Background Occupational doses from fluoroscopy-guided interventional procedures are the highest ones registered among medical staff using x-rays. The aim of the present study was to evaluate the ...order of magnitude of cancer risk caused by professional radiation exposure in modern invasive cardiology practice. Methods From the dosimetric Tuscany Health Physics data bank of 2006, we selected dosimetric data of the 26 (7 women, 19 men; age 46 ± 9 years) workers of the cardiovascular catheterization laboratory with effective dose >2 mSv. Effective dose (E) was expressed in milliSievert, calculated from personal dose equivalent registered by the thermoluminescent dosimeter, at waist or chest, under the apron, according to the recommendations of National Council of Radiation Protection. Lifetime attributable risk of cancer was estimated using the approach of Biological Effects of Ionizing Radiation 2006 report VII. Results Cardiac catheterization laboratory staff represented 67% of the 6 workers with yearly exposure >6 mSv. Of the 26 workers with 2006 exposure >2 mSv, 15 of them had complete records of at least 10 (up to 25) consecutive years. For these 15 subjects having a more complete lifetime dosimetric history, the median individual effective dose was 46 mSv (interquartile range = 24-64). The median risk of (fatal and nonfatal) cancer (Biological Effects of Ionizing Radiation 2006) was 1 in 192 (interquartile range = 1 in 137-1 in 370). Conclusions Cumulative professional radiological exposure is associated with a non-negligible Lifetime attributable risk of cancer for the most exposed contemporary cardiac catheterization laboratory staff.
Transthyretin cardiac amyloidosis (ATTR-CA) is a progressive and ultimately fatal cardiomyopathy. Biomarkers reflecting multiorgan dysfunction are of increasing importance in patients with heart ...failure; however, their significance in ATTR-CA remains largely unknown. The aims of this study were to characterize the multifaceted nature of ATTR-CA using blood biomarkers and assess the association between blood biomarkers and prognosis.
This is a retrospective cohort study of 2566 consecutive patients diagnosed with ATTR-CA between 2007 and 2023. Anemia (39%), high urea (52%), hyperbilirubinemia (18%), increased alkaline phosphatase (16%), increased CRP (C-reactive protein; 27%), and increased troponin (98.2%) were common findings in the overall population, whereas hyponatremia (6%) and hypoalbuminemia (2%) were less common. These abnormalities were most common in patients with p.(V142I) hereditary ATTR-CA, and became more prevalent as the severity of cardiac disease increased. Multivariable Cox regression analysis demonstrated that anemia (hazard ratio HR, 1.19 95% CI, 1.04-1.37;
=0.01), high urea (HR, 1.23 95% CI, 1.04-1.45;
=0.01), hyperbilirubinemia (HR, 1.32 95% CI, 1.13-1.57;
=0.001), increased alkaline phosphatase (HR, 1.20 95% CI, 1.01-1.42;
=0.04), hyponatremia (HR, 1.65 95% CI, 1.28-2.11;
<0.001), and troponin-T >56 ng/L (HR, 1.72 95% CI, 1.46-2.03;
<0.001) were all independently associated with mortality in the overall population. The association between biomarkers and mortality varied across the spectrum of genotypes and left ventricular ejection fraction, with anemia remining independently associated with mortality in p.(V142I) hereditary ATTR-CA (HR, 1.58 95% CI, 1.17-2.12;
=0.003) and in a subgroup of the overall population with a left ventricular ejection fraction ≤40% (HR, 1.39 95% CI, 1.08-1.81;
=0.01).
Cardiac and noncardiac biomarker abnormalities were common and reflect the complex and multifaceted nature of ATTR-CA, with a wide range of biomarkers remaining independently associated with mortality. Clinical trials are needed to investigate whether biomarker abnormalities represent modifiable risk factors that if specifically targeted could improve outcomes.
Aims
Ultrasound contrast agents may be used for the assessment of regional wall motion and myocardial perfusion, but are generally considered not suitable for deformation analysis. The aim of our ...study was to assess the feasibility of deformation imaging on contrast‐enhanced images using a novel methodology.
Methods and Results
We prospectively enrolled 40 patients who underwent stress echocardiography with continuous intravenous infusion of SonoVue for the assessment of myocardial perfusion imaging with flash replenishment technique. We compared longitudinal strain (Lε) values, assessed with a vendor‐independent software (2D CPA), on 68 resting contrast‐enhanced and 68 resting noncontrast recordings. Strain analysis on contrast recordings was evaluated in the first cardiac cycles after the flash. Tracking of contrast images was deemed feasible in all subjects and in all views. Contrast administration improved image quality and increased the number of segments used for deformation analysis. Lε of noncontrast and contrast‐enhanced images were statistically different (−18.8 ± 4.5% and −22.8 ± 5.4%, respectively; P < 0.001), but their correlation was good (ICC 0.65, 95%CI 0.42–0.78). Patients with resting wall‐motion abnormalities showed lower Lε values on contrast recordings (−18.6 ± 6.0% vs. −24.2 ± 5.5%, respectively; P < 0.01). Intra‐operator and inter‐operator reproducibility was good for both noncontrast and contrast images with no statistical differences.
Conclusions
Our study shows that deformation analysis on postflash contrast‐enhanced images is feasible and reproducible. Therefore, it would be possible to perform a simultaneous evaluation of wall‐motion abnormalities, volumes, ejection fraction, perfusion defects, and cardiac deformation on the same contrast recording.
Transthyretin cardiac amyloidosis (ATTR-CM) is a progressive and fatal cardiomyopathy. Treatment options in patients with advanced ATTR-CM are limited to cardiac transplantation (CT). Despite case ...series demonstrating comparable outcomes with CT between patients with ATTR-CM and non-amyloid cardiomyopathies, ATTR-CM is considered to be a contraindication to CT in some centers, partly due to a perceived risk of amyloid recurrence in the allograft. We report long-term outcomes of CT in ATTR-CM at two tertiary centers.
We retrospectively evaluated ATTR-CM patients across two tertiary centers who underwent transplantation between 1990 and 2020. Pre-transplantation characteristics were determined and outcomes were compared with a cohort of non-transplanted ATTR-CM patients. Fourteen (12 male, 2 female) patients with ATTR-CM underwent CT including 11 with wild-type ATTR-CM and 3 with variant ATTR-CM (ATTRv). Median age at CT was 62 years and median follow up post-CT was 66 months. One, three, and five-year survival was 100, 92, and 90%, respectively and the longest surviving patient was Censored > 19 years post CT. No patients had recurrence of amyloid in the cardiac allograft. Four patients died, including one with ATTRv-CM from complications of leptomeningeal amyloidosis. Survival among the cohort of patients who underwent CT was significantly prolonged compared to UK patients with ATTR-CM generally (
< 0.001) including those diagnosed under age 65 years (
= 0.008) or with early stage cardiomyopathy (
< 0.001).
CT is well-tolerated, restores functional capacity and improves prognosis in ATTR-CM. The risk of amyloid recurrence in the cardiac allograft appears to be low.
Aortic valve stenosis (AVS), including a range of disorder severities, from mild leaflet thickening without valve obstruction, 'aortic sclerosis', to severe calcific aortic stenosis, is a ...progressive, active process of valve modification, mediating by chronic inflammation (similar to atherosclerosis for cardiovascular risk factors) and biological features. AVS is the expression of early tissue damage due to endothelial damage and oxidative, inflammatory processes, and appears as a surrogate marker for cardiovascular events associated with coronary artery disease (CAD). AVS progression correlates with coronary artery risk factors, such as hypertension, age and cholesterol, and a quantitative evaluation of valve and coronary calcium score comprises a useful marker for cardiovascular prognosis. The low concordance of AVS with CAD appears to be due to other genetic or metabolic factors more specific for calcification processes. Moreover, both pathologies appear to be included within atherosclerotic disease and may be the object of the same clinical therapy and prevention.
A cutaneous force-frequency relation recording system based on first heart sound amplitude vibrations has been recently validated. Second heart sound can be simultaneously recorded in order to ...quantify both systole and diastole duration.
1- To assess the feasibility and extra-value of operator-independent, force sensor-based, diastolic time recording during stress.
We enrolled 161 patients referred for stress echocardiography (exercise 115, dipyridamole 40, pacing 6 patients).The sensor was fastened in the precordial region by a standard ECG electrode. The acceleration signal was converted into digital and recorded together with ECG signal. Both systolic and diastolic times were acquired continuously during stress and were displayed by plotting times vs. heart rate. Diastolic filling rate was calculated as echo-measured mitral filling volume/sensor-monitored diastolic time.
Diastolic time decreased during stress more markedly than systolic time. At peak stress 62 of the 161 pts showed reversal of the systolic/diastolic ratio with the duration of systole longer than diastole. In the exercise group, at 100 bpm HR, systolic/diastolic time ratio was lower in the 17 controls (0.74 +/- 0.12) than in patients (0.86 +/- 0.10, p < 0.05 vs. controls). Diastolic filling rate increased from 101 +/- 36 (rest) to 219 +/- 92 ml/m2* s-1 at peak stress (p < 0.5 vs. rest).
Cardiological systolic and diastolic duration can be monitored during stress by using an acceleration force sensor. Simultaneous calculation of stroke volume allows monitoring diastolic filling rate.Stress-induced "systolic-diastolic mismatch" can be easily quantified and is associated to several cardiac diseases, possibly expanding the spectrum of information obtainable during stress.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Patients with dilated cardiomyopathy whose symptoms and cardiac function have recovered often ask whether their medications can be stopped. The safety of withdrawing treatment in this situation is ...unknown.
We did an open-label, pilot, randomised trial to examine the effect of phased withdrawal of heart failure medications in patients with previous dilated cardiomyopathy who were now asymptomatic, whose left ventricular ejection fraction (LVEF) had improved from less than 40% to 50% or greater, whose left ventricular end-diastolic volume (LVEDV) had normalised, and who had an N-terminal pro-B-type natriuretic peptide (NT-pro-BNP) concentration less than 250 ng/L. Patients were recruited from a network of hospitals in the UK, assessed at one centre (Royal Brompton and Harefield NHS Foundation Trust, London, UK), and randomly assigned (1:1) to phased withdrawal or continuation of treatment. After 6 months, patients in the continued treatment group had treatment withdrawn by the same method. The primary endpoint was a relapse of dilated cardiomyopathy within 6 months, defined by a reduction in LVEF of more than 10% and to less than 50%, an increase in LVEDV by more than 10% and to higher than the normal range, a two-fold rise in NT-pro-BNP concentration and to more than 400 ng/L, or clinical evidence of heart failure, at which point treatments were re-established. The primary analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02859311.
Between April 21, 2016, and Aug 22, 2017, 51 patients were enrolled. 25 were randomly assigned to the treatment withdrawal group and 26 to continue treatment. Over the first 6 months, 11 (44%) patients randomly assigned to treatment withdrawal met the primary endpoint of relapse compared with none of those assigned to continue treatment (Kaplan-Meier estimate of event rate 45·7% 95% CI 28·5–67·2; p=0·0001). After 6 months, 25 (96%) of 26 patients assigned initially to continue treatment attempted its withdrawal. During the following 6 months, nine patients met the primary endpoint of relapse (Kaplan-Meier estimate of event rate 36·0% 95% CI 20·6–57·8). No deaths were reported in either group and three serious adverse events were reported in the treatment withdrawal group: hospital admissions for non-cardiac chest pain, sepsis, and an elective procedure.
Many patients deemed to have recovered from dilated cardiomyopathy will relapse following treatment withdrawal. Until robust predictors of relapse are defined, treatment should continue indefinitely.
British Heart Foundation, Alexander Jansons Foundation, Royal Brompton Hospital and Imperial College London, Imperial College Biomedical Research Centre, Wellcome Trust, and Rosetrees Trust.
Diagnostic and therapeutic advances have led to much greater awareness of transthyretin cardiac amyloidosis (ATTR-CA). We aimed to characterize changes in the clinical phenotype of patients diagnosed ...with ATTR-CA over the past 20 years.
This is a retrospective observational cohort study of all patients referred to the National Amyloidosis Centre (2002-2021) in whom ATTR-CA was a differential diagnosis.
We identified 2995 patients referred with suspected ATTR-CA, of whom 1967 had a diagnosis of ATTR-CA confirmed. Analysis by 5-year periods revealed an incremental increase in referrals, with higher proportions of patients having been referred after bone scintigraphy and cardiac magnetic resonance imaging (2% versus 34% versus 51% versus 55%, chi-square
<0.001). This was accompanied by a greater number of ATTR-CA diagnoses, predominantly of the wild-type nonhereditary form, which is now the most commonly diagnosed form of ATTR-CA (0% versus 54% versus 67% versus 66%, chi-square
<0.001). Over time, the median duration of associated symptoms before diagnosis fell from 36 months between 2002 and 2006 to 12 months between 2017 and 2021 (Mann-Whitney
<0.001), and a greater proportion of patients had early-stage disease at diagnosis across the 5-year periods (National Amyloidosis Centre stage 1: 34% versus 42% versus 44% versus 53%, chi-square
<0.001). This was associated with more favorable echocardiographic parameters of structure and function, including lesser interventricular septal thickness (18.0±3.8 mm versus 17.2±2.6 mm versus 16.9±2.3 mm versus 16.6±2.4 mm,
=0.01) and higher left ventricular ejection fraction (46.0%±8.9% versus 46.8%±11.0% versus 47.8%±11.0% versus 49.5%±11.1%,
<0.001). Mortality decreased progressively during the study period (2007-2011 versus 2012-2016: hazard ratio, 1.57 95% CI, 1.31-1.89,
<0.001; and 2012-2016 versus 2017-2021: hazard ratio, 1.89 95% CI, 1.55-2.30,
<0.001). The proportion of patients enrolled into clinical trials and prescribed disease-modifying therapy increased over the 20-year period, but even when censoring at the trial or medication start date, year of diagnosis remained a significant predictor of mortality (2012-2016 versus 2017-2021: hazard ratio, 1.05 95% CI, 1.03-1.07,
<0.001).
There has been a substantial increase in ATTR-CA diagnoses, with more patients being referred after local advanced cardiac imaging. Patients are now more often diagnosed at an earlier stage of the disease, with substantially lower mortality. These changes may have important implications for initiation and outcome of therapy and urgently need to be factored into clinical trial design.
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