Virginie Dauphinot

Prevalence and risk factors related to infections of cardiac resynchronization therapy devices

AIMS Device-related infections (DRI) are not well understood in patients implanted with a cardiac resynchronization therapy (CRT) device. The aims of this study were: (i) to evaluate the prevalence of CRT DRI; (ii) to establish the factors predictive of CRT DRI. METHODS AND RESULTS Between January 2001 and May 2007, CRT implantation was performed in 303 patients (247 men, 82%). The mean follow-up was 31 +/- 19 months. Population characteristics were a mean age of 70 +/- 10 years old; 56 female; aetiology includes (202 dilated and 101 ischaemic cardiomyopathy); NYHA class 3.2 +/- 0.3; LVEF (26 +/- 6%), and a QRS width of 171 +/- 31 ms. Thirteen patients developed a DRI: endocarditis in four, pocket erosion in three, pocket abscess in five, and septicaemia in one. The prevalence of DRI was 4.3%. By univariate analysis, predictive factors of DRI were: procedure time (skin to skin: median of 85 vs. 57.5 min; P = 0.03), re-intervention (54 vs. 6.5%; P < 0.0001), haematoma (31 vs. 8.6% P = 0.01), lead dislodgement (23 vs. 6.2%; P = 0.03), dialysis (23.1 vs. 1.72%; P = 0.003), and procedure type [CRT-ICD (8.6%) vs. CRT PM (1.6%) or system up-grade (1.5%); P = 0.03]. Significant correlations were found between re-intervention and lead dislodgement (r = 0.8; P < 0.001), haematoma (r = 0.2; P < 0.001). Four independent predictive factors of DRI were identified as procedure time (P = 0.002); dialysis (P = 0.0001); re-intervention (P = 0.006), and procedure type (CRT-ICD vs. other procedures; P = 0.01). CONCLUSION This study found that the prevalence of CRT DRI is close to 4.3% at 2.6 years (1.7% per year incidence). Four independent predictive factors of infections were identified including re-intervention, procedure time, dialysis, and primo CRT-ICD implantation. These parameters should be part of the risk-benefit evaluation in patients selected for CRT implantation.

Methods in Neuroepidemiology Autonomic Nervous System Activity and Decline as Prognostic Indicators of Cardiovascular and Cerebrovascular Events: The 'PROOF' Study Study Design and Population Sample. Associations with Sleep-Related Breathing Disorders: The 'SYNAPSE' Study

Background: Transversal studies have underlined the association between the decline in autonomic nervous system (ANS) activity and all-cause mortality. However, the predictive value of ANS has never been prospectively assessed in a general population-based cohort. Method: The PROOF (PROgnostic indicator OF cardiovascular and cerebrovascular events) cohort study was designed to prospectively assess the predictive value of ANS activity level in the general population, with regard to cardiovascular and cerebrovascular events, and death. This predictive power will be compared with the usual and newly discovered risk factors for the purposes of developing a risk model. Results: A prospective cohort of elderly subjects aged 65 years upon study entry were recruited from the electoral list of the city of Saint-Etienne, France. Three initial 2-year examination programs were scheduled for 7 years (2001–2007), followed by late events monitoring. At each examination, ANS activity was assessed along with clinical and biological cardiovascular risk factors, brain MRI, neuropsychological evaluation, physical activity profile, and sleep-related breathing disorders. The main study outcomes are stroke, myocardial infarction and death from any cause. A cohort consisting of 1,011 subjects aged 65.6 (0.8) years was constituted. Conclusion: Despite other selective characteristics, the associations between ANS activity and events will be applicable to other populations.Background: Transversal studies have underlined the association between the decline in autonomic nervous system (ANS) activity and all-cause mortality. However, the predictive value of ANS has never been prospectively assessed in a general population-based cohort. Method: The PROOF (PROgnostic indicator OF cardiovascular and cerebrovascular events) cohort study was designed to prospectively assess the predictive value of ANS activity level in the general population, with regard to cardiovascular and cerebrovascular events, and death. This predictive power will be compared with the usual and newly discovered risk factors for the purposes of developing a risk model. Results: A prospective cohort of elderly subjects aged 65 years upon study entry were recruited from the electoral list of the city of Saint-Etienne, France. Three initial 2-year examination programs were scheduled for 7 years (2001–2007), followed by late events monitoring. At each examination, ANS activity was assessed along with clinical and biological cardiovascular risk factors, brain MRI, neuropsychological evaluation, physical activity profile, and sleep-related breathing disorders. The main study outcomes are stroke, myocardial infarction and death from any cause. A cohort consisting of 1,011 subjects aged 65.6 (0.8) years was constituted. Conclusion: Despite other selective characteristics, the associations between ANS activity and events will be applicable to other populations.

New obesity body mass index threshold for self-reported data

Background: Since subjects included in population studies tend to underreport their weight and overestimate their height, obesity prevalence based on these data is often inaccurate. A reduced obesity threshold for self-reported height and weight was proposed and evaluated for its accuracy. Methods: Self-reported heights and weights were compared with measured heights and weights in a Swiss city adult population representative sample. Participants were asked their height and weight and were invited to undergo a health examination, during which these data were measured. An optimal body mass index (BMI) value was assessed using receiver operating characteristic (ROC) curve analysis and its ability to correctly estimate obesity prevalence was tested on an external French population sample. Results: The Swiss population sample consisted of 13 162 subjects (mean age 51.4). The comparison between self-reported and measured data showed that obesity prevalence calculated from declarations was underestimated: among obese subjects (according to measured BMI), 33.6% of men and 27.5% of women were considered to be non-obese according to their self-report. Considering measures as a reference, a lower BMI cut-off of 29.2 kg/m2 was identified for both genders for the definition of obesity based on self-report. Respective misclassification was reduced to 17.9% in men and 16.9% in women. The validation procedure on a French population sample (n = 1858) yielded similar results. Conclusions: The reduced threshold based on self-report allowed a better estimation of obesity prevalence. Its use should be limited to population studies only.

Metabolic Syndrome and Short-Term and Long-Term Heart Rate Variability in Elderly Free of Clinical Cardiovascular Disease: The PROOF Study

OBJECTIVE Autonomic nervous system (ANS) activity decrease has been associated with a higher risk of sudden cardiovascular and cerebrovascular disease. Thus, we explored the relationship between ANS control of the cardiovascular system and metabolic syndrome. METHODS We analyzed the relationship with both short-term and long-term heart rate variability (HRV) and metabolic syndrome in the cross-sectional PROgnostic indicator OF cardiovascular and cerebrovascular events (PROOF) cohort study of 1,011 elderly subjects recruited amongst the inhabitants of the city of Saint Etienne, France, aged 65.6 ± 0.8 years at the inclusion date. Physical examination included measurements of height, weight, systolic and diastolic blood pressure, waist circumference, and biological parameters. HRV variables were measured over 5-min, nighttime, and 24-h periods using Holter monitoring. RESULTS After adjustment for current type 2 diabetes, depression, and smoking, we found that metabolic syndrome status, high-density lipoprotein cholesterol (HDL-C), and waist circumference were significantly (p < 0.05) associated with total power, very-low frequency, low-frequency/high-frequency (LF/HF) ratio, and normalized LF. HDL-C and metabolic syndrome status were significantly associated with decreased long-term HRV variables. Both nighttime and 24-h HRV showed closer associations with metabolic syndrome than did short-term HRV (5-min). Metabolic syndrome severity was associated with a decrease in both the long-term and short-term HRV variables. CONCLUSIONS ANS control alteration of the cardiovascular system was more pronounced when evaluated by long-term than short-term HRV recordings, particularly in women.

C-reactive protein implications in new-onset hypertension in a healthy population initially aged 65 years: the Proof study

Background Because inflammation is known to be related with several cardiovascular diseases, we sought to determine whether C-reactive protein (CRP) might precede the onset of hypertension. Methods The study population was selected from the Proof study cohort including 1011 individuals initially aged 65 years at baseline and followed for 7 years. CRP, ambulatory blood pressure measurement (ABPM) and casual blood pressure were repeatedly measured during examination. Normotensive individuals were selected according to different measurements of blood pressure, self-reported history of hypertension and use of antihypertensive treatment. Results Among 335 individuals, considered normotensive at baseline with ABPM (threshold 135/85 mmHg), with no history of hypertension and no use of antihypertensive treatment, the incidence of hypertension was 9.9% 2 years later. The 2-year risk for new-onset hypertension was 18% greater for 1 mg/l increment of CRP (odds ratio, 1.18; 95% confidence interval, 1.01–1.39). This relationship remained after adjustment for low-density lipoprotein cholesterol, BMI and change in CRP between the two examinations but not after adjustment for 24-h systolic ABPM. Among the 160 individuals considered normotensive at baseline with an additional criterion (casual blood pressure below 140/90 mmHg), the incidence of hypertension was 26.9% 2 years later. The 2-year risk for new-onset hypertension was 52% greater for 1 mg/l increment of CRP (odds ratio, 1.52; 95% confidence interval, 1.17–1.96) after adjustment for systolic ABPM, change in CRP and BMI. Conclusion An elevated baseline CRP value precedes new-onset hypertension at an early stage among an elderly healthy population. Whether CRP measurement can ease the detection of patients likely to develop clinical hypertension remains to be determined.

Effects of Anticholinergic Drugs on Verbal Episodic Memory Function in the Elderly

BackgroundAn increasing number of medications that are frequently prescribed to elderly patients have been identified as having weak but definite anticholinergic properties. Few epidemiological studies have evaluated the impact of these drugs on verbal episodic memory using sensitive and specific neuropsychological testing in an elderly population presenting with cognitive impairment.ObjectivesThe aim of this study was to assess the effect of drugs with anticholinergic properties on verbal episodic memory function in elderly patients presenting for memory evaluation.Study DesignWe performed a retrospective, cross-sectional study that included 134 consecutive elderly outpatients who attended the daycare memory unit of Centre Hospitalier Sud, Lyon, France. We searched the MEDLINE database (1973–2008) to identify drugs with anticholinergic properties. All drugs with well known anticholinergic activity, mild reported anticholinergic effects or in vitro anticholinergic activity were included in the study.MeasurementsWe used the Free and Cued Selective Reminding (FCSR) test to evaluate verbal episodic memory.ResultsThe mean±SD number of drugs with anticholinergic properties taken by the subjects was 0.64±0.82. Fifty percent of the subjects (n = 67) had a prescription for at least one drug with anticholinergic properties and 16% (n = 21) had a prescription for two or more. Drugs with anticholinergic properties most frequently prescribed in our cohort were cardiovascular (furosemide, hydrochlorothiazide, digoxin), antidepressant (paroxetine, sertraline, fluoxetine) and antispasmodic (oxybutynin chloride) drugs. The number of drugs with anticholinergic properties that subjects were taking was associated with reduced performance on tasks that assessed verbal memory (p < 0.05). Neuropsychological test batteries revealed a significant unfavourable effect of use of drugs with anticholinergic activity on episodic verbal memory. Tests evaluating other cognitive functions were not affected by use of drugs with anticholinergic activity. These associations remained following multivariate analysis adjusting for age, sex, education level, number of anticholinergic drugs, number of co-morbidities, diagnosis, behavioural symptoms and depressive symptoms.ConclusionClinicians should assess the current use of drugs with anticholinergic properties in the elderly, particularly in patients presenting for memory evaluation. In such cases, use of other therapeutic alternatives should be considered.

Predictive factors of difficult implantation procedure in cardiac resynchronization therapy.

AIMS The usefulness of cardiac resynchronization therapy (CRT) in patients with congestive heart failure is offset by its long, user-dependent, and technical procedure. No studies have been published regarding factors related to CRT implantation procedure duration and X-ray exposure. Additionally, only a few studies have investigated the predictive factors of primary left ventricular (LV) lead implant failure. The aim of this prospective study was two-fold: (i) to evaluate the prevalence and predictive factors of prolonged CRT implantation procedure and (ii) to identify the predictive factors of primary LV lead implantation failure. METHODS AND RESULTS Between November 2008 and September 2009, 128 consecutive patients underwent CRT implantation; of these, 22 patients (17.2%) were excluded because of CRT generator replacement. Population characteristics were a mean age of 69 +/- 10 years, 28.3% female, New York Heart Association class 3.2 +/- 0.3, LV ejection fraction (LVEF; 29 +/- 6%), and QRS width 146 +/- 23 ms. Cardiac resynchronization therapy implantation was attempted in 106 patients, and first LV lead implantation was obtained in 96 of 106 patients (90.5% primary success). Ten primary implantations failed (9.5%), due to unsuccessful LV lead implants. A second procedure was successfully attempted in six patients with a second more experienced operator (5.7%). Among the remaining four patients, one patient required a surgical epicardial LV lead implantation, and the implantation was not reattempted in the other three patients. The overall success rate of CRT system implantation was 96.2% (102 of 106 patients). Procedure parameters were as follows: LV threshold (1.4 +/- 0.9 V); LV wave amplitude (15 +/- 8 mV); LV impedance (874 +/- 215 ohm); median procedure time (skin to skin), 55 min (45-80); and median of procedure fluoroscopy time, 11 min (6.2-29). In 24 patients (22.6%), difficult procedures requiring >or=85 min of implantation duration occurred. By univariate analysis, predictive factors of difficult implantation were LV ejection fraction (25.6 +/- 6 vs. 30.2 +/- 8%; P = 0.02), LV end-diastolic diameter (72.4 +/- 11 vs. 66 +/- 11 mm; P = 0.01), LV end-systolic diameter (LVESD; 62 +/- 12 vs. 56 +/- 12 mm, P = 0.04), and the operators experience (very experienced operator vs. less experienced operator, P = 0.006). By multivariate analysis, only primary LV lead implantation failure, LVESD, and operators experience were independently associated with difficult procedures. In this patient subset with primary LV lead implant failure (n = 10), the only independent predictive factor was the LV end-systolic volume (P = 0.03). CONCLUSION In this study, the rate of difficult CRT device implantation procedures approached 25%. Both the degree of LV dysfunction and the operators experience were independent predictors of surgical difficulties. Left ventricular end-systolic volume was the only independent predictor of primary LV lead implant failure.

Cognitive complaints, neuropsychological performance and affective disorders in elderly community residents

Background. Previous studies have assessed the relationship between subjective cognitive complaints and objective impairment. While some of them found that cognitive complaints were explained by affective disorders, other researches found a relationship between cognitive complaints and neuropsychological performance. Most of them focused on memory functioning. However, elderly normal adults also display a decline in executive functions. This study aimed to assess the relationship between cognitive complaints, objective memory and executive performance and affective disorders. Methods. This study was carried out with 937 community-dwelling elderly individuals recruited from the electoral list of the city of Saint-Etienne, France. Cognitive complaints were assessed using the MacNair scale. Cognitive performances were measured via a large battery of memory and executive-performance tests chosen for their capacity to detect subtle cognitive impairment. Anxiety and depressive symptoms were assessed using scales devised by Pichot and Goldberg. Results. Cognitive complaints were associated with lower scores on verbal-memory tests and several executive-performance tests. Moreover, affective disorders were related to some of the executive-performance test scores, but they were not related to scores on the Free and Cued Selective Reminding Test, Digit Symbol Substitution Test and Trail Making B scores. Conclusions. Cognitive complaints of the elderly can reflect objective memory and executive-performance impairments, independent of affective disorders. Cognitive complaints should be assessed using both memory and executive-performance tests.

Risk Factors of Caregiver Burden Among Patients with Alzheimer's Disease or Related Disorders: A Cross-Sectional Study

BACKGROUND Caregivers play a major role in the care of patients with dementia and are themselves at higher risk of disease. OBJECTIVES We investigate which factors are associated with caregivers burden of outpatients visiting a memory clinic and how functional autonomy and behavioral and psychological symptoms can influence caregiver burden. METHODS The study population was chosen from outpatients with progressive cognitive complaint. The caregiver burden was measured with the short version of the Zarit Burden Interview (ZBI). The relationship was assessed between the ZBI and the patients characteristics, including Neuropsychiatric Inventory (NPI), Instrumental Activities of Daily Living scale (IADL), the Mini-Mental State Examination (MMSE), etiology, and stage of the cognitive impairment. RESULTS In a population of 548 patients, IADL, NPI, antidepressant drugs, and MMSE were found to be related to ZBI, while diagnosed etiology and disease stage were not significant: ZBI decreased by 0.34 point for every unit of IADL, and by 0.03 point for every unit of MMSE; ZBI increased by 0.03 point for every unit of NPI. From the IADL scale, the ability to handle finances, food preparation, responsibility to take medications, mode of transportation, and ability to use the telephone increased the ZBI. Five areas of the NPI increased the ZBI: apathy, agitation, aberrant motor behavior, appetite disorders (p < 0.001), and irritability (p = 0.03). CONCLUSION Caregivers experience a higher burden due to disease symptoms such as impairment of functional autonomy and behavioral and cognitive impairment, whatever the etiology of the cognitive decline.

Relation of central fat mass to obstructive sleep apnea in the elderly.

STUDY OBJECTIVES Obesity is a recognized risk factor for obstructive sleep apnea syndrome (OSAS). We evaluated whether total trunk and central fat mass (CFM) is associated with OSAS in elderly subjects. DESIGN Cross-sectional. SETTING Body composition assessment by dual-energy X-ray absorbsiometry (DEXA). PARTICIPANTS 749 volunteers aged 67.2 ± 0.8 years (59.4% women). INTERVENTION All participants underwent evaluation of their body composition by DEXA in parallel with clinical and polygraphic assessments. The presence of OSAS was defined by an apnea plus hypopnea index (AHI) ≥ 15. MEASUREMENTS AND RESULTS A total of 44.8% of the population had an AHI < 15, and 55.2% presented OSAS. OSAS subjects were more frequently overweight and had a higher total trunk fat mass and central fat mass (CFM). Correlation analyses revealed that body mass index (r = 0.27, P < 0.001), neck circumference (r = 0.35, P < 0.001), and CFM (r = 0.23, P < 0.001) were significantly related to AHI. Logistic regression analysis indicated that in mild OSAS cases (> 15AHI < 30), BMI (OR: 1.10; 95% CI: 1.03-1.18; P = 0.008), and male gender (OR: 1.49; 95% CI: 1.05-2.12, P = 0.03) were key factors explaining an AHI between 15 and 30. In severe cases (AHI > 30), male gender (OR: 3.65; 95% CI: 2.40-5.55; P < 0.001) and CFM (OR: 1.10; 95% CI: 1.03-1.19; P = 0.009) were significant independent predictors of OSAS. CLINICAL TRIAL REGISTRATION NCT 00759304 and NCT 00766584. CONCLUSIONS Although central fat mass plays a role in the occurrence of severe OSAS in men older than 65 years of age, its low discriminative sensitivity in mild OSAS cases does not warrant systematic use of DEXA for the diagnosis of OSAS.