Krister Lindmark

NT-proBNP and troponin T levels differ after haemodialysis with a low versus high flux membrane

Background Brain natriuretic peptide (BNP), N-terminal-proBNP (NT-proBNP), and high sensitive cardiac troponin T (TnT) are markers that are elevated in chronic kidney disease and correlate with increased risk of mortality. Data are conflicting on the effect of biomarker levels by hemodialysis (HD). Our aim was to clarify to what extent HD with low-flux (LF) versus high-flux (HF) membranes affects the plasma levels of BNP, NT-proBNP, and TnT. Methods and Materials 31 HD patients were included in a crossover design, randomized to start dialysis with a LF-HD or HF-HD dialyzer. Each patient was his/her own control. The dialyses included in the study were the first treatments of two consecutive weeks with each mode of dialysis. Patients normally on hemodiafiltration (HDF) also performed a HDF the third week. Values after HD were corrected for extent of ultrafiltration. Results During LF-HD the biomarkers NT-proBNP and TnT increased (15 versus 6%, P≤.001) while there was a slight decrease in BNP (P<.05). During HF-HD the NT-proBNP, BNP and TnT levels decreased (P≤.01 for all). During HDF all three markers decreased (P<.01 for all). The rise in TnT during LF-HD correlated with dialysis vintage (months on HD, r = .407, P = .026), Kt/V-urea (r = .383, P = .037), HD time in hours/treatment (r = .447, P = .013) and inversely with residual urinary output (r = -.495, P = .005). The baseline levels of BNP and NT-proBNP correlated with blood pressure. Conclusions Cardiac biomarkers increase slightly during LF-HD. A HF-HD eliminates the biomarkers and can mask increases caused by, e.g., myocardial infarction.

Long-term follow-up of mitral valve regurgitation—Importance of mitral valve pathology and left ventricular function on survival

BACKGROUND Timing of surgery for mitral regurgitation (MR) is one of the more difficult decisions for the practicing cardiologist. METHODS AND RESULTS In order to determine useful clinical cut-offs, we investigated the influence of baseline echocardiographic predictors for survival in a long-time follow-up cohort. Data from 144 patients with MR were collected between 1989 and 1993. Five-year mortality for MR patients was 30% compared to 13% for age- and sex matched controls (p<0.001). Each mm increase in left ventricular end systolic diameter (LVESD increased mortality with 2.5% (p<0.05) and each percent decrease in ejection fraction (EF) increased mortality with 1.8% (p<0.05). These effects were not linear and this material suggests cut-off points for LVESD to be 40 mm and EF 50%. Degree of MR did not correlate with survival, but patients with severe MR were operated more often than those with moderate MR. Patients with functional MR had reduced survival compared to patients with structural MR (p<0.01). CONCLUSIONS MR is a disease with greatly increased mortality and these data suggest a more aggressive approach to surgery.

Serum selenium and ceruloplasmin in nigerians with peripartum cardiomyopathy.

The study aimed to determine if selenium deficiency, serum ceruloplasmin and traditional birth practices are risk factors for peripartum cardiomyopathy (PPCM), in Kano, Nigeria. This is a case-control study carried out in three hospitals, and PPCM patients were followed up for six months. Critically low serum selenium concentration was defined as <70 µg/L. A total of 39 PPCM patients and 50 controls were consecutively recruited after satisfying the inclusion criteria. Mean serum selenium in patients (61.7 ± 14.9 µg/L) was significantly lower than in controls (118.4 ± 45.6 µg/L) (p < 0.001). The prevalence of serum selenium <70 µg/L was significantly higher among patients (76.9%) than controls (22.0%) (p < 0.001). The mean ceruloplasmin and prevalence of socio-economic indices, multiparity, pregnancy-induced hypertension, obesity and twin pregnancy were not different between the groups (p > 0.05). Logistic regression showed that rural residency significantly increased the odds for serum selenium <70 µg/L by 2.773-fold (p = 0.037). Baseline serum levels of selenium and ceruloplasmin were not associated with six-month mortality. This study has shown that selenium deficiency is a risk factor for PPCM in Kano, Nigeria, and is related to rural residency. However, serum ceruloplasmin, customary birth practices and some other characteristics were not associated with PPCM in the study area.

Eligibility of sacubitril-valsartan in a real-world heart failure population: a community-based single-centre study: Sacubitril-valsartan in a real-world heart failure population

This study aims to investigate the eligibility of the Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitor (ARNI) with ACE inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM‐HF) study to a real‐world heart failure population.

One Year Survival in Nigerians with Peripartum Cardiomyopathy

Background: Peripartum cardiomyopathy (PPCM) is common in North-Western Nigeria. This study aimed to describe the 1-year survival and left ventricular reverse remodeling (LVRR) in a group of patients with PPCM from three referral hospitals in Kano, Nigeria. Methods: PPCM was defined according to recommendations of the Heart Failure (HF) Association of the European Society of Cardiology Working Group on PPCM. LVRR was defined as absolute increase in left ventricular ejection fraction (LVEF) by ≥10.0% and decrease in left ventricular (LV) end-diastolic dimension indexed to body surface area ≤33.0 mm/m2, while recovered LV systolic function as LVEF ≥55%, at 12 months follow-up. Results: A total of 54 newly diagnosed PPCM patients with mean age of 26.6 ± 6.7 years, presented with classical features of predominantly left-sided HF and 33 of them qualified for follow-up. Of the 17 survivors at 12 months, 8 patients (47.1%) satisfied the criteria for LVRR, of whom 5 (29.4%) had recovered LV systolic function (LVEF ≥55%), but LVRR was not predicted by any variable in the regression models. The prevalence of normal LV diastolic function increased from 11.1% at baseline to 35.3% at 12 months (P = 0.02). At 1-year follow-up, 41.4% of patients had died (two-thirds of them within the first 6 months), but mortality was not predicted by any variable including LVRR. Conclusions: In Kano, PPCM patients had modest LVRR but high mortality at 1-year. Further studies should be carried out to identify reasons for the high mortality and how to curb it.

Electrocardiographic predictors of peripartum cardiomyopathy.

Summary Objective To identify potential electrocardiographic predictors of peripartum cardiomyopathy (PPCM). Methods: This was a case–control study carried out in three hospitals in Kano, Nigeria. Logistic regression models and a risk score were developed to determine electrocardiographic predictors of PPCM. Results: A total of 54 PPCM and 77 controls were consecutively recruited after satisfying the inclusion criteria. After controlling for confounding variables, a rise in heart rate of one beat/minute increased the risk of PPCM by 6.4% (p = 0.001), while the presence of ST–T-wave changes increased the odds of PPCM 12.06-fold (p < 0.001). In the patients, QRS duration modestly correlated (r = 0.4; p < 0.003) with left ventricular dimensions and end-systolic volume index, and was responsible for 19.9% of the variability of the latter (R2 = 0.199; p = 0.003). A risk score of ≥ 2, developed by scoring 1 for each of the three ECG disturbances (tachycardia, ST–T-wave abnormalities and QRS duration), had a sensitivity of 85.2%, specificity of 64.9%, negative predictive value of 86.2% and area under the curve of 83.8% (p < 0.0001) for potentially predicting PPCM. Conclusion In postpartum women, using the risk score could help to streamline the diagnosis of PPCM with significant accuracy, prior to confirmatory investigations

Combined electrical and global markers of dyssynchrony predict clinical response to Cardiac Resynchronization Therapy

Abstract Aim. To assess potential additional value of global left ventricular (LV) dyssynchrony markers in predicting cardiac resynchronization therapy (CRT) response in heart failure (HF) patients. Methods. We included 103 HF patients (mean age 67 ± 12 years, 83% male) who fulfilled the guidelines criteria for CRT treatment. All patients had undergone full clinical assessment, NT-proBNP and echocardiographic examination. Global LV dyssynchrony was assessed using total isovolumic time (t-IVT) and Tei index. On the basis of reduction in the NYHA class after CRT, patients were divided into responders and non-responders. Results. Prolonged t-IVT [0.878 (range, 0.802–0.962), p = 0.005], long QRS duration [0.978 (range, 0.960–0.996), p = 0.02] and high tricuspid regurgitation pressure drop [1.047 (range, 1.001–1.096), p = 0.046] independently predicted response to CRT. A t-IVT ≥ 11.6 s/min was 67% sensitive and 62% specific (AUC 0.69, p = 0.001) in predicting CRT response. Respective values for a QRS ≥ 151 ms were 66% and 62% (AUC 0.65, p = 0.01). Combining the two variables had higher specificity (88%) in predicting CRT response. In atrial fibrillation (AF) patients, only prolonged t-IVT [0.690 (range, 0.509–0.937), p = 0.03] independently predicted CRT response. Conclusion. Combining prolonged t-IVT and the conventionally used broad QRS duration has a significantly higher specificity in identifying patients likely to respond to CRT. Moreover, in AF patients, only prolonged t-IVT independently predicted CRT response.

Obstacles to mineralocorticoid receptor antagonists in a community-based heart failure population

Summary Aim Previous studies and national assessments indicate an undertreatment of mineralocorticoid receptor antagonists (MRA) in heart failure with reduced ejection fraction (HFrEF). This study aimed to investigate why MRA is not used to full extent. Methods A complete community‐based heart failure population was studied. Several variables were collected, and medical records were scrutinized to identify reasons for not prescribing MRA. Results Of 2029 patients, 812 had EF ≤40%. Five hundred and fifty‐three patients (68%) tried MRA at some point but 184 of these (33%) discontinued therapy. There were 259 patients that never tried MRA with 177 with a listed explanation or contraindication. Eighty‐two patients, 10% of the total HFrEF population, had no clear contraindications. They were older and had less HF hospitalizations compared to patients on MRA (P < 0.05) and 32% did not have any follow‐up at the cardiology clinic. Contraindications to MRA were renal dysfunction (93 patients), hypotension (28 patients), and hyperkalemia (25 patients). Only six patients had hyperkalemia without renal dysfunction. Of the patients with renal dysfunction, 66 (72%) had eGFR >30 mL/min. Conclusions The reasons why MRA are underutilized were mainly because of contraindications. However, the data suggest that physicians are overly cautious about moderately reduced kidney function. There seems to be a 10%‐18% avoidable undertreatment with MRA, especially for elderly patients that are admitted to the hospital for other reasons than heart failure. This suggests that patients with heart failure would benefit from routine follow‐up at a cardiology clinic.

Dosing of heart failure treatments in newly diagnosed unselected patients in sweden : compliance with european society of cardiology guidelines

Recent trends in diagnostic work-up among unselected patients newly diagnosed with heart failure : a Swedish population-based studyMitral regurgitation severity correlates with symptoms and extent of left atrial dysfunction : effect of mitral valve repairHeart failure can occur in any age, no depend on sex, but in men and women the mechanism, even if is the same, the fact is that the compromise on pumping function is diferent. AIM We realized a follow-up with 100 female patients during hospitalization with heart failure as a mean diagnostic. These are patient between 60 and 75 years old, with different pathologies: diabetes mellitus, arterial hypertension, obesity, atrial fibrillation, and hypothyroidism. We observed their treatment comparing with a control group (100 men in heart failure) by administering vasodilator and diuretic drugs. Performed echocadiography doppler control, daily renal function, NT pro BNP levels control, oxide nitric response. Results: We observed that ventricular dilation, hypertrophy as tachycardia is more typical in men. Our group demonstrated very fast response to beta blockers and diuretics. The ejection fraction increased in 10-15% faster than in control group. Oxide nitric had not the result we expected. But in men the effect is very high. NT pro BNP levels no were increased as a control group. Recovering renal function in women during heart failure depends on risk factors as diabetes mellitus, obesity, more characteristics for women. Conclusions: In women heart failure has the same mechanism that in men, but more of the cardiac compensatory mechanisms during heart failure as Frank-Starling mechanism, ventricular dilation or hypertrophy and tachycardia present more complications in men; women recover sinus rhythm faster than men, hypertrophy is not characteristic and dilation recovers EF as pumping function is near normal. We do not observed increased sympathetic adrenergic activity in our patients and increased vagal activity to heart. Renin-angiotensin-aldosterone and antidiuretic hormone systems in women is compensated by vasoconstriction improving ventricular stroke volume by reducing afterload on the ventricle. Table 3. NT-pro BN characteristics NT-proBNP cutoff value of 125 pg/mL had the best sensitivity-to-specificity ratio and NPV to rule out asymptomatic LV moderate to severe diastolic or systolic dysfunction in patients at risk for heart failure: 1. Men younger than 60 years (sensitivity, 87.5%; specificity, 92.7%; NPV, 99.5%; positive predictive value [PPV], 33.3%) 2. Women younger than 60 years (sensitivity, 100%; specificity, 84.1%; NPV, 100%; PPV, 33.3%) 3. Men at least age 60 years (sensitivity, 100%; specificity, 77.1%; NPV, 100%; PPV, 32.5%) 4. Women at least age 60 years (sensitivity, 100%; specificity, 69.9%; NPV, 100%; PPV, 21%)

A description of unselected patients with heart failure : a swedish population-based study

Recent trends in diagnostic work-up among unselected patients newly diagnosed with heart failure : a Swedish population-based studyMitral regurgitation severity correlates with symptoms and extent of left atrial dysfunction : effect of mitral valve repairHeart failure can occur in any age, no depend on sex, but in men and women the mechanism, even if is the same, the fact is that the compromise on pumping function is diferent. AIM We realized a follow-up with 100 female patients during hospitalization with heart failure as a mean diagnostic. These are patient between 60 and 75 years old, with different pathologies: diabetes mellitus, arterial hypertension, obesity, atrial fibrillation, and hypothyroidism. We observed their treatment comparing with a control group (100 men in heart failure) by administering vasodilator and diuretic drugs. Performed echocadiography doppler control, daily renal function, NT pro BNP levels control, oxide nitric response. Results: We observed that ventricular dilation, hypertrophy as tachycardia is more typical in men. Our group demonstrated very fast response to beta blockers and diuretics. The ejection fraction increased in 10-15% faster than in control group. Oxide nitric had not the result we expected. But in men the effect is very high. NT pro BNP levels no were increased as a control group. Recovering renal function in women during heart failure depends on risk factors as diabetes mellitus, obesity, more characteristics for women. Conclusions: In women heart failure has the same mechanism that in men, but more of the cardiac compensatory mechanisms during heart failure as Frank-Starling mechanism, ventricular dilation or hypertrophy and tachycardia present more complications in men; women recover sinus rhythm faster than men, hypertrophy is not characteristic and dilation recovers EF as pumping function is near normal. We do not observed increased sympathetic adrenergic activity in our patients and increased vagal activity to heart. Renin-angiotensin-aldosterone and antidiuretic hormone systems in women is compensated by vasoconstriction improving ventricular stroke volume by reducing afterload on the ventricle. Table 3. NT-pro BN characteristics NT-proBNP cutoff value of 125 pg/mL had the best sensitivity-to-specificity ratio and NPV to rule out asymptomatic LV moderate to severe diastolic or systolic dysfunction in patients at risk for heart failure: 1. Men younger than 60 years (sensitivity, 87.5%; specificity, 92.7%; NPV, 99.5%; positive predictive value [PPV], 33.3%) 2. Women younger than 60 years (sensitivity, 100%; specificity, 84.1%; NPV, 100%; PPV, 33.3%) 3. Men at least age 60 years (sensitivity, 100%; specificity, 77.1%; NPV, 100%; PPV, 32.5%) 4. Women at least age 60 years (sensitivity, 100%; specificity, 69.9%; NPV, 100%; PPV, 21%)