The relationship between cardiac resynchronization therapy and serum levels of copeptin in patients with chronic heart failure

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The present study was supported by a grant from Slovak Hearth Rhythm Association (Prognostic value of MR-proANP and MR-proADM in patients undergoing cardiac resynchronization therapy).

Background

Chronic heart failure (CHF) is a complex syndrome characterized by an abnormal neurohormonal activation, including arginine vasopressin (AVP). Copeptin is an indicator of AVP activation, which levels are elevated in CHF and have prognostic importance. Cardiac resynchronization therapy (CRT) is an important device therapy for patients with advanced CHF, left ventricular (LV) systolic dysfunction and evidence of electromechanical dyssynchrony. The aim of the present study was to determine the possible relationship between CRT and serum copeptin levels.

Methods

We have included CRT patients with ischemic as well as nonischemic etiology of CHF. The levels of copeptin were measured at baseline and 12 months respectively after CRT implantation. Echocardiography was also performed pre and 12 months post CRT implantation. A CRT response was defined as a ≥ 15 % reduction in LV end-systolic volume (LVESV).

Results

The study population consisted of 41 patients. The mean copeptin level was 20.50 ± 15.77 pmol/l. Copeptin levels positively correlated with New York Heart Association class, left atrial diameter, creatinine levels and NT-proBNP levels. CRT responders have significant reduction in copeptin levels from baseline to 12 months (from 16.96 ± 12.80 pmol/l to 6.20 ± 6.44 pmol/l, p < 0.001). No significant changes in copeptin levels were observed in CRT nonresponders. Reduction > 45 % in copeptin levels was predictor of CRT-response (OR 6.72, 95 % CI 1.01 - 18.11, p = 0.045).

Conclusion

The copeptin serum levels can be a useful biomarker in the evaluation of the CRT response.

Efficacy of cryoablation in idiopathic and non-idiopathic atrial fibrillation patients

OBJECTIVES AND BACKGROUND

Studies assessing the unicentric and prospective comparison of efficacy of cryoballoon pulmonary vein isolation in idiopathic and non-idiopathic atrial fibrillation (AF) patients are missing. The aim of this study was to compare a single procedural outcome in these subgroups of AF patients.

METHODS

A total of 208 patients with drug resistant AF were included in this study. Among them, 36 patients had idiopathic AF and 172 patients had non-idiopathic AF. The efficacy endpoint was freedom from any atrial arrhythmia lasting >30 s after a 3-months blanking period.

RESULTS

The freedom from atrial arrhythmias without antiarrhythmic drugs after 1 and 3 years of follow-up, respectively, was 85.2 % and 70.4 % in patients with idiopathic AF; and 64.6 % and 39.9 % in patients with non-idiopathic AF (p=0.021). Moreover, the success rate when analysing only paroxysmal AF patients after 1 and 3 years of follow-up, respectively, was 95.7 % and 82 % in patients with idiopathic AF; and 72.6 % and 47 % in patients with non-idiopathic AF (p=0.022).

CONCLUSIONS

A single cryoballoon pulmonary vein isolation was more effective in preventing atrial arrhythmias relapses in idiopathic AF patients compared to non-idiopathic AF patients. The best efficacy outcomes were observed in patients with paroxysmal idiopathic AF (Tab. 5, Fig. 2, Ref. 25).

Predictors of Left Ventricular Remodeling After Myocardial Infarction in Patients With a Patent Infarct Related Coronary Artery After Percutaneous Coronary Intervention (from the Post-Myocardial Infarction Remodeling Prevention Therapy [PRomPT] Trial)

Left ventricular (LV) remodeling after myocardial infarction (MI) is a strong predictor of heart failure and mortality. The predictors of long-term remodeling after MI have been incompletely studied. We therefore examined the correlates of LV remodeling in patients with large ST-segment elevation myocardial infarction and a patent infarct artery after percutaneous 2coronary intervention (PCI) from the randomized Post-Myocardial Infarction Remodeling Prevention Therapy trial. Peri-infarct pacing had a neutral effect on long-term remodeling in patients with large first MI. The present analysis includes 109 patients in whom an open artery was restored after PCI, and in whom LV end-diastolic volume (LVEDV) at baseline and 18 months was assessed by transthoracic echocardiography. Multivariable models were fit to identify the independent predictors of LVEDV at baseline and 18 months. By multivariable analysis, male sex (p = 0.004) and anterior MI location (p = 0.03) were independently associated with baseline LVEDV. The following variables were independent predictors of increased LVEDV at 18 months: younger age (p = 0.01), male sex (p = 0.03), peak creatine phosphokinase (p = 0.03), shorter time from MI to baseline transthoracic echocardiography (p = 0.04), baseline LVEDV (p < 0.0001), and lack of statin use (p = 0.03). In conclusion, patients with large MI and an open infarct artery after PCI, anterior MI location, and male sex were associated with greater baseline LVEDV, but MI location was not associated with 18-month LVEDV. In contrast, younger age, peak creatine phosphokinase, male sex, baseline LVEDV, and lack of statin use were associated with long-term LV remodeling.

The effectiveness of CRT on improvement of survival of heart failure patients in real life clinical settings

Objectives Prolongation of QRS (≥ 120 ms) in patients with heart failure (HF) is associated with higher all-cause mortality than in those with narrow QRS. The aim of our study was to compare the survival of patients with HF and wide QRS after cardiac resynchronization therapy (CRT) with survival of HF patients with narrow QRS and to assess factors predictive of non-response to CRT. Methods We enrolled 680 patients with advanced HF and optimal pharmacologic therapy. All patients were assigned according to duration of QRS complex and implanted device. We acquired two groups. A first group, patients with wide QRS and implanted CRT-D (CRT-D group, n = 354) and a second group, patients having narrow QRS and implanted single/dual chamber ICD (ICD group, n = 326). The primary outcome was death from any cause. The response to CRT was defined as an increase of EF at least by 5% and/or reduction of LVEDD at least by 10%. Results The primary outcome was reached by 84 (23.7%) patients in the CRT-D group and 69 (21.2%) patients in the ICD group. We did not find a statistically significant difference in survival rate between the CRT-D and ICD group [P = 0.44; hazard ratio (HR) 1.132]. Conclusion Survival of patients with HF and wide QRS after CRT implantation is comparable to those with HF and narrow QRS. Coronary artery disease and QRS width less than 145 ms increase risk of non-response to CRT 2.2 and 2.9 times, respectively.

Safety and efficiency of ventricular pacing prevention with an AAI-DDD changeover mode in patients with sinus node disease or atrioventricular block: impact on battery longevity-a sub-study of the ANSWER trial

Aims

This ANSWER (EvaluAtioN of the SafeR mode in patients With a dual chambER pacemaker indication) sub-study assesses safety and effectiveness of SafeR™ and the impact of ventricular pacing (VP) prevention on anticipated device longevity and replacement rate.

Methods and results

Patients implanted for atrioventricular block (AVB, n = 310) or sinus node dysfunction (SND, n = 336) were randomly assigned to SafeR (n = 314) or DDD (n = 318) and followed for 36 months. Safety, median VP, estimated device longevity (mean difference, 95% confidence interval [CI]), and anticipated replacement rates were analysed by pacing mode and implant indication. No difference in mortality, syncope, or mode intolerance was observed between randomization groups regardless of the indication. Ventricular pacing on SafeR vs. DDD was 11.5 vs. 93.6% in the overall population (P < 0.001), 89.2 vs. 83.8% in permanent AVB (P = 0.944), 53.5 vs. 98.2% in intermittent AVB (P < 0.001), and 2.2 vs. 84.7% in SND (P < 0.001). Anticipated median device longevity increased on SafeR by 14 [Q1 10; Q3 17] months [10; 17] (P < 0.001) in the overall population, 9 months [−5; 22] (P = 0.193) in permanent AVB, 14 months [8; 19] (P < 0.001) in intermittent AVB, and 14 months [9; 19] (P < 0.001) in SND. In intermittent AVB and SND, prolonged estimated battery longevity translated into the prevention of one anticipated replacement in at least 23% of patients.

Conclusion

SafeR was effective in reducing VP in intermittent AVB and in SND. No effect was observed in permanent AVB. No safety issue was observed. Ventricular pacing reduction by SafeR translated into relevant estimated prolongation of device longevity and anticipated reduction of required replacements.

Peri-infarct zone pacing to prevent adverse left ventricular remodelling in patients with large myocardial infarction

AIMS

We sought to determine whether peri-infarct pacing prevents left ventricular (LV) remodelling and improves functional and clinical outcomes in patients with large first myocardial infarction (MI).

METHODS AND RESULTS

A total of 126 patients at 27 international sites within 10 days of onset of anterior or non-anterior MI with creatine phosphokinase >3000 U/L and QRS duration ≤120 ms were randomized 1:1:1 to dual-site biventricular pacing vs. single-site LV only pacing vs. non-implanted control. The primary endpoint was the echocardiographic core laboratory-assessed change in LV end-diastolic volume (ΔLVEDV) from baseline to 18 months between the pooled pacing therapy groups and the control group. ΔLVEDV increased by 15.3 ± 28.6 mL in the control group and by 16.7 ± 30.5 mL in the pooled pacing groups during follow-up (adjusted mean difference (95% CI) = 0.6 (-12.3, 13.5) mL, P = 0.92). There were also no significant between-group differences in the change in LV end-systolic volume or ejection fraction over time. Quality of life, as assessed by the Minnesota Living with Heart Failure (HF) and European Quality of Life-5 Dimension questionnaires and New York Heart Association class, was also similar between groups during 18-month follow-up. Six-minute walk distance improved during follow-up to an equal degree between groups, and there were no significant differences in the 18-month rates of death or HF hospitalization between the pooled pacing therapy vs. control groups (17.4 vs. 21.7% respectively, P = 0.59).

CONCLUSIONS

In the present multicentre, randomized trial, peri-infarct pacing did not prevent LV remodelling or improve functional or clinical outcomes during 18-month follow-up in patients with large first MI.

CLINICALTRIALSGOV IDENTIFIER

NCT01213251.

Severity of nocturnal cardiac arrhythmias correlates with intensity of sleep apnea in men

Various cardiac arrhythmias frequently occur in patients with sleep apnea, but complex analysis of the relationship between their severity and the probable arrhythmogenic risk factors is conflicting. The question is what cardiovascular risk factors and how strongly they are associated with the severity of cardiac arrhythmias in sleep apnea. Adult males (33 with and 16 without sleep apnea), matched for cardiovascular co-morbidity were studied by polysomnography with simultaneous ECG monitoring. Arrhythmia severity was evaluated for each subject by a special 7-degree scoring system. Laboratory, clinical, echocardiographic, carotid ultrasonographic, ambulatory blood pressure, and baroreflex sensitivity values were also assessed. Moderate sleep apnea patients had benign, but more exaggerated cardiac arrhythmias than control subjects (2.53 ± 2.49 vs. 1.13 ± 1.64 degrees of cumulative severity, p < 0.05). We confirmed strong correlations between the arrhythmia severity and known arrhythmogenic risk factors (left ventricular ejection fraction and dimensions, right ventricular diameter, baroreflex sensitivity, carotid intima-media thickness, age, previous myocardial infarction, and also apnea-hypopnea index). In multivariate modelling only the apnea-hypopnea index indicating the sleep apnea intensity remained highly significantly correlated with the cumulative arrhythmia severity (beta = 0.548, p < 0.005). In conclusion, sleep apnea modifying cardiovascular risk factors and structures or functions provoked various nocturnal arrhythmias. The proposed scoring system allowed a complex analysis of the contribution of various triggers to arrhythmogenesis and confirmed the apnea-hypopnea index as an independent risk for nocturnal cardiac arrhythmia severity in sleep apnea.

Catheter ablations of supraventricular tachycardias

BACKGROUND

Supraventricular tachycardias (SVT) occur at all ages. Their spectrum as well as tolerance change with increasing age.

OBJECTIVES

The aim of our study was to assess the course of SVT catheter ablations in elderly patients when compared to younger population.

METHODS

The course of the SVT radiofrequency catheter ablation (RFCA) in the group of 288 patients, who underwent catheter ablation at our department during 24 months was retrospectively evaluated. Patients were divided into two subgroups according to age. In the first group 142 patients younger than 65 years were included and 146 patients aged 65 years or more in the second group. In both groups, the occurrence of heart rhythm disorders, fluoroscopy time and the incidence of complications with varying severity were observed.

RESULTS

Life-threatening complications were observed only in three patients from the first group (one pulmonary embolism and two unintended complete atrioventricular blocks). Serious complications included a haemopericardium requiring a pericardial drainage in two cases and an arterial-venous fistula in one patient in the first group, and one retroperitoneal heamatoma in the second group. Minor complications represented by one heamatoma larger than 5x5cm occurred in one patient from each group. The occurrence of complications as well as average fluoroscopy time were not correlated between the groups.

CONCLUSION

Based on our experience, radiofrequency catheter ablation of SVT in elderly patients is a safe procedure when indicated correctly. Taking into account the physical status of patients in this age group it is advisable to simplify and thus shorten the procedure (Tab. 1, Ref. 13). Full Text in PDF www.elis.sk.

Cryothermal ablation of typical atrial flutter

OBJECTIVES

To evaluate the efficacy and safety of cryoablation compared with the radiofrequency (RF) method in the treatment of typical atrial flutter (AFL).

METHODS

12 patients with typical counterclockwise AFL underwent cryoablation of the cavotricuspid isthmus. Cryoablation was performed with a 9F catheter with an 8 mm tip electrode. Applications were delivered by point-by-point technique to create the ablation line. The end point of the procedure was achievement of bidirectional isthmus conduction block. Control group consisted of 12 consecutive patients who underwent the ablation by means of RF method.

RESULTS

We found no differences in the duration of transisthmic conduction after ablation in both groups and in the fluoroscopy time. We found significant differences in the procedural time (187 +/- 81 vs 110 +/- 35 minutes, p<0.01) and in the analgesic use (0/12 vs 12/12, p<0.01). After a 3 month follow-up all patients in both groups were free from the recurrence of AFL, 1 pacient in cryoablation group had paroxysm of atrial fibrillation.

CONCLUSIONS

Efficacy and safety profile of cryoablation are similiar with RF ablation. Procedural time in the cryoablation group is significantly longer but the use of analgesics can be completely avoided (Tab. 2, Ref. 20). Full Text (Free, PDF) www.bmj.sk.

The effect of myocardial revascularization on malignant ventricular arrhythmias in coronary artery disease

BACKGROUND

Malignant ventricular arrhythmia in coronary artery disease (CAD) is a severe life-threatening disease and a risk factor for sudden cardiac death. Myocardial revascularization influences the arrhythmogenic substrate of the malignant ventricular arrhythmia in the secondary prevention of sudden cardiac death. Its effectivity remains controversial.

OBJECTIVES

The aim of this study is to assess the inducibility of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF) in patients after myocardial revascularization and to compare the effectivity of complete and incomplete revascularization.

PATIENTS

Fifty patients with documented sustained VT or VF and CAD were examined in our department.

RESULTS

Conservatively treated patients were significantly older than revascularized patients (68 +/- 8 versus 62 +/- 9 years, p<0.05). We registered a trend towards a lower inducibility of malignant ventricular arrhythmias in the revascularized group and completely revascularized subgroup, but without statistical significance. Incompletely revascularized patients comprised only of men (100% versus 66.6%, p<0.05). Fewer ICDs were implanted in the completely revascularized group (55.6% versus 92.3%, p<0.05).

CONCLUSION

Myocardial revascularization has little effect on the inducibility of malignant ventricular arrhythmias after myocardial revascularization. Complete revascularization significantly decreases the need of ICD implantation when compared to incomplete one (Tab. 3, Fig. 4, Ref. 24). Full Text (Free, PDF) www.bmj.sk.

Systemic Inflammation in Patients With COPD and Pulmonary Hypertension

STUDY OBJECTIVES

COPD is a systemic disorder that is associated with increases of inflammatory proteins in systemic circulation. However, no data on the potential role of systemic inflammation in pulmonary hypertension secondary to COPD are available. Therefore, our aim was to investigate the degree of systemic inflammation reflected by circulatory levels of C-reactive protein (CRP), tumor-necrosis factor (TNF)-alpha, and interleukin (IL)-6 in COPD patients with and without pulmonary hypertension.

DESIGN

Cross-sectional study.

SETTING

University hospital, tertiary referral setting.

PATIENTS AND MEASUREMENTS

In 43 consecutive patients with COPD (mean [+/- SD] age, 65.0 +/- 10.5 years; mean FEV(1), 46.2 +/- 18.1% predicted), lung function was assessed using body plethysmography; pulmonary artery pressure (Ppa) levels were measured by echocardiography. Serum TNF-alpha and IL-6 levels were assessed by enzyme-linked immunosorbent assay, and high-sensitivity serum CRP levels were measured by chemiluminescent immunoassay.

RESULTS

Pulmonary hypertension was present in 19 patients and was absent in 24 patients. In patients with pulmonary hypertension, serum CRP and TNF-alpha levels were significantly higher than in those patients without hypertension (median, 3.6 mg/L [25th to 75th percentile, 1.4 to 13.0 mg/L] vs 1.8 mg/L [25th to 75th percentile, 0.8 to 2.8 mg/L; p = 0.034]; and median, 4.2 pg/mL [25th to 75th percentile, 3.4 to 10.9 pg/mL] vs 3.1 pg/mL [25th to 75th percentile, 2.1 to 4.2 pg/mL]; p = 0.042, respectively). No differences were seen in serum IL-6 (median, 10.4 pg/mL [25th to 75th percentile, 8.8 to 12.2 pg/mL] vs 10.5 pg/mL [25th to 75th percentile, 9.4 to 39.1 pg/mL]; p = 0.651) between the groups. In multiple linear regression analysis, the following two variables were independent predictors of systolic Ppa (R(2) = 0.373): Pao(2) (p = 0.011); and log-transformed serum CRP level (p = 0.044).

CONCLUSION

We conclude that increases in Ppa in patients with COPD are associated with higher serum levels of CRP and TNF-alpha, raising the possibility of a pathogenetic role for low-grade systemic inflammation in the pathogenesis of pulmonary hypertension in COPD patients.

Acute toxicity of propafenone in a case of suicidal attempt

We describe a successful treatment of 28-year old man who ingested in a suicidal attempt up to 30 pills each containing 150 mg (4500 mg) of propafenone. Results of clinical toxicology were obtained with high performance liquid chromatography from the urine sample. Semiquantitative analysis has shown a high peak for propafenone hydrochloride. The main clinical findings were coma, hypotension, acidosis, sinoatrial block, junctional tachycardia and ventricular arrhythmias necessitating defibrillation. Maximum occurence of arrhythmias was observed 2.5 hours after hospital admission, while the cessation of toxic signs started 4.5 hours later. Gastric lavage, arteficial ventilation, administration of alkalinization solutions and management of rhythm disorders were the most important therapeutic measures in this case. (Fig. 2, Ref. 18.)