Sandra Alves

Influence of remote monitoring on long-term cardiovascular outcomes after cardioverter-defibrillator implantation

AIMSnDevice-based remote monitoring (RM) has been linked to improved clinical outcomes at short to medium-term follow-up. Whether this benefit extends to long-term follow-up is unknown. We sought to assess the effect of device-based RM on long-term clinical outcomes in recipients of implantable cardioverter-defibrillators (ICD).nnnMETHODSnWe performed a retrospective cohort study of consecutive patients who underwent ICD implantation for primary prevention. RM was initiated with patient consent according to availability of RM hardware at implantation. Patients with concomitant cardiac resynchronization therapy were excluded. Data on hospitalizations, mortality and cause of death were systematically assessed using a nationwide healthcare platform. A Cox proportional hazards model was employed to estimate the effect of RM on mortality and a composite endpoint of cardiovascular mortality and hospital admission due to heart failure (HF).nnnRESULTSn312 patients were included with a median follow-up of 37.7months (range 1 to 146). 121 patients (38.2%) were under RM since the first outpatient visit post-ICD and 191 were in conventional follow-up. No differences were found regarding age, left ventricular ejection fraction, heart failure etiology or NYHA class at implantation. Patients under RM had higher long-term survival (hazard ratio [HR] 0.50, CI 0.27-0.93, p=0.029) and lower incidence of the composite outcome (HR 0.47, CI 0.27-0.82, p=0.008). After multivariate survival analysis, overall survival was independently associated with younger age, higher LVEF, NYHA class lower than 3 and RM.nnnCONCLUSIONnRM was independently associated with increased long-term survival and a lower incidence of a composite endpoint of hospitalization for HF or cardiovascular mortality.

Cardiac rehabilitation after acute coronary syndrome: Do all patients derive the same benefit?

INTRODUCTIONnCardiac rehabilitation (CR) has been demonstrated to improve exercise capacity in acute coronary syndrome (ACS), but not all patients derive the same benefit. Careful patient selection is crucial to maximize resources.nnnOBJECTIVEnTo identify in a heterogeneous ACS population which patients would benefit the most with CR, in terms of functional capacity (FC), by using cardiopulmonary exercise testing (CPET).nnnMETHODSnA retrospective analysis of consecutive ACS patients who underwent CR and CPET was undertaken. CPET was performed at baseline and after 36 sessions of exercise. Peak oxygen uptake (pVO2), percentage of predicted pVO2, minute ventilation/CO2 production (VE/VCO2) slope, VE/VCO2 slope/pVO2 and peak circulatory power (PCP) (pVO2 times peak systolic blood pressure) were assessed in two moments. The differences in pVO2 (ΔpVO2), %pVO2, PCP and exercise test duration were calculated. Patients were classified according to baseline pVO2 (group 1, <20 ml/kg/min vs. group 2, ≥20 ml/kg/min) and left ventricular ejection fraction (group A, <50% vs. group B, ≥50%).nnnRESULTSnWe analyzed 129 patients, 86% male, mean age 56.3±9.8 years. Both group 1 (n=31) and group 2 (n=98) showed significant improvement in FC after CR, with a more significant increase in pVO2, in group 1 (ΔpVO2 4.4±7.3 vs. 1.6±5.4; p=0.018). Significant improvement was observed in CPET parameters in group A (n=34) and group B (n=95), particularly in pVO2 and test duration.nnnCONCLUSIONnPatients with lower baseline pVO2 (<20 ml/kg/min) presented more significant improvement in FC after CR. CPET which is not routinely used in assessement before CR in context of ACS, could be a valuable tool to identify patients who will benefit the most.

A link to better care: The effect of remote monitoring on long-term adverse cardiac events in a propensity score-matched cohort

AIMSnThere are conflicting data regarding the clinical benefits of device-based remote monitoring (RM). We sought to assess the effect of device-based RM on long-term clinical outcomes in recipients of implantable cardioverter-defibrillators (ICDs).nnnMETHODSnWe assessed the incidence of adverse cardiac events, overall mortality and device therapy efficacy and safety in a propensity score-matched cohort of patients under RM compared to patients under conventional follow-up. Data on hospitalizations, mortality and cause of death were systematically assessed using a nationwide healthcare platform. The primary outcome was time to a composite outcome of first hospital admission for heart failure or cardiovascular death.nnnRESULTSnOf a total of 923 implantable device recipients, 164 matched patients were identified (84 under RM, 84 under conventional follow-up). The mean follow-up was 44 months (range 1-123). There were no significant differences regarding baseline characteristics in the matched cohorts. Patients under RM had a significantly lower incidence of the primary outcome (hazard ratio [HR] 0.42, confidence interval [CI] 0.20-0.88, p=0.022); there was a non-significant trend towards lower overall mortality (HR 0.53, CI 0.27-1.04, p=0.066). No significant differences between cohorts were found regarding appropriate therapies (RM vs. conventional follow-up, 8.1 vs. 8.2%, p=NS) or inappropriate therapies (6.8 vs. 5.0%, p=NS).nnnCONCLUSIONnIn a propensity score-matched cohort of ICD recipients with long-term follow-up, RM was associated with a lower rate of a combined endpoint of hospital admission for heart failure or cardiovascular death.

The arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapy.

INTRODUCTIONnBaroreflex function is an independent marker of prognosis in heart failure (HF). However, little is known about its relation to response to cardiac resynchronization therapy (CRT). The aim of this study is to assess arterial baroreflex function in HF patients who are candidates for CRT.nnnMETHODSnThe study population consisted of 25 patients with indication for CRT, aged 65±10 years, NYHA functional class ≥III in 52%, QRS width 159±15 ms, left ventricular ejection fraction (LVEF) 29±5%, left ventricular end-systolic volume (LVESV) 150±48 ml, B-type natriuretic peptide (BNP) 357±270 pg/ml, and peak oxygen consumption (peak VO2) 18.4±5.0 ml/kg/min. An orthostatic tilt test was performed to assess the baroreflex effectiveness index (BEI) by the sequence method. This group was compared with 15 age-matched healthy individuals.nnnRESULTSnHF patients showed a significantly depressed BEI during tilt (31±12% vs. 49±18%, p=0.001). A lower BEI was associated with higher BNP (p=0.038), lower peak VO2 (p=0.048), and higher LVESV (p=0.031). By applying a cut-off value of 25% for BEI, two clusters of patients were identified: lower risk cluster (BEI >25%) QRS 153 ms, LVESV 129 ml, BNP 146 pg/ml, peak VO2 19.0 ml/kg/min; and higher risk cluster (IEB ≤25%) QRS 167 ms, LVESV 189 ml, BNP 590 pg/ml, peak VO2 16.2 ml/kg/min.nnnCONCLUSIONSnCandidates for CRT show depressed arterial baroreflex function. Lower BEI was observed in high-risk HF patients. Baroreflex function correlated closely with other clinical HF parameters. Therefore, BEI may improve risk stratification in HF patients undergoing CRT.

Sortilina e risco de doença cardiovascular

Plasma low-density lipoprotein cholesterol (LDL-C) levels are a key determinant of the risk of cardiovascular disease, which is why many studies have attempted to elucidate the pathways that regulate its metabolism. Novel latest-generation sequencing techniques have identified a strong association between the 1p13 locus and the risk of cardiovascular disease caused by changes in plasma LDL-C levels. As expected for a complex phenotype, the effects of variation in this locus are only moderate. Even so, knowledge of the association is of major importance, since it has unveiled a new metabolic pathway regulating plasma cholesterol levels. Crucial to this discovery was the work of three independent teams seeking to clarify the biological basis of this association, who succeeded in proving that SORT1, encoding sortilin, was the gene in the 1p13 locus involved in LDL metabolism. SORT1 was the first gene identified as determining plasma LDL levels to be mechanistically evaluated and, although the three teams used different, though appropriate, experimental methods, their results were in some ways contradictory. Here we review all the experiments that led to the identification of the new pathway connecting sortilin with plasma LDL levels and risk of myocardial infarction. The regulatory mechanism underlying this association remains unclear, but its discovery has paved the way for considering previously unsuspected therapeutic targets and approaches.

How expensive is the decision to suture a meniscal tear? Surgical and monetary concerns in a workers’ compensation population

The cost of meniscal sutures and the rate of failure are important concerns in a workers compensation population. Hypothesis We prospectively analysed our cohort of workers’ compensation patients operated to a meniscal tear in a two years’ period (2013 and 2014) to test two hypothesis: patients submitted to a meniscus suture stay out of work for a longer period of time–monetary compensation is smaller in patients with the sutured meniscus. Material and methods We prospectively analysed a sample of 51 consecutive patients, under 45 years, submitted to either a meniscal suture or a partial meniscectomy (minimum follow-up of 12 months). The exclusion criteria where unstable knees, relevant cartilage lesion (outerbridge gradexa0>xa0=xa0III) and any concomitant surgical procedures (like ligament reconstruction). The patients were analysed using this criteria: cost of surgery (in euros) –sick leave period, permanent disability (measured in percentage) which will lead to monetary compensation, pre and postoperative Lysholm and IKDC scores. Results There were 51 patients consecutively operated due to a meniscal tear who met the inclusion criteria. The patients were divided in–Group A–31 patients submitted to partial meniscectomy, Group B–20 patients submitted to meniscal suture The follow-up was similar between groups–group A (average 21, 8xa0months; min 15, max 28) group B (average 20,3xa0months; min 12, max 47). In Group A (meniscectomy) the direct cost of the surgery was 1373,8€ (min 1241,52; max 1584,2). Clinical preoperative scores–Lysholm–average 14,9; min 1; max 57.–IKDC–average 20,8; min 5,7; max 47,1. Final postoperative scores - Lysholm- average 63,2; min 16; max 92.–IKDC–average 61,7; min 12,6; max 97,7. Overall 90,3% were satisfied with the treatment result. Permanent disability–8,94% (SD37) The sick leave period was 152,13 (average, with 72,7SD) In Group B, (meniscal suture) the direct cost of the surgery was 1979,8,8€ (min 2462,4; max 4080). Clinical preoperative scores–Lysholm–average 15,7; min 0; max 30.–IKDC–average 21,1; min 8; max 65,5. Final postoperative scores–Lysholm average 88,7; min 70; max 100.–IKDC (at discharge) –average 86; min 34,5; max 100. All patients were satisfied with the treatment result. Permanent disability–1,65% (SD 1,98) The sick leave period was 228,75 (average, with 327 SD). Conclusion The cost of surgery is significantly higher in the suture group ( P P

Original ArticleThe arterial baroreflex effectiveness index in risk stratification of chronic heart failure patients who are candidates for cardiac resynchronization therapyO índice de eficácia do barorreflexo na estratificação de risco de doentes com insuficiência cardíaca crónica candidatos à terapêutica de ressincronização cardíaca

Introduction nBaroreflex function is an independent marker of prognosis in heart failure (HF). However, little is known about its relation to response to cardiac resynchronization therapy (CRT). The aim of this study is to assess arterial baroreflex function in HF patients who are candidates for CRT.