Physician-directed patient self-management of left atrial pressure in advanced chronic heart failure

BACKGROUND

Previous studies suggest that management of ambulatory hemodynamics may improve outcomes in chronic heart failure. We conducted a prospective, observational, first-in-human study of a physician-directed patient self-management system targeting left atrial pressure.

METHODS AND RESULTS

Forty patients with reduced or preserved left ventricular ejection fraction and a history of New York Heart Association class III or IV heart failure and acute decompensation were implanted with an investigational left atrial pressure monitor, and readings were acquired twice daily. For the first 3 months, patients and clinicians were blinded as to these readings, and treatment continued per usual clinical assessment. Thereafter, left atrial pressure and individualized therapy instructions guided by these pressures were disclosed to the patient. Event-free survival was determined over a median follow-up of 25 months (range 3 to 38 months). Survival without decompensation was 61% at 3 years, and events tended to be less frequent after the first 3 months (hazard ratio 0.16 [95% confidence interval 0.04 to 0.68], P=0.012). Mean daily left atrial pressure fell from 17.6 mm Hg (95% confidence interval 15.8 to 19.4 mm Hg) in the first 3 months to 14.8 mm Hg (95% confidence interval 13.0 to 16.6 mm Hg; P=0.003) during pressure-guided therapy. The frequency of elevated readings (>25 mm Hg) was reduced by 67% (P<0.001). There were improvements in New York Heart Association class (-0.7+/-0.8, P<0.001) and left ventricular ejection fraction (7+/-10%, P<0.001). Doses of angiotensin-converting enzyme/angiotensin-receptor blockers and beta-blockers were uptitrated by 37% (P<0.001) and 40% (P<0.001), respectively, whereas doses of loop diuretics fell by 27% (P=0.15).

CONCLUSIONS

Physician-directed patient self-management of left atrial pressure has the potential to improve hemodynamics, symptoms, and outcomes in advanced heart failure. Clinical Trial Registration Information- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00547729.

Catheter-based renal sympathetic denervation for resistant hypertension: a multicentre safety and proof-of-principle cohort study

BACKGROUND

Renal sympathetic hyperactivity is associated with hypertension and its progression, chronic kidney disease, and heart failure. We did a proof-of-principle trial of therapeutic renal sympathetic denervation in patients with resistant hypertension (ie, systolic blood pressure >/=160 mm Hg on three or more antihypertensive medications, including a diuretic) to assess safety and blood-pressure reduction effectiveness.

METHODS

We enrolled 50 patients at five Australian and European centres; 5 patients were excluded for anatomical reasons (mainly on the basis of dual renal artery systems). Patients received percutaneous radiofrequency catheter-based treatment between June, 2007, and November, 2008, with subsequent follow-up to 1 year. We assessed the effectiveness of renal sympathetic denervation with renal noradrenaline spillover in a subgroup of patients. Primary endpoints were office blood pressure and safety data before and at 1, 3, 6, 9, and 12 months after procedure. Renal angiography was done before, immediately after, and 14-30 days after procedure, and magnetic resonance angiogram 6 months after procedure. We assessed blood-pressure lowering effectiveness by repeated measures ANOVA. This study is registered in Australia and Europe with ClinicalTrials.gov, numbers NCT 00483808 and NCT 00664638.

FINDINGS

In treated patients, baseline mean office blood pressure was 177/101 mm Hg (SD 20/15), (mean 4.7 antihypertensive medications); estimated glomerular filtration rate was 81 mL/min/1.73m(2) (SD 23); and mean reduction in renal noradrenaline spillover was 47% (95% CI 28-65%). Office blood pressures after procedure were reduced by -14/-10, -21/-10, -22/-11, -24/-11, and -27/-17 mm Hg at 1, 3, 6, 9, and 12 months, respectively. In the five non-treated patients, mean rise in office blood pressure was +3/-2, +2/+3, +14/+9, and +26/+17 mm Hg at 1, 3, 6, and 9 months, respectively. One intraprocedural renal artery dissection occurred before radiofrequency energy delivery, without further sequelae. There were no other renovascular complications.

INTERPRETATION

Catheter-based renal denervation causes substantial and sustained blood-pressure reduction, without serious adverse events, in patients with resistant hypertension. Prospective randomised clinical trials are needed to investigate the usefulness of this procedure in the management of this condition.

[Enterocystoplasty for interstitial cystitis. Deferred results]

INTRODUCTION

Interstitial cystitis is clinically diagnosed entity, characterized by irritative bladder symptoms and suprapubic pain. It is reported that up to 10% of patients are refractory to conservative management. In these patients' supratrigonal cystectomy and bladder enlargement enterocystoplasty has been used.

OBJECTIVE

To evaluate the results of our series of patients that underwent this surgical technique due they were suffering interstitial cystitis refractory to conservative treatment.

MATERIALS AND METHODS

We reviewed the medical records of patients that underwent supratrigonal cystectomy and bladder enlargement enterocystoplasty in our hospital between 1999 and 2006. Mictional rhythm, pre and postoperative bladder capacity measured by cystodistention, postoperative bladder capacity measured as mictional volume, surgical complications and the degree of satisfaction of patients measured by means of application of a survey were recorded. Mictional rhythms and pre and postoperative bladder capacity were compared.

RESULTS

15 interventions were performed. Mean preoperative bladder capacity was 125 cc, Mean preoperative mictional rhythm was 30.5 times a day. There were perioperative complications in 5 patients. The mean postoperative mictional volume was 355 cc and mean frequency was 8.26. When comparing pre and postoperative rythms and urinary volume there were statistically significant differences (p:0.0008 y p:0.0007 respectively). Regarding the survey, 13 patients were satisfied in terms of mictional frequency and 11 patients were satisfied in terms of suprapubic pain.

A Taqman assay for high-throughput genotyping of the multiple sclerosis-associated HLA-DRB1*1501 allele

The human leukocyte antigen (HLA)-DRB1*1501 allele has long been established as the main genetic risk factor for multiple sclerosis (MS), and it therefore follows that stratification of study populations for this allele could aid in the identification of novel susceptibility genes and/or in establishing interactions. To this end, we have developed a simple Taqman-based assay allowing cost-efficient medium-throughput HLA-DRB1*1501 genotyping. We have validated this assay in 444 trio families with MS and 1066 individuals from the UK 1958 birth cohort (3908 independent chromosomes). In this validation cohort, the correlation coefficient (r(2)) between rs3135388*A and HLA-DRB1*1501 was >0.94. Subsequently, applying the assay to a group of MS patients and controls from Belgium confirmed the association of HLA-DRB1*1501 and MS in this population (P = 5 x 10(-21)).

Randomised, placebo controlled trial of nebulised furosemide for breathlessness in patients with cancer

BACKGROUND

Breathlessness is a common and difficult symptom to treat in patients with cancer. Case reports suggest that nebulised furosemide can relieve breathlessness in such patients but few data are available.

METHOD

Patients with primary or secondary lung cancer and a Dyspnoea Exertion Scale score of >or=3 were recruited. Following familiarisation, patients received either nebulised furosemide 40 mg or nebulised 0.9% saline under double blind conditions or no treatment, in random order on 3 consecutive days. Patients undertook number reading and arm exercise tests to assess breathlessness and its impact, and were asked to report subjective benefit and any preference between nebulised treatments.

RESULTS

15 patients took part. There were no differences between furosemide, saline and no treatment in the outcomes of the number reading test (eg, mean number read per breath was 6.7, 6.4 and 6.7, respectively) or arm exercise test (eg, mean Borg score at maximum equivalent workload was 2.3, 2.5 and 2.7, respectively). No adverse effects were reported, although there was a small fall in forced expiratory volume in 1 s and forced vital capacity following saline. Six patients considered that their breathlessness improved with nebulised treatment, three preferring saline, one furosemide and two reporting they were of equal benefit.

CONCLUSIONS

Our findings do not support a beneficial effect from nebulised furosemide in patients with cancer related breathlessness. Listed on the National Research Register (N0170118249) and the UK Clinical Research Network Portfolio Database (1428).

Investigation of TGFB2 as a candidate gene in multiple sclerosis and Parkinson’s disease

Given the known roles of TGFbeta2 in both regulating the immune system and promoting the survival of dopaminergic neurons, it is feasible that genetic variations in TGFB2 might play an aetiological role in neurological diseases such as Multiple Sclerosis (MS) and Parkinson's disease (PD). Hence we performed an indirect association analysis of TGFB2 using 8 haplotype-tagging SNPs in a population of 937 MS patients, 538 PD cases and 2022 controls. We found no evidence for association with susceptibility or progression of MS, but have demonstrated a trend towards association of the 5' region of the gene with susceptibility to PD. Further analysis of TGFB2 is warranted in other PD cohorts.

Contemporary treatment of in-stent restenosis and the incidence of recurrent in-stent restenosis in the era of drug-eluting stents

BACKGROUND

Optimal treatment of in-stent restenosis (ISR) remains uncertain in the era of drug-eluting stents (DES). This study aims to determine contemporary treatment of ISR and to assess recurrent ISR rates in the era of DES.

METHODS

We examined 60 patients presenting for treatment of ISR (one lesion per patient) who were enrolled in the Melbourne Interventional Group Registry (4% of total population of 1423 patients) between April 2004 and January 2005. Twelve-month follow-up is complete for all patients.

RESULTS

The majority of ISR treated occurred in bare metal stents [BMS (n=52, 87%)] and had a focal (<10 mm) pattern of ISR (53%). In-stent restenosis of DES occurred in eight (13%) patients. The majority of ISR were treated with additional stenting with a preference for DES over BMS in almost all cases. At 12 months, one patient died of non-cardiac cause and four patients (7%) presented with recurrent ISR. The incidence of recurrent ISR in DES was 5% (n=3). No late thrombosis was reported despite only 50% of patients having >or=12 months of clopidogrel therapy.

CONCLUSIONS

Our study suggests drug-eluting stents are safe, effective and the preferred therapy for in-stent restenosis. The incidence of recurrent drug-eluting stent restenosis at 12 months is low.