Mona Olofsson

Relation of left ventricular geometry and function to aortic root dilatation in patients with systemic hypertension and left ventricular hypertrophy (the LIFE study)

In summary, in hypertensive patients with electrocardiographic LV hypertrophy, aortic root dilatation is associated with increased LV mass, eccentric hypertrophy, and lower chamber contractility as measured by circumferential end-systolic stress/end-systolic volume index. This subgroup of hypertensive patients may be predisposed to increased cardiovascular morbidity and mortality.

Are elderly patients with suspected HF misdiagnosed? : a primary health care center study

Background: Few studies are published on heart failure patients in primary health care, in elderly in advanced age. Objective: The purpose of this study was to examine the accuracy of the diagnosis of heart failure in all men and women with focus on age and gender. Methods: The patients were recruited from one selected primary health care in the city of Skellefteå, Sweden. The general practitioners included all patients who had symptoms and signs indicating heart failure. The patients were then referred for an echocardiographic examination and a final cardiology consultation. Results: The general practitioners identified 121 women and 49 men with suspected heart failure of whom 39% (51 women and 16 men) were above 80 years. Women were significantly older than men (mean age 78 and 75 years, respectively, p = 0.03). The main symptom was dyspnoea (80%). Confirmed heart failure was verified in 45% of the patients and was significantly more common in men than women (p = 0.02). Of all men and women above 80 years, 75% and 22%, respectively (p = 0.01) had a verified systolic heart failure, while there were no significant gender differences in patients younger than 80. In a multivariate regression analysis taking gender, age, smoking, atrial fibrillation, hypertension, angina, myocardial infarction and diabetes into account, myocardial infarction (OR = 4.3, CL = 1.8–10.6) hypertension (OR = 3.4, CI = 1.6–6.9) atrial fibrillation (OR = 2.8, CL = 1.0–7.9) remained significantly predictive of a confirmed diagnosis of heart failure. Conclusion: This study showed the difficulty of diagnosing heart failure accurately based only on clinical symptoms, especially in women above 80 years.

Gender makes a difference in the description of dyspnoea in patients with chronic heart failure.

Background: Dyspnoea is a common symptom of chronic heart failure (CHF). In the community setting, patients with CHF are most often women. Aim: To examine the impact of gender on the description of dyspnoea and to explore which clinical variables support a diagnosis of CHF. Methods: From four primary health care centres, 158 patients with CHF were included. Patients were examined with echocardiography and a cardiologist assessed the diagnosis of CHF. The patients filled in a questionnaire containing 11 descriptors of dyspnoea. Results: A diagnosis of CHF was confirmed in 87 (55%) patients (47 males and 40 females). One descriptor, I feel that I am suffocating, was significantly scored higher in CHF patients (p=0.014) as compared to non-CHF patients. Three descriptors, My breath does not go in all the way (p=0.006), I feel that I am suffocating (p=0.040), and I cannot get enough air (p=0.0327) were significantly scored higher among men with CHF, compared to no descriptor among women with CHF. Being male (OR=2.7; CI: 1.3–5.6, p=0.008), having diabetes (OR=5.6; CI: 1.7–18.2, p=0.004), IHD (OR=3.3; CI: 1.3–8.5, p=0.014), and a borderline significance for age (OR=1.04; CI: 0.99–1.08, p=0.058) predicted a confirmed diagnosis of CHF. Conclusion: Three descriptors of dyspnoea were associated with CHF among men, whereas no such association was found among women. Our results suggest that gender is an important factor and should—together with age, underlying heart disease, and diabetes—be taken into account when symptoms are evaluated in the diagnosis of CHF in primary care.

Remote-Controlled Robotic Arm for Real-Time Echocardiography: The Diagnostic Future for Patients in Rural Areas?

There exists a great clinical need for improving specialist consultation and utilization of echocardiography in areas remote from hospital-based care. This paper presents the development and first technical assessment of a concept of cardiovascular consultation utilizing long distance, real-time echocardiography as a diagnostic tool in rural areas. The development of CARdiological consultation at a DISTance (CARDISTA) was achieved in three stages, comprising tests of different broadband infrastructures, videoconference systems, microphones, cameras, monitors, and loudspeakers. The CARDISTA concept includes a cardiologist and a sonographer, a robotic arm (Medirob), a portable ultrasound machine, and presently available information technology using an advanced broadband backbone. The three stages provided, with some remaining doubts, echocardiographic examination at a distance comparable to hospital-based examinations. A continuous broadband capacity of 20 megabits per second (Mbps) seemed to be a vital component of CARDISTA for achieving the highest-quality imaging. With this broadband capacity, it was possible to achieve a transmission delay below 200 ms. The technical tests of the CARDISTA concept revealed promising results in enabling long distance real-time echocardiography for specialist consultation. CARDISTA is now ready for clinical testing and evaluation in rural areas for patients with heart diseases, especially heart failure.

Exercise and cardiovascular outcomes in hypertensive patients in relation to structure and function of left ventricular hypertrophy: the LIFE study.

Background Exercise lowers blood pressure and improves cardiovascular function, but little is known about whether exercise impacts cardiovascular morbidity and mortality independent of left ventricular hypertrophy (LVH) and LV geometry. Design Observational analysis of prospectively obtained echocardiographic data within the context of a randomized trial of antihypertensive treatment. Methods A total of 937 hypertensive patients with ECG LVH were studied by echocardiography in the Losartan Intervention For Endpoint reduction in hypertension study. Baseline exercise status was categorized as sedentary (never exercise), intermediate (≤ 30 min twice/week), or physically active (>30 min twice/week). During 4.8-year follow-up, 105 patients suffered the primary composite endpoint of myocardial infarction (MI), stroke, or cardiovascular death. Ml occurred in 39, stroke in 60, and cardiovascular death in 33 patients. Results Sedentary individuals (n = 212) had, compared with those physically active (n = 511), higher heart rate (P < 0.001), weight (P < 0.001), body surface area (P = 0.02), body mass index (P < 0.001), LV mass (LVM, P = 0.04), LVM indexed for height or body surface area (P = 0.004); thicker ventricular septum (P = 0.012) and posterior wall (P = 0.016); and larger left atrium (P = 0.006). Systolic variables did not differ. In Cox regression analysis, physically active compared with sedentary patients had lower risk of primary composite endpoint [odds ratio (OR): 0.42, 95% confidence interval (CI): 0.26-0.68, P < 0.001], cardiovascular death (OR: 0.50, 95% CI: 0.22-0.1.10, NS), and stroke (OR: 0.26, 95% CI: 0.13-0.49, P < 0.001) without significant difference for Ml (OR: 0.79, 95% CI: 0.35-1.75, NS) independent of systolic blood pressure, LVM index, or treatment. Conclusion In hypertensive patients with LVH, physically active patients had improved prognosis for cardiovascular endpoints, mortality, and stroke that was independent of LVM. Eur J Cardiovasc Prev Rehabil 16:242-248

Usefulness of natriuretic peptides in primary health care: An exploratory study in elderly patients

Abstract Objective. To explore the negative predictive value (NPV), positive predictive value (PPV), sensitivity, and specificity of natriuretic peptides, cut-off levels, and the impact of gender and age in elderly patients with systolic heart failure (HF). Design. Cross-sectional exploratory study. Setting. One primary healthcare centre. Patients. A total of 109 patients with symptoms of HF were referred for echocardiographic examination with a cardiovascular consultation. Systolic HF was diagnosed (ESC guidelines) in 48 patients (46% men, 54% women, mean age 79 years) while 61 patients (21% men, 79% women, mean age 76 years) had no HF. Main outcome measures. NPV, PPV, sensitivity, specificity, and cut-off levels. Results. Including all 109 patients, NPV was 88% for NT-proBNP (200 ng/L) and 87% for BNP (20 pg/ml). PPV was 81% for NT-proBNP (500 ng/L) and 68% for BNP (50 pg/ml). Sensitivity was 96% for NT-proBNP (100 ng/L) and 96% for BNP (10-20 pg/ml). Specificity was 87% for NT-proBNP (500 ng/L) and 71% for BNP (50 pg/ml). Nt-proBNP (β = 0.035; p < 0.001) and BNP (β = 0.030; p < 0.001) were associated with age, but not with gender. In a multivariate analysis age (β = 0.036; p < 0.001) and male gender (β = 0.270; p = 0.014) were associated with NT-proBNP, but only age for BNP (β = 0.030; p < 0.001). Conclusion. Natriuretic peptides in an elderly population showed high NPVs, but not as high as in younger patients with HF in other studies. Age and male gender were associated with higher levels of NT-proBNP while only age was related to elevated BNP levels.

Telemedicine improves the monitoring process in anticoagulant treatment

We compared the INR (International Normalized Ratio) monitoring process using a telemedicine device with the conventional approach in which blood samples were sent to the hospital for analysis. We conducted a randomized controlled trial. We enrolled 40 patients on chronic warfarin therapy from two primary healthcare centres (PHCs). Half were monitored using the telemedicine device and half were monitored conventionally. Each patient received three INR measurements. The total processing time was measured from blood sampling until warfarin dosing was performed in the anticoagulant clinic. The median total processing time was significantly shorter with telemedicine than usual care (34 vs. 260 min, P < 0.001). This was mainly because sample transport was avoided using the point-of-care device and automatic data transmission. Telemedicine reduced the total processing time for INR monitoring and has the potential to improve the management of patients undergoing anticoagulant treatment at PHCs.

Effects of Atenolol or Losartan on Fibrinolysis and von Willebrand Factor in Hypertensive Patients With Left Ventricular Hypertrophy

Objectives: To compare the effects of the β-blocker atenolol with the angiotensin receptor blocker (ARB) losartan on plasma tissue-type plasminogen activator (tPA) activity and mass concentration, plasminogen activator inhibitor-1 (PAI-1) activity, tPA/PAI-1 complex, and von Willebrand factor (VWF). Design: A prespecified, explorative substudy in 22 patients with hypertension and left ventricular hypertrophy (LVH) performed within randomized multicenter, double-blind prospective study. Results: After a median of 36 weeks of treatment, there were significant differences between the treatment groups, atenolol versus losartan, in plasma median levels of tPA mass (11.9 vs 7.3 ng/mL, P = .019), PAI-1 activity (20.7 vs 4.8 IU/mL, P = .030), and tPA/PAI-1 complex (7.1 vs 2.5 ng/mL, P = .015). In patients treated with atenolol, median levels of tPA mass (8.9-11.9 ng/mL, P = .021) and VWF (113.5%-134.3%, P = .021) increased significantly, indicating a change toward a more prothrombotic state. No significant changes occurred in the losartan group. Conclusion: Losartan treatment was associated with preserved fibrinolytic balance compared to a more prothrombotic fibrinolytic and hemostatic state in the atenolol group. These findings suggest different fibrinolytic and hemostatic responses to treatment in hypertensive patients with LVH.

NTproBNP and ST2 as predictors for all-cause and cardiovascular mortality in elderly patients with symptoms suggestive for heart failure

Abstract Background: A new biomarker, suppression of tumorigenicity 2 (ST2) has been introduced as a marker for fibrosis and hypertrophy. Its clinical value in comparison with N-terminal pro-hormone of brain natriuretic peptide /Amino-terminal pro-B-type natriuretic peptide (NTproBNP) in predicting mortality in elderly patients with symptoms of heart failure (HF) is still unclear. Aim: To evaluate the prognostic value for all-cause- and cardiovascular mortality of ST2 or NTproBNP and the combination of these biomarkers. Patients and methods: One hundred seventy patients patients with clinical symptoms of HF (77 (45%) were with verified HF) were recruited from one selected primary health care center (PHC) in Sweden and echocardiography was performed in all patients. Blood samples were obtained from 159 patients and stored frozen at –70 °C. NTproBNP was analyzed at a central core laboratory using a clinically available immunoassay.ST2 was analyzed with Critical Diagnostics Presage ST2 ELISA immunoassay. Results: We studied 159 patients (mean age 77 ± 8.3 years, 70% women). During ten years of follow up 78 patients had died, out of which 50 deaths were for cardiovascular reasons. Continuous NTproBNP and ST2 were both significantly associated with all-cause mortality (1.0001; 1.00001–1.0002, p = 0.04 and 1.03; 1.003–1.06, p = 0.03), NTproBNP but not ST2 remained significant for cardiovascular mortality after adjustments (1.0001; 1.00001–1.0002, p = 0.03 and 1.01; 0.77–1.06, p = 0.53), respectively. NTproBNP above median (>328 ng/L) compared to below median was significantly associated with all-cause mortality(HR: 4.0; CI :2.46–6.61; p < 0.001) and cardiovascular mortality (HR: 6.1; CI: 3.11–11.95; p < 0.001). Corresponding analysis for ST2 above median (25.6 ng/L) was not significantly associated neither with all-cause mortality (HR; 1.4; CI: 0.89–2.77) nor cardiovascular mortality (HR: 1.3; CI: 0.73–2.23) and no significant interaction of NTproBNP and ST2 (OR: 1.1; CI: 0.42–3.12) was found. Conclusion: In elderly patients with symptoms of heart failure ST2 was not superior to NTproBNP to predict all cause or cardiovascular mortality. Furthermore, it is unclear if the combination of ST2 and NTproBNP will improve long-term prognostication beyond what is achieved by NTproBNP alone.

Anaemia, but not iron deficiency, is associated with clinical symptoms and quality of life in patients with severe heart failure and palliative home care: A substudy of the PREFER trial

BACKGROUND To explore the relationships between anaemia or iron deficiency (ID) and symptoms, quality of life (QoL), morbidity, and mortality. METHODS A post-hoc, non-prespecified, explorative substudy of the prospective randomized PREFER trial. One centre study of outpatients with severe HF and palliative need managed with advanced home care. Associations between anaemia, ID, and the Edmonton Symptom Assessment Scale (ESAS), Euro QoL (EQ-5D), Kansas City Cardiomyopathy Questions (KCCQ) were examined only at baseline but at 6months for morbidity and mortality. RESULTS Seventy-two patients (51 males, 21 females), aged 79.2±9.1years. Thirty-nine patients (54%) had anaemia and 34 had ID (47%). Anaemia was correlated to depression (r=0.37; p=0.001), anxiety (r=0.25; p=0.04), and reduced well-being (r=0.26; p=0.03) in the ESAS; mobility (r=0.33; p=0.005), pain/discomfort (r=0.27; p=0.02), and visual analogue scale of health state (r=-0.28; p=0.02) in the EQ-5D; and physical limitation (r=-0.27; p=0.02), symptom stability; (r=-0.43; p<0.001); (r=-0.25; p=0.033), social limitation;(r=-0.26; p=0.03), overall summary score; (r=-0.24, p=0.046) and clinical summary score; (r=-0.27; p=0.02) in the KCCQ. ID did not correlate to any assessment item. Anaemia was univariably associated with any hospitalization (OR: 3.0; CI: 1.05-8.50, p=0.04), but not to mortality. ID was not significantly associated with any hospitalization or mortality. CONCLUSION Anaemia, but not ID, was associated although weakly with symptoms and QoL in patients with advanced HF and palliative home care.