NT-proBNP is emerging as a novel tool for improving management of patients with heart failure (HF). The concept of health-related outcomes as the primary endpoint for therapeutic intervention in ...chronic disease, such as HF, should be the focal point going forward.
We conducted a prospective real-world study in heart failure with reduced ejection fraction (HFrEF) patients. The main target was to evaluate the impact on patient's health-related outcomes of a personalized medical follow-up procedure, based on a laboratory model of risk stratification supported by NT-proBNP. One hundred and five consecutive patients admitted to the Hospital Heart-Failure unit were stratified into three groups (low, medium, and high risk) and prospective follow-ups during the 12 months post discharge.
It was found that patients under this new approach experienced early and robust improvements in patient health-related outcomes with consistency in most domains which persisted beyond 12 months post follow-up. Improvements in health related quality of life score (HRQLS) was observed over the time of the study. After 6 months we found a significant improvement in HRQLS of 18.2% (from 76.5 ± 22.4 to 95.0 ± 15.7) and 14.4% (from 76.5 ± 22.4 to 96.3 ± 15.9) after 12 months of follow-up (p < 0.001). The highest improvements were found in the symptom severity domain where patients reported an improvement of 22.6% after 6 months and 18.9% after 12 months (p < 0.001). The lowest scores were reported in the physical domain with increase of 11.0% and 4.3% after 6 months and 12 months (p = 0.089). Psychosocial domain and the ability to carry out the activities of normal life showed improvement as well.
Our strategy based on NT-proBNP optimizes HFrEF management and represents a major new approach for clinical laboratories to improve patient health-related outcomes in HFrEF.
Background or Purpose
His bundle pacing (HBP) is the most physiological form of ventricular pacing. Few prospective studies have analyzed lead localization using imaging techniques and its ...relationship with electrical parameters and capture patterns. The objective of this study is to examine the correlation between electrical parameters and lead localization using three-dimensional transthoracic echocardiography (3D TTE).
Methods
This single-center, prospective, nonrandomized clinical research study (January 2018 to June 2020) included patients with an indication of permanent pacing, in whom 3D TTE was performed to define lead localization as supravalvular or subvalvular.
Results
A total of 92 patients were included: 56.5% of leads were supravalvular, and 43.5% were subvalvular, which resembles previous anatomic descriptions of autopsied hearts of His bundle localization within the triangle of Koch (ToK). R-wave sensing was higher when the His lead was localized subvalvular instead of supravalvular. His lead localization was not associated with HBP threshold or impedance differences, nor with the two different HBP patterns of capture, or with the ability of HBP to correct baseline BBB. The thresholds remained stable during follow-up visits, regardless of His lead localization. Higher R-wave sensing was observed during follow-up than at baseline, mainly in the subvalvular His leads. However, lead impedances in both positions decreased during follow-up.
Conclusions
Lead localization in relation to the tricuspid valve did not influence the electrical performance of HBPs. Wide anatomical variations of the His bundle within the ToK explain our findings, reinforcing the idea that the technique for HBP should be fundamentally guided by electrophysiological and not anatomical parameters.
Background
Cardiac resynchronization therapy (CRT) through permanent His bundle pacing (p-HBP) normalizes interventricular conduction disorders and
QRS
. Similarly, there are immediate and long-term ...changes in repolarization, which could be prognostic of a lower risk of sudden death (SD) at follow-up. We aimed to compare the changes in different electrocardiographic (ECG) repolarization parameters related to the risk of SD before and after CRT through p-HBP.
Methods
In this prospective, descriptive single-center study (May 2019 to December 2021), we compared the ECG parameters of repolarization related to SD in patients with non-ischemic dilated cardiomyopathy, left bundle branch block (LBBB), and CRT indications, at baseline and after CRT through p-HBP.
Results
Forty-three patients were included. Compared to baseline, after CRT through p-HBP, there were immediate significant changes in the
QT
interval (ms): 445 407.5–480 vs 410 385–440 (
p
= 0.006),
QT
dispersion (ms): 80 60–100 vs 40 40–65 (
p
< 0.001),
Tp
-
Te
(ms): 90 80–110 vs 80 60–95 (
p
< 0.001),
Tp
-
Te
/
QT
ratio: 0.22 0.19–0.23 vs 0.19 0.16–0.21 (
p
< 0.001),
T
wave amplitude (mm): 6.25 4.88–10 vs − 2.5 − 7–2.25 (
p
< 0.001), and
T
wave duration (ms): 190 157.5–200 vs 140 120–160 (
p
= 0.001). In the cases of the corrected
QT
(Bazzett and Friederichia) and the
Tp
-
Te
dispersion, changes only became significant at 1 month post-implant (468.5 428.8–501.5 vs 440 410–475.25 (
p
= 0.015); 462.5 420.8–488.8 vs 440 400–452.5 (
p
= 0.004), and 40 30–52.5 vs 30 20–40 (
p
< 0.001), respectively) (Table
1
). Finally, two parameters did not improve until 6 months post-implant: the
rdT
/
JT
index, 0.25 0.21–0.28 baseline vs 0.20 0.19–0.23 6 months post-implant (
p
= 0.011), and the
JT
interval, 300 240–340 baseline vs 280 257–302 6 months post-implant (
p
= 0.027). Additionally, most of the parameters continued improving as compared with immediate post-implantation.
Conclusions
After CRT through His bundle pacing and LBBB correction, there was an improvement in all parameters of repolarization related to increased SD reported in the literature.
BACKGROUNDThe association between digoxin and mortality is an unclear issue. In older patients with atrial fibrillation (AF), where use of digoxin is frequent, the evidence of its safety is scarce. ...Our aim is to assess the safety of digoxin in nonagenarian patients with AF. METHODSWe evaluated data from 795 nonagenarian patients with non-valvular AF from the Spanish Multicenter Registry. We analyzed the relationship between digoxin and all-cause mortality with the Cox proportional-hazards model. RESULTSFollow-up was 27.7 ± 18.3 months. Mean age was 92.5 ± 3.8 years, and 71% of nonagenarian patients were female. Digoxin was not associated with increased risk of mortality adjusted hazard ratio (aHR) = 1.16, 95% CI: 0.96-1.41,P = 0.130. However, we found a significant increase in mortality in the subgroup with estimated glomerular filtration rate (eGFR) < 30 mL/min per 1.73 m 2 (aHR = 2.01, 95% CI: 1.13-3.57,P = 0.018), but not in the other subgroups of eGFR (30-59 mL/min per 1.73 m2 and ≥ 60 mL/min per 1.73 m2). When exploring the risk of mortality according to sex, male subgroup was associated with an increase in mortality (aHR = 1.48, 95% CI: 1.02-2.14,P = 0.041). This was not observed in females subgroup (aHR = 1.03, 95% CI: 0.81-1.29,P = 0.829). Based on the presence or absence of heart failure, we did not find significant differences (aHR = 1.20, 95% CI: 0.87-1.65,P = 0.268 vs. aHR = 1.15, 95% CI: 0.90-1.47,P = 0.273, respectively). CONCLUSIONSIn our large registry of nonagenarian patients with AF, we did not find an association between digoxin and mortality in the total sample. However, in the subgroup analyses, we found an increase in mortality with the use of digoxin in men and in patients with an eGFR < 30 mL/min per 1.73 m 2.
The prevalence of atrial fibrillation (AF) increases with age. The prescription of anticoagulation in very elderly patients is controversial and sometimes underused. Our objective is to report the ...incidence and predictors of major bleeding in anticoagulated nonagenarian patients with non valvular atrial fibrillation (NVAF).
We analyzed a large multicentre registry of anticoagulated nonagenarian patients diagnosed with NVAF from three health areas of Spain, between 2013 and 2017. Predictors of major bleeding were studied with a competing risk analysis and the impact of major bleeding with a time-dependent mortality analysis.
The incidence rate of major bleeding was 5 per100 person-year (95% Confidence Interval CI: 4.59–6.35), similar in the group of patients with vitamin K antagonists (VKAs) and direct oral anticoagulants (DOAC). In the VKAs group we found as predictors of major bleeding: previous admission for bleeding (sub-distribution hazard ratio sHR 3.25, 95% CI: 1.48–7.13), creatinine (sHR 1.38, 95% CI: 1.16–1.64,) and control out-of-range INR (sHR 1.90, 95% CI: 1.02–3.55). In DOAC group, male sex (sHR 1.92, 95% CI: 1.18–3.13) and the history of previous admission for bleeding (sHR 2.60, 95% CI 1.33–5.06) were found as a predictor. The HAS-BLED was not associated with major bleeding. Major bleeding was associated with increased mortality in both VKAs and DOAC groups without significant differences.
We found an incidence rate of major bleeding with relative low values, similar in those treated with VKAs and those treated with DOAC, with different predictors of major bleeding in each group. Major bleeding was associated with increased mortality, with no significant difference by oral anticoagulation therapy (OAT).
•The incidence rate of major bleeding in nonagenarian patients underwent oral anticoagulation therapy (OAT) is low.•Different predictors of bleeding were found for vitamin K antagonists (VKAs) and direct oral anticoagulants (DOAC). 3) HAS-BLED was not a predictor of major bleeding in our study with nonagenarians.
