Different prognostic significance of right and left ventricular diastolic dysfunction in heart failure

BACKGROUND

Left (LV) and right (RV) ventricular diastolic dysfunction is common in heart failure but the prognostic value of RV diastolic dysfunction is not known.

HYPOTHESIS

As a follow-up to a previously undertaken study, this study was carried out to investigate whether LV and RV diastolic dysfunction affect prognosis differently and, in addition, whether changes in diastolic filling patterns over time correlate with clinical outcome.

METHODS

We studied a cohort of 105 patients (mean age 62.7 +/- 1.3 years, 66% male) with heart failure (ejection fraction < 50%) by Doppler echocardiography in both RV and LV.

RESULTS

An LV restrictive filling pattern (RFP) was present in 48% of the patients and, when compared with non-RFP subgroups, it was associated with poorer systolic function, higher New York Heart Association functional class, and higher cardiac mortality at 1 year (all p < 0.001). The coexistence of an LV-RFP and poor LV systolic function (ejection fraction < 25%) markedly decreased the 1-year survival that was significant when compared with other subgroups (p = 0.001). In contrast, RV diastolic dysfunction that occurred in 21% of patients was not a prognostic factor for mortality either alone or in combination with LV diastolic dysfunction, but predicted nonfatal hospital admissions for heart failure or unstable angina (p = 0.016).

CONCLUSION

An LV restrictive filling pattern is a powerful predictor of a poor prognosis, especially when combined with low ejection fraction, but in this study RV diastolic dysfunction did not appear to be an independent predictor of subsequent mortality.

Left ventricular systolic dyssynchrony is a predictor of cardiac remodeling after myocardial infarction

OBJECTIVES

We sought to determine whether early assessment of left ventricular (LV) dyssynchrony by tissue Doppler imaging may predict progressive ventricular enlargement and cardiac dysfunction after acute myocardial infarction (MI).

METHODS

Forty-seven patients (mean age 59.9 +/- 11.6 years) with normal QRS duration underwent tissue Doppler imaging and contrast-enhanced cardiac magnetic resonance imaging (Ce-MRI) at days 2 to 6, 3 months, and at 1 year after the index MI. Systolic dyssynchrony index (Ts-SD) was calculated from 12 LV segments, and infarct size (IS) by Ce-MRI.

RESULTS

The remodeling group (n = 16) (defined as an increase in end-systolic volume > or =10% between 1 year and baseline) had greater initial IS (27.2 +/- 9.6 vs 13.7 +/- 4.1%, P < .001) and Ts-SD (50.9 +/- 12.8 vs 33.6 +/- 7.7 milliseconds, P < .001) than nonremodeling group (n = 31). At 1 year, the remodeling group had progressive increase in Ts-SD and decrease in LV ejection fraction (57.3 +/- 18.5 and 36.0 +/- 7.6%, respectively; both P < .05 vs baseline). Both Ts-SD (odds ratio 1.19 [1.07-1.32], P = .001) and IS (odds ratio 1.65 [1.19-2.29], P = .003) were shown to be independent predictors of progressive LV remodeling. A cutoff value of Ts-SD > or =45 milliseconds predicted LV remodeling at 1 year (sensitivity 90.5%, specificity 90.9%, Area-under-curve 0.907) (P = .0005).

CONCLUSIONS

Left ventricular systolic dyssynchrony is a newly identified predictor of chronic LV remodeling after acute MI, which is independent and incremental to conventional assessment and IS as measured by Ce-MRI.

Lipids, lipoproteins, and apolipoproteins as risk markers of myocardial infarction in 52 countries (the INTERHEART study): a case-control study

BACKGROUND

Whether lipoproteins are better markers than lipids and lipoproteins for coronary heart disease is widely debated. Our aim was to compare the apolipoproteins and cholesterol as indices for risk of acute myocardial infarction.

METHODS

We did a large, standardised case-control study of acute myocardial infarction in 12,461 cases and 14,637 age-matched (plus or minus 5 years) and sex-matched controls in 52 countries. Non-fasting blood samples were available from 9345 cases and 12,120 controls. Concentrations of plasma lipids, lipoproteins, and apolipoproteins were measured, and cholesterol and apolipoprotein ratios were calculated. Odds ratios (OR) and 95% CI, and population-attributable risks (PARs) were calculated for each measure overall and for each ethnic group by comparison of the top four quintiles with the lowest quintile.

FINDINGS

The apolipoprotein B100 (ApoB)/apolipoprotein A1 (ApoA1) ratio had the highest PAR (54%) and the highest OR with each 1 SD difference (1.59, 95% CI 1.53-1.64). The PAR for ratio of LDL cholesterol/HDL cholesterol was 37%. PAR for total cholesterol/HDL cholesterol was 32%, which was substantially lower than that of the ApoB/ApoA1 ratio (p<0.0001). These results were consistent in all ethnic groups, men and women, and for all ages.

INTERPRETATION

The non-fasting ApoB/ApoA1 ratio was superior to any of the cholesterol ratios for estimation of the risk of acute myocardial infarction in all ethnic groups, in both sexes, and at all ages, and it should be introduced into worldwide clinical practice.

Ventricular optimization of biventricular pacing: a systematic review

Biventricular pacing has been shown to improve the overall clinical outcomes in patients with systolic heart failure and ventricular conduction delay on electrocardiogram. As correction of ventricular dyssynchrony is the putative mechanism of benefit, biventricular pacing is also termed as cardiac resynchronization therapy. The development of separate programmability of right and left ventricular output has led to a growing number of reports on the potential benefit of optimization of cardiac resynchronization by sequential biventricular pacing with different techniques and endpoints. This systematic review summarizes the current data for the optimization of sequential (V-V delay) compared with (default) simultaneous biventricular pacing in heart failure.

Serum 25-hydroxyvitamin D status and cardiovascular outcomes in chronic peritoneal dialysis patients: a 3-y prospective cohort study

BACKGROUND

Patients with kidney disease are at high risk of developing 25-hydroxyvitamin D [25(OH)D] deficiency.

OBJECTIVE

We studied the association between serum 25(OH)D status and clinical outcomes of chronic peritoneal dialysis patients.

DESIGN

We measured serum 25(OH)D concentrations in 230 prevalent peritoneal dialysis patients and then followed these patients prospectively for 3 y or until death.

RESULTS

Serum 25(OH)D was deficient or insufficient (ie, <75 nmol/L) in 87% of the patients. Adjusting for clinical and demographic factors, every 1-unit increase in log-transformed serum 25(OH)D was associated with a 44% reduction in the hazard of fatal or nonfatal cardiovascular events (95% CI: 0.35, 0.91; P = 0.018). However, the association was gradually lost when additional adjustment was made in a stepwise fashion for residual glomerular filtration rate (P = 0.078) and echocardiographic measures (P = 0.39). Kaplan-Meier estimates showed a significantly greater fatal or nonfatal cardiovascular event-free survival probability among patients with serum 25(OH)D > 45.7 nmol/L (median) than among patients with concentrations <or= 45.7 nmol/L (P = 0.004). In addition, patients with 25(OH)D > 45.7 nmol/L had a significantly higher cardiovascular event-free survival probability than did patients with 25(OH)D <or= 45.7 nmol/L in the stratified analysis for patients with left ventricular mass index less than the median (P = 0.013) or normal systolic function (P = 0.005).

CONCLUSIONS

A lower serum 25(OH)D concentration was associated with an increased risk of cardiovascular events in chronic peritoneal dialysis patients. Furthermore, serum 25(OH)D status appeared to show a differential influence on the cardiovascular outcomes of peritoneal dialysis patients depending on the degree of left ventricular hypertrophy and systolic dysfunction.

Left ventricular filling pressure by Doppler echocardiography in patients with end-stage renal disease

Left ventricular hypertrophy and systolic dysfunction predict mortality in patients with end-stage renal disease. However, the prognostic value of left ventricular filling pressure has remained uncertain in this population. We evaluated whether the early mitral inflow velocity to peak mitral annulus velocity (E/Em) ratio, an estimate of left ventricular filling pressure by tissue Doppler imaging, has significant additional prognostic value to conventional echocardiographic parameters and other clinical and biochemical parameters in 220 patients with end-stage renal disease. The E/Em ratio was elevated (>15) in 62% of the patients. Multivariate analysis showed that an elevated E/Em ratio had the highest correlation with left ventricular volume index, followed by loss of residual glomerular filtration rate, increasing age, worsening ejection fraction, and diabetes. During the median follow-up of 48 months, the E/Em ratio emerged as an independent predictor of all-cause mortality (adjusted hazard ratio: 1.027; 95% CI: 1.003 to 1.051; P=0.026) and cardiovascular death (adjusted hazard ratio: 1.033; 95% CI: 1.002 to 1.065; P=0.035) in the multivariable Cox regression analysis. In addition, the E/Em ratio added significant incremental prognostic value for all-cause mortality (P=0.035) and cardiovascular death (P=0.035) beyond the standard clinical, biochemical, and dialysis parameters and echocardiographic measurements. In conclusion, the E/Em ratio displayed important additional long-term prognostic information above and beyond that of left ventricular mass and systolic function. Our data suggest that left ventricular filling pressure should be estimated during echocardiographic examination for additional prognostication in patients with end-stage renal disease.

Increased circulating inflammatory proteins predict a worse prognosis with valvular calcification in end-stage renal disease: a prospective cohort study

BACKGROUND

It remains unknown whether inflammation may predict a worse prognosis with valvular calcification (VC) in end-stage renal disease (ESRD) patients.

METHOD

We prospectively performed echocardiography in 231 ESRD patients receiving chronic peritoneal dialysis treatment to detect VC and then followed them for 3 years or until death.

RESULTS

Patients with VC had higher C-reactive protein (CRP; p = 0.001), higher interleukin-6 (IL-6; p = 0.002) and lower fetuin-A (p = 0.004). Stratifying patients into 4 groups on the basis of VC, CRP, IL-6 and fetuin-A, respectively, those with VC and CRP in the upper tertile had 3.68-fold (95% confidence intervals [CI], 1.72-7.88; p = 0.001) and 3.13-fold (95% CI, 1.57-6.24; p = 0.001) respective increases in the adjusted risk of mortality and major adverse cardiovascular event (MACE) than those with no VC and CRP in the lower/middle tertiles. The adjusted hazard ratios (HR) in relation to mortality and MACE were 3.56 (95% CI, 1.53-8.26; p = 0.003) and 2.51 (95% CI, 1.24-5.11; p = 0.011), respectively, for patients with VC and IL-6 in the upper tertile compared to those with no VC and IL-6 in the lower/middle tertiles. The adjusted HR in relation to mortality and MACE were 3.56 (95% CI, 1.53-8.26; p = 0.003) and 2.51 (95% CI, 1.24-5.11; p = 0.011), respectively, for patients with VC and fetuin-A in the lower tertile compared to those with no VC and fetuin-A in the middle/upper tertiles.

CONCLUSIONS

Increased circulating inflammatory proteins predict a worse prognosis of VC in chronic peritoneal dialysis patients.

The Hong Kong diastolic heart failure study: a randomised controlled trial of diuretics, irbesartan and ramipril on quality of life, exercise capacity, left ventricular global and regional function in heart failure with a normal ejection fraction

BACKGROUND

Although heart failure with a preserved or normal ejection fraction (HFNEF or diastolic heart failure) is common, treatment outcomes on quality of life and cardiac function are lacking. The effect of renin-angiotensin blockade by irbesartan or ramipril in combination with diuretics on quality of life (QoL), regional and global systolic and diastolic function was assessed in HFNEF patients.

METHODS

150 patients with HFNEF (LVEF >45%) were randomised to (1) diuretics alone, (2) diuretics plus irbesartan, or (3) diuretics plus ramipril. QoL, 6-minute walk test (6MWT) and Doppler echocardiography were performed at baseline, 12, 24 and 52 weeks.

RESULTS

The QoL score improved similarly in all three groups by 52 weeks (-46%, 51%, and 50% respectively, all p<0.01), although 6MWT increased only slightly (average +3-6%). Recurrent hospitalisation rates were equal in all groups (10-12% in 1 year). At 1 year, LV dimensions or LVEF had not changed in any group, though both systolic and diastolic blood pressures were lowered in all three groups from 4 weeks onwards. At baseline both mean peak systolic (Sm) and early diastolic (Em) mitral annulus velocities were reduced, and increased slightly in the diuretic plus irbesartan (Sm 4.5 (SEM 0.17) to 4.9 (SEM 0.16) cm/sec; Em 3.8 (SEM 0.25) to 4.2 (SEM 0.25) cm/sec) and ramipril (Sm 4.5 (SEM 0.24) to 4.9 (SEM 0.20) cm/sec; Em 3.3 (SEM 0.25) to 4.04 (SEM 0.32) cm/sec) groups (both p<0.05). NT-pro-BNP levels were raised at baseline (595 (SD 905) pg/ml; range 5-4748) and fell in the irbesartan (-124 (SD 302) pg/ml, p = 0.01) and ramipril (-173 (SD 415) pg/ml, p = 0.03) groups only.

CONCLUSIONS

In this typically elderly group of HF patients with normal LVEF, diuretic therapy significantly improved symptoms and neither irbesartan nor ramipril had a significant additional effect. However, diuretics in combination with irbesartan or ramipril marginally improved LV systolic and diastolic longitudinal LV function, and lowered NT-proBNP over 1 year.

Aldosterone receptor antagonism induces reverse remodeling when added to angiotensin receptor blockade in chronic heart failure

OBJECTIVES

The objective of this study was to determine if adding spironolactone to an angiotensin II receptor blocker improves left ventricular (LV) function, mass, and volumes in chronic heart failure.

BACKGROUND

Add-on spironolactone therapy substantially improves clinical outcomes among patients with severe heart failure (HF) on standard therapy. However, the value of combining spironolactone with an angiotensin II receptor blocker on LV reverse remodeling in mild-to-moderate systolic HF is unclear.

METHODS

Fifty-one systolic HF patients with left ventricular ejection fraction (LVEF) <40% were randomly assigned to receive 1-year treatment of candesartan and spironolactone (combination group) or candesartan and placebo (control group). Reverse remodeling was assessed by serial cardiac magnetic resonance imaging and echocardiographic tissue Doppler imaging (TDI).

RESULTS

There were significant improvements in LVEF (35 +/- 3% vs. 26 +/- 2%, p < 0.01) and reduction of LV end-diastolic volume index (121 +/- 16 ml/m2 vs. 155 +/- 14 ml/m2, p = 0.001), end-systolic volume index (88 +/- 17 ml/m2 vs. 120 +/- 15 ml/m2, p < 0.0005), and LV mass index (81 +/- 6 g/m2 vs. 93 +/- 6 g/m2, p = 0.002) in the combination group at 1 year. In addition, there was significant increase in peak basal systolic velocity and strain by TDI, decrease in index of filling pressure, and increase in cyclic variation integrated backscatter. In the control group, there were no significant changes in all these parameters after 1 year.

CONCLUSIONS

The addition of spironolactone to candesartan has significant beneficial effects on LV reverse remodeling in patients with mild-to-moderate chronic systolic HF.

Differential associations of traditional and non-traditional risk factors with carotid intima-media thickening and plaque in peritoneal dialysis patients

BACKGROUND

This study sought to examine the associations of traditional and non-traditional cardiovascular risk factors with carotid intima-media thickening and plaque in peritoneal dialysis (PD) patients.

METHODS

A cross-sectional study was performed in 147 PD patients with carotid intima-media thickness (IMT) and plaque assessed by B-mode ultrasonography and fasting blood collected for biochemical measurements.

RESULTS

On univariate analysis, age, smoking history, fibrinogen, C-reactive protein (CRP), adiponectin, fetuin-A, lipoprotein(a) and diastolic blood pressure were associated with carotid IMT while age, smoking history, diabetes, CRP and diastolic blood pressure were associated with carotid plaque. Using multivariate analysis, elevated CRP (p = 0.015) and serum calcium (p = 0.022) were associated with carotid plaque but not with IMT. CRP and serum calcium were synergistically associated with carotid plaque in that those with CRP > median and serum calcium > median showed the highest prevalence of carotid plaque than either factor alone (p = 0.003).

CONCLUSIONS

An elevated CRP appeared to be a better biomarker of presence of carotid plaque than intima-media thickening. Furthermore, CRP and serum calcium showed synergistic association with presence of carotid plaque. However, our study was limited by the cross-sectional design and baseline laboratory abnormalities were inevitably confounded by the treatment already given, resulting in difficulty to distinguish cause and effect relationship. Nevertheless, these observations warrant further investigation as it may potentially have important implications on differentiating therapeutic strategies for reducing carotid IMT and plaque progression in PD patients.

Tissue Doppler imaging a new prognosticator for cardiovascular diseases

Tissue Doppler imaging (TDI) is evolving as a useful echocardiographic tool for quantitative assessment of left ventricular (LV) systolic and diastolic function. Recent studies have explored the prognostic role of TDI-derived parameters in major cardiac diseases, such as heart failure, acute myocardial infarction, and hypertension. In these conditions, myocardial mitral annular or basal segmental (Sm) systolic and early diastolic (Ea or Em) velocities have been shown to predict mortality or cardiovascular events. In particular, those with reduced Sm or Em values of <3 cm/s have a very poor prognosis. In heart failure and after myocardial infarction, noninvasive assessment of LV diastolic pressure by transmitral to mitral annular early diastolic velocity ratio (E/Ea or E/Em) is a strong prognosticator, especially when E/Ea is > or =15. In addition, systolic intraventricular dyssynchrony measured by segmental analysis of myocardial velocities is another independent predictor of adverse clinical outcome in heart failure subjects, even when the QRS duration is normal. In heart failure patients who received cardiac resynchronization therapy, the presence of systolic dyssynchrony at baseline is associated with favorable LV remodeling, which in turn predicts a favorable long-term clinical outcome. Finally, TDI and derived deformation parameters improve prognostic assessment during dobutamine stress echocardiography. A high mean Sm value in the basal segments of patients with suspected coronary artery disease is associated with lower mortality rate or myocardial infarction and is superior to the wall motion score.

How to diagnose diastolic heart failure: a consensus statement on the diagnosis of heart failure with normal left ventricular ejection fraction by the Heart Failure and Echocardiography Associations of the European Society of Cardiology

Diastolic heart failure (DHF) currently accounts for more than 50% of all heart failure patients. DHF is also referred to as heart failure with normal left ventricular (LV) ejection fraction (HFNEF) to indicate that HFNEF could be a precursor of heart failure with reduced LVEF. Because of improved cardiac imaging and because of widespread clinical use of plasma levels of natriuretic peptides, diagnostic criteria for HFNEF needed to be updated. The diagnosis of HFNEF requires the following conditions to be satisfied: (i) signs or symptoms of heart failure; (ii) normal or mildly abnormal systolic LV function; (iii) evidence of diastolic LV dysfunction. Normal or mildly abnormal systolic LV function implies both an LVEF > 50% and an LV end-diastolic volume index (LVEDVI) <97 mL/m(2). Diagnostic evidence of diastolic LV dysfunction can be obtained invasively (LV end-diastolic pressure >16 mmHg or mean pulmonary capillary wedge pressure >12 mmHg) or non-invasively by tissue Doppler (TD) (E/E' > 15). If TD yields an E/E' ratio suggestive of diastolic LV dysfunction (15 > E/E' > 8), additional non-invasive investigations are required for diagnostic evidence of diastolic LV dysfunction. These can consist of blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, electrocardiographic evidence of atrial fibrillation, or plasma levels of natriuretic peptides. If plasma levels of natriuretic peptides are elevated, diagnostic evidence of diastolic LV dysfunction also requires additional non-invasive investigations such as TD, blood flow Doppler of mitral valve or pulmonary veins, echo measures of LV mass index or left atrial volume index, or electrocardiographic evidence of atrial fibrillation. A similar strategy with focus on a high negative predictive value of successive investigations is proposed for the exclusion of HFNEF in patients with breathlessness and no signs of congestion. The updated strategies for the diagnosis and exclusion of HFNEF are useful not only for individual patient management but also for patient recruitment in future clinical trials exploring therapies for HFNEF.

Prognostic value of cardiac troponin T is independent of inflammation, residual renal function, and cardiac hypertrophy and dysfunction in peritoneal dialysis patients

BACKGROUND

We investigated whether cardiac troponin T (cTnT) independently predicted outcome and added prognostic value over other clinical risk predictors in chronic peritoneal dialysis (PD) with end-stage renal disease.

METHODS

Baseline cTnT, echocardiography, indices of dialysis adequacy, and biochemical characteristics were assessed in 238 chronic PD patients who were followed prospectively for 3 years or until death.

RESULTS

Using multivariable Cox regression analysis, cTnT remained predictive of all-cause mortality [hazard ratio 4.43, 95% CI 1.87-10.45, P = 0.001], cardiovascular death (4.12, 1.29-13.17, P = 0.017), noncardiovascular death (8.06, 1.86-35.03, P = 0.005), and fatal and nonfatal cardiovascular events (CVEs) (3.59, 1.48-8.70, P = 0.005) independent of background coronary artery disease, inflammation, residual renal function, left ventricular hypertrophy, and systolic dysfunction. cTnT alone had better predictive value than C-reactive protein (CRP) alone for mortality [area under the ROC curve (AUC) 0.774 vs 0.691; P = 0.089] and first CVE (AUC 0.711 vs 0.593; P = 0.009) at 3 years. Survival models including age, sex, and clinical, biochemical, and echocardiographic characteristics yielded AUCs of 0.813 (95% CI, 0.748-0.877), 0.800 (95% CI, 0.726-0.874), and 0.769 (95% CI, 0.708-0.830), respectively, in relation to all-cause mortality, cardiovascular death, and fatal and nonfatal cardiovascular events. After addition of cTnT, AUCs of the above models increased significantly to 0.832 (95% CI, 0.669-0.894; P = 0.0037), 0.810 (95% CI, 0.739-0.883; P = 0.0036), and 0.780 (95% CI, 0.720-0.840; P = 0.0002), respectively; no AUCs increased when CRP was added.

CONCLUSIONS

cTnT is an independent predictor of long-term mortality, cardiovascular death and events, and noncardiovascular death in PD patients.

Comparison of intensive and low-dose atorvastatin therapy in the reduction of carotid intimal-medial thickness in patients with coronary heart disease

BACKGROUND

Intensive statin therapy has been shown to improve prognosis in patients with coronary heart disease (CHD). It is unknown whether such benefit is mediated through the reduction of atherosclerotic plaque burden.

AIM

To examine the efficacy of high-dose atorvastatin in the reduction of carotid intimal-medial thickness (IMT) and inflammatory markers in patients with CHD.

DESIGN

Randomised trial.

SETTING

Single centre.

PATIENTS

112 patients with angiographic evidence of CHD.

INTERVENTIONS

A high dose (80 mg daily) or low dose (10 mg daily) of atorvastatin was given for 26 weeks.

MAIN OUTCOME MEASURES

Carotid IMT, C-reactive protein (CRP) and proinflammatory cytokine levels were assessed before and after therapy.

RESULTS

The carotid IMT was reduced significantly in the high-dose group (left: mean (SD), 1.24 (0.48) vs 1.15 (0.35) mm, p = 0.02; right: 1.12 (0.41) vs 1.01 (0.26) mm, p = 0.01), but was unchanged in the low-dose group (left: 1.25 (0.55) vs 1.20 (0.51) mm, p = NS; right: 1.18 (0.54) vs 1.15 (0.41) mm, p = NS). The CRP levels were reduced only in the high-dose group (from 3.92 (6.59) to 1.35 (1.83) mg/l, p = 0.01), but not in the low-dose group (from 2.25 (1.84) to 3.36 (6.15) mg/l, p = NS). A modest correlation was observed between the changes in carotid IMT and CRP (r = 0.21, p = 0.03).

CONCLUSIONS

In patients with CHD, intensive atorvastatin therapy results in regression of carotid atherosclerotic disease, which is associated with reduction in CRP levels. On the other hand, a low-dose regimen only prevents progression of the disease.

Atrial strain rate echocardiography can predict success or failure of cardioversion for atrial fibrillation: A combined transthoracic tissue Doppler and transoesophageal imaging study

AIMS

The purpose of this study was to assess the feasibility of measuring left atrial dysfunction with tissue Doppler imaging derived strain rate and to explore its role in predicting the maintenance of sinus rhythm after cardioversion for atrial fibrillation.

METHODS AND RESULTS

Strain rate (SR) and tissue Doppler imaging (TDI) were performed with offline analysis of the basal left atrial wall (LA). SR detected a systolic (Ssr) and early diastolic (Esr) deformation induced by ventricular motion. LA dimensions and volume were measured. Left atrial appendage emptying (LAA_EV) and filling (LAA_FV) velocities were also obtained by transesophageal echocardiography. 27 healthy age-matched controls and 42 patients with AF before cardioversion were studied. Patients were grouped into (1): those who remained in sinus rhythm (group S, n=12) and (2) those who either failed cardioversion or reverted to AF within 4 weeks (group F, n=30). LA dimensions were significantly larger and atrial Esr was significantly lower in group F than group S (all p<0.01). LAA_EV and LAA_FV were not different between groups S and F. Multivariate regression analysis showed that a lower Esr and larger transverse LA diameter (LADtr) were independent predictors of failure of cardioversion (HR, 95% CI: 0.36, 0.14-0.88 and 2.85, 1.33-6.10, respectively). Esr combined with LADtr improved the sensitivity and specificity for predicting successful cardioversion.

CONCLUSIONS

SR can be measured in the basal LA wall in atrial fibrillation and the magnitude of the early diastolic SR could predict the success of cardioversion and the likelihood of maintenance of sinus rhythm.

N-Terminal Pro-Brain Natriuretic Peptide: An Independent Risk Predictor of Cardiovascular Congestion, Mortality, and Adverse Cardiovascular Outcomes in Chronic Peritoneal Dialysis Patients

This study was performed to determine whether the N-terminal pro-brain natriuretic peptide (NT-pro-BNP) is a useful biomarker in predicting cardiovascular congestion, mortality, and cardiovascular death and event in chronic peritoneal dialysis (PD) patients. A prospective cohort study was conducted in 230 chronic PD patients in a dialysis unit of a university teaching hospital. Serum NT-pro-BNP was measured at baseline together with echocardiography and dialysis indices. Each patient was followed for 3 yr from the day of enrollment or until death. Time to develop first episode of cardiovascular congestion and other cardiovascular event and time to mortality and cardiovascular death were studied in relation to NT-pro-BNP. NT-pro-BNP showed the strongest correlation with residual GFR, followed by left ventricular ejection fraction and left ventricular mass index. In the univariate Cox regression model, NT-pro-BNP was a significant predictor of cardiovascular congestion, mortality, and cardiovascular death and event. In the fully adjusted multivariable Cox regression analysis that included residual GFR, left ventricular ejection fraction, and left ventricular mass index, the hazard ratios for cardiovascular congestion, mortality, composite end point of mortality and cardiovascular congestion, and cardiovascular death and event for patients of the fourth quartile were 4.25 (95% confidence interval [CI] 1.56 to 11.62; P = 0.005), 4.97 (95% CI 1.35 to 18.28; P = 0.016), 5.03 (95% CI 2.07 to 12.26; P < 0.001), 7.50 (95% CI 1.36 to 41.39; P = 0.021), and 9.10 (95% CI 2.46 to 33.67; P = 0.001), respectively, compared with the first quartile. These data showed that NT-pro-BNP is an important risk predictor of cardiovascular congestion, mortality, and adverse cardiovascular outcomes in chronic PD patients and adds important prognostic information beyond that contributed by left ventricular hypertrophy, systolic dysfunction, and other conventional risk factors.