P4535Discharge treatment with ACE inhibitor/ARB after a heart failure hospitalization is associated with a better prognosis irrespectively of left ventricular ejection fraction

Background

Medical therapy could improve the prognosis of real-life patients discharged after a heart failure (HF) hospitalization.

Purpose

We aimed to determine the impact of discharge HF treatment on mortality and readmissions in different left ventricular ejection fraction (LVEF) groups.

Methods

Multicentre prospective registry in 20 Spanish hospitals. Patients were enrolled after a HF hospitalization.

Results

A total of 1831 patients were included (583 [31.8%] HF with reduced ejection fraction [HFrEF]; 227 [12.4%] HF with midrange ejection fraction [HFmrEF]; 610 [33.3%] HF with preserved ejection fraction [HFpEF], and 411 [22.4%] with unknown LVEF. Angiotensin-converting enzyme (ACE) inhibitors/Angiotensin II receptor blockers (ARB) at discharge were independently associated with a reduction in: i) all-cause mortality: hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.41–0.74, P<0.001, with a similar effect in the four groups; ii) mortality due to refractory HF HR 0.45, 95% CI 0.29–0.64, P<0.001, with a similar effect in the three groups with known LVEF; iii) mortality/HF admissions (HR 0.61; 95% CI: 0.50–0.74), more evident in HFrEF (HR 0.54; 95% CI: 0.38–0.78) compared to HRmEF (HR 0.64; 95% CI 0.40–1.02), orHFpEF (HR 0.70; 95% CI 0.53–0.92).Inpatients with HFrEFtriple therapy (ACE inhibitor/ARB+ betablocker+ mineralocorticoid receptor antagonist) was associated with the lowest mortality risk (HR 0.21; 95% CI: 0.08–0.57, P=0.002) compared to patients that received none of these drugs.

Events according to the number of drugs – HFrEF (n=583) 0 (n=14) 1 (n=98) 2 (n=160) 3 (n=294) P Death or heart failure readmissions 10 (71.4) 58 (59.2) 66 (41.3) 106 (36.1) <0.001 All-cause mortality 9 (64.3) 28 (28.6) 31 (19.4) 36 (12.2) <0.001 Mortality due to refractory heart failure 7 (50.0) 14 (14.3) 17 (10.6) 17 (5.8) <0.001 – HFmrEF (n=227) 0 (n=18) 1 (n=57) 2 (n=81) 3 (n=65) P Death or heart failure readmissions 9 (50.0) 35 (61.4) 34 (42.0) 25 (38.5) 0.057 All-cause mortality 5 (27.8) 18 (31.6) 15 (18.5) 11 (16.9) 0.191 Mortality due to refractory heart failure 3 (16.7) 7 (12.3) 7 (8.6) 4 (6.2) 0.475 – HFpEF (n=610) 0 (n=61) 1 (n=242) 2 (n=219) 3 (n=69) P Death or heart failure readmissions 32 (52.5) 97 (40.1) 89 (40.6) 20 (29.0) 0.057 All-cause mortality 20 (32.8) 41 (16.9) 32 (14.6) 10 (14.5) 0.017 Mortality due to refractory heart failure 11 (18.0) 18 (7.4) 13 (5.9) 4 (5.8) 0.041 Outcomes according to the number of medications at discharge.

Kaplan-Meier Curves for study outcomes

Conclusions

Discharge treatment with ACE inhibitor/ARB after a HF hospitalization is associated with a reduction in all-cause and refractory HF mortality, irrespectively of LVEF.

Acute myocardial infarction with cardiogenic shock: treatment with mechanical circulatory assistance and heart transplantation

The mortality of cardiogenic shock (CS) after an acute myocardial infarction (AMI) still remains high. Thrombolysis, PTCA or CABG, when possible, can improve the results, but when all the treatments fail death is almost certain.

OBJECTIVE

We investigate the use of the mechanical circulatory assistance (MCA) and heart transplantation (HT) to improve the adverse results in this irreversible situation.

METHODS

Among 11 patients with irreversible CS after an AMI we used a MCA (Abiomed BVS-5000). After improvement and hemodynamic stabilization, we performed heart transplantation in 7 patients of mean age 52 years (35-60) including two women. The MCA was univentricular in 7 patients and biventricular in 4. Mean duration of the MCA was 5 days (1-12).

RESULTS

Three patients died during the MCA: two due to cerebrovascular accidents and one multiorgan failure. Weaning was possible in one patient. Among Seven transplanted patients one died due to sepsis. Seven (64%) patients are long-term survivors.

CONCLUSION

When all the treatments have failed for CS after an AMI, MCA may be used as a bridge to heart transplantation in a select group of patients where the procedure is not contraindicated. The long-term results of 64% survivors in our experience is satisfactory.

[Management of myocardial infarction in Spain (1995-99). Data from the registry of the Ischaemic Heart Disease Working Group (RISCI) of the Spanish Society of Cardiology]

INTRODUCTION AND OBJECTIVES

Limited information is available on how patients with myocardial infarction are treated in Spain. In order to make up for this deficiency, in October 1994, the Ischaemic Heart Disease Working Group of the Spanish Society of Cardiology initiated a myocardial infarction registry, which is currently active.

METHODS

Patients are recruited from hospitals with intensive coronary care facilities. Demographic characteristics coronary risk factors and previous conditions are collected, as well as clinical events, and diagnostic and therapeutic procedures performed during the stay in the coronary care unit.

RESULTS

From 1995 to 1999, 28,357 patients were registered. During this period the mean age increased slightly (from 64.4 +/- 12.2 to 65.2 +/- 12.7; p < 0.001), although the male proportion remained stable (from 76.7% to 77.1%). The median "onset of symptoms-hospital arrival for 1st emergency" time fell from 135 min to 120 min, and the median "onset of symptoms-needle" time from 180 to 175 (NS). The use of thrombolytic therapy did not change (from 42.4 to 43.9%), but the use of aspirin (from 87.4 to 91.7%), beta-blockers (from 32.7 to 39.6%) and angiotensin-converting inhibitors (from 27.9 to 34.8%) increased significantly (p < 0.001). The Swan-Ganz catheter and the intra-aortic balloon counterpulsation were rarely placed during the five years (4.2% and 1.2% respectively in 1999). Both early mortality (11.4 to 9.3%) and the median duration of intensive coronary care stay declined, in these 5 years.

CONCLUSIONS

In Spain, during the 1995-1999 period, the use of aspirin, beta-blockers, and angiotensin-converting inhibitors increased significantly during the acute phase of infarction in the coronary care unit. However, both the usage of thrombolytic therapy and the delay between the onset of symptoms and therapy initiation remained unchanged. At the same time, the length of stay in the coronary care unit and early mortality declined, although the clinical profile of the patients did not improve.

[The clinical management guidelines of the Sociedad Española de Cardiología in acute myocardial infarct]

In the recent years, new possibilities have emerged in the diagnosis and management of acute myocardial infarction with ST segment elevation and its complications. Moreover, a deep transformation has taken place in the health care system organization, particularly in aspects related to care of patients presenting non-traumatic chest pain, both in pre-hospital and hospital areas. All these issues warrant a consensus document in Spain dealing with the role that these important changes should play in the whole management of myocardial infarction patients. This document revises and updates all the main clinical issues of acute myocardial infarction patients from the moment they contact with the health care system outside the hospital until they return home, after staying at the coronary care unit and the general hospitalization ward. All those aspects are considered not only in the uncomplicated myocardial infarction but also in the complicated one. This review also includes a set of recommendations on structural and organisational aspects, mainly referred to the prehospital and emergency levels.

Low incidence of ventricular arrhythmias induced by ischaemia at the borders of a chronic infarct in a model with local postinfarction denervation

OBJECTIVE

The aim was to assess the arrhythmogenic potential of acute ischaemia superimposed at the borders of a chronic myocardial infarct and to analyse the effects of myocardial necrosis on local autonomic innervation in pigs.

METHODS

Ventricular arrhythmias were measured in alpha chloralose (100 mg.kg-1) anaesthetised open chest pigs during 60 min occlusion of the left anterior descending coronary artery 2 cm above the first diagonal branch (group I, n = 11) or just below this branch (group II, n = 12). These arrhythmias were compared with those induced in pigs with a one month old anteroseptal infarction (coronary ligature as in group II) submitted to a second occlusion 2 cm above the first (group III, n = 12). The area at risk after high or low ligature was measured in 12 control pigs using fluorescein. Sympathetic and parasympathetic innervation of the anteroseptal myocardium was studied in three pigs with a chronic anteroseptal infarction and in six pigs without infarction using adrenergic histofluorescence and acetylcholinesterase reaction.

RESULTS

Compared with ischaemia alone, ischaemia at the borders of a chronic infarct induced a lower incidence of ventricular fibrillation (1/12 pigs v 11/11 in group I, p < 0.001, or 6/12 in group II, p < 0.05) and a tendency towards a lower occurrence of ventricular tachycardia (2/12 pigs v 8/11 in group I, p = 0.01, and 4/12 in group II) and fewer ventricular premature beats (mean number: 105 in group I v 30 in group III, p < 0.05). The mass of the ischaemic regions after low or high occlusion was 13.3(SD 3.0) g and 23.2(5.8) g, respectively. Adrenergic and cholinergic denervation was observed inside the necrotic area, along the subendocardium surviving the necrosis, and in a band of normal bordering myocardium [width: 3.2(2.0) mm for adrenergic and 2.1(1.2) mm for cholinergic denervation].

CONCLUSIONS

Acute ischaemia at the borders of a chronic anteroseptal infarct has a low arrhythmogenic potential in pigs. In this model the peri-infarction zone shows a band of sympathetic and parasympathetic denervation secondary to the necrosis.

T-Q, S-T segment mapping and hyperemia in reperfused pig heart with ischemic preconditioning

The effects of ischemic preconditioning on epicardial T-Q and S-T segment mapping, local activation, and coronary blood flow were analyzed in nine barbiturate-anesthetized pigs during four coronary occlusion (5 min)-reperfusion (20 min) sequences. In seven sham pigs, one occlusion was performed after a control period of 75 min. The first reperfusion induced a marked coronary hyperemia [11 +/- 4 ml/min (baseline) to 33 +/- 16 ml/min, P < 0.005] and a rapid recovery (30 to 150 s) of epicardial activation delays, T-Q segment depression, and S-T segment elevation in the ischemia area. This recovery was transiently associated with enlargement of intersite T-Q potential variability (alpha: 2.5 +/- 0.6 to 3.4 +/- 0.7 mV, P < 0.05), T-Q segment overshoot to +1.4 +/- 0.9 mV, and S-T segment reelevation. A brief T-Q segment depression (-2.3 +/- 0.9 mV) occurred during early reperfusion in 60 of 91 electrodes overlying the normal myocardium. Compared with the first, the fourth occlusion induced lower S-T segment elevation (3.4 +/- 2.0 to 1.7 +/- 1.9 mV, P < 0.05), and the fourth reperfusion elicited a faster reversal of T-Q segment dispersion (53 +/- 21 to 43 +/- 16 s, P < 0.05), S-T segment elevation (149 +/- 101 to 81 +/- 45 s, P < 0.05), and coronary hyperemia (8 +/- 2 to 5 +/- 1 min, P < 0.05). This trend of changes was not observed during a fourth occlusion in sham pigs.(ABSTRACT TRUNCATED AT 250 WORDS)

Reperfusion arrhythmias after chronic regional denervation of the ischaemic myocardium in pigs

OBJECTIVE

The aim was to assess the effects of chronic regional denervation of the ischaemic myocardium on reperfusion arrhythmias in a model with sparse coronary collateral circulation.

METHODS

Baseline ventricular refractoriness and epicardial activation times were measured together with reperfusion arrhythmias after 15 min (I-15') or 30 min (I-30') of left anterior descending coronary artery occlusion in 38 barbiturate anaesthetised open chest pigs. Twenty pigs (11 in I-15' and nine in I-30') had a chronic (two week) denervation of the left anteroseptal region, whereas 18 pigs (10 in I-15' and eight in I-30') were sham operated (non-denervated) controls. Denervation was induced by pericoronary application of phenol and verified by absence of adrenergic histofluorescence.

RESULTS

As compared with controls, denervated pigs showed: (1) longer activation times: 20.3 (SD 5.2) ms v 16.5 (4.6) ms, p < 0.001; (2) slightly longer refractory periods: 348(28) ms v 334(27) ms; (3) a tendency to lower postreperfusion ectopic activity: ectopic beats divided by time free of ventricular tachycardia: 0.13(0.19) v 0.34(0.40) in I-15', and 0.21(0.24) v 0.39(0.44) in I-30'; (4) slower ventricular tachycardia in I-30': 140(29) beats.min-1 v 185(29) beats.min-1, p < 0.009; and (5) comparable incidence of postreperfusion ventricular fibrillation: 4/11 pigs v 2/10 in I-15', and 5/9 v 4/8 in I-30'.

CONCLUSIONS

Selective chronic denervation of the ischaemic myocardium was unable to protect against malignant reperfusion arrhythmias in hearts with human-like coronary collaterals. This was confirmed at two ischaemic periods known to produce progressive catecholamine accumulation and increased adrenoceptor density in the ischaemic myocardium.

[A superior vena cava syndrome secondary to intracavitary pacemakers. The diagnostic and therapeutic aspects]

Two cases of superior vena cava syndrome secondary to an endocardial pacemaker are reported. We discuss diagnosis methods and we point out the use of radioisotope cavography in patients with iodate contrast allergy. We suggest early administration of thrombolytic therapy besides of anticoagulants and we review the literature of previous observation of venous occlusion.

Induced ventricular arrhythmias in regionally denervated porcine heart with healed myocardial infarction

STUDY OBJECTIVE

The aim was to test the hypothesis that chronic sympathetic denervation of the boundaries of a healed myocardial infarction may modify the arrhythmogenic response to programmed electrical stimulation.

DESIGN

Electrical induction of ventricular arrhythmias and infarct size were evaluated in a control group of pigs with a one month old myocardial infarction induced by ligature of the left anterior descending coronary artery below the first diagonal branch. These were compared with a group of similarly infarcted pigs subjected to regional denervation of the peri-infarction area induced by topical pericoronary application of phenol. Denervation was verified by the absence of adrenergic histofluorescent reaction to glyoxylic acid in myocardial samples.

EXPERIMENTAL MATERIAL

24 pigs (weight 15-20 kg) with myocardial infarction were studied, 13 of which were subjected to regional peri-infarction denervation, and 11 acted as controls.

MEASUREMENTS AND MAIN RESULTS

Programmed ventricular stimulation with one to four extrastimuli at 500 and 400 ms basic cycle length at the left and right ventricles induced fewer episodes of ventricular fibrillation in the denervated than in the non-denervated group (five episodes in three pigs v 14 in nine pigs, p less than 0.005), but more episodes of sustained ventricular tachycardia (79 in eight pigs v 23 in two, p less than 0.001). Unlike fibrillation, induction of ventricular tachycardia increased with multiple extrastimuli and with short basic cycle length. The denervated preparations tended to develop smaller infarcts but this difference was not statistically significant: infarct weight (g) relative to total ventricular mass (g) = 7.2 (SD 2.4)% v 10.5(4.5)%.

CONCLUSIONS

Neural integrity of the non-ischaemic myocardium bordering a healed infarction modulates inducibility of ventricular tachycardia and fibrillation during programmed ventricular stimulation.

Clinical evaluation of a prospective protocol for the timing of surgery in chronic aortic regurgitation

Out of 160 prospectively followed patients with aortic regurgitation, the clinical courses of 53 patients with pure, severe, and chronic aortic regurgitation and without coronary artery disease who were selected for surgery on the basis of predefined criteria is discussed. Surgical criteria were either unequivocal symptoms or documentation of impaired left ventricular dysfunction (defined as angiographic ejection fraction of less than 50% plus and end-systolic volume index greater than 60 ml/m2). According to preoperative status, patients were divided as follows: 11 asymptomatic patients (group A), 30 patients with moderate (classes II to III) symptoms (group B), and 12 patients with dyspnea at rest and pulmonary edema when first seen (group C). Surgical mortality was one patient (from group C). Late death occurred in four patients (one from group B, three from group C). At the end of follow-up (minimum 1 year, mean 3.6 years) 41 patients were in functional class I, four patients in class II, and one patient in class III. All patients except one in functional classes II and III belonged to group C. Before surgery, patients from groups A and B had similar ventricular dimensions and ejection fractions, whereas patients from group C had larger end-systolic diameters and volumes and lower ejection fractions. End-diastolic and end-systolic diameters decreased significantly at 1 and 2 years after surgery. Patients from group C continued to have dilated hearts as did those patients from groups A and B who had preoperative end-systolic diameters greater than 55 mm.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of anaesthesia on acute ischaemic arrhythmias and epicardial electrograms in the pig heart in situ

STUDY OBJECTIVE

The aim of the study was to assess the influence of general anaesthesia on electrocardiographic and arrhythmogenic responses to left anterior descending coronary artery occlusion.

DESIGN

Pigs weighing 18-20 kg were anaesthetised with alpha chloralose 100 mg.kg-1 (n = 9) or thiopentone 30 mg.kg-1 (n = 9) and the arrhythmogenic effects of coronary artery occlusion were examined by sequential electrocardiographic measurements every 5 min and arrhythmia analysis every minute over a 60 min period.

RESULTS

alpha Chloralose predisposed to lower ST segment elevation (analysis of variance for repeated measurements p less than 0.002), less marked epicardial conduction delay (p less than 0.01) with slower progression to monophasic potentials, and in contrast, to a greater number of episodes of ventricular premature beats (p less than 0.005), ventricular tachycardia (51 v 32 episodes), and ventricular fibrillation (6 v 2 pigs) than barbiturate anaesthesia.

CONCLUSIONS

alpha Chloralose and barbiturates exerted opposite electrocardiographic and arrhythmogenic effects in a porcine model of acute myocardial ischaemia. Due to its proarrhythmic effect chloralose should probably be used in studies dealing with spontaneous and induced ischaemic arrhythmias.