Francesco Accardi

Atrial fibrillation in heart failure patients: Prevalence in daily practice and effect on the severity of symptoms. Data from the ALPHA study registry

Estimates of the prevalence of atrial fibrillation (AF) in heart failure (HF) originate from patients enrolled in clinical trials.

Prevention of Syncope through Permanent Cardiac Pacing in Patients with Bifascicular Block and Syncope of Unexplained Origin: The PRESS Study

Background—Syncope in patients with bifascicular block (BFB) is a common event whose causes might be difficult to assess. Methods and Results—Prevention of syncope through permanent cardiac pacing in patients with bifascicular block (PRESS) is a multicenter, prospective, randomized, single-blinded study designed to demonstrate a reduction in symptomatic events in patients with bifascicular block and syncope of undetermined origin implanted with permanent pacemaker. Device programming mode (NASPE/BPEG code) at DDD with a lower rate of 60 ppm is compared with backup pacing at DDI with a lower rate of 30 ppm. The end point consisted of (1) syncope, (2) symptomatic presyncopal episodes associated with a device intervention (ventricular pacing), and (3) symptomatic episodes associated with intermittent or permanent atrioventricular block (any degree). One hundred one patients were enrolled and randomized. Primary end point events at 2 years were observed in 23 patients, with a significant lower incidence in the study group (hazard ratio, 0.32; 95% confidence interval [CI], 0.10–0.96; P=0.042). Reduction of any symptoms, associated or not with device intervention, was superior in DDD60 compared with DDI30 (hazard ratio, 0.4; 95% confidence interval, 0.25–0.78; P=0.0053). Fourteen patients developed other rhythm diseases and met class I indication for pacing. The annual incidence of rhythm disease development was 7.4%. Conclusions—In patients with bifascicular block and syncope of undetermined origin, the use of a dual chamber pacemaker programmed to DDD60 led to a significant reduction of syncope or symptomatic events associated with a cardioinhibitory origin, compared with DDI30 programming. Symptoms associated with a new onset of rhythm disease were found in 15% of the population at 2 years.

Risk stratification of ischaemic patients with implantable cardioverter defibrillators by C-reactive protein and a multi-markers strategy: results of the CAMI-GUIDE study

AIMS Patients at risk of sudden cardiac death (SCD) after myocardial infarction (MI) can be offered therapy with implantable cardioverter defibrillators (ICDs). Whether plasma biomarkers can help risk stratify for SCD and ventricular arrhythmias (VT/VF) is unclear. METHODS AND RESULTS The primary objective of the CAMI-GUIDE study is to assess the predictive role of C-reactive protein for SCD or VT/VF in ischaemic patients with the ejection fraction <30% and ICDs. Secondary endpoints included all-cause mortality, hospitalizations, and death from heart failure. Additional analyses incorporated cystatin-C and NT-ProBNP in multi-marker approach for the prediction of adverse outcomes. A total of 300 patients were enrolled. All-cause mortality at 2 years was 22.6%, mortality from heart failure was 8.3%. Primary endpoint occurred in 17.3%. At a competing risk multivariable analysis adjusted for baseline variables, no significant difference in primary endpoint was found between patients with C-reactive protein ≤3 vs. >3 mg/L [heart rate (HR) 0.91 (0.50-1.64) P = 0.76], while C-reactive protein >3 mg/L was strongly associated with mortality due to heart failure [HR: 3.17 (1.54-6.54) P = 0.002]. NT-proBNP above median was significantly associated with the primary endpoint [adjusted HR: 1.46 (1.020-2.129) P = 0.042]. A risk function, including the three biomarkers, NYHA class and resting HR, allowed stratification of patient mortality risk from 5 to 50%. CONCLUSION C-reactive protein >3 mg/L is not associated with SCD or fast VT/VF, however, is a strong predictor of HF mortality. Biomarkers combined with clinical markers allow an excellent risk stratification of mortality at 2 years.

Predictors of mortality and hospitalization for cardiac causes in patients with heart failure and nonischemic heart disease: a subanalysis of the ALPHA study.

Background: Several studies have searched for predictors of clinical outcome in patients with heart failure (HF). However, since they were collected in clinical trials, most data were subject to selection biases and do not specifically apply to patients with nonischemic heart disease. This study examined the impact of several variables on combined all‐cause mortality and hospitalization for cardiac causes, in consecutive ambulatory patients with HF included in the ALPHA registry.

Compliance to MADIT and MUSTT criteria for implantable cardioverter defibrillator therapy in the pre-SCD-Heft and MADIT II era. Data from a multicenter Italian study

The follow-up of 1440 consecutive post-MI patients (68.9 ± 10.9 years) with an LVEF ≤ 40% was analyzed in 19 Italian hospitals to evaluate how many patients with clinical nonsustained VT and inducible sustained VT or VF underwent post-discharge risk assessment (RA). During 38 (range, 4-76) months follow-up, 611 patients (42.4%) qualified for and 294 (20.4%) effectively underwent RA combining LVEF assessment and Holter monitoring, 29 (2.0%) subsequently underwent programmed electrical stimulation and 19 (1.3%) received an ICD.

Effects of cardiac resynchronization therapy on insulin-like growth factor-1 in patients with advanced heart failure

Background Although a more favorable neurohormonal balance may contribute to improving symptoms following cardiac resynchronization therapy (CRT), no information is available regarding the effects of CRT on insulin-like growth factor-1 (IGF-1). This study assessed the effects of CRT on IGF-1 levels and their correlation with changes in quality of life and left ventricular (LV) function. Methods and Results Patients with cardiomyopathy in New York Heart Association class III or IV (n = 18; age 71 ± 10 years), left ventricular ejection fraction (LVEF) ≤ 40% and QRS ≥ 130 ms or ventricular dyssynchrony were enrolled in the study and followed up for 6 months. After 3 months, there was an improvement in LVEF (from 29 ± 7 to 33 ± 10%, P = 0.0136) and quality of life (from 33 ± 14 to 13 ± 12, P = 0.0000) and an increase in IGF-1 levels (from 137 ± 79 to 175 ± 111 ng/ml, P = 0.01353). The change in quality of life correlated with changes in IGF-1 levels (P = 0.02) but not with LVEF changes. Conclusions In patients with advanced heart failure, CRT leads to a significant increase in plasma IGF-1 levels within 3 months. This increase is correlated with the improvement in quality of life, whereas the increase in LVEF is not. This finding suggests that IGF-1 may play a role as a mediator in the early phase of symptomatic improvement after CRT.