Heart failure with mildly reduced ejection fraction: retrospective study of ejection fraction trajectory risk

AIMS

Heart failure with mildly reduced ejection fraction (HFmrEF) is associated with a favourable prognosis compared with heart failure (HF) with reduced ejection fraction (EF). We assessed whether left ventricular ejection fraction (LVEF) trajectory can be used to identify groups of patients with HFmrEF who have different clinical outcomes in a large retrospective study of patients with serial imaging.

METHODS AND RESULTS

Patients with HF and ≥2 echocardiograms performed ≥6 months apart were included if the LVEF measured 40-49% on the second study. Patients were classified as HFmrEF-Increasing if LVEF had increased ≥10% (n = 450), HFmrEF-Decreasing if LVEF had decreased ≥10% (n = 512), or HFmrEF-Stable if they did not meet other criteria (n = 389). The primary outcome was all-cause mortality or cardiovascular hospitalization after the second echocardiogram. Associations with time to first event were assessed with multivariable Cox analyses adjusted for age, co-morbidities, and medications. In total, 1351 patients with HFmrEF (median age 74, 64.2% male) were included with 28.8% exhibiting stable LVEF. During median follow-up of 15.3 months, the composite outcome occurred in 811 patients. During follow-up, patients with HFmrEF-Increasing were less likely to experience the primary outcome [adjusted hazard ratio (HR) 0.72, 95% confidence interval (CI) 0.60-0.88, P < 0.001] compared with HFmrEF-Stable. Patients with HFmrEF-Decreasing were more likely to experience the composite outcome in unadjusted analyses (unadjusted HR 1.19, 95% CI 1.01-1.40, P = 0.040) but not adjusted analyses (adjusted HR 1.16, 95% CI 0.98-1.37, P = 0.092). Associations with death or HF hospitalizations were similar (HFmrEF-Increasing: adjusted HR 0.72, 95% CI 0.59-0.88, P = 0.005; HFmrEF-Decreasing: adjusted HR 1.20, 95% CI 1.01-1.44, P = 0.044). Patients with HFmrEF-Decreasing had a similar risk of the composite outcome as patients with HF with reduced EF (adjusted HR 1.03, 95% CI 0.89-1.20, P = 0.670). Patients with HFmrEF-Increasing were less likely to experience the composite outcome compared with patients with HF with preserved EF (adjusted HR 0.73, 95% CI 0.62-0.87, P < 0.001).

CONCLUSIONS

Amongst patients with HFmrEF, those exhibiting positive LVEF trajectory were less likely to experience adverse outcomes after correcting for important confounders including medical therapy. Categorizing HFmrEF patients based on LVEF trajectory provides meaningful clinical information and may assist clinicians with management decisions.

Testing the Enemy Release Hypothesis on tall-statured grasses in South Africa, using Arundo donax, Phragmites australis, and Phragmites mauritianus as models

The Enemy Release Hypothesis (ERH) predicts that introduced plant species can escape herbivory and therefore have a competitive advantage over native plants, which are exposed to both generalist and specialist natural enemies. In this study, the ERH was explored using the invasive alien species, Arundo donax and two native tall-statured grasses, the cosmopolitan Phragmites australis and African endemic Phragmites mauritianus in South Africa. It was predicted that A. donax would have reduced species richness of herbivores compared with the native Phragmites spp., that it would be devoid of specialist herbivores and would thus be experiencing enemy escape in the adventive range. The herbivore assemblages were determined from both field surveys and a literature review. The assumptions of the ERH were for the most part not met; 13 herbivores were found on A. donax compared with 17 on P. australis and 20 on P. mauritianus. Arundo donax had two specialist herbivores from its native range, and shared native herbivores with Phragmites spp. Although A. donax had reduced species richness and diversity compared with that found in the native distribution, it has partially re-acquired a herbivore assemblage which is similar to that found on analogous native species. This suggests that enemy release may not fully explain the invasive success of A. donax in South Africa.

Chloroquine-induced cardiomyopathy: a reversible cause of heart failure

Chloroquine (CQ) and hydroxychloroquine (HCQ) are anti‐rheumatic medications frequently used in the treatment of connective tissue disorders. We present the case of a 45‐year‐old woman with CQ‐induced cardiomyopathy leading to severe heart failure. Electrocardiographic abnormalities included bifascicular block, while structural disease consisted of severe biventricular and biatrial hypertrophy. Appropriate diagnosis via endomyocardial biopsy led to cessation of CQ and subsequent dramatic improvement in symptoms and structural heart disease. Cardiac toxicity is an under‐recognized adverse effect of CQ/HCQ leading to cardiomyopathy with concentric hypertrophy and conduction abnormalities, with the potential for significant morbidity and mortality. Predisposing factors for CQ/HCQ‐induced cardiomyopathy have been proposed. CQ/HCQ cardiomyopathy is a phenocopy of Fabry disease, and α‐galactosidase A polymorphism may account for some heterogeneity of disease presentation.

Influenza H1N1 Infection Leading To Cardiac Tamponade in a Previously Healthy Patient: A Case Report

Introduction

The cardiac manifestations of influenza A are broad, ranging from self-limited pericarditis to fatal cardiomyopathy. The 2009 H1N1 influenza A (H1N1) strain is a rare cause of pericarditis, and its role in developing a pericardial effusion leading to tamponade has infrequently been reported.

Case Presentation

We describe a case of a young female with no prior cardiovascular history who presents with a pericardial effusion and shock secondary to cardiac tamponade from pericarditis due to H1N1 influenza A.

Conclusions

This case highlights the potential severity of H1N1 infections and the utility of considering cardiac tamponade in patients presenting with influenza symptoms and circulatory collapse.

The use of loperamide for treatment of "difficult to manage" chronic diarrhoea in adults

An open study of loperamide in seven chronic diarrhoea patients who were inadequately controlled by previous anti-diarrhoeal therapy is reported. All patients were well controlled by small amounts of loperamide and most could not eat a normal diet. No side-effect were reported.