This study was conducted to evaluate compliance with guideline-directed optimal medical therapy (OMT) and its association with early implantable cardioverter-defibrillator (ICD) activation in ...patients with heart failure and reduced ejection fraction (HFrEF).BackgroundThis study was conducted to evaluate compliance with guideline-directed optimal medical therapy (OMT) and its association with early implantable cardioverter-defibrillator (ICD) activation in patients with heart failure and reduced ejection fraction (HFrEF).Retrospective data from 307 patients who underwent ICD implantation for primary prevention from 2011 to 2017 were collected and analyzed.MethodsRetrospective data from 307 patients who underwent ICD implantation for primary prevention from 2011 to 2017 were collected and analyzed.Among the study participants, only 23.8% received the maximum tolerated dose of OMT prior to ICD implantation, with 59.0% receiving all three OMT medication groups. No significant difference in OMT compliance was found between patients with ischemic cardiomyopathy (ICM) and those with non-ischemic dilated cardiomyopathy (DCM). However, DCM patients received ICDs more frequently at the time of diagnosis than ICM patients (13.8% vs. 0.7%). Early ICD activation (within 3 months) occurred in only one patient who had not received appropriate OMT, representing 0.7% of all ICM patients. Furthermore, early activation was also infrequent in patients who received OMT (2.9% of ICM patients and 2.6% of DCM patients). Echocardiography follow-up data revealed that 20.4% of ICM patients and 29.8% of DCM patients who did not receive OMT before ICD implantation showed improvement in the left ventricular ejection fraction (EF) to 35% or more.ResultsAmong the study participants, only 23.8% received the maximum tolerated dose of OMT prior to ICD implantation, with 59.0% receiving all three OMT medication groups. No significant difference in OMT compliance was found between patients with ischemic cardiomyopathy (ICM) and those with non-ischemic dilated cardiomyopathy (DCM). However, DCM patients received ICDs more frequently at the time of diagnosis than ICM patients (13.8% vs. 0.7%). Early ICD activation (within 3 months) occurred in only one patient who had not received appropriate OMT, representing 0.7% of all ICM patients. Furthermore, early activation was also infrequent in patients who received OMT (2.9% of ICM patients and 2.6% of DCM patients). Echocardiography follow-up data revealed that 20.4% of ICM patients and 29.8% of DCM patients who did not receive OMT before ICD implantation showed improvement in the left ventricular ejection fraction (EF) to 35% or more.This study found suboptimal compliance with OMT prior to ICD implantation in HFrEF patients. The results showed that early ICD activation was rare in all patient groups, especially those who did not receive the prescribed 3 months of OMT. More research is needed to investigate longer waiting periods for the evaluation of potential EF improvement, and to better evaluate the eligibility of HFrEF patients for ICD. The current findings have potential implications for clinical practice and patient outcomes.ConclusionsThis study found suboptimal compliance with OMT prior to ICD implantation in HFrEF patients. The results showed that early ICD activation was rare in all patient groups, especially those who did not receive the prescribed 3 months of OMT. More research is needed to investigate longer waiting periods for the evaluation of potential EF improvement, and to better evaluate the eligibility of HFrEF patients for ICD. The current findings have potential implications for clinical practice and patient outcomes.
Observational studies have indicated potential benefits of CYP2C9- and VKORC1-guided dosing of warfarin but randomized clinical trials have resulted in contradictory findings. One of the reasons for ...contradiction may be the negligence of possible differences between warfarin indications. This study aims to determine efficacy and safety of genotype-guided and clinically guided dosing of warfarin in atrial fibrillation (AF), deep-vein thrombosis (DVT), and pulmonary embolism (PE) within the first 5 days after the introduction of therapy.
In this single-center, single-blinded, randomized, controlled trial including patients of both sexes, ≥18 years of age, and diagnosed with AF, DVT, or PE, a total of 205 consecutive patients were allocated into the group where warfarin therapy was genotype-guided pharmacogenetics guided (PHG), and where it was adjusted according to the clinical parameters non pharmacogenetics guided (NPHG). Genotyping of CYP2C9*2, *3, and VKORC1 was performed using the real-time polymerase chain reaction method. The primary outcomes were the percentage of time in the therapeutic international normalized ratio (INR) (2.0-3.0) range and the percentage of patients who achieved a stable anticoagulation defined as the INR (2.0-3.0) range in at least 2 consecutive measurements.
In patients with AF, the percentage of time spent in the therapeutic range of INR was higher in the PHG group mean = 26% (SD 25.0) than in the NPHG group mean = 14% (SD 18.6), Δ = 12; 95% confidence interval, 0-23; P = 0.040. There was no significant difference in other 2 indications for warfarin treatment. A stable dose of warfarin was achieved in a statistically higher number of patients in the PHG group 14/30 (47%) than in the NPHG group 7/32 (22%) (odds ratio = 3.13, 95% confidence interval, 0.92-10.98; P = 0.039).
CYP2C9 and VKORC1 genotype-guided dosing of warfarin may be beneficial in patients diagnosed with AF. There is no evidence for such conclusion in patients with DVT and PE.
Hyperuricemia is a well-known cardiovascular risk factor. The aim of our study was to investigate the connection between postoperative hyperuricemia and poor outcomes after elective cardiac surgery ...compared to patients without postoperative hyperuricemia. In this retrospective study, a total of 227 patients after elective cardiac surgery were divided into two groups: 42 patients with postoperative hyperuricemia (mean age 65.14 ± 8.9 years) and a second group of 185 patients without it (mean age 62.67 ± 7.45 years). The time spent on mechanical ventilation (hours) and in the intensive care unit (days) were taken as the primary outcome measures while the secondary measure comprised postoperative complications. The preoperative patient characteristics were similar. Most of the patients were men. The EuroSCORE value of assessing the risk was not different between the groups nor the comorbidities. Among the most common comorbidities was hypertension, seen in 66% of all patients (69% in patients with postoperative hyperuricemia and 63.7% in those without it). A group of patients with postoperative hyperuricemia had a prolonged time of treatment in the intensive care unit (
= 0.03), as well as a prolonged duration of mechanical ventilation (
< 0.01) and a significantly higher incidence of the following postoperative complications: circulatory instability and/or low cardiac output syndrome (LCOS) (χ2 = 4486,
< 0.01), renal failure and/or continuous venovenous hemodiafiltration (CVVHDF's) (χ2 = 10,241,
< 0.001), and mortality (χ2 = 5.22,
< 0.01). Compared to patients without postoperative hyperuricemia, elective cardiac patients with postoperative hyperuricemia have prolonged postoperative treatment in intensive care units, extended durations of mechanically assisted ventilation, and a higher incidence of postoperative circulatory instability, renal failure, and death.
Background
Trastuzumab and trastuzumab emtansine are specific antibody and antibody–drug conjugates used in the treatment of human epidermal growth factor receptor 2 (HER2) positive metastatic breast ...cancer. The aim of this study was to test their effect on the QTc interval duration and left ventricular ejection fraction (LVEF) in our patients, two parameters used in evaluation of cardiotoxicity. From May 2015 to October 2017, 26 patients with preserved LVEF were included in the study. All of them were previously treated with standard paclitaxel and cisplatin-based chemotherapy regimens. Electrocardiogram (ECG) was recorded just before each trastuzumab dose application and six months after the last dose. Echocardiography with LVEF measurement was performed several days before the application of the initial dose, and six months after the last cycle. Later, 24 patients with metastatic disease received additional treatment with trastuzumab emtansine after six months and the same ECG and echocardiography protocol was performed again. Due to reduction in LVEF, two patients were discontinued from additional treatment.
Results
A statistically significant QTc prolongation was found after each drug dose application, with an increase in mean QTc duration with every successive application, reaching the peak QTc values just before the fifth cycle of treatment. The QTc interval returned to its initial value six months after the last cycle (
p
< 0.001). These results were similar for both drugs. Mean LVEF before both treatment protocols was significantly higher compared to LVEF value after the treatment. LVEF before trastuzumab emtansine treatment was non-significantly higher than LVEF after trastuzumab treatment.
Conclusion
Trastuzumab and trastuzumab emtansine cardiotoxicity manifested as a significant and progressive QTc prolongation after successive drug applications, reaching the peak value just before the fifth cycle of both drugs. Both medications also caused statistically significant but asymptomatic LVEF reduction. Complete reversibility of cardiotoxic effects of both drugs was confirmed by QTc interval and LVEF normalisation after the treatment discontinuation.
Background: Diabetes is the primary contributor to cardiovascular disease risk, and when combined with obesity, it further underscores the significance of cardiovascular risk assessment. Methods: A ...retrospective study of 64 patients with type 2 diabetes (T2D) and obesity on once-weekly subcutaneous semaglutide stratified by cardiovascular risk categories determined using the SCORE2/SCORE2-OP, SCORE2-Diabetes, and ASCVD score calculations. We compare the differences between groups (ASCVD: low + borderline + intermediate versus high-risk group; SCORE2/SCORE2-OP: low + moderate versus high + very high-risk group and SCORE2-Diabetes: low + moderate versus high + very high-risk group) in terms of change from baseline in body mass index (BMI) and HbA1c and weight loss outcomes. Results: Patients in the high-risk group, according to ASCVD risk score, had statistically better results in weight loss ≥ 3%, ≥5%, and ≥10% compared to ASCVD low + borderline + intermediate and without difference regarding HbA1c. According to SCORE2/SCORE2-OP, the high + very high-risk group had statistically better HbA1c and weight loss results but only for ≥5% versus the low + moderate risk group. Based on the score SCORE2-Diabetes, the high + very high-risk group had statistically significant better results in lowering HbA1c and weight loss but only for ≥5% versus the low + moderate risk group. Conclusions: To the best of our knowledge, this study represents the initial investigation linking glycemic control and weight reduction outcomes in individuals with T2D and obesity treated with once-weekly semaglutide stratified by cardiovascular risk categories determined using the SCORE2/SCORE2-OP, SCORE2-Diabetes and ASCVD score calculations.
A recently discovered haplotype-
-determines the ultrarapid metabolism of several CYP2C19 substrates. The platelet inhibitor clopidogrel requires CYP2C19-mediated activation: the risk of ischemic ...events is increased in patients with a poor (PM) or intermediate (IM) CYP2C19 metabolizer phenotype (vs. normal, NM; rapid, RM; or ultrarapid, UM). We investigated whether the
haplotype affected efficacy/bleeding risk in clopidogrel-treated patients. Adults (
= 283) treated with clopidogrel over 3-6 months were classified by CYP2C19 phenotype based on the
genotype, and based on the
cluster genotype, and regarding carriage of the
haplotype, and were balanced on a number of covariates across the levels of phenotypes/haplotype carriage. Overall, 45 (15.9%) patients experienced ischemic events, and 49 (17.3%) experienced bleedings. By either classification, the incidence of ischemic events was similarly numerically higher in PM/IM patients (21.6%, 21.8%, respectively) than in mutually similar NM, RM, and UM patients (13.2-14.8%), whereas the incidence of bleeding events was numerically lower (13.1% vs. 16.6-20.5%). The incidence of ischemic events was similar in
carries and non-carries (14.1% vs. 16.1%), whereas the incidence of bleedings appeared mildly lower in the former (14.9% vs. 20.1%). We observed no signal to suggest a major effect of the
cluster genotype or
haplotype on the clinical efficacy/safety of clopidogrel.
The objective of this study was to determine the long-term efficacy and dynamics of systolic and diastolic luminal changes within the bridged segments of coronary arteries after intracoronary ...stenting with drug-eluting stent (DES) in patients (pts) with symptomatic myocardial bridging (SMB) in the absence of coronary atherosclerosis.
Although myocardial bridging (MB) represents a benign disease in the majority of pts, in its severest forms it is clinically manifested as typical or atypical angina, myocardial ischemia, myocardial infarction, left ventricular dysfunction, atrioventricular conduction disturbance, exercise-induced ventricular tachycardia, or sudden death. The only existing prospective study of 11 pts with SMB treated with bare-metal stent (BMS) reported a 36% in-stent restenosis (ISR) rate at 7 weeks repeated quantitative coronary angiography (QCA).
The study consisted of 15 consecutive patients (13 men and 2 women) with SMB of the mid-portion of the left anterior descending (LAD) coronary artery (and in 1 patient, concomitant MB of the left circumflex LCX coronary artery) and luminal diameter systolic narrowing of the tunneled segment of ≥50%, underwent percutaneous coronary intervention with DES. Clinical and non-invasive assessments of myocardial ischemia were determined every 6 months over 5 years and QCA was performed 12 and 24 months post procedure if not urged differently by deterioration of clinical symptoms and/or presence of positive ischemia tests. The minimal systolic and diastolic luminal diameters of the bridged/stented segments were measured before, immediately after, and 12 and 24 months post procedure by two independent observers blinded to each other's readings, using QCA commercial software. The endpoints of the study were ISR, target lesion revascularization (TLR) rate, in-stent diameter late luminal loss (LLL), and permanent disappearance or significant improvement of clinical symptoms.
After 12 months, ISR and TLR in 16 treated vessels was 18.7%, LLL was 0.2 ± 0.6 mm and permanent disappearance or significant improvement of symptoms was achieved in all 15 pts. In 3 pts, clinically-driven repeat revascularization was necessary within the first 6 months. In 1 patient, coronary perforation complicated stent deployment and was immediately resolved by stent-graft implantation, followed by completely uneventful recovery.
DES implantation in pts with SMB resistant to medical treatment results in prompt and long-term increase of systolic and diastolic luminal diameters, and long-lasting relief of clinical symptoms. Compared to BMS, stenting of SMB with DES resulted in significantly lower ISR and TLR rate.
U ovom pregledu obrađeni su osnovni epidemiološki podaci o atrijalnoj fibrilaciji (AF), najčešćoj aritmiji u populaciji, i o čimbenicima rizika od njezina nastanka. Navedeni su osnovni patofiziološki ...mehanizmi nastanka te klinički pristup bolesniku s AF-om. Opisani su osnovni lijekovi za liječenje AF-a te metoda odabira ili kontrole srčanog ritma ili srčane frekvencije. Također je objašnjena potreba za prevencijom tromboemboličkih incidenata te odabir prikladne terapije. Redovita, umjerena i pravilna prehrana jedan je od najvažnijih čimbenika na koji možemo utjecati kako bismo znatno smanjili rizik od nastanka bolesti srca i krvnih žila.
Our aim was to analyze characteristics of atrial fibrillation (AF) patients with chronic kidney disease (CKD) from the Croatian cohort of the ESH A Fib survey and to determine the association of ...estimated glomerular filtration rate (eGFR) with cardiovascular (CV) mortality after 24 months of follow-up.Consecutive sample of 301 patients with AF were enrolled in the period 2014 to 2018. Hypertension was defined as BP > 140/90 mm Hg and/or antihypertensive drugs treatment, CKD was defined as eGFR (CKD Epi) < 60 ml/min/1.73 m2 which was confirmed after 3 months.CKD was diagnosed in 45.2% of patients (13.3% in CKD stage > 3b). CKD patients were older than non-CKD and had significantly more frequent coronary heart disease, heart failure and valvular disease. CKD patients had significantly higher CHA2DS2-VASc score and more CKD than non-CKD patients had CHA2DS2-VASc > 2. Crude CV mortality rate per 1000 population at the end of the first year of the follow-up was significantly higher in CKD vs non-CKD group who had shorter mean survival time. CV mortality was independently associated with eGFR, male gender, CHA2DS2VASc and R2CHA2DS2VASc scores.Prevalence of CKD, particularly more advanced stages of CKD, is very high in patients with AF. Observed higher CV mortality and shorter mean survival time in CKD patients could be explained with higher CHA2DS2VASc score which is a consequence of clustering of all score components in CKD patients. However, eGFR was independently associated with CV mortality. In our cohort, R2CHA2DS2VASc score was not associated significantly more with CV mortality than CHA2DS2VASc score.
Background
Syncope, as the most frequent consciousness disorder, is very common in young individuals. The aim of this study was to analyze ECG parameters and clinical properties obtained during ...tilt-up testing in 12 to 30-year-old subjects. We enrolled a total of 142 patients from our outpatient clinic (39 males, 103 females) with a true positive tilt-up test and analyzed ECG records obtained during tilt-testing. Data were stratified according to the age, gender, and type of syncope.
Results
PR interval shortening preceding syncope was found in all syncope types, irrespective of the gender. All types of syncope were more frequent in women (72.5%). Mixed syncope type was found to be the most common (47.18%). Male and female subjects differed in initial heart rate (71.56 vs 76.23/min,
p
=0.05), as well as heart rate dynamics during tilt-up testing. A gender difference was also found in systolic blood pressure (116.92 vs 110.44 mmHg,
p
<0.01), time to syncope onset (20.77 vs. 16.44 min,
p
=0.03), and the total number of syncopal episodes in patient history (2.79 vs. 4.62,
p
<0.05). Subjects with cardioinhibitory syncope had the longest PR interval (average 154.3 ms). PR interval prolongation and loss of variability during tilt-up testing positively correlated with aging (
r
=0.22,
p
<0.05). Nodal rhythm was found in 8 patients.
Conclusion
PR interval shortening on ECG tracings during a tilt-up test can be found in all subtypes of vasovagal syncope, thereby contrasting previous reports that these changes are a hallmark of the cardioinhibitory type of syncope. PR shortening, if observed during ECG monitoring, could be a potential predictor of syncope.
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