Arcadio García-Alberola

A systematic Review of the Literature on Home Monitoring for Patients with Heart Failure

We conducted a systematic review of the literature for assessing the value of home monitoring for heart failure (HF) patients. The abstracts of 383 articles were read. We excluded those in which either no home monitoring was done or only the technical aspects of the telemedicine application were described. Forty-two studies met the selection criteria. We classified the results into feasibility (technical and institutional) and impact (on the clinical process, on patient health, on accessibility and acceptability of the health system, and on the economy). Evaluating the articles showed that home monitoring in HF patients is viable, given that: (1) it appears to be technically effective for following the patient remotely; (2) it appears to be easy to use, and it is widely accepted by patients and health professionals; and (3) it appears to be economically viable. Furthermore, home monitoring of HF patients has been shown to have a positive impact on: (1) the clinical process, supported by a significant improvement of patient follow-up by adjustment of treatment, diet or behaviour, as well as hospital readmissions and emergency visits reduction; (2) the patients health, supported by a relevant improvement in quality of life, a reduction of days in hospital, and a decrease in mortality; and (3) costs resulting from the use of health resources.

Incidence, Clinical Characteristics, and Prognostic Significance of Right Bundle-Branch Block in Acute Myocardial Infarction: A Study in the Thrombolytic Era

BACKGROUNDnWhereas the significance of right bundle-branch block (RBBB) in acute myocardial infarction was extensively studied in the prethrombolytic era, a possible change in the overall incidence and meaning of RBBB as a consequence of thrombolytic therapy is not well known.nnnMETHODS AND RESULTSnA multicenter, prospective study of 1238 patients consecutively diagnosed with acute myocardial infarction and admitted to three coronary care units was conducted. ECGs during the acute phase and clinical events until discharge and 1-year follow-up were monitored. In the 135 (10.9%) patients in whom RBBB was found, there were 51 (37.8%) new cases, 46 (34.1%) old cases, and 38 (28.1%) cases with an indeterminate time of origin. New RBBB was permanent in 26 and transient in 25 patients. RBBB was isolated in 76 (56%) and bifascicular in the remaining 59 (44%) patients. The following complications were more frequently associated with RBBB than non-RBBB patients: heart failure, 24% versus 46% (P<.001); use of pacemaker because of atrioventricular block, 3.6% versus 11% (P<.001); and 1-year mortality, 17.6% versus 40.7% (P<.001). Early mortality was significantly higher for new RBBB (43.1%, P<.001) than for old (15.5%) and indeterminate (15.3%) RBBB. These figures for 1-year mortality were 58.8% (P<.001), 35.5 (P<.01), and 23% (NS), respectively. Permanent and transient RBBB had different mortality rates: early mortality, 76% versus 8%, and 1-year mortality, 84% versus 32% (P<.001 for both). For isolated RBBB versus bifascicular block, early mortality was 14.4% versus 40.6%, and 1-year mortality was 30.2% versus 54.2% (P<.05 for both). Multivariate analysis showed an independent prognostic value of RBBB for early and 1-year mortality.nnnCONCLUSIONSnThe overall meaning of RBBB in acute myocardial infarction has not changed in the thrombolytic era, although a higher rate of new and transient RBBB and a lower rate of bifascicular block may represent a beneficial effect of thrombolytic therapy.

Prognostic significance of diabetes in acute myocardial infarction. Are the differences linked to female gender

A prospective study of acute myocardial infarction was carried out in 1239 patients in order to assess both the prognostic significance of diabetes mellitus and the clinical characteristics associated with age and gender. Diabetes mellitus (DM) was found in 386 cases, often associated with old age, female gender, and more prevalent history of angina, heart failure, and hypertension. DM patients were admitted later and they were less likely to receive thrombolytic therapy, 47.9 vs. 58.1% (P<0.001). Complications more often associated with DM were: heart failure, 45 vs. 24.5% (P<0.01), and early, in-hospital and 1-year mortalities, 7.2 vs. 3.9% (P<0.05), 17.6 vs. 9.1% (P<0.001), and 29.2 vs. 16.2% (P<0.001), respectively. Compared with diabetic men, diabetic women were older and had a more prevalent history of hypertension and congestive heart failure. Diabetic women also had a higher rate of heart failure during hospitalisation, and of mortality, than diabetic men: early: 11.7 vs. 4.5% (P<0.01); in-hospital: 29.6 vs. 10.3% (P<0.001); and 1-year: 42.7 vs. 21.1% (P>0.001). DM was not selected by the multivariate analysis as a variable with independent prognostic value for mortality. In separate multivariate analysis for diabetic and non-diabetic patients, female gender had independent prognostic value for mortality only in the case of the diabetic population.

High-sensitivity troponin T as a biomarker for the development of atrial fibrillation after cardiac surgery.

OBJECTIVESnAtrial fibrillation (AF) occurs in ∼ 30% of patients undergoing coronary artery bypass grafting (CABG) and in 40% of patients after valve surgery. High-sensitivity cardiac troponin T (hsTnT) is a specific and high-sensitivity marker of myocardial injury, while N-terminal proB-type natriuretic peptide (NT-proBNP) is an established biomarker for wall remodelling. We investigated whether hsTnT and NT-proBNP levels could be used as valuable biomarkers for AF occurrence after cardiac surgery.nnnMETHODSnWe included consecutive haemodynamically stable patients undergoing programmed cardiac surgery with cardiopulmonary bypass pump. We determined hsTnT and NT-proBNP levels before and after cardiac surgery and recorded AF development by prolonged electrocardiogram monitoring.nnnRESULTSnWe included 100 patients with predominantly aortic valve (n = 42) or ischaemic heart (n = 58) diseases. Twenty-nine patients (29%) developed post-surgical AF. Patients developing AF had a longer hospital stay (P = 0.005). hsTnT levels increased after surgery [P < 0.001], indicating perioperative myocardial injury, with higher presurgery levels in patients who developed AF [P = 0.015]. Body mass index and EuroSCORE risk scale were independently associated with higher hsTnT levels presurgery. On univariate analysis, age (P = 0.048), male sex (P = 0.031), indexed left atrial volume (P = 0.042), β-blockers treatment (P = 0.024), type of surgery (valve surgery vs CABG; P = 0.034), EuroSCORE risk scale (P = 0.025) and higher preoperative hsTnT levels (P = 0.009) were predictors of AF development, but NT-proBNP did not reach statistical significance (P = 0.060). hsTnT levels in blood samples obtained the day after surgery were not associated with post-surgical AF development (P = 0.165). In a multivariate model, only higher hsTnT levels before cardiac surgery (>11.87 ng/l) [Odds Ratio, OR; (95% Confidence interval, CI) 4.27 (1.43-12.77), P = 0.009] and male sex [OR 5.10 (1.72-15.13), P = 0.003)] were independently associated with the occurrence of post-surgical AF.nnnCONCLUSIONnHigh presurgical hsTnT levels were independently predictive of patients developing AF after cardiac surgery. hsTnT levels determined post-surgery suggest that cardiac perioperative myocardial injury is not associated with postoperative AF development. NT-proBNP did not reach statistical significance as a biomarker for AF prediction.

Clinical and prognostic characteristics associated with age and gender in acute myocardial infarction: a multihospital perspective in the Murcia region of Spain.

Age and female gender have been associated with poor prognosis in acute myocardial infarction (AMI). Data currently available about the prognostic significance of gender in AMI might well have led to inappropriate/incomplete conclusions. A multicenter, prospective study on 1239 patients with AMI was conducted. Clinical characteristics, complications during the acute phase and one-year follow-up were monitored. Women constituted 24.1% of all patients. Female patients were older with more prevalence of diabetes, hypertension, and previous congestive heart failure. Compared with men, the following complications were more frequently found in women: heart failure, 43% vs. 22% (pu2009<u20090.001); reinfarction, 5% vs. 2% (pu2009<u20090.05); use of pacemaker, 7% vs. 4% (pu2009<u20090.05). Women had higher mortality: early, during the first 24 hours post-admission, 10.7 vs. 3.1%; in-hospital, 23% vs. 8.1%; and 1-year, 33.7% vs. 16% (pu2009<u20090.001 for all the 3 cases of mortality). In the age-groups considered (<65, 65–74, and ≥u200975 years), 1-year mortality increased exponentially with ageing in men: 7.8%, 21.3%, and 38.9%, whereas in women the figures were: 15.3%, 41.5%, and 38.8%. Multivariate analysis showed that, among other variables, age and female gender had independent prognostic value for in-hospital mortality whereas gender lost its prognostic significancy for 1-year mortality. Multivariate analysis restricted to those patients aged over 75 years showed that age but not gender had independent prognostic value. In conclusion, age and female sex have independent prognostic value for predicting mortality in patients with AMI. Mortality increases exponentially with ageing in men whereas it stabilises in the case of women over 65 years. Female gender loses its independent value for predicting mortality in patients over 75 years.

Comparative determination and monitoring of biomarkers of necrosis and myocardial remodeling between radiofrequency ablation and cryoablation.

Biomarkers of necrosis and inflammation have been found raised after radiofrequency ablation (RF). There is scarce information on biomarkers’ behavior after cryoablation. Our aim was to study biomarkers of necrosis, inflammation, and interstitial remodeling after two different approaches: RF versus cryoablation.

Short-Term Variability of Heart Rate Turbulence in Chronic Heart Failure

BACKGROUNDnHeart rate turbulence (HRT) is associated with risk in chronic heart failure (CHF). The objectivexa0of this study was to assess the short-term variability of HRT and to compare the diagnostic yield of 7-day (7DH) versus 24-hour (1DH) Holter monitoring for calculating HRT in a CHF population.nnnMETHODS AND RESULTSnForty-nine consecutive patients with CHF were studied. At inclusion, 7DH was performed to evaluate the variability of HRT parameters. For categorized analyses, turbulence onset (TO) ≥0% and turbulence slope (TS) ≤2.5 ms/RR were defined as abnormal, and patients were classified into subgroups based on the number of abnormal HRT parameters.The cumulative percentage of patients with calculable HRT increased from 69.4% with 1DH to 93.9% with 7DH. The intraclass correlation coefficients across the 7-day monitoring were 0.81 (95% confidence interval [CI] 0.70-0.89) for TO and 0.90 (95% CI 0.84-0.95) for TS. When comparing 2 randomly selected days, TO and TS values were similar (P > .1) and showed a strong correlation (TO: rxa0= 0.79; TS: rxa0= 0.84: P < .001). Bland-Altman plots showed a mean difference of 0.31% (95% CI -0.07 to 0.70) for TO and 0.44 ms/RR (95% CI -1.37 to 0.48) for TS. In contrast, categorized analyses showed that up to 16% of patients changed their HRT subgroup score from day 1 to day 2 of comparison.nnnCONCLUSIONSnIn this population, 7DH significantly increased the percentage of patients with calculable HRT parameters. The short-term variability of the quantitative HRT values was good, but when patients were categorized into the established HRT subgroups, the concordance was suboptimal.

Galectin-3 as a marker of interstitial atrial remodelling involved in atrial fibrillation

Remodelling in the atria could appear as a result of hypertension, diabetes or ischaemic heart disease. Galectin-3 (Gal-3) is a mediator of profibrotic pathways and a potential biomarker of cardiac remodelling. We prospectively recruited consecutive patients undergoing elective cardiac surgery. Preoperative Gal-3 levels were determined from serum samples, and the presence of fibrosis was assessed from atrial appendage tissue samples obtained during cardiac surgery. We included 100 patients with aortic valve or ischaemic heart diseases and 15 controls with permanent AF. Gal-3 levels were associated with sex, left atrial volume, previous cardiac disease, diabetes mellitus, hypertension, NYHA and NT-proBNP. We observed differences in serum Gal-3 concentrations between patients and controls with permanent AF (pu2009=u20090.020). We performed ROC curves related to fibrosis and established a cutoff point for Gal-3 >13.65u2009ng/ml. Multivariate analyses showed previous cardiac disease, NYHA scale and high Gal-3 to be independent predictors of fibrosis. After adjustment for confounding factors, atrial fibrosis remained the only independent factor for the development of AF (pu2009=u20090.022). High Gal-3 serum levels predict fibrosis of the atrial appendage. NYHA scale and previous cardiac disease were also associated with tissue fibrosis in patients undergoing surgery. Atrial fibrosis was the only independent predictor for post-operative AF occurrence in our model after correcting for confounding factors.

Long-term characterization of persistent atrial fibrillation: wave morphology, frequency, and irregularity analysis

AbstractnShort-term properties of atrial fibrillation (AF) frequency, f-wave morphology, and irregularity parameters have been thoroughly studied, but not long-term properties. In the present work, f-wave morphology is characterized by principal component analysis, introducing a novel temporal parameter defined by the cumulative normalized variance of the three largest principal components