Aims
The purpose of this study was to evaluate the effectiveness, feasibility, and safety of a 4‐week high‐intensity inspiratory muscle training (hi‐IMT) in patients with chronic heart failure (CHF).
...Methods and results
A double‐blind randomized clinical trial was carried out in 22 patients with CHF. Participants were assigned to the hi‐IMT or sham‐IMT group. The trainer device was a prototype of the Orygen‐Dual Valve®. The training workloads were adjusted weekly at the inspiratory pressure which allowed the performance of 10 consecutive maximal repetitions (10RM). Main outcomes were strength and endurance of the respiratory muscles assessed by maximal respiratory pressures (PImax and PEmax) and a 10RM manoeuvre, respectively. Twenty‐one patients presented impairment in respiratory muscle strength and endurance. Patients in the hi‐IMT group showed a significant improvement in both strength and endurance: inspiratory muscle strength in the intervention group increased 57.2% compared with 25.9% in the control group (P = 0.001). The percentage change in endurance was 72.7% for the hi‐IMT group compared with 18.2% in the sham‐IMT group (P < 0.001). No adverse effects occurred during the intervention.
Conclusion
A 4‐week hi‐IMT with the use of the Orygen‐Dual Valve® is shown to be an effective, feasible, and safe tool to improve weakness and fatigue of the inspiratory muscles. The key point of this study is to discuss immediate practical implications in terms of respiratory muscle dysfunction postulated as a potential prognostic factor and as an additional therapeutic target.
Trials registration
NCT01606553.
Background The clinical yield of cavotricuspid isthmus (CTI) radiofrequency ablation of atrial flutter (AF) is limited by a high incidence of atrial fibrillation (AFib) in the long term. Among other ...acknowledged variables, the association of obstructive sleep apnea (OSA) could favor incomplete arrhythmia control in this setting. We assessed the impact of CPAP in reducing the occurrence of AFib after CTI ablation. Methods Consecutive patients with AF who were undergoing CTI ablation were screened for OSA. Relationship of the following variables with the occurrence of AFib during follow-up (12 months) was investigated: CPAP initiation, hypertension, BMI, underlying structural heart disease, left atrial diameter, and AFib documentation prior to ablation. Results We prospectively included 56 patients (mean age: 66 (± 11) years; 12 female patients), of whom 46 (82%) had OSA and 25 (45%) had severe OSA. Twenty-one patients (38%) had AFib during follow-up after CTI ablation. Both freedom from AFib prior to ablation and CPAP initiation in those patients without previously documented AFib at inclusion were associated with a reduction of AFib episodes during follow-up ( P = .019 and P = .025, respectively). Inversely, CPAP was not protective from AFib recurrence when this arrhythmia was documented prior to ablation ( P = .25). Conclusions OSA is a prevalent condition in patients with AF. Treatment with CPAP is associated with a lower incidence of newly diagnosed AFib after CTI ablation. Screening for OSA in patients with AF appears to be a reasonable clinical strategy.
Introduction:
Stent delivery in complex coronary anatomy with severe calcification and tortuosity is still a common cause of percutaneous coronary interventions (PCI) failure. Recently, a new ...support rapid exchange catheter, the Guideliner, has been designed specifically for device delivery.
Methods:
From June 2010 to December 2010, we performed 10 cases using the Guideliner catheter to improve backup support and facilitate stent delivery: 2 emergent PCI for ST elevation myocardial infarction, and 8 stable elective PCI. In 3 cases the operator chose the femoral access, in 2 cases crossover from radial to femoral access was needed, and the other cases were performed radially. In 2 cases PTCA with drug‐eluting balloon was performed; in the other cases second‐generation drug‐eluting stent was implanted.
Results:
One case, the first one, failed, as stent could not be delivered to the target lesion. The other 9 cases were performed successfully. Three proximal dissections were detected and sealed with stent implantation. In 2 cases, we had stent damage due to the passage of the stent through the Guideliner metal collar. Another stent had to be used.
Conclusions:
In our experience, the Guideliner catheter is safe to use and helps device delivery in difficult settings. We describe here our experience with the Guideliner catheter for stent delivery and backup support; we discuss its utility and drawbacks in acute and stable clinical settings. Moreover, the aim of this article is to help interventional cardiologists using the device in difficult lesions to avoid potential complications. (J Interven Cardiol 2011;24:450–461)
Decisive information on the parameters involved in cognitive impairment in patients with chronic heart failure is as yet lacking. Our aim was to determine the functional and psychosocial variables ...related with cognitive impairment using the mini-mental-state examination (MMSE) with age-and education-corrected scores.
A cohort study of chronic heart failure patients included in an integrated multidisciplinary hospital/primary care program. The MMSE (corrected for age and education in the Spanish population) was administered at enrolment in the program. Analyses were performed in 525 patients. Demographic and clinical variables were collected. Comprehensive assessment included depression (Yesavage), family function (family APGAR), social network (Duke), dependence (Barthel Index), frailty (Barber), and comorbidities. Univariate and multivariate logistic regression were performed to determine the predictors of cognitive impairment.
Cognitive impairment affected 145 patients (27.6 %). Explanatory factors were gender (OR: 2.77 (1.75-4.39) p < 0.001), ischemic etiology (OR: 1.99 (1.25-3.17) p = 0.004), frailty (OR: 1.58 (0.99 to 2.50, p =0.050), albumin > 3.5 (OR: 0.59 (0.35-0.99) p = 0.048), and beta-blocker treatment (OR: 0.36 (0.17 to 0.76, p = 0.007)). No association was found between cognitive impairment and social support or family function.
The observed prevalence of cognitive impairment using MMSE corrected scores was 27.6 %. A global approach in the management of these patients is needed, especially focusing on women and patients with frailty, low albumin levels, and ischemic aetiology heart failure.
Abstract Objective To evaluate the association between brachial-ankle pulse wave velocity (baPWV), a convenient, non-radiating, readily available measurement of arterial stiffness, and coronary ...artery calcium (CAC), a reliable marker of coronary atherosclerosis, in a large sample of young and middle-aged asymptomatic adults; and to assess the incremental value of baPWV for detecting prevalent CAC beyond traditional risk factors. Methods Cross-sectional study of 15,185 asymptomatic Korean adults who voluntarily underwent a comprehensive health screening program including measurement of baPWV and CAC. BaPWV was measured using an oscillometric method with cuffs placed on both arms and ankles. CAC burden was assessed using a multi-detector CT scan and scored following Agatston's method. Results The prevalence of CAC > 0 and CAC > 100 increased across baPWV quintiles. The multivariable-adjusted odds ratios (95% CI) for CAC > 0 comparing baPWV quintiles 2–5 versus quintile 1 were 1.06 (0.87–1.30), 1.24 (1.02–1.50), 1.39 (1.15–1.69) and 1.60 (1.31–1.96), respectively (P trend < 0.001). Similarly, the relative prevalence ratios for CAC > 100 were 1.30 (0.74–2.26), 1.59 (0.93–2.71), 1.74 (1.03–2.94) and 2.59 (1.54–4.36), respectively (P trend < 0.001). For CAC > 100, the area under the ROC curve for baPWV alone was 0.71 (0.68–0.74), and the addition of baPWV to traditional risk factors significantly improved the discrimination and calibration of models for detecting prevalent CAC > 0 and CAC > 100. Conclusions BaPWV was independently associated with the presence and severity of CAC in a large sample of young and middle-aged asymptomatic adults. BaPWV may be a valuable tool for identifying apparently low-risk individuals with increased burden of coronary atherosclerosis.
Abstract Background Obese patients with chronic Heart Failure (HF) have better outcome than their lean counterparts, although little is known about the pathophysiology of this obesity paradox. Our ...aim was to evaluate the hypothesis that patients with chronic HF and obesity (defined as body mass index (BMI) ≥ 30 kg / m2 ), may have an attenuated neurohormonal activation in comparison with non-obese patients. Methods and results The present study is the post-hoc analysis of a cohort of 742 chronic HF patients from a single-center study evaluating sympathetic activation by measuring baseline levels of norepinephrine (NE). Obesity was present in 33% of patients. Higher BMI and obesity were significantly associated with lower NE levels in multivariable linear regression models adjusted for covariates (p < 0.001). Addition to NE in multivariate Cox proportional hazard models attenuated the prognostic impact of BMI in terms of outcomes. Finally, when we explored the prognosis impact of raised NE levels (> 70th percentile) carrying out a separate analysis in obese and non-obese patients we found that in both groups NE remained a significant independent predictor of poorer outcomes, despite the lower NE levels in patients with chronic HF and obesity: all-cause mortality hazard ratio = 2.37 (95% confidence interval, 1.14–4.94) and hazard ratio = 1.59 (95% confidence interval, 1.05–2.4) in obese and non-obese respectively; and cardiovascular mortality hazard ratio = 3.08 (95% confidence interval, 1.05–9.01) in obese patients and hazard ratio = 2.08 (95% confidence interval, 1.42–3.05) in non-obese patients. Conclusion Patients with chronic HF and obesity have significantly lower sympathetic activation. This finding may partially explain the obesity paradox described in chronic HF patients.
The efficacy of heart failure programs has been demonstrated in clinical trials but their applicability in the real world practice setting is more controversial. This study evaluates the feasibility ...and efficacy of an integrated hospital-primary care program for the management of patients with heart failure in an integrated health area covering a population of 309 345.
For the analysis, we included all patients consecutively admitted with heart failure as the principal diagnosis who had been discharged alive from all of the hospitals in Catalonia, Spain, from 2005 to 2011, the period when the program was implemented, and compared mortality and readmissions among patients exposed to the program with the rates in the patients of all the remaining integrated health areas of the Servei Català de la Salut (Catalan Health Service).
We included 56 742 patients in the study. There were 181 204 hospital admissions and 30 712 deaths during the study period. In the adjusted analyses, when compared to the 54 659 patients from the other health areas, the 2083 patients exposed to the program had a lower risk of death (hazard ratio=0.92 95% confidence interval, 0.86-0.97; P=.005), a lower risk of clinically-related readmission (hazard ratio=0.71 95% confidence interval, 0.66-0.76; P<.001), and a lower risk of readmission for heart failure (hazard ratio=0.86 95% confidence interval, 0.80-0.94; P<.001). The positive impact on the morbidity and mortality rates was more marked once the program had become well established.
The implementation of multidisciplinary heart failure management programs that integrate the hospital and the community is feasible and is associated with a significant reduction in patient morbidity and mortality.
Los programas de insuficiencia cardiaca han demostrado su eficacia en ensayos clínicos, aunque su aplicabilidad en un entorno de práctica real es más controvertida. Este estudio evalúa la factibilidad y la eficacia de un programa integrado hospital-atención primaria para la gestión de pacientes con insuficiencia cardiaca en un área integral de salud de 309.345 habitantes.
Para el análisis, se incluyó a todos los pacientes consecutivos ingresados por insuficiencia cardiaca como diagnóstico principal y dados de alta vivos en todos los hospitales de Cataluña durante el periodo 2005-2011, en el que se implantó el programa y se comparó la mortalidad y los reingresos entre los pacientes expuestos al programa y todos los pacientes de las demás áreas integrales de salud del Servei Català de la Salut.
Se incluyó en el estudio a 56.742 pacientes. Se produjeron 181.204 hospitalizaciones y 30.712 defunciones en ese periodo. En los análisis ajustados, los 2.083 pacientes expuestos al programa, respecto los 54.659 pacientes de las otras áreas sanitarias, tuvieron menor riesgo de muerte (hazard ratio=0,92 intervalo de confianza del 95%, 0,86-0,97; p=0,005), menor riesgo de reingreso clínicamente relacionado (hazard ratio=0,71 intervalo de confianza del 95%, 0,66-0,76; p<0,001) y menor riesgo de rehospitalización por insuficiencia cardiaca (hazard ratio=0,86 intervalo de confianza del 95%, 0,80-0,94; p<0,001). Se observó que el impacto positivo en la morbimortalidad fue más notorio en el periodo de consolidación del programa.
La implantación de programas multidisciplinarios para la gestión de la insuficiencia cardiaca que integran hospital y comunidad es factible y se asocia a una reducción significativa de la morbimortalidad de los pacientes.
To evaluate the effect of iron deficiency and anemia on submaximal exercise capacity in patients with chronic heart failure.
We undertook a single-center cross-sectional study in a group of stable ...patients with chronic heart failure. At recruitment, patients provided baseline information and completed a 6-minute walk test to evaluate submaximal exercise capacity and exercise-induced symptoms. At the same time, blood samples were taken for serological evaluation. Iron deficiency was defined as ferritin < 100 ng/mL or transferrin saturation < 20% when ferritin is < 800 ng/mL. Additional markers of iron status were also measured.
A total of 538 heart failure patients were eligible for inclusion, with an average age of 71 years and 33% were in New York Heart Association class III/IV. The mean distance walked in the test was 285 ± 101 meters among those with impaired iron status, vs 322 ± 113 meters (P=.002). Symptoms during the test were more frequent in iron deficiency patients (35% vs 27%; P=.028) and the most common symptom reported was fatigue. Multivariate logistic regression analyses showed that increased levels of soluble transferrin receptor indicating abnormal iron status were independently associated with advanced New York Heart Association class (P < .05). Multivariable analysis using generalized additive models, soluble transferrin receptor and ferritin index, both biomarkers measuring iron status, showed a significant, independent and linear association with submaximal exercise capacity (P=.03 for both). In contrast, hemoglobin levels were not significantly associated with 6-minute walk test distance in the multivariable analysis.
In patients with chronic heart failure, iron deficiency but not anemia was associated with impaired submaximal exercise capacity and symptomatic functional limitation.
To determine the prevalence, clinical correlates and the effects on outcome of vitamin B12 and folic acid levels in patients with chronic heart failure (HF).
We studied an international pooled cohort ...comprising 610 patients with chronic HF. The main outcome measure was all-cause mortality.
Mean age of the patients was 68±12 years and median serum N-terminal prohormone brain natriuretic peptide level was 1801 pg/mL (IQR 705-4335). Thirteen per cent of the patients had an LVEF >45%. Vitamin B12 deficiency (serum level <200 pg/mL), folate deficiency (serum level <4.0 ng/mL) and iron deficiency (serum ferritin level <100 µg/L, or 100-299 µg/L with a transferrin saturation <20%) were present in 5%, 4% and 58% of the patients, respectively. No significant correlation between mean corpuscular volume and vitamin B12, folic acid or ferritin levels was observed. Lower folate levels were associated with an impaired health-related quality of life (p=0.029). During a median follow-up of 2.10 years (1.31-3.60 years), 254 subjects died. In multivariable proportional hazard models, vitamin B12 and folic acid levels were not associated with prognosis.
Vitamin B12 and folate deficiency are relatively rare in patients with chronic HF. Since no significant association was observed between mean corpuscular volume and neither vitamin B12 nor folic acid levels, this cellular index should be used with caution in the differential diagnosis of anaemia in patients with chronic HF. In contrast to iron deficiency, vitamin B12 and folic acid levels were not related to prognosis.
In this article, the name of the GLORIA-AF investigator Anastasios Kollias was given incorrectly as Athanasios Kollias in the Acknowledgements. The original article has been corrected.
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