Fulminant myocarditis (FM) is a form of acute myocarditis characterized by severe left ventricular systolic dysfunction requiring inotropes and/or mechanical circulatory support. A single-center ...study found that a patient with FM had better outcomes than those with acute nonfulminant myocarditis (NFM) presenting with left ventricular systolic dysfunction, but otherwise hemodynamically stable. This was recently challenged, so disagreement still exists.
This study sought to provide additional evidence on the outcome of FM and to ascertain whether patient stratification based on the main histologic subtypes can provide additional prognostic information.
A total of 220 patients (median age 42 years, 46.3% female) with histologically proven acute myocarditis (onset of symptoms <30 days) all presenting with left ventricular systolic dysfunction were included in a retrospective, international registry comprising 16 tertiary hospitals in the United States, Europe, and Japan. The main endpoint was the occurrence of cardiac death or heart transplantation within 60 days from admission and at long-term follow-up.
Patients with FM (n = 165) had significantly higher rates of cardiac death and heart transplantation compared with those with NFM (n = 55), both at 60 days (28.0% vs. 1.8%, p = 0.0001) and at 7-year follow-up (47.7% vs. 10.4%, p < 0.0001). Using Cox multivariate analysis, the histologic subtype emerged as a further variable affecting the outcome in FM patients, with giant cell myocarditis having a significantly worse prognosis compared with eosinophilic and lymphocytic myocarditis. In a subanalysis including only adults with lymphocytic myocarditis, the main endpoints occurred more frequently in FM compared with in NFM both at 60 days (19.5% vs. 0%, p = 0.005) and at 7-year follow up (41.4% vs. 3.1%, p = 0.0004).
This international registry confirms that patients with FM have higher rates of cardiac death and heart transplantation both in the short- and long-term compared with patients with NFM. Furthermore, we provide evidence that the histologic subtype of FM carries independent prognostic value, highlighting the need for timely endomyocardial biopsy in this condition.
Display omitted
Abstract
Proteomics in heart failure (HF) is aimed to study and identify proteins involved in the pathophysiology of this clinical syndrome. Proteins have a role as diagnostic, prognostic and ...therapeutic markers. This review will unravel the developments and impact of proteomics in HF, focusing on its role in the diagnosis, prognosis and definition of new HF therapies. Proteomics promises to change our approach to HF in the near future, accepting the need for precision medicine, tailored on the characteristics of the single patient.
Aim
Contemporary survival trends in dilated cardiomyopathy (DCM) are largely unknown. The aim of this study is to investigate clinical descriptors, survival trends and the prognostic impact of ...aetiological characterization in DCM patients.
Methods and results
Dilated cardiomyopathy patients were consecutively enrolled and divided into four groups according to the period of enrolment (1978–1984; 1985–1994; 1995–2004; and 2005–2015). A subset of patients with DCM of specific aetiology, enrolled from 2005 to 2015, was also analysed. Over a mean follow‐up of 12 ± 8 years, 1284 DCM patients (52 in the 1978–1984 group, 326 in the 1985–1994 group, 379 in the 1995–2004 group, and 527 in the 2005–2015 group) were evaluated. Despite older age (mean age 51 ± 15, 43 ± 15, 45 ± 14, and 52 ± 15 years for the 1978–1984, 1985–1994, 1995–2004, and 2005–2015 groups, respectively; P < 0.001), most of the baseline clinical characteristics improved in the 2005–2015 group, suggesting a less advanced disease stage at diagnosis. Similarly, at competing risk analysis, the annual incidence of all outcome parameters progressively decreased over time (global P < 0.001). At multivariable analysis, the last period of enrolment emerged as independently associated with a reduction in all‐cause mortality/heart transplantation (HTx)/ventricular assist device (VAD) implantation (1.46 events/100 patients/year), cardiovascular death/HTx/VAD implantation (0.82 events/100 patients/year) and sudden cardiac death (0.15 events/100 patients/year). Lastly, in 287 patients with DCM of specific aetiology, patients with environmental, toxic, or removable factors appeared to have different phenotypes and prognosis compared to those with genetic, post‐myocarditis, or idiopathic DCM (P < 0.001).
Conclusions
Contemporary survival trends in DCM significantly improved, mainly due to a reduction of cardiovascular events. Appropriate aetiological characterization might help in prognostication of DCM patients.
A reduced cardiac output (CO) response during exercise is a major limiting factor in heart failure (HF). Oxygen consumption (VO2) is directly proportional to CO. Peripheral mechanisms via ...arteriovenous oxygen difference (Δ(a-v)O2) play a pivotal role in chronic HF. We hypothesized a weak correlation between peak VO2 and peak CO with a greater Δ(a-v)O2 variability in most severe HF.
We analyzed 278 HF patients (NYHA II–III) who performed maximal cardiopulmonary exercise test with non-invasive CO measurement by inert gas rebreathing.
Median peakVO2, CO and Δ(a-v)O2 were 0.96 (0.78–1.28) L/min, 6.3 (5.1–8.0) L/min and 16.0 (14.2–18.0) mL/100mL respectively, with a linear relationship between VO2 and CO: CO=5.3×VO2+1.13 (r2=0.705, p<0.001). Patients were grouped according to exercise limitation. Group 1 (101 patients) peakVO2<50% pred: peakVO2 0.80 (0.67–0.94) L/min, peakCO 5.6 (4.7–6.5) L/min, peakΔ(a-v)O2 14.8 (12.9–17.1) mL/100mL. Group 2 (89 patients) peakVO2≥50–<65% pred: peakVO2 1.02 (0.84–1.29) L/min, peakCO 6.4 (5.1–8.0) L/min, peakΔ(a-v)O2 16.7 (15.0–18.5) mL/100mL. Group 3 (88 patients) peakVO2≥65% pred: peakVO2 1.28 (0.93–1.66) L/min, peakCO 8.0 (6.2–9.7) L/min, peakΔ(a-v)O2 16.8 (14.6–18.3) mL/100mL. A peakVO2 and peakCO linear relationship was observed in Group 1 (r2=0.381, p<0.001), Group 2 (r2=0.756, p<0.001) and Group 3 (r2=0.744, p<0.001).
With worsening HF we observed a progressive reduction of peak CO and peak VO2. However in most compromised patients also peripheral mechanisms play a role as indicated by reduced Δ(a-v)O2.
Abstract
Advanced heart failure (AHF) represents an ominous stage of heart failure (HF), where the expected prognosis remains poor regardless of the improvement in medical knowledge. In this review, ...we summarize the definition, prognosis, physiopathology, and clinical/therapeutic management of the disease, focusing on the fast and timely referral of the patient to the AHF facilities. We provide an insight of the diagnostic and therapeutic ‘work up’ performed in an Italian AHF hub, implying a deep phenotypical patients characterization in order to evaluate candidacy to the therapeutic gold standards as heart transplantation (HTx) and left ventricular assist device (LVAD).
Cardiac output (Q˙) is a key parameter in the assessment of cardiac function, its measurement being crucial for the diagnosis, treatment, and prognostic evaluation of all heart diseases. Until ...recently, Q˙ determination at peak exercise has been possible through invasive methods, so that normal values were obtained in studies based on small populations.
Nowadays, peak Q˙ can be measured noninvasively by means of the inert gas rebreathing (IGR) technique. The present study was undertaken to provide reference values for peak Q˙ in the normal general population and to obtain a formula able to estimate peak exercise Q˙ from measured peak oxygen uptake (V˙o2).
We studied 500 normal subjects (age, 44.9 ± 1.5 years; range, 18-77 years; 260 men, 240 women) who underwent a maximal cardiopulmonary exercise test with peak Q˙ measurement by IGR. In the overall study sample, peak Q˙ was 13.2 ± 3.5 L/min (men, 15.3 ± 3.3 L/min; women, 11.0 ± 2.0 L/min; P < .001) and peak V˙o2 was 95% ± 18% of the maximum predicted value (men, 95% ± 19%; women, 95% ± 18%). Peak V˙o2 and peak Q˙ progressively decreased with age (R2, 0.082; P < .001; and R2, 0.144; P < .001, respectively). The V˙o2-derived formula to measure Q˙ at peak exercise was (4.4 × peak V˙o2) + 4.3 in the overall study cohort, (4.3 × peak V˙o2) + 4.5 in men, and (4.9 × peak V˙o2) + 3.6 in women.
The simultaneous measurement of Q˙ and V˙o2 at peak exercise in a large sample of healthy subjects provided an equation to predict peak Q˙ from peak V˙o2 values.
Available data on the clinical characteristics and prognosis of patients with heart failure (HF) due to dilated cardiomyopathy (DCM) derive mainly from tertiary care centres for cardiomyopathies or ...from drug trial sub-studies, which may entail a referral bias.
From 2008 to 2021, we enrolled in a nationwide HF Registry 1886 DCM patients and 3899 with ischemic heart disease (IHD).
Patients with DCM were younger, more often female, had more commonly recent onset HF, left bundle branch block, and showed higher LV end-diastolic volume and lower LVEF than IHD. With respect to IHD, DCM patients received more often mineralocorticoid receptor antagonists, renin angiotensin system inhibitors and betablockers, the latter more commonly at doses ≥50% of target, and triple guideline-directed medical therapy (GDMT) (adjusted OR 1.411, 95% CI 1.247-1.595, p < .0001). During one-year follow-up, 819 patients (14.2%) died or were hospitalized for HF 187 (9.9%) DCM, 632 (16.2%) IHD; DCM was associated with lower risk of the combined end-point (adjusted HR 0.745, 95% CI 0.625- 0.888, p = .0011). Among the 1954 patients with 1-year echocardiograms available, 1483 had LVEF≤40% at baseline; of these,166 (30.6%) DCM and 165 (17.5%) IHD improved their LVEF to >40% (p < .0001). DCM aetiology was associated with higher likelihood of LVEF improvement (adjusted OR 1.722, 95% CI 1.328 -2.233, p < .0001).
DCM patients have a different clinical profile, greater uptake of GDMT and better outcomes than IHD subjects. A comprehensive management approach is needed to further address the risk of unfavorable outcomes in DCM.
•Tertiary centres or trials are primary data sources for patients with DCM and HF.•Real-world HF registry findings may provide a more unbiased perspective.•DCM had more common recent onset HF, left bundle branch block.•DCM patients showed higher LV end-diastolic volume and lower LVEF than IHD.•DCM patients had greater uptake of GDMT and better outcomes than IHD subjects.
•Continuous home inotropic infusion represents a possible and efficient therapy in patients with advanced heart failure (HF), documenting an improvement in quality of life, end organ damage and ...hospitalization rate.•Tailored inotropic therapy can provide benefits not only as bridge to Heart Transplantation, bridge to mechanical circulatory support or bridge to candidacy but also in patients with a palliative care (PC) program.•A multidisciplinary team with HF and PC specialists, HF specialist nurses and general practitioner is fundamental for the management of advanced HF patients intravenous continuous home inotropic therapy.
Intravenous inotropic support represents an important therapeutic option in advanced heart failure (HF) as bridge to heart transplantation, bridge to mechanical circulatory support, bridge to candidacy or as palliative therapy. Nevertheless, evidence regarding risks and benefits of its use is lacking.
we conducted a retrospective single center study, analysing the effect of inotropic therapies in an outpatient cohort, evaluating the burden of hospitalizations, the improvement in quality of life, the incidence of adverse events and the evolution of organ damage.
twenty-seven patients with advanced HF were treated in our Day Hospital service from 2014 to 2021. Nine patients were treated as bridge to heart transplant while eighteen as palliation. Comparing data regarding the year before and after the beginning of inotropic infusion, we observed a reduction of hospitalization (46 vs 25, p<0,001), an improvement of natriuretic peptides, renal and hepatic function since the first month (p<0,001) and a better quality of life in 53% of the population treated. Two hospitalizations for arrhythmias and seven hospitalizations for catheter-related complications were registered.
in a selected population of advanced HF patients, continuous home inotropic infusion were able to reduce hospitalizations, improving end organ damage and quality of life. We provide a practical guidance on starting and maintaining home inotropic infusion while monitoring a challenging group of patients.
The primary end-points were all-cause mortality or heart transplantation (D/HT) and sudden cardiac death or malignant ventricular arrhythmias (SD/MVA). ...29 out of 175 mid-range EF patients (17%) ...evolved to reduced EF at a mean follow-up of 69 (24;91) months, consistently worsening their long-term prognosis.
PDF
