Rhidian J. Shelton

A randomised, controlled study of rate versus rhythm control in patients with chronic atrial fibrillation and heart failure: (CAFÉ-II Study)

Background: Atrial fibrillation (AF) and heart failure (HF) often coexist. The aim was to investigate whether restoring sinus rhythm (SR) could improve cardiac function, symptoms, exercise capacity and quality of life (QoL) in patients with chronic heart failure. Methods: Patients with HF and persistent AF receiving guideline-recommended treatments, including anticoagulants, were eligible for the study. Patients were randomised to either rhythm (treated with amiodarone for at least 3 months prior to attempting biphasic external cardioversion and continued amiodarone long-term if SR was restored) or rate control. Anticoagulants were continued throughout the study regardless of rhythm, unless contraindications developed. Both groups were treated with beta blockers and/or digoxin to reduce the heart rate to <80 bpm at rest and <110 bpm after walking. Symptoms, walk distance (6-minute corridor walk test, 6MWT), QoL and cardiac function were assessed at baseline and 1 year. Results: 61 patients with HF and persistent AF (median duration 14 months (IQR 5 to 32)) were randomly assigned to a rate or rhythm control strategy. Of patients assigned to rhythm control (n = 30), 66% were in SR at 1 year, and 90% of those assigned to rate control (n = 31) achieved the heart rate target. At 1 year, NYHA class (p = 0.424) and 6MWT distance (p = 0.342) were similar between groups but patients assigned to rhythm control had improved LV function (p = 0.014), NT-proBNP concentration (p = 0.046) and QoL (p = 0.019) compared with those assigned to rate control. Greatest improvement was seen in patients in whom SR was maintained. Conclusion: Restoring SR in patients with AF and heart failure may improve QoL and LV function when compared with a strategy of rate control.

Effect of a community heart failure clinic on uptake of β blockers by patients with obstructive airways disease and heart failure

Objective: To determine the pattern of β blocker prescribing over one year in a heart failure clinic with a structured approach towards initiation and dose titration and to give a real life perspective on β blocker use, compliance, and target dose achievement. Methods: Data were retrospectively analysed on 513 consecutive patients regularly attending a community heart failure clinic over a year. Systolic dysfunction was determined from two dimensional echocardiography (left ventricular ejection fraction ⩽ 40%) and lung function was assessed by spirometry. All patients were considered for β blocker initiation and dose up titration. Results: Within one year 157 patients died. 143 patients started β blockers resulting in 315 (88%) patients taking β blockers at one year; 38% were taking the target dose. 124 had evidence of airways obstruction at baseline, 100 (81%) of whom were taking β blockers at one year. Forced expiratory volume in one second (1.1 v 1.5 l, p < 0.01) and forced vital capacity (2.3 v 2.5 l/min, p  =  0.2) were not reduced in patients with airways obstruction who received β blockers. Daily doses of β blockers at one year did not differ statistically between patients with obstructive and patients with non-obstructive spirometry results. 12 patients discontinued β blockers and 14 required dose reduction due to side effects. Conclusion: The majority of patients with heart failure and obstructive airways disease can safely tolerate low dose initiation and gradual up titration of β blockers.

Clinical trials update from the American Heart Association meeting: Omega-3 fatty acids and arrhythmia risk in patients with an implantable defibrillator, ACTIV in CHF, VALIANT, the Hanover autologous bone marrow transplantation study, SPORTIF V, ORBIT and PAD and DEFINITE

The American Heart Association meeting reported the results of several clinical trials of particular interest to those who care for patients with heart failure. Ω‐3 fatty acids were associated with a trend to increased recurrence of ventricular arrhythmias but not mortality in patients with an implantable debrillator. The ACTIV in CHF study provides more evidence of a therapeutic role for arginine vasopressin antagonists in the treatment of heart failure. The VALIANT study provides further evidence to suggest that a combination of angiotensin receptor antagonist and ACE inhibitor does not reduce mortality but may reduce morbidity in post‐MI patients with heart failure or major LV systolic dysfunction. A study of autologous bone marrow cell transplantation into myocardial scar give gave encouraging results. SPORTIF V showed ximelagation to be as effective as warfarin but with improved safety. ORBIT and PAD showed public access defibrillators saved lives but questioned their cost effectiveness. DEFINITE supported a role for ICDs in patients with non‐ischemic cardiomyopathy, although cost‐effectiveness remains in doubt.

Clinical trials update from the American Heart Association meeting: ACORN‐CSD, primary care trial of chronic disease management, PEACE, CREATE, SHIELD, A‐HeFT, GEMINI, vitamin E meta‐analysis, ESCAPE, CARP, and SCD‐HeFT cost‐effectiveness study

This article provides information and a commentary on landmark trials presented at the American Heart Association meeting held in November 2004, relevant to the pathophysiology, prevention, and treatment of heart failure. An open trial of the ACORN Cardiac Support Device (CSD) showed encouraging preliminary results in patients with severe heart failure. The PEACE (Prevention of Events with Angiotensin‐Converting Enzyme inhibition) study supports data from previous studies showing that ACE inhibitors reduce vascular events in patients at increased risk. The CREATE (clinical trial of metabolic modulation in acute MI treatment evaluation) study of patients with acute myocardial infarction (MI) showed no mortality benefit of a glucose/insulin/potassium regimen, but treatment with reviparin reduced the incidence of death, MI, or stroke. Azimilide was not associated with a significant reduction in shocks, but reduced the shocks or episodes of markedly symptomatic ventricular tachycardia terminated by pacing in the SHIELD (Shock Inhibition Evaluation with Azimilide) study. The addition of isosorbide dinitrate plus hydralazine to standard therapy improved survival in black heart failure patients in the A‐HeFT (African—American Heart Failure Trial) study. In an investigation of hypertensive patients with diabetes, carvedilol had fewer adverse effects on diabetic control than metoprolol. A meta‐analysis of high‐dose vitamin E supplementation suggested an association with increased mortality. The ESCAPE (Evaluation Study of CHF and Pulmonary Artery Catheterisation Effectiveness) study showed no benefit of pulmonary artery catheterisation over clinical management in patients with severe heart failure. Routine prophylactic coronary revascularisation for stable coronary disease prior to major vascular surgery showed no benefit in the CARP (Coronary Artery Revascularization Prophylaxis) study. Analysis of data from SCD‐HeFT supports the cost‐effectiveness of ICDs in heart failure, although overall cost implications may be prohibitive.

Real-world outcome from ST elevation myocardial infarction in the very elderly before and after the introduction of a 24/7 primary percutaneous coronary intervention service

BACKGROUND It remains unclear whether the superiority of primary percutaneous coronary intervention (PPCI) over thrombolysis for the treatment of ST elevation myocardial infarction (STEMI) extends to the very elderly. Furthermore, the deliverability and efficacy of PPCI in over the 80s has not been investigated in a real-world setting. The aim of this study was to compare outcome from STEMI in patients aged > or =80 before and after the introduction of routine 24/7 PPCI. METHODS Retrospective observational analysis of all patients aged > or =80 presenting with STEMI to 2 neighboring hospitals in the 3-year period after the introduction of a 24/7 PPCI service and in the preceding 2 years when reperfusion therapy was by thrombolysis. RESULTS Two hundred fifty-six STEMI patients aged > or =80 were included. After the introduction of PPCI, 84% (136/161) received reperfusion therapy, 73% PPCI, and 12% thrombolysis, compared to 77% ([73/95] 1% PPCI, 76% thrombolysis) previously. Mortality after inception of PPCI was reduced at 12 months (29% vs 41%, P = .04) and 3 years (43% vs 58%, P = .02). Improved outcome was attributable to treatment by PPCI, which was associated with numerically lower 12-month (26% vs 37%, P = .07) and significantly reduced 3-year (42% vs 55%, P = .05) mortality compared to thrombolysis. CONCLUSIONS Primary PCI can be effectively delivered to very elderly patients presenting with ST elevation MI in a real-world setting and leads to a substantial reduction in mortality compared to patients treated by thrombolysis.

Cardiac output does not limit submaximal exercise capacity in patients with chronic heart failure.

Mechanisms of exercise limitation in patients with chronic heart failure (CHF) are incompletely understood. During matched submaximal, fixed‐rate exercise, oxygen uptake is similar in patients and healthy controls. However, the importance of cardiac output (CO) remains unresolved. We aimed to determine the effect of submaximal exercise on CO and other haemodynamic variables in patients with CHF using a validated non‐invasive inert gas rebreathing system.

The Atrial Fibrillation Paradox of Heart Failure

The prevalence of atrial fibrillation (AF) in patients with heart failure (HF) is high, but longitudinal studies suggest that the incidence of AF is relatively low. The authors investigated this paradox prospectively in an epidemiologically representative population of patients with HF and persistent AF. In all, 891 consecutive patients with HF [mean age, 70+/-10 years; 70% male; left ventricular ejection fraction, 32%+/-9%] were enrolled. The prevalence of persistent AF at baseline was 22%. The incidence of persistent AF at 1 year was 26 per 1000 person-years, ranging from 15 in New York Heart Association class I/II to 44 in class III/IV. AF occurred either at the same time or prior to HF in 76% of patients and following HF in 24%. A risk score was developed to predict the occurrence of persistent AF. The annual risk of persistent AF developing was 0.5% (0%-1.3%) for those in the low-risk group compared with 15% (3.4%-26.6%) in the high-risk group. Despite a high prevalence of persistent AF in patients with HF, the incidence of persistent AF is relatively low. This is predominantly due to AF coinciding with or preceding the development of HF. The annual risk of persistent AF developing can be estimated from clinical variables.

Three‐Year Clinical Outcome with the Endeavor™ Zotarolimus‐Eluting Stent in Primary Percutaneous Coronary Intervention for ST Elevation Myocardial Infarction: The Endeavor™ Primary PCI Study (E‐PPCI)

Primary percutaneous coronary intervention (PPCI) is superior to thrombolysis in STEMI (ST segment elevation myocardial infarction) patients. Data on late stent thrombosis (ST) have raised concerns regarding the use of drug-eluting stents during PPCI. We report the first 3-year clinical evaluation of the zotarolimus-eluting stent (ZES) in patients undergoing PPCI for STEMI, a single-center, prospective cohort study of consecutive patients admitted with STEMI. All underwent PPCI within 12 hours of symptoms; each received one or more ZES in one or more target lesions. All patients received aspirin 300 mg, clopidogrel 600 mg, abciximab, and unfractionated heparin. A total of 102 STEMI patients (76 male, mean 62 years) received 162 ZES (mean 1.6 stents/patient). Median call-to-balloon time was 123 (102-152) minutes. Thirty-day combined major adverse cardiovascular event (MACE) rate was 3.9% (n = 4). Subacute ST occurred in 2 patients (1.96%). Combined MACE rates at 12 months and 3 years were 7.8% (n = 8) and 13.7% (n = 14). Late ST occurred in 1 patient (1%) with no occurrence of very late ST. This is the first 3-year report of the use of the ZES in an unselected, consecutive PPCI population. Overall 3-year incidence of MACE and target lesion revascularization (5.9%) was low, and was comparable to that seen with sirolimus- and paclitaxel-eluting stents in randomized controlled trials. At 3 years there was no occurrence of very late ST.

A comparison between monophasic and biphasic defibrillation for the cardioversion of persistent atrial fibrillation in patients with and without heart failure

AIMS Atrial fibrillation (AF) and heart failure commonly coexist. Restoring sinus rhythm using external direct current cardioversion (DCCV) may improve left ventricular function, exercise capacity and quality of life (QoL). However, DCCV may be less successful at restoring sinus rhythm in patients with heart failure. We aimed to determine whether biphasic DCCV was superior to monophasic DCCV for the restoration of sinus rhythm in patients with heart failure. METHODS 592 consecutive cardioversion procedures were performed on 503 patients for persistent AF, 261 (44%) procedures using monophasic defibrillation and 331 (56%) using biphasic. Patients with symptomatic heart failure were identified for further analysis. RESULTS 173 cardioversions were performed on 149 patients with heart failure. The overall success rate of cardioversion in this group was 82.7% (83.3% and 82.2% for monophasic and biphasic respectively). There was no difference in the success rate of cardioversion for those with heart failure compared to those without heart failure (p = 0.141). Furthermore, there was no substantial difference in success rates according to defibrillation type (83.3% v. 84.2% for monophasic and 82.2% v. 88.5% for biphasic, p = 0.502 and 0.085 respectively). CONCLUSION External defibrillation is similarly effective at restoring SR in patients with and without HF and both mono- and biphasic shocks have a high rate of success. However, significantly less energy (maximal and cumulative) is required to restore SR using biphasic defibrillation.

Improving quality of life and functional capacity in atrial fibrillation and congestive heart failure.

We read with interest the paper by Suman-Horduna et al. ([1][1]) published in the January 2013 issue of the Journal . The investigators analyzed important quality-of-life data from a substantial substudy (n = 749) of a landmark trial ([2][2]), comparing rate control to rhythm control for patients