The importance and complexity of neurohumeral over-activity in chronic heart failure

Deceleration capacity for rapid risk stratification in patients suffering from acute ischemic stroke: A prospective exploratory pilot study

Deceleration capacitiy for rapid risk stratification in stroke patientsCerebral ischemia is a major cause of neurologic deficit and patients suffering from ischemic stroke bear a relevant risk of mortality. Identifying stroke patients at high mortality risk is of crucial clinical relevance. Deceleration capacity of heart rate (DC) as a parameter of cardiac autonomic function is an excellent predictor of mortality in myocardial infarction and heart failure patients.The aim of our study was to evaluate whether DC provides prognostic information regarding mortality risk in patients with acute ischemic stroke.From September 2015 to March 2018 we prospectively enrolled consecutive patients presenting at the Stroke Unit of our university hospital with acute ischemic stroke who were in sinus rhythm. In these patients 24 hours-Holter-ECG recordings and evaluation of National Institute of Health Stroke Scale (NIHSS) were performed. DC was calculated according to a previously published algorithm. Primary endpoint was intrahospital mortality.Eight hundred seventy eight stroke patients were included in the study. Intrahospital mortality was 2.8% (25 patients). Both DC and NIHSS were significantly different between non-survivors and survivors (Mean ± SD: DC: 4.1 ± 2.8 ms vs 6.3 ± 3.3 ms, P < .001) (NIHSS: 7.6 ± 7.1 vs 4.3 ± 5.5, P = .02). DC achieved an area under the curve value (AUC) of 0.708 for predicting intrahospital mortality, while the AUC value of NIHSS was 0.641. In a binary logistic regression analysis, DC, NIHSS and age were independent predictors for intrahospital mortality (DC: HR CI 95%: 0.88 (0.79-0.97); P = .01; NIHSS: HR CI 95%: 1.08 (1.02-1.15); P = .01; Age: HR CI 95%: 1.07 (1.02-1.11); P = .004. The combination of NIHSS, age and DC in a prediction model led to a significant improvement of the AUC, which was 0.757 (P < .001, incremental development index [IDI] 95% CI: 0.037 (0.018-0.057)), compared to the individual risk parameters.Our study demonstrated that DC is suitable for both objective and independent risk stratification in patients suffering from ischemic stroke. The application of a prediction model combining NIHSS, age and DC is superior to the single markers in identifying patients at high mortality risk.

Deceleration capacity as a risk predictor in patients presenting to the emergency department with syncope: A prospective exploratory pilot study

Syncope is a common cause for admission to the emergency department (ED). Due to limited clinical resources there is great interest in developing risk stratification tools that allow identifying patients with syncope who are at low risk and can be safely discharged. Deceleration capacity (DC) is a strong risk predictor in postinfarction and heart failure patients. The aim of this study was to evaluate whether DC provides prognostic information in patients presenting to ED with syncope.We prospectively enrolled 395 patients presenting to the ED due to syncope. Patient's electrocardiogram (ECG) for the calculation of DC was recorded by monitoring devices which were started after admission. Both the modified early warning score (MEWS) and the San Francisco syncope score (SFSS) were determined in every patient. Primary endpoint was mortality after 180 days.Eight patients (2%) died after 180 days. DC was significantly lower in the group of nonsurvivors as compared with survivors (3.1 ± 2.5 ms vs 6.7 ± 2.4 ms; P < .001), whereas the MEWS was comparable in both was comparable in both groups. (2.1 ± 0.8 vs 2.1 ± 1.0; P = .84). The SFSS failed at identifying 4 of 8 nonsurvivors (50%) as high risk patients. No patient with a favorable DC (≥7 ms) died (0.0% vs 3.7%; P = .01, OR 0.55 (95% CI 0.40-0.76), P < .001). In the receiver operating characteristic (ROC) analysis DC yielded an area under the curve of 0.85 (95% CI 0.71-0.98).Our study demonstrates that DC is a predictor of 180-days-mortality in patients admitted to the ED due to syncope. Syncope patients at low risk can be identified by DC and may be discharged safely.

Deceleration capacity of heart rate predicts 1-year mortality of patients undergoing transcatheter aortic valve implantation

BACKGROUND

Risk prediction in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve implantation (TAVI) is challenging. Development of novel markers for patient risk assessment is of great clinical value. Deceleration capacity (DC) of heart rate is a strong risk predictor in post-infarction patients.

HYPOTHESIS

DC provides prognostic information in patients undergoing TAVI.

METHODS

We enrolled 374 consecutive patients with severe AS undergoing TAVI. All patients received 24-hour Holter recording or continuous heart-rate monitoring to assess DC before intervention. Primary endpoint was all-cause mortality after 1 year.

RESULTS

Forty-nine patients (13.1%) died within 1 year. DC was significantly lower in nonsurvivors than in survivors (1.2 ± 4.8 ms vs 3.3 ± 2.9 ms; P < 0.001), whereas the logistic EuroSCORE and EuroSCORE II were comparable between groups (logistic EuroSCORE: 27.3% ± 17.0% vs 22.9% ± 14.2%; P = 0.122; EuroSCORE II: 8.0% ± 6.9% vs 6.7% ± 4.8%, P = 0.673). One-year mortality in the 116 patients with impaired DC (<2.5 ms) was significantly higher than in patients with normal DC (23.3% vs 8.5%; P < 0.001). In multivariate Cox regression analysis that included DC, sex, paroxysmal atrial fibrillation, hemoglobin level before TAVI, and logistic EuroSCORE, DC was the strongest predictor of 1-year mortality (hazard ratio: 0.88, 95% confidence interval: 0.85-0.94, P < 0.001). DC yielded an AUC in the ROC analysis of 0.645.

CONCLUSIONS

DC of heart rate is a strong and independent predictor of 1-year mortality in patients with severe AS undergoing TAVI.

Do results of the ENABLE (Endothelin Antagonist Bosentan for Lowering Cardiac Events in Heart Failure) study spell the end for non-selective endothelin antagonism in heart failure?

The last two decades have seen major advances in the treatment of chronic heart failure, primarily as a result of therapeutic manipulation of activated neurohormonal systems. Despite this progress, many patients still suffer significant morbidity and premature death. Antagonism of the biological effects of endothelin, a potent vasoconstrictor, represents a further potential target. To date, positive results from animal models of heart failure have not been translated into clinical practice, perhaps as a consequence of the high doses of drug used. The ENABLE (Endothelin Antagonist Bosentan for Lowering Cardiac Events in Heart Failure) study evaluated the effects of low dose bosentan, a non-selective endothelin receptor antagonist, in patients with severe heart failure (left ventricular ejection fraction <35%, New York Heart Association class IIIb-IV). A total of 1,613 patients were randomized to receive either bosentan (125 mg twice a day) or placebo. The preliminary results were presented at the 51st Annual Scientific Session of the American College of Cardiology (17-20 March 2002, Atlanta, GA, USA). The primary endpoint of all-cause mortality or hospitalization for heart failure was reached in 321/808 patients on placebo and 312/805 receiving bosentan. Treatment with bosentan appeared to confer an early risk of worsening heart failure necessitating hospitalization, as a consequence of fluid retention. It has been suggested that further studies using even lower doses of bosentan or more aggressive concomitant diuretic therapy may avoid this adverse effect. The results from the ENABLE study have, however, thrown further doubt on the potential benefits of non-specific endothelin receptor blockade in heart failure.

Angiotensin type-1 receptor blockers in heart failure

Chronic heart failure is a common condition with a poor prognosis, usually associated with poor exercise tolerance and debilitating symptoms despite optimal modern therapy. Standard therapy includes diuretics, digoxin, angiotensin-converting enzyme inhibitors (ACEIs) and beta-blockers. Despite this, many patients remain symptomatic, and interest is high as to whether the angiotensin receptor blockers (ARBs) would offer further advantage to a patient already receiving quadruple therapy. In addition, some patients are intolerant of ACEIs, and for this group the ARBs seem a logical choice. This article reviews the evidence for the use of ARBs as a class in heart failure concentrating on clinical recommendations and clinical needs and evidence rather than purely on statistical issues of significance in trials. The trials to date have demonstrated clearly similar hemodynamic effects to those seen with ACEIs and variety of ancillary benefits such as improvements in endothelial function, anti-thrombotic effects, and effects on neurohormonal inhibition. There is consistent evidence of a preservation of exercise tolerance when patients with heart failure are crossed over from stable ACEI therapy, and when added to ACEIs exercise tolerance appears to increase with ARBs. In terms of major outcomes, the two largest trials, Elite-II and Val-Heft, demonstrate that angiotensin receptor blockers probably have a clinical role in improving mortality and morbidity as an alternative to ACEIs in those patients unable to tolerate these agents, which remain, however, the first choice in unselected patients with heart failure. There is a worrying suggestion of a negative interaction when ARBs are added to beta-blockers, which is a reason for caution in using the ARBs, not a reason not to use beta-blockers.