multivariate regression analysis, the preablation NLR (hazard ratio 2.15, 95% confidence interval 1.70 to 2.73, p <0.001), left atrial diameter (hazard ratio 1.09, 95% confidence interval 1.04 to 1.14, p <0.001) and early AF recurrence (hazard ratio 2.99, 95% confidence interval 1.71 to 5.23, p <0.001) were independent predictors of AF recurrence after cryoablation. Using a cutoff level of 3.15, the preablation NLR predicted AF recurrence during follow-up with a sensitivity of 84% and specificity of 75%. Patients with a preablation NLR >3.15 had a 2.5-fold increased risk of developing AF recurrence after cryoablation. In conclusion, an elevated preablation NLR was associated with increased AF recurrence after cryoballoon-based catheter ablation. Our results support the role of a preablation inflammatory environment in the development of AF recurrence after ablation therapy but suggest that other factors are also important.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Although cryoballoon based catheter ablation is an effective therapeutic option in atrial fibrillation (AF), a significant amount of patients failed to remain in sinus rhythm at ...long term follow-up. Appropriate selection of patients for catheter ablation reduces unnecessary interventions and prevents complications related with catheter ablation. The purpose of our study is to propose a new scoring system in the prediction of recurrence after AF ablation with cryoballoon. Method A total of 236 patients (54% male, age 54.6 ± 10.45 years and 79.6% paroxysmal) with symptomatic AF underwent an index cryoablation. The first 3 months after AF ablation is defined as blanking period. Predictors of AF recurrence after cryoablation were analyzed with multivariate Cox regression analysis. BASE-AF2 score acronym stands for B ody mass index > 28 kg/m2 (1); A trial dilatation > 40 mm (1); current S moking (1); E arly recurrence (1); duration of AF history > 6 years (1) and non-paroxysmal type (1) of AF is identified by the total number of significant predictors of recurrence in each patient (range = 0–6). Results At median 20 (range: 12–30) months follow-up, 74.5% of the patients were free from AF recurrence. Of these patients, 64 (27.1%) patients had a BASE-AF2 score of ≥ 3. Patients with AF recurrence had a higher mean BASE-AF2 score (3.27 ± 0.82 vs. 1.1 ± 0.95, p < 0.001) compared to patients without AF recurrence. ROC analysis showed that a BASE-AF2 score of ≥ 3 well predicted AF recurrence with a sensitivity of 80.8% and a specificity of 91.6% (AUC = 0.94; 95% CI: 0.89–0.97, p < 0.001). A BASE-AF2 score of ≥ 3 was found to be an independent predictor of AF recurrence (HR: 3.34, 95% CI: 2.34–4.76, p = 0.001). Conclusion BASE-AF2 , which was identified as a new scoring system, has well predicted AF recurrence and could be helpful in selecting appropriate patients for interventional strategy.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Background
Angiotensin receptor neprilysin inhibitors (ARNI; sacubitril/valsartan combination) decrease morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). Increased ...P‑wave duration and P‑wave dispersion (P
d
) reflect prolongation of atrial conduction and correlate with atrial fibrillation. Here, we aimed to assess the effects of switching from valsartan to ARNI treatment on the basis of P‑wave indices.
Methods
A total of 28 patients with HFrEF (mean age, 64.8 ± 10.6 years; 18 males, 78.6% ischemic etiology) were included. All patients had New York Heart Association functional class II–III, left ventricular ejection fraction ≤35%, and had been switched from valsartan to ARNI treatment. Standard 12-lead electrocardiograms from patients on valsartan treatment and electrocardiograms 1 month after ARNI treatment were analyzed; heart rate, maximum P‑wave duration (P
max
), minimum P‑wave duration (P
min
), and P
d
were calculated. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores and N‑terminal pro-brain natriuretic peptide (NT-proBNP) values were recorded.
Results
The P
max
(135.6 ± 32.1 ms vs. 116.1 ± 14.1 ms,
p
= 0.041) and P
d
(33.6 ± 7.9 vs. 28.6 ± 5.3,
p
= 0.006) values were significantly reduced after ARNI treatment. Furthermore, ARNI treatment was associated with an improvement in MLWHFQ scores (31.2 ± 6.2 ms vs. 23.2 ± 7.0 ms,
p
< 0.001) and with a reduction in NT-proBNP values (1827.3 ± 1287.3 pg/ml vs. 1074.4 ± 692.3 pg/ml,
p
< 0.001). There were moderately positive correlations between the reduction in P
d
and the improvement in MLWHFQ scores (
r
= 0.408,
p
= 0.031) and the reduction in NT-proBNP values (
r
= 0.499,
p
= 0.007)
Conclusion
Switching to ARNI treatment alters P
d
and P
max
favorably in patients with HFrEF. The reduction in atrial inhomogeneous conduction assessed by P
d
was correlated with clinical improvement and reduced NT-proBNP levels in patients with HFrEF.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
Evidence is accumulating that toll-like receptors (TLR) are involved in the initiation and progression of cardiovascular disease. Enhanced expression of these receptors on monocytes has been shown in ...patients with acute coronary syndrome (ACS). However, expression on platelets in this group of patients has not been evaluated yet. We aimed to demonstrate the possible relationship of platelet TLR-2 and TLR-4 expressions with stable coronary artery disease and ACS pathogenesis. In this observational case–control study, 40 patients diagnosed with ACS (unstable angina pectoris, non–ST-segment elevation and ST-segment elevation ACS), 40 patients diagnosed with stable coronary artery disease, and 40 age- and gender-matched subjects with normal coronary arteries were involved. Platelet TLR-2 and TLR-4 expressions were evaluated by flow cytometry in peripheral venous blood samples obtained before coronary angiography. A total of 120 patients (60.7 ± 12.3 years, 50% men) were included. Median platelet TLR-2 and TLR-4 expressions were greater in patients with ACS compared to those with stable angina pectoris and normal coronary arteries (29.5% vs 10.5% vs 3.0%, p <0.001 and 40.5% vs 11.5% vs 3.0%, p <0.001, respectively). Median platelet TLR-2 and TLR-4 expressions were also greater in patients with stable angina pectoris compared to those with normal coronary arteries (p <0.05). In conclusion, this is the first study demonstrating enhanced TLR-2 and TLR-4 expressions on platelets in patients with ACS. These findings may suggest that platelet TLR expression as a novel potential prophylactic and therapeutic target in ACS.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Summary Background Treatment with prasugrel and aspirin improves outcomes compared with clopidogrel and aspirin for patients with acute coronary syndrome who have had angiography and percutaneous ...coronary intervention; however, no clear benefit has been shown for patients managed first with drugs only. We assessed outcomes from the TRILOGY ACS trial based on whether or not patients had coronary angiography before treatment was chosen. Methods TRILOGY ACS ( ClinicalTrials.gov number NCT00699998 ) was a randomised controlled trial, done at more than 800 sites worldwide. Patients with non-ST-elevation acute coronary syndrome who were selected for management without revascularisation were randomly assigned to clopidogrel or prasugrel. The primary endpoint was cardiovascular death, myocardial infarction, or stroke at 30 months. In the present analysis we assessed differences in the primary endpoint by angiography status and whether the effects of treatment on the primary endpoint differed between patients who had angiography before enrolment and those who had not. Findings 7243 patients younger than 75 years were included in the TRILOGY ACS primary analysis. 3085 (43%) had angiography at baseline, 4158 (57%) had not. Fewer patients who had angiography reached the primary endpoint at 30 months compared with those who did not have angiography, according to Kaplan-Meier analysis (281/3085 12·8% vs 480/4158 16·5%, adjusted hazard ratio HR 0·63, 95% CI 0·53–0·75; p<0·0001). The proportion of patients who reached the primary endpoint was lower in the prasugrel group than in the clopidogrel group for those who had angiography (122/1524 10·7% vs 159/1561 14·9%, HR 0·77, 95% CI 0·61–0·98; p=0·032) but did not differ between groups in patients who did not have angiography (242/2096 16·3% vs 238/2062 16·7%, HR 1·01, 0·84–1·20; p=0·94; pinteraction =0·08). Overall, TIMI major bleeding and GUSTO severe bleeding were rare. Bleeding outcomes tended to be higher with prasugrel but did not differ significantly between treatment groups in either angiography cohort. Interpretation Among patients who had angiography who took prasugrel there were fewer cardiovascular deaths, myocardial infarctions, or strokes than in those who took clopidogrel. This result needs to be corroborated, but it is consistent with previous trials of more versus less intensive antiplatelet treatment. When angiography is done for acute coronary syndrome and anatomic coronary disease confirmed, the benefits and risks of intensive antiplatelet treatment exist whether the patient is treated with drugs or percutaneous coronary intervention. Funding Daiichi Sankyo, Eli Lilly.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Abstract Background Left atrial (LA) fibrosis is known as the hallmark for arrhythmogenic substrate in atrial fibrillation (AF). Quantification of LA fibrosis by using delayed-enhanced magnetic ...resonance imaging (DE-MRI) in AF patients is a pioneering noninvasive technique. Vitamin D (vitD) negatively regulates the renin–angiotensin system, binds to vitD receptors on cardiac myocytes, and has antioxidant properties that may ameliorate the inflammation and proarrhythmic substrate formation. However, its role in LA fibrosis is unclear. We aimed to investigate the association of serum 25(OH)D level with the extent of LA fibrosis by using DE-MRI and also predictors for AF recurrence after cryoablation was assessed in patients with paroxysmal AF. Methods A total of 48 patients with lone paroxysmal AF (41.7% female; age: 48.5 ± 8.4 years) who underwent DE-MRI at 1.5 T and initial cryoballoon-based catheter ablation along with 48 healthy control subjects were enrolled. Fibrosis degree was categorized according to Utah class defined in the DECAAF study. Results Serum 25(OH)D levels were significantly lower in AF group compared to control group (25.8 ± 7.6 ng/ml vs. 31.0 ± 9.5 ng/ml, p = 0.004). Serum 25(OH)D levels were associated with moderate–severe LA fibrosis independent of other measures (OR: 0.72, 95% CI: 0.54–0.97, p = 0.028). At a mean 16.5 ± 2.6 months follow-up, late recurrence was observed in 10 (20.8%) patients. In multivariable Cox regression analysis, LA volume index (HR: 1.42, 95% CI: 1.01–2.01, p = 0.045) and the extent of LA fibrosis (HR: 1.14, 95% CI: 1.01–1.28, p = 0.034) were found as independently associated with late AF recurrence during follow-up. Conclusion Lower levels of serum 25(OH)D are significantly associated with more extensive LA fibrosis in patients with lone paroxysmal AF and may be implicated in the pathophysiology of AF recurrence after cryoablation. Further large-scale studies are needed to elucidate the exact role of vitD deficiency and replacement on LA fibrosis.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Guidance for device closure of ASD with three-dimensional transesophageal echocardiography (3DTEE) is the method of choice in experienced centers which provides size, shape, orientation, numbers of ...orifices and rim status in one single en face view.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
Approximately 1-5% of PVLs can lead to serious clinical consequences, including congestive heart failure and/or hemolytic anemia. Real-time three-dimensional transesophageal echocardiography (RT-3D ...TEE) has emerged as an efficient tool that provides essential information concerning leakage size, location, and shape as well as navigation of catheters and wires. Case 2 A...
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK
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