Abstract Objectives The purpose of the study was to evaluate the benefit of care guided by the detection of stage B heart failure (SBHF) using advanced echocardiography for the reduction of new HF in ...the community. Background The detection of nonischemic SBHF has been facilitated by advanced echocardiographic imaging modalities. However, improved outcomes have not been proven as they are predicated on benefit of treatment. Methods Between September 13, 2013 and November 6, 2015, 618 asymptomatic community-based patients with HF risks (age 71 ± 5 years) were randomized to care guided by advanced echocardiography (myocardial deformation and detailed diastolic function) versus usual care. Evidence of SBHF led to advice to the patients and their primary physicians to initiate treatment with angiotensin-converting enzyme inhibition and beta-adrenoceptor blockade. The trial followed the PROBE (Prospective Randomized Open Blinded Endpoint) design. Participants were followed for 1 year for the primary composite endpoint of death from cardiovascular causes and new HF. Results Advanced echocardiography identified 219 as having SBHF and treatment was advised. Over a mean follow-up of 13 ± 6 months, 67 reached the primary endpoint. The incidence rate of HF was no different between the 2 arms (p = 0.47), likely because only 43% initiated therapy, and only 9% achieved target dose. Among subjects needing therapy on the basis of imaging and adherence to therapy, imaging-guided care showed a 77% lower hazard for the primary outcome (p = 0.04). Conclusions The detection of SBHF from strain and diastolic function evaluation was associated with a higher incidence of incidence HF and death. The efficacy of pharmacological intervention with angiotensin-converting enzyme inhibition and beta-adrenoceptor blockade is limited by its uptake, and alternative strategies should be considered. (Tasmanian Study of Echocardiographic Detection of Left Ventricular Dysfunction TAS-ELF; ACTRN12614000080628 )
Abstract This investigation sought to identify and quantify any increased risk of long-term heart failure after thoracic radiotherapy for cancer, and identify any population covariates that ...corresponded with increased risk. Electronic databases were systematically searched for studies reporting relative risk, odds ratio and hazard ratio for symptomatic heart failure more than 5 years after radiotherapy administration. Clinical characteristics, study design, univariable effect sizes and associated 95% confidence intervals were extracted. Univariable effect size was pooled and computed in a meta-analysis using random-effects models weighted by inverse variance. Six studies (45,669 patients) with weighted median follow-up duration of 13.9 years were included, each data-linkage study that reported hazard ratios for heart failure. Pooled hazard ratio for long-term heart failure was significant (HR 1.83, 1.09 to 3.08, p = 0.022), with significant between-study heterogeneity (Q 43.38, df 5, p<0.001, I2 88.47%). Statistical significance was lost when excluding studies of malignancies other than breast cancer or haematological malignancies, and excluding studies with Newcastle-Ottawa scores <8, but the direction of effect and magnitude remained approximately the same. Subgroup analyses and meta-regression demonstrated that study differences in age at time of radiotherapy administration and duration of follow-up explained approximately 80% of observed heterogeneity. Earlier publication date was associated with increased heart failure risk. Other variables, including female proportion, proportion of adjuvant chemotherapy use and sample size did not significantly impact the conclusions. In conclusion, radiotherapy approximately doubled the long-term risk of heart failure. This finding was associated with younger age at time of radiotherapy and longer follow-up duration, which explained approximately 80% of inter-study heterogeneity
A process to identify and target a selected population at risk of heart failure (HF) could facilitate screening and prevention. We sought to develop an effective screening process from clinical ...characteristics, functional capacity, and electrocardiogram (ECG). Asymptomatic subjects ≥65 years, with ≥1 HF risks were recruited from the community. Subjects with valvular disease, ejection fraction <40%, and atrial fibrillation were excluded. All underwent clinical evaluation including assessment of HF risk using Framingham HF score and Atherosclerosis Risk in Communities (ARIC) score, ECG, echocardiography, and 6-minute walk (6 MW) test. After 14 ± 4 months, new HF was assessed using Framingham criteria. A randomly selected derivation cohort was used to integrate ARIC score and 6 MW in a classification and regression tree (CART) analysis, with the remaining population used for validation. Of the 419 subjects (age 70 ± 5; 48% men), 52 developed HF. ARIC was more effective than the Framingham HF score (area under the curve 0.65 vs 0.53, p = 0.01). CART selected ARIC (>9.5%) and 6 MW (<501 m) as cutoffs to define low-, intermediate-, and high-risk groups. Abnormal ECG further divided the intermediate group into high and low risks. The 134 subjects identified as high risk by a combined clinical and electrocardiographic strategy showed more echocardiographic features of cardiac dysfunction including LV mass, mitral e′, mitral E/e′, and longitudinal strain (p <0.01). New HF was significantly more frequent than in the remaining patients (20% vs 10%, p = 0.003; hazard ratio 2.08, 95% confidence interval 1.21 to 3.57, p = 0.008). Thus, initial clinical risk and electrocardiographic assessment facilitate effective HF screening by identifying a high-risk group.
Abstract Identifying patients at risk is now important as there are demonstrable ways to alter disease progression which could potentially prevent atrial fibrillation (AF) and its complications. We ...sought whether impaired functional capacity was associated with risk of AF, independent of myocardial dysfunction. In this community-based study, asymptomatic participants ≥65 years were recruited if they had > 1 risk factor (eg. hypertension, diabetes mellitus and obesity). Participants underwent baseline echocardiography (including measurement of myocardial mechanics) and six minute walk test (SMWT). The CHARGE-AF score was used to calculate 5 year risk of developing AF. Receiver operator characteristics (ROC) curves were used to assess for independent risk factors for AF. A total of 607 patients (age 71±5 years, male 47%) were studied at baseline and followed for at least 6 months. Patients in the higher AF risk groups were older and had increased rates of hypertension, diabetes mellitus and ischemic heart disease (p<0.05). Higher AF risk was associated with lower exercise capacity, independent of lower mean global longitudinal strain (GLS), global circumferential strain (GCS), higher mean E/e’ ratio, indexed left atrial (LA) volume and LV mass. Multivariable linear regression confirmed association of LV and functional capacity parameters with AF risk. Although functional capacity is impaired in AF, this association precedes the onset of AF. In conclusion, poor functional status is associated with AF risk, independent of LV function.
PM2·5 is an important but modifiable environmental risk factor, not only for pulmonary diseases and cancers, but for cardiovascular health. However, the evidence regarding the association between air ...pollution and acute cardiac events, such as out-of-hospital cardiac arrest (OHCA), is inconsistent, especially at concentrations lower than the WHO daily guideline (25 μg/m3). This study aimed to determine the associations between exposure to ambient air pollution and the incidence of OHCA.
In this nationwide case-crossover study, we linked prospectively collected population-based registry data for OHCA in Japan from Jan 1, 2014, to Dec 31, 2015, with daily PM2·5, carbon monoxide (CO), nitrogen dioxide (NO2), photochemical oxidants (Ox), and sulphur dioxide (SO2) exposure on the day of the arrest (lag 0) or 1–3 days before the arrest (lags 1–3), as well as the moving average across days 0–1 and days 0–3. Daily exposure was calculated by averaging the measurements from all PM2·5 monitoring stations in the same prefecture. The effect of PM2·5 on risk of all-cause or cardiac OHCA was estimated using a time-stratified case-crossover design coupled with conditional logistic regression analysis, adjusted for daily temperature and relative humidity. Single-pollutant models were also investigated for the individual gaseous pollutants (CO, NO2, Ox, and SO2), as well as two-pollutant models for PM2·5 with these gaseous pollutants. Subgroup analyses were done by sex and age.
Over the 2 years, 249 372 OHCAs were identified, with 149 838 (60·1%) presumed of cardiac origin. The median daily PM2·5 was 11·98 μg/m3 (IQR 8·13–17·44). Each 10 μg/m3 increase in PM2·5 was associated with increased risk of all-cause OHCA on the same day (odds ratio OR 1·016, 95% CI 1·009–1·023) and at lags of up to 3 days, ranging from OR 1·015 (1·008–1·022) at lag 1 to 1·033 (1·023–1·043) at lag 0–3. Results for cardiac OHCA were similar (ORs ranging from 1·016 1·007–1·025 at lags 1 and 2 to 1·034 1·021–1·047 at lag 0–3). Patients older than 65 years were more susceptible to PM2·5 exposure than younger age groups but no sex differences were identified. CO, Ox, and SO2 were also positively associated with OHCA while NO2 was not. However, in two-pollutant models of PM2·5 and gaseous pollutants, only PM2·5 (positive association) and NO2 (negative association) were independently associated with increased risk of OHCA.
Short-term exposure to PM2·5 was associated with an increased risk of OHCA even at relatively low concentrations. Regulatory standards and targets need to incorporate the potential health gains from continual air quality improvement even in locations already meeting WHO standards.
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