Marcelo Trivi

Relation of left ventricular ejection fraction and functional capacity with metabolism and inflammation in chronic heart failure with reduced ejection fraction (from the MIMICA Study).

Catabolism and inflammation play a role in the physiopathology of heart failure with reduced ejection fraction and are more pronounced in the advanced stages of the disease. Our aim was to demonstrate that in patients with stable heart failure with reduced ejection fraction adequately treated, a direct relation exists between functional impairment, as evaluated by left ventricular ejection fraction (LVEF) and the 6-minute walking distance (6MWD), and catabolic and inflammatory markers. In 151 outpatients with heart failure and a LVEF of < or =40% (median age 64 years, LVEF 29%, and 6MWD 290 m) we measured the laboratory and body composition parameters that indicate directly or indirectly inflammatory activation, anabolic-catabolic balance, and nutritional status. We performed an analysis stratified by quartiles of LVEF and 6MWD and linear regression analysis to explore our hypothesis. In the linear regression analysis, after adjusting for age, gender, and etiology, LVEF was not related to the metabolic, inflammatory, or nutritional parameters. The 6MWD was directly related to albumin (p = 0.002) and log transformation of dehydroepiandrosterone (p = 0.013) and inversely to adiponectin (p = 0.001) and the log-transformation of high-sensitivity C-reactive protein (p = 0.037). In conclusion, in a population with stable heart failure with reduced ejection fraction, the 6MWD was related to the degree of inflammatory activity and catabolism, but LVEF was not. Even a slightly diminished functional capacity implies underlying inflammation and catabolic activation.

Mechanism involved in the paradoxical effects of active smoking following primary angioplasty: a subanalysis of the protection of distal embolization in high-risk patients with acute myocardial infarction trial.

Objective Cigarette smokers have an unexplained low mortality following ST-segment elevation acute myocardial infarction (STEMI). Our aim was to determine whether the presence of active smoking has a beneficial effect on myocardial reperfusion following primary percutaneous intervention (PCI). Methods A total of 140 STEMI patients treated with primary PCI were included in the analysis. All patients have 24-h ST-segment monitoring, each analyzed by an independent, blinded core laboratory. We divided the population according to the smoking status: active (n = 56) and nonactive smokers (n = 84). Results Both groups had similar baseline characteristics, except that active smokers were younger than nonsmokers. Postprocedural thrombolysis in myocardial infarction (TIMI) flow grade and TIMI frame were better in smokers whereas myocardial blush grade was similar between groups. Percentage of complete (≥70%) ST-segment resolution (STR) at 60 min was higher in active smokers than in nonactive smokers (76.4 versus 50%, P = 0.002). Multivariate logistic regression analysis identified active smoking as an independent predictor of complete STR at 60 min (OR 3.47; 95% CI 1.48–8.14; P = 0.004). At 30 days, no significant differences were found either in mortality (P = 0.62) or in major adverse cardiac events rates (death, reinfarction and congestive heart failure; P = 0.82) between the two groups. Conclusion In STEMI patients undergoing primary PCI, active smoking is associated with better myocardial reperfusion than nonsmoking. This finding may be the mechanism behind the smokers paradox and its beneficial effect in the short-term clinical outcome. These results await further confirmation in larger primary PCI databases.

High-sensitive troponin T levels and complex coronary lesions

window with well-known adverse effects, some of which may themselves be life-threatening. These include ventricular arrhythmias, angina, myocardial infarction, pulmonary edema, sudden sharp increase in blood pressure, and intracranial hemorrhage [8]. Milder adverse effects include anxiety, fear, restlessness, headache, dizziness, palpitations, pallor, and tremor. Patients at higher risk for serious adverse effects from epinephrine are those with comorbidities such as underlying heart disease and those taking monoamine oxidase inhibitors, tricyclic antidepressants, antiarrhythmics, and cocaine [8]. Errors associated with epinephrine administration relate to dosing (related to concentration and ratio dose expressions, ie, 1:1000 and 1:10 000), name (mistaken with ephedrine), and route [8,9]. Furthermore, based on the recommended dosing for children (0.01 mg/kg of 1:1000 solution) and that only 2 fixed doses of epinephrine are available by autoinjector (0.15 and 0.3 mg), children weighing less than 15 kg are overdosed with the 0.15-mg autoinjector, whereas children weighing between 15 and 30 kg are underdosed if treated with 0.15 mg, yet overdosed if treated with 0.3 mg [8]. Despite the potential for adverse effects, medication interactions, and administration errors, epinephrine still remains the first-line treatment for anaphylaxis [2]. For the potentially fatal cases of anaphylaxis refractory to epinephrine, alternative therapies are essential. We feel that the benefits, highlighted in our report [1], compared with the risks, summarized in both our report and this correspondence, favor the use of methylene blue in cases of anaphylaxis refractory to conventional treatment.

Aortic Valve Replacement in a Patient With Osler-Rendu-Weber Disease

Osler-Rendu-Weber (hereditary hemorrhagic telangiectasia) disease is an uncommon disease characterized by the presence of abnormal telangiectasias and arteriovenous malformations that cause recurrent episodes of bleeding. We present a patient with Osler-Rendu-Weber disease, with a history of multiple major bleeding events and severe aortic valve stenosis, who underwent aortic valve replacement. Unexpectedly, the postoperative course was uneventful, and there was no untoward bleeding in the early or in the late postoperative follow-up.

B-type natriuretic peptide predicts complexity and severity of the coronary lesions in patients with acute coronary syndromes

this view. Through paresternal LV long(Fig. 2A) and short-axis views (Figs. 1B and 2B), the hypotrophy pattern of the myocardium can be clearlyvisualizedandquantified(Figs.2 and3);also, valvepathologycan also be ruled out by using both 2-dimensional/color Doppler image. Apical 5-/4-chamber view is recommended during diagnosis of HCM complications such as dynamic LVOT obstruction, mitral valve SAM condition, as well as MR (Fig. 3). Doppler ultrasonography of LVOT flow in this view could also largely facilitate the measurement of pressure gradient during systolic phase (mean pressure gradient≥30 mm Hg at rest) (Fig. 3C). This view can also help to rule out the LV hypotrophy caused by aortic stenosis (Fig. 4A). Different from LVOT obstruction in HCM, the blood flow acceleration point should be located in the aortic valve level rather than the LV flow tract (Fig. 4B-C).

Relationship between collateral circulation and successful myocardial reperfusion in acute myocardial infarction: a subanalysis of the PREMIAR trial.

The aim of this study was to determine whether the presence of collateral circulation had a beneficial effect following primary angioplasty. In all, 114 patients who underwent primary angioplasty were included. Patients with collateral circulation had lower basal ST-segment deviation (P = .004), white cell count ( P = .001), peak creatine kinase (P = .001), and regional wall motion score values (P = .03) than patients without collateral circulation. After the procedure, the group with collaterals was associated with higher rates of normal myocardial blush, complete ST resolution, and shorter time to stable ST-recovery. Multivariable logistic analysis identified the presence of collateral circulation as independent predictor of normal myocardial blush (adjusted odds ratio = 3.98, 95% confidence interval, 1.12-14.09; P = .033) and rapid reperfusion (time to stable ST-segment recovery <7 minutes, adjusted odds ratio = 4.0, 95% confidence interval, 1.57-10.20; P = .004). The presence of collateral circulation has a protective effect on infarct size, resulting in faster reperfusion.

High-sensitivity troponin is associated with high risk clinical profile and outcome in acute heart failure.

BACKGROUND The aim of the study was to evaluate the value of high-sensitivity cardiac troponin (hs-cTn) for identifying high-risk patients. METHODS AND RESULTS One hundred and eighty-seven patients admitted with acute heart failure (HF) (without myocardial infarction) were consecutively included; hs-cTn was measured at admission; the relation between elevated hs-cTn and the clinical outcome during hospitalization and at 90 days was analyzed; 93% (n = 174) had hs-cTn above the maximal normal value (14 ng/L); median hs-cTn was 42 ng/L (IQR 24-81). Patients with ejection fraction (EF) ≤ 45% had higher hs-cTn values (p = 0.0004). Patients with low cardiac output syndrome (LCOS) or shock had higher troponin levels compared with those with less severe clinical presentations (p = 0.004). Patients who required inotropic presented higher troponin values (p = 0.002), troponin values were also higher in those requiring complex therapies (intra-aortic balloon pump, mechanical ventilation or hemodialysis, p = 0.002). At 90-day follow-up, 28 (15.5%) patients died and 27 rehospitalizations occurred (55 events). The risk of events was greater in patients with hs-cTn > 42 ng/L (0.021), low blood pressure at admission (p = 0.002), LCOS or shock (p < 0.0001), EF ≤ 45% (p = 0.005) and inotropic use (p < 0.0001). In multivariate analysis, only inotropic agents requirements was associated independently with a high risk of death or rehospitalizations at 90 days (p = 0.007). CONCLUSIONS Elevation of hs-cTn is a finding almost constant in patients with decompensated HF. In subjects with higher troponin levels ventricular dysfunction is frequent. The use of hs-cTn for risk stratification at admission helps to identify populations with poor outcome during hospitalization and increased risk of death or rehospitalizations during follow-up who will require rapid implementation of aggressive treatment.

Prognostic utility of ischemic response in functional imaging tests (SPECT or stress echocardiography) in low-risk unstable angina patients

BACKGROUND The aim of this study is to determine the ability of ischemic response in imaging stress tests (single-photon emission computed tomography [SPECT] or stress echocardiography [SE]) to predict events in low-risk unstable angina patients. METHODS Three hundred and fifty-nine patients with unstable angina (< 24 h), asymptomatic at admission, without ST-segment elevation or depression, normal troponins, and undergoing SPECT (n = 188) or SE (n = 171) during hospitalization (median = 1 day) were included. A positive imaging test (IMAGING+) was defined as the presence of reversible perfusion defects or wall motion abnormalities in at least 2 contiguous segments. Multivariate models were constructed using these results and clinical variables to predict events at 6 months. RESULTS Ninety-nine (27%) patients had IMAGING+, 72/188 (38%) in SPECT and 27/17 (16%) in SE (p < 0.0001). Events occurred in 84 (23%) patients: 4 had myocardial infarction, 47 new hospitalizations due to angina and 33 coronary artery revascularizations. Independent predictors of coronary artery disease were: IMAGING+ (OR: 6.4, 95% CI: 3.4-11.8, p < 0.0001), history of coronary artery disease (OR: 2.5, 95% CI: 1.2-5.2, p < 0.02) and TIMI risk (OR: 1.5, 95% CI: 1.1-2.2, p < 0.03). CONCLUSIONS In low-risk unstable angina patients, an ischemic response in functional stress tests (SPECT or SE) was associated with adverse events and severe coronary artery disease.

Vernakalant: Perception of state of health in patients with a recent-onset atrial fibrillation

BACKGROUND Vernakalant is a new, safe and effective drug used intravenously, which has proved to be more rapid in converting recent onset atrial fibrillation (AF) to sinus rhythm compared to placebo, amiodarone, propafenone, and flecainide in clinical studies. Until now no study has been conducted comparing the perception of state of health in patients who received vernakalant versus propafenone or flecainide for conversion of recent-onset AF. The aim of our study is to compare the change of perception of state of health from screening to hour 2 in patients treated with vernakalant and propafenone or flecainide for conversion of recent-onset AF. METHODS Eighty hemodynamically stable patients with recent onset AF without structural heart disease were prospectively included. A single oral dose of propafenone 600 mg was administered to 30 patients, 30 patients received intravenous vernakalant and the remaining 20 patients received a single oral dose of flecainide 300 mg. Clinical, laboratory variables and perception of state of health from screening to hour 2 treated with these drugs measured by the EQ-5 D quality-of-life assessments visual analog scale were recorded. RESULTS Baseline characteristics were similar in the three groups. Treatment with vernakalant resulted in a significantly greater improvement in patient perception of state of health at hour 2 compared with propafenone and flecainide. In the vernakalant group, a mean increase (from baseline) of 12.1 points was seen compared with a mean increase of 5.4 points in the propafenone group or 5.2 points in flecainide group (p < 0.01). CONCLUSIONS The change of perception of state of health from screening to hour 2 treated with vernakalant had a significantly statistical improvement compared with propafenone or flecainide for conversion recent-onset AF.

Flecainide or Propafenone vs Vernakalant for Conversion of Recent-Onset Atrial Fibrillation

To the Editor: Several studies have demonstrated the efficacy of flecainide and propafenone for conversion of recent-onset atrial fibrillation (AF) to sinus rhythm. Randomized controlled studies demonstrated conversion to sinus rhythm within 8 hours in about 70% of patients treated with either agent. A single oral dose of flecainide or propafenone is widely used for conversion of recent-onset AF in hemodynamically stable patients without structural heart disease. The European guidelines consider flecainide or propafenone class IA agents for this application. Vernakalant is a novel, rapidly acting intravenous drug with proven effectiveness and safety compared with placebo and amiodarone in randomized clinical trials. Our study compared the time for conversion of recent-onset AF in patients treated with vernakalant vs flecainide or propafenone. Hemodynamically stable patients (n 1⁄4 51) with recentonset AF without structural heart disease were prospectively and consecutively included. Patients received single oral doses of flecainide 300 mg (n 1⁄4 15) or propafenone 600 mg (n 1⁄4 19), or intravenous vernakalant (n 1⁄4 17) at standard doses. Baseline characteristics were similar in all groups. Median time to conversion to sinus rhythm was 161 minutes (interquartile range [IQR], 125-312 minutes) in the flecainide group, 166 minutes (IQR, 120-300 minutes) in the propafenone group, and 9 minutes (IQR, 6-18 minutes) in the vernakalant group (P 1⁄4 0.0001 vs flecainide or propafenone). Median hospital stay was shorter in the vernakalant group, 238 minutes (IQR, 190-278 minutes), vs flecainide, 402 minutes (IQR, 337-741 minutes; P 1⁄4 0.001), or propafenone, 416 minutes (IQR, 337-741 minutes; P 1⁄4 0.001). We conclude that conversion of AF to sinus rhythm is faster with vernakalant than with flecainide or propafenone