Maria Vittoria Matassini

Cardiac resynchronization therapy improves ejection fraction and cardiac remodelling regardless of patients' age

AIMS Cardiac resynchronization therapy (CRT) improves symptoms and reduces mortality in heart failure (HF) patients, but little data exist on the efficacy of CRT in the elderly. The aim of our study is to define CRT-related benefits in terms of left ventricular ejection fraction (LVEF) improvement in two subgroups of patients (<75 and ≥75 years old) and test possible differences between these two groups. METHODS AND RESULTS Single-centre prospective observational study including 65 patients with optimally treated, advanced HF and indication to CRT. All patients were investigated with clinical evaluation, Minnesota Living with Heart Failure Questionnaire (MLHFQ), 12-lead electrocardiogram, and full echocardiographical study before CRT implant and 3 and 12 months after. Left ventricular ejection fraction showed a time-related improvement in the whole population (+10.6% over 12 months) as well as in each subgroup. The magnitude of LVEF improvement was similar in elderly and non-elderly patients (+13.6 vs. +7.9%; P = ns). Left ventricular diameters, pulmonary artery systolic pressure, New York Heart Association class, MLHFQ score, and QRS width all showed a time-related improvement in the whole population as well as in each subgroup. End-diastolic left ventricular diameter remodelling and QRS width reduction were significantly more pronounced in the elderly, whereas other clinical and instrumental secondary endpoints showed a similar improvement between ≥75 and <75 years old patients. There was no significant difference regarding mortality between elderly and non-elderly patients. CONCLUSION Cardiac resynchronization therapy is as effective in improving LVEF in elderly as in non-elderly patients. Age alone should not be a determinant to restrict resynchronization therapy in HF patients.

Exercise: A "new drug" for elderly patients with chronic heart failure

Patients with chronic heart failure (CHF) experience progressive deterioration of functional capacity and quality of life (QoL). This prospective, randomized, controlled trial assesses the effect of exercise training (ET) protocol on functional capacity, rehospitalization, and QoL in CHF patients older than 70 years compared with a control group. A total of 343 elderly patients with stable CHF (age, 76.90±5.67, men, 195, 56.9%) were randomized to ET (TCG, n=170) or usual care (UCG, n=173). The ET protocol involved supervised training sessions for 3 months in the hospital followed by home-telemonitored sessions for 3 months. Assessments, performed at baseline and at 3 and 6 months, included: ECG, resting echocardiography, NT-proBNP, 6-minute walk test (6MWT), Minnesota Living with Heart Failure Questionnaire, and comprehensive geriatric assessment with the InterRAI-HC instrument. As compared to UCG, ET patients at 6 months showed: i) significantly increased 6MWT distance (450±83 vs. 290±97 m, p<0.001); ii) increased ADL scores (5.00±2.49 vs. 6.94±5.66, p=0.037); iii) 40% reduced risk of rehospitalisation (hazard ratio=0.558, 95%CI, 0.326-0.954, p=0.033); and iv) significantly improved perceived QoL (28.6±12.3 vs. 44.5±12.3, p<0.001). In hospital and home-based telemonitored exercise confer significant benefits on the oldest CHF patients, improving functional capacity and subjective QoL and reducing risk of rehospitalisation.

Feasibility of a cardiologist-only approach to sedation for electrical cardioversion of atrial fibrillation: A randomized, open-blinded, prospective study

BACKGROUND/OBJECTIVES Sedation with propofol should be administered by personnel trained in advanced airway management. To overcome this limitation, the use of short acting benzodiazepines by cardiologists spread widely, causing concerns about the safety of this procedure in the absence of anesthesiology assistance. The aim of the study was to compare feasibility of a cardiologist-only approach with an anesthesiologist-assisted sedation protocol during elective direct-current cardioversion (DCC) of persistent atrial fibrillation (AF). METHODS This prospective, open-blinded, randomized study included 204 patients, which were admitted for scheduled cardioversion of persistent AF, and randomized in a 1:1 fashion to either propofol or midazolam treatment arm. Patients in the propofol group underwent DCC with anesthesiologist assistance, while patients in the midazolam group saw the cardiologist as the only responsible for both sedation and DCC. RESULTS Twenty-three adverse events occurred: 13 in the propofol group and 10 in the midazolam group (p=NS). Most of them were related to bradyarrhythmias and respiratory depressions. There was no need of intubation or other advanced resuscitation techniques in any of these patients. No differences were found regarding procedure tolerability and safety endpoints between the two groups. DCC procedures with anesthesiology support were burdened by higher delay from scheduled time and higher costs. CONCLUSIONS Sedation with midazolam administered by cardiologist-only appears to be as safe as sedation with propofol and anesthesiologist assistance. Adverse events were few in both groups and easily handled by the cardiologist alone. A cardiologist-only approach to sedation provides less procedural delay, thus being easier to schedule and correlated with fewer costs.

Sleep-disordered Breathing and Atrial Fibrillation: Review of the Evidence

Sleep-disordered breathing and atrial fibrillation are two common medical conditions. A strong association between them has been described and has prompted significant research in understanding the mechanism connecting the two conditions while explaining the synergic negative effects in terms of morbidity and mortality in affected patients. This review focuses first on the pathophysiologic mechanisms favoring the development of atrial fibrillation in patients with sleep-disordered breathing, considering specifically and separately obstructive sleep apnea and central sleep apnea. Then, the effects of these two disorders in specific clinical settings are addressed.

Prognostic implications of mitral regurgitation in patients after cardiac resynchronization therapy

Mitral regurgitation (MR) is a common finding in patients with heart failure with debatable effects on prognosis. Reduction in MR is one of the mechanisms by which cardiac resynchronization therapy (CRT) exerts its beneficial effects. We investigated the prognostic impact of baseline MR and MR persistence after CRT on outcomes of treated patients.

Intravenous vernakalant for the rapid conversion of recent onset atrial fibrillation: systematic review and meta-analysis

Atrial fibrillation is the most common cardiac arrhythmia and is associated with increased mortality and morbidity. Conversion to sinus rhythm is usually appropriate in patients with acute, symptomatic atrial fibrillation in order to reduce symptoms and prevent complications. Electrical cardioversion is the most used and widespread technique, but requires deep sedation and a fasting state. Pharmacological alternatives are burdened by a delayed onset of action and potential proarrhythmic effects. Therefore, new therapeutic options are being sought. Among those, vernakalant, showed a good efficacy profile and a short onset of action, but with conflicting evidence regarding potential serious adverse events. This drug profile will summarize the pharmacology behind this new drug and review recent evidence in terms of safety and efficacy.

Symptomatic atrial fibrillation and risk of cardiovascular events: data from the Euro Heart Survey

Aims Atrial fibrillation (AF) is associated with a wide range of clinical presentations. Whether and how AF symptoms can affect prognosis is still unclear. Aims of the present analysis were to investigate potential predictors of symptomatic AF and to determine if symptoms are associated with higher incidence of cardiovascular (CV) events at 1-year follow-up. Methods and results The Euro Heart Survey on Atrial Fibrillation included 3607 consecutive patients with documented AF and available follow-up regarding symptoms status. Patients found symptomatic at baseline were classified into still symptomatic (SS group; n = 896) and asymptomatic (SA; n = 1556) at 1 year. Similarly, asymptomatic patients at baseline were classified into still asymptomatic (AA group; n = 903) and symptomatic (AS group; n = 252) at 1 year. Demographics, as well as clinical variables and medical treatments, were tested as potential predictors of symptoms persistence/development at 1-year. We also compared CV events between SS and SA groups, and AS and AA groups at 1-year follow-up. Both persistence and development of AF symptoms were associated with an increased risk of CV hospitalization, stroke, heart failure worsening, and thrombo-embolism. AF type, hypothyroidism, chronic heart failure, and chronic obstructive pulmonary disease (COPD), were independently associated with an increased risk of symptomatic status at 1-year follow-up between SS and SA groups. Conclusion Persistence or development of symptoms after medical treatment are associated with an increased risk of CV events during a 1-year follow-up. Type of AF, along with hypothyroidism, COPD and chronic heart failure are significantly associated with symptoms persistence despite medical treatment.

Current Therapeutic Options for Heart Failure in Elderly Patients

Heart failure (HF) is a major and growing public health problem with high morbidity and mortality (Ponikowski et al., 2016). It affects 1-2% of the general population in developed countries, and the average age at diagnosis is 76 years. Because of a better management of acute phase and comorbidities, HF incidence is increasing in elderly patients, with a prevalence rising to 10% among people aged 65 years or older (Mozaffarian et al., 2014). Therefore, a substantial number of elderly patients need to be treated. However, because of clinical trial exclusion criteria or coexisting comorbidities, currently recommended therapies are widely based on younger population with a much lower mean age. In this review, we will focus on available pharmacological, electrical, and mechanical therapies, underlining pros, cons, and practical considerations of their use in this specific patient population.

ST Elevation Related to the Site of Coronary Occlusion

Coronary artery disease (CAD) is the most common cause of death in the whole world. Acute myocardial infarction with ST elevation (STEMI) is a clinical syndrome characterized by the typical symptoms of myocardial ischemia with electrocardiographic ST elevation (persistent for more than 20 min) and following release in cardiac biomarkers. Coronary atherosclerosis complicated by coronary thrombosis with totally occlusion of the coronary artery is the main cause of STEMI. So, mechanical or pharmacological reperfusion should be considered as soon as possible and dual antiplatelet therapy and anticoagulant drugs should be administered. Arrhythmias are very frequent in the acute phase of STEMI, and every kind of arrhythmia could be seen.

New anthyarrhythmic drugs for atrial fibrillation

Atrial fibrillation (AF) is a common arrhythmia associated with increased mortality and morbidity. Different studies have shown no significant difference between rhythm and rate control strategies in terms of mortality. Moreover, the use of antiarrhythmic drugs is afflicted by cardiac and extracardiac toxicity and related costs of hospitalization. Nevertheless, some patients require a rhythm-control strategy and new anti-AF agents are being sought. Only few novel agents showed promising results in term of efficacy and safety. Dronedarone and vernakalant are two of these compounds, respectively introduced for the chronic and acute rhythm control of AF. This article will review pharmacology and clinical evidence on the use of dronedarone and vernakalant and will mention currently investigated new antiarrhythmic drugs.