Epidemiology and impact of frailty in patients with atrial fibrillation in Europe

BACKGROUND

Frailty is a medical syndrome characterised by reduced physiological reserve and increased vulnerability to stressors. Data regarding the relationship between frailty and atrial fibrillation (AF) are still inconsistent.

OBJECTIVES

We aim to perform a comprehensive evaluation of frailty in a large European cohort of AF patients.

METHODS

A 40-item frailty index (FI) was built according to the accumulation of deficits model in the AF patients enrolled in the ESC-EHRA EORP-AF General Long-Term Registry. Association of baseline characteristics, clinical management, quality of life, healthcare resources use and risk of outcomes with frailty was examined.

RESULTS

Among 10,177 patients [mean age (standard deviation) 69.0 (11.4) years, 4,103 (40.3%) females], 6,066 (59.6%) were pre-frail and 2,172 (21.3%) were frail, whereas only 1,939 (19.1%) were considered robust. Baseline thromboembolic and bleeding risks were independently associated with increasing FI. Frail patients with AF were less likely to be treated with oral anticoagulants (OACs) (odds ratio 0.70, 95% confidence interval 0.55-0.89), especially with non-vitamin K antagonist OACs and managed with a rhythm control strategy, compared with robust patients. Increasing frailty was associated with a higher risk for all outcomes examined, with a non-linear exponential relationship. The use of OAC was associated with a lower risk of outcomes, except in patients with very/extremely high frailty.

CONCLUSIONS

In this large cohort of AF patients, there was a high burden of frailty, influencing clinical management and risk of adverse outcomes. The clinical benefit of OAC is maintained in patients with high frailty, but not in very high/extremely frail ones.

Increased urinary aquaporin-2 excretion in response to furosemide in patients with chronic heart failure

OBJECTIVE

Patients with chronic heart failure (CHF) have decreased ability to excrete water and increased urinary excretion of aquaporin-2 (U-AQP2). The natriuretic and diuretic effects of furosemide are antagonized by an increased reabsorption of sodium and water in the collecting ducts. It is unknown whether aquaporin-2 (AQP2) renal water channels are involved in this compensatory reabsorption. We tested the hypothesis that U-AQP2 increases after a single intravenous dose of furosemide in CHF patients.

MATERIAL AND METHODS

In a randomized, single-blind, placebo-controlled, crossover study, we measured the effect of furosemide (80 mg) on U-AQP2, urine volume, free water clearance (C(H2O)) and fractional excretion of sodium (FE(Na)) in 12 CHF patients. Plasma concentrations of vasopressin (AVP), renin (PRC), angiotensin II (Ang II), aldosterone (Aldo), atrial (ANP) and brain natriuretic peptides (BNP) were measured during the study. U-AQP2 and hormones were determined by radioimmunoassays.

RESULTS

Furosemide increased U-AQP2 (140 %), urine volume (280 %), C(H2O) (95 %) and FE(Na) by a factor of 15 (p<0.008 for all), and also AVP (51 %), PRC, Ang II (86 %) and Aldo (59 %) (p<0.021 for all). ANP and BNP did not change.

CONCLUSIONS

In CHF, furosemide increased the vasopressin level, which stimulated water reabsorption via the APQ2 water channels. This is most likely a compensatory phenomenon in addition to the increase in the renin-angiotensin system to prevent excess loss of sodium and water. However, both these effects were overridden by the effect of furosemide, as shown by increased free water clearance and sodium excretion.

Influence of training habits on exercise-induced changes in plasma atrial and brain natriuretic peptide and urinary excretion of aquaporin-2 in healthy man

The purpose of this study was to quantify the influence of training habits on the changes in plasma atrial natriuretic peptide (ANP), plasma brain natriuretic peptide (BNP) and urine aquaporin-2 (u-AQP2) during exercise by studying trained and untrained healthy subjects. Eleven trained subjects (7 males, 4 females) and 10 untrained subjects (8 males, 2 females) performed a maximal aerobic exercise test. ANP and BNP were determined every 3 min and at maximum exercise by radioimmunoassay (RIA), and u-AQP2 was determined before and after the exercise test by RIA. The absolute increase in ANP during exercise was higher in the trained subjects (trained subjects: 5.6 pmol/L; untrained subjects: 2.4 pmol/L, p < 0.05) and was positively correlated to ANP at rest (p < 0.03). The maximum absolute increase in BNP during exercise was the same in the two groups (trained subjects: 0.5 pmol/L; untrained subjects: 0.6 pmol/L, NS) and tended to correlate positively with resting BNP in the trained subjects (p = 0.07). Exercise did not change u-AQP2 excretion in either trained subjects (rest: 372 ng/mmol creatinine; exercise: 314 ng/mmol creatinine, NS) or untrained subjects (rest: 263 ng/mmol creatinine; exercise: 338 ng/mmol creatinine, NS). The absolute increase in ANP during exercise was higher in trained subjects than in untrained subjects and was positively correlated to ANP at rest. This might reflect the normal cardiovascular adaptation to exercise. The increase in BNP during exercise was unrelated to training habits. Training habits did not affect the u-AQP2 excretion during exercise.

Chlamydia pneumoniae DNA in peripheral blood mononuclear cells in dialysis patients, renal transplant recipients and healthy controls

It has been suggested that infection with Chlamydia pneumoniae plays a role in the development and maintenance of atherosclerosis based on differences in the prevalence of antibodies against Chlamydia pneumoniae in patients with and without atherosclerotic lesions and on the presence of bacteria in atherosclerotic lesions. It is well known that patients undergoing chronic dialysis treatment and renal transplant recipients have a considerably increased risk of cardiovascular disease. In this study it is hypothesized that patients with these conditions have a higher prevalence of Chlamydia pneumoniae DNA in the white cells of the peripheral blood. Blood samples from 196 dialysis patients, 114 renal transplant recipients and 342 healthy controls were analysed with an in-house nested polymerase chain reaction (nPCR) and tested for the presence of Chlamydia pneumoniae DNA. The prevalence of Chlamydia pneumoniae DNA was significantly higher in dialysis patients (16.3%) than in healthy controls (8.5%, p < 0.01), whereas no significant difference was found between the prevalence in renal transplant recipients (9.6%) and healthy controls. The prevalence was not related to gender or age in either group, and it was the same in diabetics and non-diabetics. Dialysis patients have a higher prevalence of Chlamydia pneumoniae DNA than healthy controls. The lower prevalence of Chlamydia pneumoniae DNA in renal transplant recipients than in dialysis patients may be due to selection of dialysis patients with few or no cardiovascular complications for renal transplantation. Our results are consistent with the hypothesis that Chlamydia pneumoniae is associated with the pathogenesis of atherosclerosis.

Urinary aquaporin-2 in healthy humans and patients with liver cirrhosis and chronic heart failure during baseline conditions and after acute water load

BACKGROUND

Patients with liver cirrhosis and chronic heart failure (CHF) have a reduced capacity to excrete water. Studies in healthy humans have shown that an acute water load reduces the excretion of aquaporin-2 in urine (u-AQP-2). We wanted to test the hypothesis that an acute water load reduces u-AQP-2 less in patients with liver cirrhosis or CHF than in healthy humans.

METHODS

Fourteen healthy subjects, 14 patients with liver cirrhosis, and 14 patients with CHF were given an oral water load of 20 mL/kg. Urine was collected every 30 minutes for 4 hours for analysis of u-AQP-2. Blood samples were drawn at the beginning and at the end of the study for analysis of arginine vasopressin (AVP). u-AQP-2 was determined by radioimmunoassay.

RESULTS

During the study period, urinary output was 22.8% higher than water intake in the healthy controls and increased 14-fold from baseline, but in patients with liver cirrhosis and CHF urinary output was 14% and 24% less than the intake, while urinary output increased 7- and 19-fold from baseline, respectively. u-AQP2 decreased significantly more in patients with CHF (39%) than in healthy controls (17%) but it was unchanged in those with liver cirrhosis. AVP decreased 46% in patients with CHF, but was unchanged in healthy controls and those with liver cirrhosis. A 24-hour urinary excretion of AQP-2 was significantly elevated in patients with CHF (median, 25.7 nmol/mol creatinine) compared to healthy controls (15.7 nmol/mol creatinine) and those with liver cirrhosis (17 nmol/mol creatinine).

CONCLUSION

The excretion of AQP-2 in urine is abnormal both in liver cirrhosis in which we find less suppression of u-AQP2 by an acute water load and in CHF in which we find a high baseline level and an exaggerated suppression of u-AQP2 by an acute water load.

Comparison of degrees of left ventricular dilation within three hours and up to six days after onset of first acute myocardial infarction

Following an acute myocardial infarction (AMI) there is immediate deterioration of contractility in the infarcted left ventricular (LV) wall. This can be followed by regional dilation (expansion) as well as global remodeling. We examined 35 consecutive patients--with no history of myocardial ischemia--who were admitted to hospital within 3 hours after initial symptoms and with ST-segment changes on an electrocardiogram consistent with transmural ischemia. Echocardiography was performed at admission, and at 6 hours, 12 hours, 24 hours, 3 days, and 6 days after onset of the AMI. Within 3 hours after onset of symptoms an increase in both end-diastolic volume index (EDVI) and end-systolic volume index (ESVI) was found in both anterior and inferior infarcts when compared with healthy controls (mean +/- SD EDVI: 99 +/- 13 ml/m2 [anterior], 69 +/- 17 ml/m2 [inferior], 51 +/- 15 ml/m2 [controls], p < or = 0.00001; ESVI: 62 +/- 12 ml/m2 [anterior], 38 +/- 11 ml/m2 [inferior], 17 +/- 6 ml/m2 [controls], p < or = 0.00001). At all points in time, volumes were larger in anterior infarcts than in inferior infarcts (p < 0.05). The volumes did not change during the 6 days (p > 0.1). Thus, major LV dilation is present within 3 hours after onset of symptoms of first AMI. The dilation is more pronounced in anterior versus inferior infarcts. From 3 hours until day 6 no further changes in LV volumes occurred.

Late bioprosthetic valve endocarditis caused by Phialemonium aff. curvatum and Streptococcus sanguis: a case report

Dual fungal and Streptococcus sanguis endocarditis is reported in a 63-year-old woman 7 months after placement of a porcine aortic valve prosthesis. Both micro-organisms were isolated by blood cultures, and the patient succumbed after a full course of antibacterial chemotherapy without having received antifungal chemotherapy. The best possible designation of the fungus was Phialemonium aff. curvatum W. Gams & W. B. Cooke, as represented by CBS 331.93. At autopsy hyphae were revealed in the porcine valve tissue by conventional staining. A hyperimmune rabbit antiserum raised towards strain CBS 331.93 and extensively absorbed with heterologous fungal antigens reacted strongly with hyphae in the valve tissue by indirect immunofluorescence technique. We consider it most likely that the Phialemonium infection evolved insidiously from the time of open heart surgery and led to a haematogenous streptococcal infection of a more fulminant course.

Subacute cor pulmonale due to microscopic pulmonary tumour cell embolization

A case of a clinically occult ovarian carcinoma leading to subacute cor pulmonale in a 62-year-old woman is described. The patient was admitted to hospital with increasing respiratory distress. Physical examination and echocardiography showed signs of pulmonary hypertension. She died from circulatory failure. Autopsy revealed a bilateral ovarian carcinoma with diffuse carcinosis of the peritoneum. No gross evidence of pulmonary embolism was present, but microscopic investigation revealed tumour-related microangiopathic lesions causing the lethal pulmonary hypertension.

Uptake of labelled free and esterified cholesterol from plasma by the aortic intima--media tissue measured in vivo in three animal species

Hyperlipemic stilboestrol-treated cockerels, cholesterol-fed rabbits and minipigs, as well as normolipemic cockerels and rabbits were injected intravenously with homologous plasma of corresponding lipid concentration labelled in vivo with radioactive cholesterol. The ratios between labelled free cholesterol and labelled esterified cholesterol in the intima--media from the thoracic aorta of these 5 groups of animals were respectively 1-, 2-, 8-, 2- and 20-fold greater than the corresponding average tracer ratio in plasma during the uptake period of 4--6 h. The intima--media tissue in the coronary arteries studied in one minipig contained 2--5 times more labelled cholesterol per mg wet weight than corresponding aortic tissue. This arterial uptake of labelled cholesterol in the minipigs was measured concomitantly with the uptake of phosphatidylcholine and plasma protein labelled in vivo. The uptake for these various tracers in the minipig suggested entry of labelled free and esterified cholesterol into the arterial wall, mainly as part of the plasma lipoproteins, with subsequent hydrolysis in the arterial wall of some of the cholesterol ester. In the stilboestrol-treated cockerels hydrolysis of cholesterol ester seems to be absent. The relatively higher uptake in the minipig of the labelled plasma protein (albumin) than of the lipoprotein (as traced by its lipids) suggests a molecular weight-dependent arterial entry of these plasma macromolecules.