Abstract Objectives This study sought to examine whether imaging of the atrioventricular (AV) membranous septum (MS) by computed tomography (CT) can be used to identify patient-specific anatomic risk ...of high-degree AV block and permanent pacemaker (PPM) implantation before transcatheter aortic valve implantation (TAVI) with self-expandable valves. Background MS length represents an anatomic surrogate of the distance between the aortic annulus and the bundle of His and may therefore be inversely related to the risk of conduction system abnormalities after TAVI. Methods Seventy-three consecutive patients with severe aortic stenosis underwent contrast-enhanced CT before TAVI. The aortic annulus, aortic valve, and AV junction were assessed, and MS length was measured in the coronal view. Results In 13 patients (18%), high-degree AV block developed, and 21 patients (29%) received a PPM. Multivariable logistic regression analysis revealed MS length as the most powerful pre -procedural independent predictor of high-degree AV block (odds ratio OR: 1.35, 95% confidence interval CI: 1.1 to 1.7, p = 0.01) and PPM implantation (OR: 1.43, 95% CI: 1.1 to 1.8, p = 0.002). When taking into account pre- and post -procedural parameters, the difference between MS length and implantation depth emerged as the most powerful independent predictor of high-degree AV block (OR: 1.4, 95% CI: 1.2 to 1.7, p < 0.001), whereas the difference between MS length and implantation depth and calcification in the basal septum were the most powerful independent predictors of PPM implantation (OR: 1.39, 95% CI: 1.2 to 1.7, p < 0.001 and OR: 4.9, 95% CI: 1.2 to 20.5, p = 0.03; respectively). Conclusions Short MS, insufficient difference between MS length and implantation depth, and the presence of calcification in the basal septum, factors that may all facilitate mechanical compression of the conduction tissue by the implanted valve, predict conduction abnormalities after TAVI with self-expandable valves. CT assessment of membranous septal anatomy provides unique pre-procedural information about the patient-specific propensity for the risk of AV block.
Background Increased body mass index (BMI) and obesity are associated with increased risk of new-onset atrial fibrillation (AF) among middle-aged adults. Objectives The objective of the study is to ...investigate the association between BMI and the risk for new-onset AF among middle-aged adults. Methods We investigated 18,290 men and women who were annually screened in a tertiary medical center. Participants were divided at baseline into 3 groups: normal weight (BMI ≥18 and <25 kg/m2 , n = 7,692), overweight (BMI ≥25 and <30 kg/m2 , n = 8,032), and obese (BMI ≥30 kg/m2 , n = 2,566). The primary end point was new-onset AF during follow-up. Results Mean age of study population was 49 ± 11 years, and 73% were men. A total of 288 incident events (1.6%) occurred during 6 ± 4 years. Kaplan-Meier survival analysis showed that the cumulative probability of AF at 6 years was highest among obese participants, intermediate among overweight participants, and lowest among participants with normal weight (2.1%, 1.7%, and 0.8% respectively, P < .001). Multivariable Cox regression analysis showed that overweight and obesity were independently associated with increased AF risk (hazard ratio 1.54 P = .004 and 2.41 P < .001, respectively). Assessment of BMI change as a time-dependent covariate in the multivariable model showed that each 1 kg/m2 reduction in BMI during follow-up was associated with a significant 7% reduction in the risk for the occurrence of a first AF event (hazard ratio 0.93, 95% CI 0.88-0.99, P = .019). Consistently, similar analysis showed that each 5-kg weight loss during follow-up was independently associated with a significant 12% reduced risk of new-onset AF (95% CI 0.81-0.98, P = .02). Conclusions Our findings suggest that overweight and obesity are associated with increased AF risk, whereas weight reduction is independently associated with reduced risk of de novo AF.
Heart rate variability (HRV) has been shown to be attenuated in patients with coronary artery disease (CAD) and may, therefore, be possibly used for the early detection of myocardial ischemia. We ...aimed to evaluate the diagnostic yield of a novel short-term HRV algorithm for the detection of myocardial ischemia in subjects without known CAD. We prospectively enrolled 450 subjects without known CAD who were referred to tertiary medical centers for exercise stress testing (EST) with single-photon emission computed tomography myocardial perfusion imaging (MPI). All subjects underwent 1-hour Holter testing with subsequent HRV analysis before EST with MPI. The diagnostic yield of HRV analysis was compared with EST, using MPI as the gold standard for the noninvasive detection of myocardial ischemia. All subjects had intermediate pretest probability for CAD. Mean age was 62 years, 38% were women, 51% had hypertension, and 25% diabetes mellitus. HRV analysis showed superior sensitivity (77%) compared with standard EST (27%). After multivariate adjustment, HRV was independently associated with an 8.4-fold (p <0.001) increased likelihood for the detection of myocardial ischemia by MPI, whereas EST did not show a statistically significant association with a positive MPI (odds ratio 2.1; p = 0.12). Of subjects who were referred for subsequent coronary angiography, the respective sensitivities of HRV and EST for the detection of significant CAD were 73% versus 26%. Our data suggest that HRV can be used as an important noninvasive technique for the detection of myocardial ischemia in subjects without known CAD, providing superior sensitivity to conventional EST in this population.
Background We aimed to evaluate whether reduced cardiovascular fitness has a direct or indirect effect for the development of cardiovascular disease. Methods We investigated 15,595 men and women who ...were annually screened in a tertiary medical center. All subjects were free of ischemic heart disease and had completed maximal exercise stress test according to the Bruce protocol at their first visit. Fitness was categorized into age- and sex-specific quintiles (Q) according to Bruce protocol treadmill time with Q1 as lowest fitness. Subjects were categorized at baseline into 3 groups: low fitness (Q1), moderate fitness (Q2-Q4), and high fitness (Q5). The primary end point of the current analysis was the development of a first cardiovascular event during follow-up. Results Mean age of study patients was 48 ± 10 years, and 73% were men. A total of 679 events occurred during 92,092 person-years of follow-up. Kaplan-Meier survival analysis showed that the cumulative probability of cardiovascular events at 6 years was significantly higher among subjects with low fitness ( P < .001). Low fitness was associated with known cardiovascular risk factors, including hypercholesterolemia (odds ratio OR 1.58, 95% CI 1.31-1.89), diabetes mellitus (OR 2.32, 95% CI 1.58-3.41), and obesity (OR 10.46, 95% CI 8.43-12.98). The effect of low fitness on cardiovascular events was no longer significant when including diabetes mellitus, hypercholesterolemia, and obesity as mediators (hazard ratio 0.99, 95% CI 0.82-1.19). Conclusions The association between cardiovascular fitness and adverse cardiovascular outcomes may be modulated through traditional cardiovascular risk factors. These findings need to be further validated in prospective clinical trials.
Triggers and Timing of Acute Coronary Syndromes Tofler, Geoffrey H., MD; Kopel, Eran, MD; Klempfner, Robert, MD ...
The American journal of cardiology,
05/2017, Letnik:
119, Številka:
10
Journal Article
Recenzirano
Abstract Prior studies have shown that an acute coronary syndrome (ACS) may be triggered by external activities, however their frequency, predictors and significance are uncertain. We evaluated data ...from The National Israel Survey of Acute Coronary Syndromes, which was conducted in 2004 (February-March) in all 25 coronary care units and cardiac wards in Israel. Demographic and clinical data were recorded for consecutive participants, including potential triggers and time of symptom onset of ACS. Among the 1849 patients who completed the trigger question, one quarter (25.9%) reported a possible trigger, comprising heavy physical exertion (15.2%), emotional stress (8.3%), anger (1.1%), heavy meal (1.3%) and sexual activity (0.5%). Predictors of a triggered ACS were age <65 years, prior angina, no prior ACE / AT2 inhibitors, impaired functional class, not having typical chest pain on admission, and a final diagnosis of unstable angina. The highest proportion of triggered ACS was between noon- 6pm. Physical exertion as a trigger was associated with reduced in-hospital mortality (0.4 versus 2.8%, p <0.05) and 1-year mortality. Emotional stress as a trigger did not influence in-hospital or 1-year mortality, however among those discharged from hospital, it was associated with increased 30-day rehospitalisation (27.6 versus 19.3%, p <0.05) and a trend towards increased mortality (4.1 versus 2.0%, p=0.10).
Men tend to develop cardiovascular disease (CVD) earlier in life than women. Whether this difference is attributable only to gender is a matter of debate. The purpose of this study was to evaluate ...gender differences in cardiovascular risk in a large cohort of asymptomatic men and women and explore gender-related risk in prespecified risk factor subgroups. We investigated 14,966 asymptomatic men and women free of diabetes, hypertension, or ischemic heart disease who were annually screened. The primary end point of the present study was the occurrence of ischemic or cerebrovascular disease as composite end point. Multivariate Cox proportional hazards regression modeling was used to assess the gender difference regarding CVD and to examine the association between CVD risk factors and gender. Mean age of the study population was 47 ± 10 years and 30% were women. Kaplan–Meier survival analysis showed that at 6.2 ± 3.9 years' follow-up, the rate of CVD events was 6.1% among men compared with 1.8% among women (log-rank p <0.001). Consistently, multivariate analysis demonstrated that male gender was independently associated with a significant threefold increased risk for development of CVD events (hazard ratio 3.05, CI 2.25 to 4.14). The CVD risk associated with male gender was consistent in each risk subset analyzed, including older age, low high-density lipoprotein, impaired fasting glucose, and positive family history for ischemic heart disease (all p values for gender-by-risk factor interactions <0.05). Higher performance on treadmill test had a protective effect regarding CVD development in both men and women. In conclusions, healthy middle-aged men experienced increased risk for the development of CVD events compared with women independently of traditional CVD risk factors. However, better exercise capacity is associated with a protective effect.
Abstract Background Coronary CT has become the foremost noninvasive imaging modality for detecting coronary stenoses in patients with suspected coronary artery disease. Nevertheless, little is known ...about its performance in patients undergoing transcatheter aortic valve replacement (TAVR). Objective This study investigates the diagnostic performance of coronary CT angiography in patients referred for TAVR. Methods One hundred and fifteen consecutive patients with severe aortic stenosis underwent CT angiography with retrospective electrocardiography triggered acquisition and an iterative reconstruction algorithm, of whom 23 (20%) had prior coronary artery bypass graft (CABG) surgery. Diagnostic accuracy of CT for detecting significant coronary stenosis (≥50% luminal diameter stenosis in segments ≥2 mm) in the left main, proximal, or middle segments of coronary arteries and bypass grafts was compared with that of invasive coronary angiography. Results In the overall study population, the sensitivity, specificity, and positive and negative predictive value of CT angiography for the detection of coronary segment or bypass graft lesions were 96% (47 of 49), 73% (48 of 66), 72% (47 of 65), and 96% (48 of 50), respectively. The per-patient diagnostic yield of CT angiography was consistent among patients without prior CABG (93% 28 of 30, 73% 45 of 62, 62% 28 of 45, and 96% 45 of 47, respectively) and among patients with prior CABG (100% 19 of 19, 75% 3 of 4, 95% 19 of 20, and 100% 3 of 3, respectively). Conclusion Among patients referred for TAVR, coronary CT angiography with retrospective gating and iterative reconstruction may allow detection of significant stenosis in the proximal or middle segments of coronary arteries and could permit the evaluation of patients after bypass grafts.
Because of its safety profile, cryoablation has become an alternative therapy for septal arrhythmias, including parahisian accessory pathways (APs). Data regarding its efficacy, safety, and late ...outcome for parahisian APs in children are limited.
The purpose of this study was to evaluate the safety and efficacy of cryoablation of parahisian APs in children.
Fifty-nine cryoablations of parahisian APs were performed in 50 patients 76% males; median age 16.5 years (range 5.3-20 years). Thirty-three had manifest APs and 17 had concealed APs. The time to effect was defined as the duration of time from reaching -30°C to the disappearance of AP during the cryomapping phase. The acute success rate for the first ablation was 94% (47/50).
Mean fluoroscopy time and number of cryoablations were 28.5 ± 23.3 minutes and 2.6 ± 1.2 seconds, respectively. The time to effect was 8.5 ± 7.1 seconds. The overall recurrence rate was 14.9%, decreasing from 40% in the first 10 cases to 8.1% in the next 37 (P <.02). Multivariate analysis showed that the only independent predictor for recurrence rate was time to effect <10 seconds (P <.001). A high recurrence rate was also associated with concealed APs and ablation during supraventricular tachycardia (P <.03 and P <.05, respectively). The patients who had recurrence underwent a second successful cryoablation. During median follow-up of 59.7 months (range 6-102 months), a long-term success rate of 94% was achieved. No permanent ablation-related complications occurred.
Cryoablation of parahisian APs has excellent short- and long-term efficacy and safety profile. Increased physician experience is associated with a reduced recurrence rate.
Background Heart failure with preserved ejection fraction (HFpEF) comprises a large portion of heart failure patients and portends poor prognosis with similar outcome to heart failure with reduced ...ejection fraction (HFrEF). Thus far, no medical therapy has been shown to improve clinical outcome in this common condition. Trial Design The study is a randomized-controlled, multicenter clinical trial aimed to determine whether early posthospitalization comprehensive cardiac rehabilitation (CR) including exercise training (ET) in recently hospitalized HFpEF patients reduces the composite end point of all-cause mortality and hospitalizations in comparison with usual care (UC). After undergoing baseline evaluation, patients are randomized to either UC or to ambulatory comprehensive CR program. Patients in the CR arm will participate in a 6-month biweekly ET program according to a predefined protocol, in addition to a complementary home exercise prescribed by a specialist in CR. Exercise training will include endurance and low-intensity resistance training. Patients in the UC arm will be followed up at the outpatient clinic, with management according to current heart failure guidelines. Physician follow-up visits will be conducted at 3, 6, and 12 months for assessment of adherence to therapy and ET, functional status, quality of life, and clinical events. Secondary end points will include quality-of-life questionnaire, economic end points, blood pressure, and hemoglobin A1 C levels. Conclusions Cardiac rehabilitation and ET are relatively inexpensive and accessible and can be beneficial in HFpEF patients. Our trial is designed to evaluate the impact of early posthospitalization comprehensive rehabilitation program on clinical end points of mortality, hospitalization, and quality of life in HFpEF patients.
Abstract Background Transcatheter aortic valve implantation (TAVI) has become the treatment of choice for the symptomatic patients with aortic stenosis (AS) and high surgical risk. Pulmonary ...hypertension (PHTN) has been shown to be associated with worse early and late outcomes after aortic valve surgery. Data regarding the effect of TAVI on PHTN are limited. Methods and results We evaluated the characteristics and outcome of the patients with various degrees of systolic PHTN referred for TAVI. PHTN was defined as systolic pulmonary arterial pressure (SPAP) ≥50 mmHg as assessed by echocardiography. The patients with SPAP decrease after TAVI to below 50 mmHg were compared to the patients with persistent PHTN following TAVI. Of the 122 patients included in the present study, 49 (40%) patients had elevated SPAP prior to TAVI. This group of patients presented with smaller aortic valve areas, greater degrees of mitral or tricuspid regurgitation, lower left ventricular ejection fraction, and more prevalent chronic obstructive pulmonary disease (COPD) (all p < 0.05). Following TAVI, 57% of the patients with prior PHTN experienced a reduction in SPAP to below 50 mmHg. Multivariable analysis identified COPD to be the most powerful predictor for PHTN presence post-TAVI (hazard ratio 3.9, 95% confidence interval 1.5–9.9, p = 0.005). Post-TAVI PHTN (SPAP ≥50 mmHg) was associated with a 3.4-fold, independent, 2-year mortality risk ( p = 0.04). Conclusions Our data suggest that TAVI is associated with a significant reduction in pulmonary pressure in more than half of the patients with preprocedural PHTN. COPD identifies the patients with persistent PHTN after TAVI. Post-TAVI PHTN is associated with markedly worse outcome.
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