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Sandoe JAT, Ahmed F, Arumugam P, Guleri A, Horner C, Howard P, Perry J, Prendergast BD, Schwiebert R, Steeds RP, Watkin R, Wendler O, Chambers JB. Expert consensus recommendations for the provision of infective endocarditis services: updated guidance from the Joint British Societies. Heart 2023; 109:e2. [PMID: 36898706 PMCID: PMC10423555 DOI: 10.1136/heartjnl-2022-321791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
Infective endocarditis (IE) remains a difficult condition to diagnose and treat and is an infection of high consequence for patients, causing long hospital stays, life-changing complications and high mortality. A new multidisciplinary, multiprofessional, British Society for Antimicrobial Chemotherapy (BSAC)-ledWorking Party was convened to undertake a focused systematical review of the literature and to update the previous BSAC guidelines relating delivery of services for patients with IE. A scoping exercise identified new questions concerning optimal delivery of care, and the systematic review identified 16 231 papers of which 20 met the inclusion criteria. Recommendations relating to endocarditis teams, infrastructure and support, endocarditis referral processes, patient follow-up and patient information, and governance are made as well as research recommendations. This is a report of a joint Working Party of the BSAC, British Cardiovascular Society, British Heart Valve Society, British Society of Echocardiography, Society of Cardiothoracic Surgeons of Great Britain and Ireland, British Congenital Cardiac Association and British Infection Association.
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Affiliation(s)
- Jonathan A T Sandoe
- Microbiology department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Fozia Ahmed
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK
- The University of Manchester, Manchester, UK
| | - Parthiban Arumugam
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Achyut Guleri
- Microbiology department, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Carolyne Horner
- Formerly British Society of Antimicrobial Chemotherapy, Birmingham, UK
| | - Philip Howard
- NHS England North East & Yorkshire, Leeds, UK
- University of Leeds, Leeds, UK
| | - John Perry
- Microbiology department, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Bernard D Prendergast
- Cardiology department, Guy's and St Thomas' NHS Foundation Trust, London, UK
- Cleveland Clinic, London, UK
| | - Ralph Schwiebert
- Microbiology department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
- School of Medicine, University of Leeds, Leeds, UK
| | - Richard Paul Steeds
- Cardiology department, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Watkin
- Cardiology department, University Hospitals Birmingham NHS Foundation Trust, Sutton Coldfield, UK
| | - Olaf Wendler
- Cardiothoracic Surgery, King's College Hospital, King's Health Partners, London, UK
| | - John B Chambers
- Cardiology department, Guy's and St Thomas' NHS Foundation Trust, London, UK
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Vijapurapu R, Roy A, Demetriades P, Warfield A, Hughes DA, Moon J, Woolfson P, de Bono J, Geberhiwot T, Kotecha D, Steeds RP. Systematic review of the incidence and clinical risk predictors of atrial fibrillation and permanent pacemaker implantation for bradycardia in Fabry disease. Open Heart 2023; 10:e002316. [PMID: 37460269 DOI: 10.1136/openhrt-2023-002316] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
INTRODUCTION Fabry disease (FD) is an X-linked lysosomal storage disorder caused by enzyme deficiency, leading to glycosphingolipid accumulation. Cardiac accumulation triggers local tissue injury, electrical instability and arrhythmia. Bradyarrhythmia and atrial fibrillation (AF) incidence are reported in up to 16% and 13%, respectively. OBJECTIVE We conducted a systematic review evaluating AF burden and bradycardia requiring permanent pacemaker (PPM) implantation and report any predictive risk factors identified. METHODS We conducted a literature search on studies in adults with FD published from inception to July 2019. Study outcomes included AF or bradycardia requiring therapy. Databases included Embase, Medline, PubMed, Web of Science, CINAHL and Cochrane. The Risk of Bias Agreement tool for Non-Randomised Studies (RoBANS) was utilised to assess bias across key areas. RESULTS 11 studies were included, eight providing data on AF incidence or PPM implantation. Weighted estimate of event rates for AF were 12.2% and 10% for PPM. Age was associated with AF (OR 1.05-1.20 per 1-year increase in age) and a risk factor for PPM implantation (composite OR 1.03). Left ventricular hypertrophy (LVH) was associated with AF and PPM implantation. CONCLUSION Evidence supporting AF and bradycardia requiring pacemaker implantation is limited to single-centre studies. Incidence is variable and choice of diagnostic modality plays a role in detection rate. Predictors for AF (age, LVH and atrial dilatation) and PPM (age, LVH and PR/QRS interval) were identified but strength of association was low. Incidence of AF and PPM implantation in FD are variably reported with arrhythmia burden likely much higher than previously thought. PROSPERO DATABASE CRD42019132045.
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Affiliation(s)
- Ravi Vijapurapu
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
| | - Ashwin Roy
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | - Adrian Warfield
- Department of Histopathology, Queen Elizabeth Hospital, Birmingham, UK
| | | | - James Moon
- Department of Cardiology, Saint Bartholomew's Hospital Barts Heart Centre, London, UK
| | - Peter Woolfson
- Department of Cardiology, Salford Royal Hospital, Salford, UK
| | - Joseph de Bono
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
| | - Tarekegn Geberhiwot
- Department of Metabolic Medicine, Queen Elizabeth Hospital, Birmingham, UK
- University of Birmingham, Birmingham, UK
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Richard Paul Steeds
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
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3
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Sharma H, Liu B, Yuan M, Shakeel I, Morley-Smith A, Hatch A, Bradley J, Chue C, Myerson SG, Steeds RP, Lim S. Predictors and clinical implications of residual mitral regurgitation following left ventricular assist device therapy. Open Heart 2023; 10:e002240. [PMID: 37316326 DOI: 10.1136/openhrt-2022-002240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/23/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Correction of mitral regurgitation (MR) at the time of left ventricular assist device (LVAD) implantation remains controversial. There is conflicting evidence regarding the clinical impact of residual MR, and studies have not examined whether MR aetiology or right heart function impacts the likelihood of residual MR. METHODS This is a retrospective single-centre study of 155 consecutive patients with LVAD implantation from January 2011 to March 2020. Exclusion criteria were no MR pre-LVAD (n=8), inaccessible echocardiography (n=9), duplicate records (n=10) and concomitant mitral valve repair (n=1). Statistical analysis was performed using STATA V.16 and SPSS V.24. RESULTS Carpentier IIIb MR aetiology was associated with more severe MR pre-LVAD (severe 18/27 (67%) vs non-severe 32/91 (35%), p=0.004) and a higher likelihood of residual MR (8/11 (72%) vs 30/74 (41%), p=0.045). Of 95 patients with significant MR pre-LVAD, 15 (16%) had persistent significant MR, which was associated with higher mortality (p=0.006), post-LVAD right ventricle (RV) dilatation (10/15 (67%) vs 28/80 (35%), p=0.022) and RV dysfunction (14/15 (93%) vs 35/80 (44%), p<0.001). Aside from ischaemic aetiology, other pre-LVAD parameters that were associated with significant residual MR included left ventricular end-systolic diameter (LVESD) (6.9 cm (5.7-7.2) vs 5.9 cm (5.5-6.5), p=0.043), left atrial volume index (LAVi) (78 mL/m2 (56-88) vs 57 mL/m2 (47-77), p=0.021), posterior leaflet displacement (2.5 cm (2.3-2.9) vs 2.3 cm (1.9-2.7), p=0.042) and basal right ventricular end-diastolic diameter (RVEDD) (5.1±0.8 cm vs 4.5±0.8 cm, p=0.010). CONCLUSION LVAD therapy improves MR and tricuspid regurgitation severity in the majority, but 14% have persistent significant residual MR, associated with right ventricular dysfunction and higher long-term mortality. This may be predicted pre-LVAD by greater LVESD, RVEDD and LAVi and by ischaemic aetiology.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Boyang Liu
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mengshi Yuan
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Iqra Shakeel
- Institute of Cardiovascular Sciences, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Andrew Morley-Smith
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Harefield Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Alice Hatch
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Joseph Bradley
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Colin Chue
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Saul G Myerson
- Department of Cardiovascular Medicine, University of Oxford, Oxford, UK
| | - Richard Paul Steeds
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Sern Lim
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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4
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Rudolph TK, Messika-Zeitoun D, Frey N, Lutz M, Krapf L, Passefort S, Fryearson J, Simpson H, Mortensen K, Rehse S, Tiroke A, Dodos F, Mies F, Deutsch C, Kurucova J, Thoenes M, Bramlage P, Steeds RP. Severe aortic stenosis management in heart valve centres compared with primary/secondary care centres. Heart 2023; 109:944-950. [PMID: 36657962 DOI: 10.1136/heartjnl-2022-321566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 01/03/2023] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Current guidelines recommend use of heart valve centres (HVCs) to deliver optimal quality of care for patients with valve disease but there is no evidence to support this. The hypothesis of this study is that patient care with severe aortic stenosis (AS) will differ in HVCs compared with satellite centres. We aimed to compare the treatment of patients with AS at HVCs (tertiary care hospitals with full access to AS interventions) to satellites (hospitals without such access). METHODS IMPULSE enhanced is a European, observational, prospective registry enrolling consecutive patients with newly diagnosed severe AS at four HVCs and 10 satellites. Clinical characteristics, interventions performed and outcomes up to 1 year by site-type were examined. RESULTS Among 790 patients, 594 were recruited in HVCs and 196 in satellites. At baseline, patients in HVCs had more severe valve disease (higher peak aortic velocity (4.3 vs 4.1 m/s; p=0.008)) and greater comorbidity (coronary artery disease (CAD) (44% vs 27%; p<0.001) prior myocardial infarction (MI) (11% vs 5.1%; p=0.011) and chronic pulmonary disease (17% vs 8.9%; p=0.007)) than those presenting in satellites. An aortic valve replacement was performed more often by month 3 in HVCs than satellites in the overall population (52.6% of vs 31.3%; p<0.001) and in symptomatic patients (66.7% vs 43.2%, p<0.001). One-year survival rate was higher for patients in HVCs than satellites (HR2.19; 95% CI 1.28 to 3.73 total population and 2.89 (95%CI 1.64 to 5.11) for symptomatic patients. CONCLUSIONS Our data support the implementation of referral pathways that direct patients to HVCs performing both surgery and transcatheter interventions. TRIAL REGISTRATION NUMBER NCT03112629.
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Affiliation(s)
- Tanja K Rudolph
- Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Nordrhein-Westfalen, Germany
| | - David Messika-Zeitoun
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Norbert Frey
- Department of Cardiology and Angiology, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Schleswig-Holstein, Germany.,Department of Cardiology, Angiology and Pneumology, Heidelberg University, Heidelberg, Baden-Württemberg, Germany
| | - Matthias Lutz
- Department of Cardiology and Angiology, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Laura Krapf
- Department of Cardiology, Hospital Max Fourestier, Nanterre, Île-de-France, France
| | - Stephanie Passefort
- Department of Cardiology, Hopital Andre Gregoire, Montreuil, Île-de-France, France
| | - John Fryearson
- Department of Cardiology, South Warwickshire NHS Foundation Trust, Warwick, Warwickshire, UK
| | - Helen Simpson
- Birmingham Heartlands Hospital, Birmingham, West Midlands, UK
| | - Kai Mortensen
- Kardiologische Gemeinschaftspraxis Kiel, Kiel, Germany
| | - Sebastian Rehse
- Departmet of Internal Medicine, Klinik Preetz, Preetz, Germany
| | | | - Fotini Dodos
- Praxis für Innere Medizin, Kardiologie, Pneumologie am Wiener Platz, Vienna, Austria
| | - Florian Mies
- Kardiologische Gemeinschaftspraxis Hohenlind, Cologne, Germany
| | - Cornelia Deutsch
- 1Institute for Pharmacology and Preventive Medicine, IPPMed, Cloppenburg, Germany
| | - Jana Kurucova
- Edwards Lifesciences AG Czech Republic Branch, Prague, Czech Republic
| | | | - Peter Bramlage
- 1Institute for Pharmacology and Preventive Medicine, IPPMed, Cloppenburg, Germany
| | - Richard Paul Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
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5
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Bunting KV, Mehta S, Gill SK, Steeds RP, Kotecha D. Digoxin improves systolic cardiac function in patients with AF and HFpEF: the RATE-AF randomised trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The RAte control Therapy Evaluation in permanent AF trial (RATE-AF; NCT02391337) was the first head-to-head controlled trial of beta-blockers versus digoxin in patients with permanent atrial fibrillation (AF) and symptoms of heart failure. Patients randomised to digoxin had similar physical-related quality of life and heart rate, with significantly improved functional class, reduced N-terminal pro-brain natriuretic peptide (NT-proBNP) and substantially less adverse events. The impact of rate control therapy on measures of cardiac function is not currently understood.
Purpose
To compare the effect of digoxin versus beta-blockers on systolic and diastolic cardiac function according to heart failure sub-type.
Methods
Blinded echocardiograms assessing systolic and diastolic function were performed at baseline and 12 month follow-up, using a robust method to account for rhythm irregularity (average of three index-beats acquired in appropriate cardiac cycles). Outcomes were the change in left-ventricular ejection fraction (LVEF), systolic tissue Doppler velocity (s'), stroke volume, global longitudinal strain (GLS), diastolic tissue Doppler (e'), mitral E wave deceleration time, E/e', pulmonary vein diastolic deceleration time, isovolumic relaxation time and left atrial ejection fraction. Analyses were stratified by baseline LVEF (≥50%, 40–50% and <40%).
Results
160 patients were randomised, of which 145 patients survived to 12-month follow-up with median age 75 years (IQR 69–82) and 44% women. Median baseline heart rate was 96 beats/min (IQR 86–112), blood pressure 135/85 mmHg (IQR 124/77–146/91), NTproBNP 1049 pg/mL (744–1463) and mean NYHA class 2.4 (SD 0.6). In 119 patients with LVEF ≥50% at baseline, diastolic and systolic parameters improved over time with digoxin therapy. There was a significantly greater improvement in systolic function in 63 patients on digoxin compared to 67 with beta-blockers; Figure 1. Patients randomised to digoxin had a higher LVEF at follow-up (adjusted mean difference [AMD] 2.3%, 95% CI 0.3–4.2; p=0.021), higher s' (1.1cm/s, 1.0–1.2; p=0.003) and higher stroke volume (6.5mL, 0.4–12.6; p=0.037) compared to beta-blockers, without any difference in diastolic parameters (Figure 2). In 16 patients with LVEF 40–50% at baseline, s' significantly increased with digoxin compared to beta-blockers (AMD 1.5 cm/s, 1.2–1.7; p=0.001), with no difference for other systolic or diastolic parameters. 10 patients with LVEF <40% at baseline showed no difference between digoxin and beta-blockers for any echocardiographic measures.
Conclusion
Patients randomised to digoxin with permanent AF, heart failure symptoms and preserved LVEF have significantly greater improvement in multiple parameters of systolic function compared to conventional treatment with beta-blockers.
Funding Acknowledgement
Type of funding sources: Public Institution(s). Main funding source(s): National Institute of Health Research
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Affiliation(s)
- K V Bunting
- University of Birmingham, Institute of Cardiovascular Sciences , Birmingham , United Kingdom
| | - S Mehta
- University of Birmingham, Birmingham Clinical Trials Unit , Birmingham , United Kingdom
| | - S K Gill
- University of Birmingham, Institute of Cardiovascular Sciences , Birmingham , United Kingdom
| | - R P Steeds
- University of Birmingham, Institute of Cardiovascular Sciences , Birmingham , United Kingdom
| | - D Kotecha
- University of Birmingham, Institute of Cardiovascular Sciences , Birmingham , United Kingdom
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6
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Pallikadavath S, Greenwood JP, Berry C, Dawson DK, Hogrefe K, Kelly DJ, Lang CC, Khoo JP, Springings D, Steeds RP, McCann GP, Singh A. Transaortic flow rate to predict short and long term outcomes in individuals with asymptomatic aortic stenosis. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Echocardiographic derived transaortic flow rate (TFR), defined as stroke volume over left ventricular ejection time, has been shown to be associated with increased mortality in asymptomatic mild to severe aortic stenosis (AS) and superior to stroke volume index (SVi) in individuals with symptomatic discordant AS undergoing aortic valve replacement. However, TFR has not been explored alongside SVi in asymptomatic moderate to severe AS, who are a group of interest in risk stratifying for early intervention. Moreover, there is no data where TFR is indexed to body surface area (TFRi).
Purpose
We explored the prognostic value of TFR, TFRi and SVi in a homogenous cohort of asymptomatic patients with moderate to severe AS.
Methods
Subjects with asymptomatic moderate to severe AS were prospectively recruited to the Prognostic Importance of Microvascular Dysfunction in asymptomatic patients with AS (PRIMID) study, a multi-centre observational study in the UK conducted between April 2012 and November 2014. All subjects underwent extensive phenotyping with transthoracic echocardiography, bicycle exercise testing and cardiovascular magnetic resonance (CMR) imaging, with blinded core-lab analysis. Patients were followed up in person for a minimum of 12 months, and through health records thereafter. The composite outcome of interest was: cardiovascular mortality, AVR for symptoms and major adverse cardiovascular events (hospitalisation with heart failure, myocardial infarction, syncope and arrhythmia) at one-year and at five years. A cox proportional hazards model was used to calculate a hazard ratio (HR) and 95% confidence intervals (95% CI). Known co-variables associated with the composite outcome were added into the multivariable model.
Results
Overall, 173 individuals were included with a mean age of 66.3—-±13.3 years and 76.4% were male. Most individuals had severe AS (71.1%, n=123). There were 47 (64.4%) primary outcome events at one-year and 110 (63.6%) events at five-years. Age, sex, N-terminal pro brain natriuretic peptide (NT-pro-BNP), peak aortic velocity (AV Vmax), a positive exercise tolerance test (ETT), myocardial perfusion reserve and right ventricular ejection fraction measured on cardiac magnetic resonance were included in the multivariable model in addition to TFR or TFRi or SVi. Decreasing TFR and TFRi remained independently associated with one-year and five-year composite outcome (Figure 1). However, SVi was only associated with the composite outcome at five-years. AV Vmax (HR: 4.36, 95% CI: 2.59, 7.34, p<0.01) and a positive ETT (HR: 1.87, 95% CI: 1.03, 3.37, p=0.04) were independently associated with the primary outcome at one-year.
Conclusion
Both TFR and TFRi have a potential role in risk stratifying asymptomatic patients with AS and identifying those for earlier intervention, and may be superior to SVi. However, further prospectively designed studies are needed before this becomes part of the routine clinical practice.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Independent research from a Post-Doctoral Fellowship supported by the National Institute for Health Research (NIHR-PDF 2011-04-51 Geral P McCann).
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Affiliation(s)
- S Pallikadavath
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - J P Greenwood
- Leeds Teaching Hospitals NHS Trust, Leeds Institute for Cardiovascular and Diabetes Research , Leeds , United Kingdom
| | - C Berry
- University of Glasgow, BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - D K Dawson
- University of Aberdeen, Cardiovascular Medicine Research Unit , Aberdeen , United Kingdom
| | - K Hogrefe
- Kettering General Hospital, Cardiology Department , Kettering , United Kingdom
| | - D J Kelly
- Royal Derby Hospital, Cardiology Department , Derby , United Kingdom
| | - C C Lang
- Ninewells Hospital, Division of Cardiovascular and Diabetes Medicine , Dundee , United Kingdom
| | - J P Khoo
- Glenfield Hospital, NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - D Springings
- Northampton General Hospital , Northampton , United Kingdom
| | - R P Steeds
- Queen Elizabeth Hospital Birmingham, Cardiovascular Medicine , Birmingham , United Kingdom
| | - G P McCann
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
| | - A Singh
- NIHR Biomedical Research Unit in Cardiovascular Disease , Leicester , United Kingdom
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7
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Vijapurapu R, Maanja M, Schlegel T, Augusto J, Kurdi H, Moon JC, Hughes DA, Geberhiwot T, Ugander M, Steeds RP, Kozor R. Advanced electrocardiography predicts early cardiac involvement and incident arrhythmias in Fabry disease. Europace 2022. [DOI: 10.1093/europace/euac053.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: None.
Background
Fabry disease is an X-linked disorder, with cardiovascular involvement characterised by progressive myocardial sphingolipid deposition. Cardiac disease is a major contributor to morbidity and mortality. Cardiac magnetic resonance (CMR) with T1 mapping and advanced electrocardiography (A-ECG) offer both diagnostic and prognostic potential.
Purpose
To evaluate the predictive power of A-ECG markers in identifying: 1) early cardiac involvement defined as low myocardial T1 on CMR, and 2) adverse cardiovascular outcomes defined as any arrhythmia requiring therapy, atrial fibrillation, hospitalisation for heart failure or mortality.
Methods
Patients included in this longitudinal, multi-centre study underwent same-day standard resting 12-lead ECG and CMR. CMR included standard cine imaging, T1 mapping with modified Look Locker inversion recovery (MOLLI, 5s(3s)3s), and late gadolinium enhancement (LGE). ECG digital files were analysed using in-house A-ECG software. A-ECG analysis included conventional ECG measures, derived vectorcardiographic measures, and singular value decomposition measures of waveform complexity. Significant A-ECG variables were identified using stepwise forward regression and incorporated in a multivariable logistic regression A-ECG score. A Youden index was applied to identify best threshold score and bootstrapping performed to calculate the area under the receiver operating characteristics curve (AUC), sensitivity, specificity, and 95% confidence intervals (CI).
Results
Among included patients (n=155, 40% male, age 46±14 years, 39% on enzyme replacement therapy), left ventricular mass index was higher in males compared to females (106 vs. 59 g/m2, p<0.001), 80% of patients had myocardial native T1 below the local reference range (933 vs. 968 ms, p=0.06), and 51% (70/136) had focal LGE. Multivariable A-ECG scores for detecting low T1, any arrhythmia, or atrial fibrillation had an AUC [95%CI], sensitivity, and specificity of 0.82 [0.75-0.89], 72 [55-95]%, 85 [66-71]%; 0.89 [0.82-0.95], 82 [68-94]%, 88 [70-96]%; and 0.89 [0.80-0.96], 92 [77-100]%, 83 [76-92]%, respectively, Figure 1. No predictors of heart failure hospitalisation or mortality were found.
Conclusion
A-ECG analysis of the resting 12-lead ECG has good diagnostic performance for predicting early myocardial involvement and the occurrence of arrhythmias in Fabry disease. This supports the use of A-ECG both as a screening tool to diagnose early cardiac disease, and for identifying those at risk of adverse arrhythmic outcomes.
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Affiliation(s)
- R Vijapurapu
- Queen Elizabeth Hospital Birmingham, Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - M Maanja
- Karolinska University Hospital, Department of Clinical Physiology, Stockholm, Sweden
| | - T Schlegel
- Karolinska University Hospital, Department of Clinical Physiology, Stockholm, Sweden
| | - J Augusto
- Barts Heart Centre, Department of Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - H Kurdi
- Barts Heart Centre, Department of Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - JC Moon
- Barts Heart Centre, Department of Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - DA Hughes
- Royal Free Hospital, Lysosomal Storage Disorder Unit, London, United Kingdom of Great Britain & Northern Ireland
| | - T Geberhiwot
- Queen Elizabeth Hospital Birmingham, Endocrinology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - M Ugander
- Karolinska University Hospital, Department of Clinical Physiology, Stockholm, Sweden
| | - RP Steeds
- Queen Elizabeth Hospital Birmingham, Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - R Kozor
- Royal North Shore Hospital, Kolling Institute, Sydney, Australia
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8
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Sharma H, Yuan M, Shakeel I, Radhakrishnan A, Brown S, May J, Zia N, O'Connor K, Hothi SS, Myerson SG, Nadir MA, Steeds RP. Changes in mitral regurgitation following acute myocardial infarction: early and long-term follow-up. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Mitral regurgitation (MR) is commonly observed following acute myocardial infarction (MI). Localised left ventricular (LV) remodelling in the region of papillary muscles together with impaired myocardial contractility promote MR. There is a paucity of long-term follow-up studies to determine whether the severity of MR observed post-MI, changes with time.
Purpose
This study retrospectively followed up patients with MR detected following acute MI (AMI) to investigate changes in MR severity with time and assess for pre-discharge predictors of MR regression or progression.
Methods
Clinical records of 1000 patients admitted with AMI between 2016 and 2017 to a single centre were retrospectively interrogated. One hundred and nine patients met the inclusion criteria of MR on pre-discharge transthoracic echocardiography (TTE) and follow-up TTE scans. Echocardiographic parameters were investigated to determine predictors of progression or regression at follow-up. Patients were divided according to those who had early follow-up TTE (within 1-year) and late follow-up TTE (beyond 1-year).
Results
Early follow-up TTE was performed in 73 patients at a median of 6 (IQR 3–9) months. Patients had a mean age of 69±13 years and were predominantly male 50/73 (68%). At baseline, relative MR severities were: 49/73 (67%) mild MR, 23/73 (32%) moderate MR and 1 (1%) severe MR. At follow-up, MR had completely resolved in 18/73 (23%) patients, while 39/73 (53%) had mild MR, 15/73 (21%) moderate MR and 1 (1%) severe MR. Compared to patients with no resolution of MR, those with completel resolution were younger (mean age 62±16 vs 72±11 years; p=0.015) but there were no other significant differences between the groups. Resolution at early follow-up did not significantly influence long-term mortality rates. Late follow-up TTE was performed in 69 patients at a median 2.4 (IQR 2–3.2) years. Pre-discharge, 49/69 (71%) patients had mild MR and 20/69 (29%) moderate MR. At follow-up, MR had completely resolved in 18/69 (26%), and amongst patients with persistent MR, proportion of severities were: 37/69 (54%) mild MR, 11/69 (16%) moderate MR and 3/69 (4%) severe MR. Patients with progression of mild MR were more likely to have lower left ventricular ejection fraction (LVEF: 47±15 vs 57±12%; p=0.010) and greater indexed left ventricular end-systolic volume (LVESVi: 37±23 vs 25±14 ml/m2; p<0.001) on pre-discharge TTE. Resolution of MR at late follow-up was associated with a reduction in long-term mortality [deaths: 2/55 (3%) vs 3/14 (21%); p=0.022] at a mean follow-up of 4.2 years from MI.
Conclusion
MR observed following AMI completely resolved in approximately one-quarter of patients at 6-month and 2-year follow-up. Progression of mild MR at long-term follow-up appears to be associated with increased mortality and is predicted by lower LVEF and greater LVESVi pre-discharge.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- H Sharma
- University of Birmingham, Birmingham, United Kingdom
| | - M Yuan
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - I Shakeel
- University of Birmingham, Birmingham, United Kingdom
| | | | - S Brown
- University of Birmingham, Birmingham, United Kingdom
| | - J May
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - N Zia
- University of Birmingham, Birmingham, United Kingdom
| | - K O'Connor
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - S S Hothi
- New Cross Hospital, Wolverhampton, United Kingdom
| | - S G Myerson
- University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom
| | - M A Nadir
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - R P Steeds
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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9
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Sharma H, Yuan M, Shakeel I, Morley-Smith A, Nadir MA, Chue C, Myerson SG, Steeds RP, Lim S. Left ventricular assist device therapy improves severe secondary mitral regurgitation without mitral valve repair. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Severe secondary mitral regurgitation (MR) worsens prognosis in patients with medically managed heart failure (HF). In patients treated by left ventricular assist device (LVAD), it is unclear whether severe MR should be corrected at time of LVAD implantation.
Purpose
To evaluate impact of LVAD therapy on severe and non-severe secondary MR over 1 year.
Methods
Retrospective single centre study of consecutive patients who underwent HeartMate (HM)2 or HM3 LVAD implantation between January 2011 and March 2020.
Results
Of 155 patients, 20 were excluded due to LVAD exchange (n=10), mitral valve repair (n=1), or inaccessible pre-LVAD echocardiography (n=9). Based on multiparametric grading, 29/135 patients had severe secondary MR and 106/135 had non-severe secondary MR (including none). Severe MR patients were more often female [10/29 (34%) vs 11/106 (10%); p=0.002] but were of similar age (54±12 vs 55±9 years; p=0.624), size (27±5 vs 27±4 kg/m2; p=1.0), with equivalent renal function (53±22 vs 55±20 ml/min/1.73m2; p=0.641) and median pre-operative NT-proBNP [4076 (IQR 206–5438) vs 4914 (IQR 2706–7518) ng/L; p=0.488]. There were similar proportions of patients with ischaemic aetiology [16/29 (55%) vs 66/106 (62%); p=0.488) and those receiving HM2 [11/29 (38%) vs 32/106 (30%)] and HM3 [18/29 (62%) vs 74/106 (70%); p=0.575] LVAD. Echocardiography before LVAD implantation demonstrated similar left ventricular (LV) size (LV end-diastolic volume: 133±44 vs 118±50ml/m2; p=0.145, end-systolic volume: 107±41 vs 96±59ml/m2; p=0.348) and LV ejection fraction (17±9 vs 17±7%; p=1.0). Severe MR patients had significantly greater (p<0.001) MR by proximal isovolumetric surface area (0.93±0.27 vs 0.60±0.16cm), vena contracta (0.79±0.32 vs 0.57±0.18cm), regurgitant volume (47±25 vs 24±12ml), and fraction (54±15 vs 37±13%). Follow-up (f/u) echocardiography was performed at a median 222 days (range 356 days). Patients who received cardiac transplantation before f/u echocardiography were excluded. Relative severities of MR at f/u were: none = 12 (46%), mild = 8 (31%), moderate = 5 (19%), severe = 1 (4%) amongst patients with severe MR pre-LVAD, and none = 55 (58%), mild = 26 (27%), moderate = 13 (14%), severe = 1 (1%) amongst patients with non-severe MR pre-LVAD. At 1-year, after excluding all patients who underwent cardiac transplantation (severe MR n=4; non-severe MR n=2), rates of HF hospitalisation [5/25 (20%) vs 16/104 (15%); p=0.575] and all-cause mortality [2/25 (18%) vs 22/104 (21%); p=0.129)] were similar, irrespective of pre-LVAD MR severity. No patient who died during follow-up had severe MR prior to death.
Conclusion
LVAD improves severe secondary MR in 96% of cases, resulting in 1-year rates of HF hospitalisation and mortality similar to patients without severe MR pre-LVAD. These data suggest mitral valve surgery at time of LVAD implantation is not warranted.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- H Sharma
- University of Birmingham, Birmingham, United Kingdom
| | - M Yuan
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - I Shakeel
- University of Birmingham, Birmingham, United Kingdom
| | - A Morley-Smith
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - M A Nadir
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - C Chue
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - S G Myerson
- University of Oxford Centre for Clinical Magnetic Resonance Research, Oxford, United Kingdom
| | - R P Steeds
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - S Lim
- Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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10
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Steeds RP, Potter A, Mangat N, Fröhlich M, Deutsch C, Bramlage P, Thoenes M. Community-based aortic stenosis detection: clinical and echocardiographic screening during influenza vaccination. Open Heart 2021; 8:openhrt-2021-001640. [PMID: 34021069 PMCID: PMC8144056 DOI: 10.1136/openhrt-2021-001640] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/14/2021] [Indexed: 11/25/2022] Open
Abstract
Background Degenerative aortic stenosis (AS), the most common valvular heart disease in the Western world, is often diagnosed late when the mortality risk becomes substantial. We determined the feasibility of AS screening during influenza vaccination at general practitioner (GP) surgeries in the UK. Methods Consecutive subjects aged >65 years presenting to a GP for influenza vaccination underwent heart auscultation and 2D echocardiography (V-scan). Based on these findings, a patient management strategy was determined (referral to cardiologist, review within own practice or no follow-up measures) and status at 3 months was determined. Results 167 patients were enrolled with a mean age of 75 years. On auscultation, a heart murmur was detected in 30 of 167 (18%) patients (6 subjects with an AS-specific and 24 with a non-specific murmur). 75.2% of those with no murmur had a negative V-scan finding. Conversely, 16 of 30 (53%) patients with any murmur had an abnormal V-scan finding that was largely related to the aortic valve. Using clinical auscultation and V-scan screening, a decision not to pursue follow-up measures was taken in 147 (88%) cases, whereas 18 (10.8%) subjects were referred onward; with 5 of 18 (27.8%) and 3 of 18 (16.7%) being diagnosed with mild and moderate AS. Conclusions Our pilot study confirms feasibility of valvular heart disease screening in the elderly in a primary care setting. Using simple and inexpensive diagnostic measures and 7.3 million UK inhabitants undergoing influenza vaccination, nationwide screening could potentially identify 130 000 patients with moderate AS and a significant number of patients with severe AS.
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Affiliation(s)
- Richard Paul Steeds
- Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Maren Fröhlich
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Cornelia Deutsch
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Martin Thoenes
- Leman Research Institute, Schaffhausen, Switzerland.,Medical Department, Edwards Lifesciences, Nyon, Switzerland
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11
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Radhakrishnan A, Pickup LC, Price AM, Law JP, Mcgee KC, Fabritz L, Senior R, Steeds RP, Ferro CJ, Townend JN. Anaemia and coronary microvascular dysfunction in end-stage renal disease. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): (1) University Hospitals Birmingham Charity (2) Metchley Park Medical Society
Introduction
Coronary microvascular dysfunction (CMD) is common among patients with end-stage renal disease (ESRD) and confers poor prognosis. Coronary flow velocity reserve (CFVR) is a marker of coronary microvascular function and can be reliably measured using Doppler echocardiography. Reduced CFVR in ESRD has been attributed to factors such as hypertension and left ventricular hypertrophy (LVH). Anaemia is prevalent in ESRD but the association between haemoglobin and CFVR in ESRD has not been studied.
Purpose
To assess if CFVR is related to haemoglobin among patients with ESRD.
Methods
22 subjects with ESRD and awaiting kidney transplant (8 pre-dialysis and 14 on peritoneal dialysis) were studied with adenosine myocardial contrast echocardiography, Doppler CFVR assessment and serum multiplex immunoassay analysis. Individuals with diabetes, uncontrolled hypertension or ischaemic heart disease were excluded.
Results
7/22 (32%) of subjects had CMD (defined as CFVR <2). Age (47 years ± 15 vs 55 ± 10, p = 0.177), estimated glomerular filtration rate [7ml/min/1.73m² (5-11) vs 9 (7-10), p = 0.837], systolic blood pressure (129mmHg ± 25 vs 137 ± 20, p = 0.398) and left ventricular mass index (98g/m² ± 31 vs 98 ± 28, p = 0.936) did not significantly differ between subjects with or without CMD. There were no significant differences in other demographic, haemodynamic, laboratory or echocardiographic variables between the two groups. A panel of biomarkers of inflammation, myocardial stretch, cardiac fibrosis and LVH studied by multiplex immunoassay also did not show any significant differences between the two groups. No subjects had wall motion abnormalities or perfusion defects on myocardial contrast echocardiography.
CFVR was significantly lower in subjects with CMD (1.6 ± 0.2 vs 3.2 ± 0.9, p < 0.001). Subjects with CMD had significantly lower haemoglobin than subjects without CMD (102g/L ± 12 vs 117g/L ± 11, p = 0.008). There was a moderate positive correlation between haemoglobin and CFVR (r = 0.65, p = 0.001) – figure 1. In a stepwise multiple regression model with CFVR as the dependent variable and age, haemoglobin, systolic blood pressure, left ventricular mass index and estimated glomerular filtration rate as independent variables, only haemoglobin was an independent predictor of CFVR (β=0.051 95%CI 0.023-0.079, p = 0.001).
Conclusions
Among our cohort of ESRD patients awaiting kidney transplant, there was a high prevalence of CMD despite well controlled blood pressure and no significant LVH. Subjects with CMD had significantly lower haemoglobin than subjects without CMD. Reduced haemoglobin causes impaired oxygen carrying capacity to the myocardium, which may lead to microvascular ischaemia and adverse microvascular remodelling, causing CMD. Thus, anaemia may be a potentially correctible driver of CMD in ESRD. This association needs to be confirmed in larger studies.
Abstract Figure 1
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Affiliation(s)
- A Radhakrishnan
- University of Birmingham, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - LC Pickup
- University of Birmingham, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - AM Price
- University of Birmingham, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - JP Law
- University of Birmingham, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - KC Mcgee
- University of Birmingham, Institute of Inflammation and Ageing, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - L Fabritz
- University of Birmingham, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - R Senior
- Royal Brompton Hospital, Department of Cardiology, London, United Kingdom of Great Britain & Northern Ireland
| | - RP Steeds
- University of Birmingham, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - CJ Ferro
- University of Birmingham, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - JN Townend
- University of Birmingham, Birmingham Cardio-Renal Group, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
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12
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Parolin M, Dassie F, Vettor R, Steeds RP, Maffei P. Electrophysiological features in acromegaly: re-thinking the arrhythmic risk? J Endocrinol Invest 2021; 44:209-221. [PMID: 32632903 DOI: 10.1007/s40618-020-01343-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 06/22/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acromegaly is disease associated with a specific cardiomyopathy. Hitherto, it has been widely understood that acromegaly carries an increased risk of arrhythmia. PURPOSE In this review we show that evidences are limited to a small number of case-control studies that reported increased rates of premature ventricular beats (PVB) but no more significant arrhythmia. In contrast, there are several studies that have reported impaired preclinical markers of arrhythmia, including reduced heart rate variability, increased late potentials, QT interval dispersion, impaired heart rate recovery after physical exercise and left ventricular dysynchrony. Whilst these markers are associated with an adverse cardiovascular prognosis in the general population, they do not have a high independent positive predictive accuracy for arrhythmia. In acromegaly, case reports have described sudden cardiac death, ventricular tachyarrhythmia and advanced atrio-ventricular block that required implantation of a cardio-defibrillator or permanent pacemaker. Treatment with somatostatin analogues can reduce cardiac dysrhythmia in some cases by reducing heart rate, PVBs and QT interval. Pegvisomant reduces mean heart rate. Pasireotide is associated with QT prolongation. In the absence of good quality data on risk of arrhythmia in acromegaly, the majority of position statements and guidelines suggest routine 12-lead electrocardiography (ECG) and transthoracic echocardiography (TTE) in every patient at diagnosis and then follow up dependent on initial findings.
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Affiliation(s)
- M Parolin
- Department of Medicine (DIMED), University of Padua, Clinica Medica 3, via Giustiniani 2, 35128, Padova, Italy.
| | - F Dassie
- Department of Medicine (DIMED), University of Padua, Clinica Medica 3, via Giustiniani 2, 35128, Padova, Italy
| | - R Vettor
- Department of Medicine (DIMED), University of Padua, Clinica Medica 3, via Giustiniani 2, 35128, Padova, Italy
| | - R P Steeds
- University Hospital Birmingham and University of Birmingham, Cardiology, Birmingham, West Midlands, UK
| | - P Maffei
- Department of Medicine (DIMED), University of Padua, Clinica Medica 3, via Giustiniani 2, 35128, Padova, Italy
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13
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Stiles CE, Lloyd G, Bhattacharyya S, Steeds RP, Boomla K, Bestwick JP, Drake WM. Incidence of Cabergoline-Associated Valvulopathy in Primary Care Patients With Prolactinoma Using Hard Cardiac Endpoints. J Clin Endocrinol Metab 2021; 106:e711-e720. [PMID: 33247916 PMCID: PMC7823250 DOI: 10.1210/clinem/dgaa882] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Controversy exists as to whether low-dose cabergoline is associated with clinically significant valvulopathy. Few studies examine hard cardiac endpoint data, most relying on echocardiographic findings. OBJECTIVES To determine the prevalence of valve surgery or heart failure in patients taking cabergoline for prolactinoma against a matched nonexposed population. DESIGN Population-based cohort study based on North East London primary care records. METHODS Data were drawn from ~1.5 million patients' primary care records. We identified 646 patients taking cabergoline for >6 months for prolactinoma. These were matched to up to 5 control individuals matched for age, gender, ethnicity, location, diabetes, hypertension, ischemic heart disease, and smoking status. Cumulative doses/durations of treatment were calculated. Cardiac endpoints were defined as cardiac valve surgery or heart failure diagnosis (either diagnostic code or prescription code for associated medications). RESULTS A total of 18 (2.8%) cabergoline-treated patients and 62 (2.33%) controls reached a cardiac endpoint. Median cumulative cabergoline dose was 56 mg (interquartile range [IQR] 27-123). Median treatment duration was 27 months (IQR 15-46). Median weekly dose was 2.1 mg. Neither univariate nor multivariate analysis demonstrated a significant association between cabergoline treatment at any cumulative dosage/duration and an increased incidence of cardiac endpoints. In a matched analysis, the relative risk for cardiac complications in the cabergoline-treated group was 0.78 (95% CI, 0.41-1.48; P = 0.446). Reanalysis of echocardiograms for 6/18 affected cabergoline-treated patients showed no evidence of ergot-derived drug valvulopathy. CONCLUSIONS The data did not support an association between clinically significant valvulopathy and low-dose cabergoline treatment and provide further evidence for a reduction in frequency of surveillance echocardiography.
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Affiliation(s)
- Craig Edward Stiles
- Queen Mary University of London, London, UK
- Department of Endocrinology, Saint Bartholomew’s Hospital, London, UK
| | - Guy Lloyd
- Department of Cardiology, Saint Bartholomew’s Hospital, London, UK
| | | | - Richard Paul Steeds
- University Hospital Birmingham, Birmingham, UK
- Institute of Cardiology, University of Birmingham, Birmingham, UK
| | - Kambiz Boomla
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Jonathan Paul Bestwick
- Centre for Environmental and Preventive Medicine, Queen Mary University of London, London, UK
| | - William Martyn Drake
- Queen Mary University of London, London, UK
- Department of Endocrinology, Saint Bartholomew’s Hospital, London, UK
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14
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Lauten A, Rudolph TK, Messika-Zeitoun D, Thambyrajah J, Serra A, Schulz E, Frey N, Maly J, Aiello M, Lloyd G, Bortone AS, Clerici A, Delle-Karth G, Rieber J, Indolfi C, Mancone M, Belle L, Arnold M, Bouma BJ, Lutz M, Deutsch C, Kurucova J, Thoenes M, Bramlage P, Steeds RP. Management of patients with severe aortic stenosis in the TAVI-era: how recent recommendations are translated into clinical practice. Open Heart 2021; 8:openhrt-2020-001485. [PMID: 33431618 PMCID: PMC7802661 DOI: 10.1136/openhrt-2020-001485] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/02/2020] [Accepted: 12/21/2020] [Indexed: 11/25/2022] Open
Abstract
Objective Approximately 3.4% of adults aged >75 years suffer from aortic stenosis (AS). Guideline indications for aortic valve replacement (AVR) distinguish between patients with symptomatic and asymptomatic severe AS. The present analysis aims to assess contemporary practice in the treatment of severe AS across Europe and identify characteristics associated with treatment decisions, namely denial of AVR in symptomatic patients and assignment of asymptomatic patients to AVR. Methods Participants of the prospective, multinational IMPULSE database of patients with severe AS were grouped according to AS symptoms, and stratified into subgroups based on assignment to/denial of AVR. Results Of 1608 symptomatic patients, 23.8% did not undergo AVR and underwent medical treatment. Denial was independently associated with multiple factors, including severe frailty (p=0.024); mitral (p=0.002) or tricuspid (p=0.004) regurgitation grade III/IV, and the presence of renal impairment (p=0.017). Of 392 asymptomatic patients, 86.5% had no prespecified indication for AVR. Regardless, 36.3% were assigned to valve replacement. Those with an indexed aortic valve area (AVA; p=0.045) or left ventricular ejection fraction (LVEF; p<0.001) below the study median; or with a left ventricular end systolic diameter above the study median (p=0.007) were more likely to be assigned to AVR. Conclusions There may be considerable discrepancies between guideline-based recommendations and clinical practice decision-making in the treatment of AS. It appears that guidelines may not fully capture the complete clinical spectrum of patients with AS. Thus, there is a need to find ways to increase their acceptance and the rate of adoption.
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Affiliation(s)
| | - Tanja K Rudolph
- Department of Cardiology, Hear and Diabetes Center Bad Oeynhausen, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | | | | | - Antonio Serra
- Interventional Cardiology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Catalunya, Spain
| | - Eberhard Schulz
- Cardiology Department, AKH Celle, Celle, Niedersachsen, Germany
| | - Norbert Frey
- Department of Cardiology and Angiology, University of Kiel, Kiel, Schleswig-Holstein, Germany
| | - Jiri Maly
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.,Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marco Aiello
- Department of Cardiothoracic Surgery, Foundation IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Guy Lloyd
- St Bartholomew's Hospital, London, UK
| | | | | | | | - Johannes Rieber
- Herzkatheterlabor Nymphenburg and Department of Cardiology, University of Munich, Munich, Bayern, Germany
| | - Ciro Indolfi
- Division of Cardiology and URT CNR of IFC, University Magna Graecia, Catanzaro, Calabria, Italy
| | | | - Loic Belle
- Centre Hospital d'Annecy, Annecy, France
| | - Martin Arnold
- Department of Cardiology, University Hospital Erlangen, Erlangen, Bayern, Germany
| | | | - Matthias Lutz
- Department of Cardiology and Angiology, University of Kiel, Kiel, Schleswig-Holstein, Germany
| | - Cornelia Deutsch
- Institut für Pharmakologie und Präventive Medizin GmbH, Cloppenburg, Germany
| | | | | | - Peter Bramlage
- Institut für Pharmakologie und Präventive Medizin GmbH, Cloppenburg, Germany
| | - Richard Paul Steeds
- Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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15
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Steeds RP, Messika-Zeitoun D, Thambyrajah J, Serra A, Schulz E, Maly J, Aiello M, Rudolph TK, Lloyd G, Bortone AS, Clerici A, Delle-Karth G, Rieber J, Indolfi C, Mancone M, Belle L, Lauten A, Arnold M, Bouma BJ, Lutz M, Deutsch C, Kurucova J, Thoenes M, Bramlage P, Frey N. IMPULSE: the impact of gender on the presentation and management of aortic stenosis across Europe. Open Heart 2021; 8:openhrt-2020-001443. [PMID: 33419934 PMCID: PMC7798778 DOI: 10.1136/openhrt-2020-001443] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/09/2020] [Accepted: 12/01/2020] [Indexed: 11/10/2022] Open
Abstract
Aims There is an increasing awareness of gender-related differences in patients with severe aortic stenosis and their outcomes after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI). Methods Data from the IMPULSE registry were analysed. Patients with severe aortic stenosis (AS) were enrolled between March 2015 and April 2017 and stratified by gender. A subgroup analysis was performed to assess the impact of age. Results Overall, 2171 patients were enrolled, and 48.0% were female. Women were characterised by a higher rate of renal impairment (31.7 vs 23.3%; p<0.001), were at higher surgical risk (EuroSCORE II: 4.5 vs 3.6%; p=0.001) and more often in a critical preoperative state (7.0vs 4.2%; p=0.003). Men had an increased rate of previous cardiac surgery (9.4 vs 4.7%; p<0.001) and a reduced left ventricular ejection fraction (4.9 vs 1.3%; p<0.001). Concomitant mitral and tricuspid valve disease was substantially more common among women. Symptoms were highly prevalent in both women and men (83.6 vs 77.3%; p<0.001). AVR was planned in 1379 cases. Women were more frequently scheduled to undergo TAVI (49.3 vs 41.0%; p<0.001) and less frequently for SAVR (20.3 vs 27.5%; p<0.001). Conclusions The present data show that female patients with severe AS have a distinct patient profile and are managed in a different way to males. Gender-based differences in the management of patients with severe AS need to be taken into account more systematically to improve outcomes, especially for women.
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Affiliation(s)
- Richard Paul Steeds
- Queen Elizabeth Hospital & Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | | | - Antonio Serra
- Interventional Cardiology Unit, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Jiri Maly
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marco Aiello
- Department of Cardiothoracic Surgery, Foundation IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Tanja K Rudolph
- Department of Cardiology, Heart and Diabetes Center Bad Oeynhausen, Ruhr-University of Bochum, Bad Oeynhausen, Germany
| | - Guy Lloyd
- St Bartholomew's Hospital, London, UK
| | | | | | | | - Johannes Rieber
- Herzkatheterlabor Nymphenburg and Department of Cardiology, University of Munich, Munich, Germany
| | - Ciro Indolfi
- Division of Cardiology and URT CNR of IFC, University Magna Graecia, Catanzaro, Italy
| | | | - Loic Belle
- Centre Hospital d'Annecy, Annecy, France
| | - Alexander Lauten
- Department for Cardiology, Helios Erfurt Clinic, Erfurt, Germany
| | - Martin Arnold
- Department of Cardiology, University of Erlangen, Erlangen, Germany
| | | | - Matthias Lutz
- Department of Cardiology and Angiology, University of Kiel, Kiel, Germany
| | - Cornelia Deutsch
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Norbert Frey
- Department of Cardiology and Angiology, University of Kiel, Kiel, Germany
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16
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Lutz M, Messika-Zeitoun D, Rudolph TK, Schulz E, Thambyrajah J, Lloyd G, Lauten A, Frey N, Kurucova J, Thoenes M, Deutsch C, Bramlage P, Steeds RP. Differences in the presentation and management of patients with severe aortic stenosis in different European centres. Open Heart 2020; 7:openhrt-2020-001345. [PMID: 32934015 PMCID: PMC7493097 DOI: 10.1136/openhrt-2020-001345] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/21/2020] [Accepted: 08/07/2020] [Indexed: 11/08/2022] Open
Abstract
Background An investigation into differences in the management and treatment of severe aortic stenosis (AS) between Germany, France and the UK may allow benchmarking of the different healthcare systems and identification of levers for improvement. Methods Patients with a diagnosis of severe AS under management at centres within the IMPULSE and IMPULSE enhanced registries were eligible. Results Data were collected from 2052 patients (795 Germany; 542 France; 715 UK). Patients in Germany were older (79.8 years), often symptomatic (89.5%) and female (49.8%) and had a lower EF (53.8%) than patients in France and UK. Comorbidities were more common and they had a higher mean Euroscore II. Aortic valve replacement (AVR) was planned within 3 months in 70.2%. This was higher (p<0.001) in Germany than France/ UK. Of those with planned AVR, 82.3% received it within 3 months with a gradual decline (Germany>France> UK; p<0.001). In 253 patients, AVR was not performed, despite planned. Germany had a strong transcatheter aortic valve implantation (TAVI) preference (83.2%) versus France/ UK (p<0.001). Waiting time for TAVI was shorter in Germany (24.9 days) and France (19.5 days) than UK (40.3 days). Symptomatic patients were scheduled for an AVR in 79.4% (Germany> France> UK; p<0.001) and performed in 83.6% with a TAVI preference (73.1%). 20.4% of the asymptomatic patients were intervened. Conclusion Patients in Germany had more advanced disease. The rate of intervention within 3 months after diagnosis was startlingly low in the UK. Asymptomatic patients without a formal indication often underwent an intervention in Germany and France.
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Affiliation(s)
- Matthias Lutz
- Department of Cardiology and Angiology, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | - David Messika-Zeitoun
- Department of Cardiology, University of Ottawa Heart Institue, Ottawa, Ontario, Canada
| | - Tanja K Rudolph
- Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Bad Oeynhausen, Germany
| | | | | | - Guy Lloyd
- Department of Cardiology, St Bartholomew's Hospital, London, UK
| | - Alexander Lauten
- Department of Cardiology, HELIOS Klinikum Erfurt, Erfurt, Germany
| | - Norbert Frey
- Department of Cardiology and Angiology, University Hospital Schleswig-Holstein - Campus Kiel, Kiel, Germany
| | | | | | - Cornelia Deutsch
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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17
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Affiliation(s)
- Richard Paul Steeds
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK .,Honorary Reader, Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Saul G Myerson
- Cardiovascular Medicine, University of Oxford, Oxford, UK
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18
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Abstract
The surveillance strategy for patients taking low dose cabergoline for hyperprolactinaemia is controversial. As more evidence has emerged that the risks of cardiac valvulopathy in this population of patients are low, fewer and fewer endocrinologists adhere strictly to the original medicines and healthcare products agency MHRA guidance of "at least" annual echocardiography. Strict adherence to this guidance would be costly in monetary terms (£5.76 million/year in the UK) and also in resource use (90,000 extra echocardiograms/year). This article reviews the proposed pathophysiological mechanism underlying the phenomenon of dopamine agonist valvulopathy, the characteristic echocardiographic changes seen, summarises the published literature on the incidence of valvulopathy with low dose cabergoline and examines the previous and current evidence-based screening guidelines.
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Affiliation(s)
- C E Stiles
- Department of Endocrinology, Queen Mary University of London, E1 4NS London, United Kingdom; Department of Endocrinology, Saint-Bartholomew's Hospital, EC1A 7BE London, United Kingdom.
| | - R P Steeds
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, B15 2GW Birmingham, United Kingdom; Institute of Cardiovascular Sciences, University of Birmingham, B15 2TT Birmingham, United Kingdom
| | - W M Drake
- Department of Endocrinology, Queen Mary University of London, E1 4NS London, United Kingdom; Department of Endocrinology, Saint-Bartholomew's Hospital, EC1A 7BE London, United Kingdom
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19
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Affiliation(s)
| | - William E Moody
- Cardiovascular Medicine, University of Birmingham, Birmingham, UK.,Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Richard Paul Steeds
- Cardiovascular Medicine, University of Birmingham, Birmingham, UK.,Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
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20
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Landells M, Mcaloon CJ, Steeds RP. P1719 A rare complication of homozygous sickle cell disease and high output cardiac failure. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.1081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction/Background
Sickle cell disease (SCD) is an autosomal recessive blood disorder characterised by chronic anaemia and abnormally shaped red blood cells. SCD impacts multiple organ systems causing effects on morbidity and mortality, including cardiovascular (CV). Long term SCD can have a significant impact on the heart through multiple pathways, including chronic anaemia, microvascular dysfunction and the development of hypertension and chronic kidney disease, leading to the development of a high-output state and adverse cardiac remodelling. We report a rare case of homozygous SCD with the development of high output cardiac failure complicated by the development of associated pulmonary hypertension.
Case summary
A 58 yr old female patient (Height 158cm, weight 51.25kg, cardiac index 4.01 L/min/m²) with known homozygous SCD (HbSS) undergoing regular transfusions for chronic anaemia was admitted following a routine transthoracic echocardiogram (Figure 1a & 1b) due to the presence of a moderate sized global pericardial effusion, severe tricuspid regurgitation, dilated right heart with impaired longitudinal function, and good left ventricular (LV) systolic function (LVEF Simpson’s biplane = 62 +/- 5%). In the months preceding this, the patient described progressive dyspnoea associated with decreasing workload and orthopnoea. On clinical examination there was evidence of right sided heart failure. Blood results demonstrated a longstanding anaemia (Hb 57 g/L) with MCV 109.6. NT-proBNP was 10233 ng/L. Cardiac magnetic resonance imaging demonstrated LV dilatation with hyperdynamic function, severe LV hypertrophy, and impaired longitudinal function (global longitudinal strain -9.7%). Cardiac output was elevated at 6.5 L/min. There was no late gadolinium enhancement and T2* mapping did not demonstrate cardiac iron loading (29.6ms). Right heart catheterisation confirmed pulmonary hypertension (pulmonary artery pressure 55/33, mean 46mmHg) due to left heart disease (PC wedge pressure (24/30, mean 24mmHg). The pericardial effusion was drained and the aspirate demonstrated a cellular infiltrate reflecting pericardial inflammation (moderate pus cells, no growth after 48hrs, total protein = 56 g/L, no histological evidence of malignancy). Additionally, the patient underwent intravenous diuresis and blood transfusion with improvement in clinical status.
Discussion
We report a rare cause of pulmonary hypertension due to elevated left ventricular end-diastolic pressure as a result of long-term high cardiac output in a patient who has established homozygous SCD. Long-term adverse cardiac remodelling in SCD is well described. Pulmonary hypertension is a rare multifactorial complication of this process and the precise mechanisms remain unclear. It confers a poor prognosis and the only current treatment is the management of the underlying condition. Pulmonary hypertension should always be considered in SCD patients with clinical and cardiac imaging evidence.
Abstract P1719 Figure 1
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Affiliation(s)
- M Landells
- University Hospital Birmingham, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - C J Mcaloon
- University Hospital Birmingham, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - R P Steeds
- University Hospital Birmingham, Birmingham, United Kingdom of Great Britain & Northern Ireland
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21
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Bicho Augusto JA, Nordin S, Kozor R, Vijapurapu R, Knott K, Ramaswami U, Geberhiwot TD, Steeds RP, Baig S, Hughes D, Moon JC. P340Inflammatory cardiomyopathy in Fabry disease. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Fabry disease (FD) is an X-linked lysosomal storage disorder caused by mutations in α-galactosidase A. Cardiovascular magnetic resonance (CMR) has helped unveil the pathogenesis of Fabry cardiomyopathy: sphingolipid storage (low T1 mapping values), left ventricular hypertrophy (LVH) and myocardial fibrosis with late gadolinium enhancement (LGE) characteristically present in the basal inferolateral (BIFL) wall. Recent evidence has suggested that the LGE may be inflammation and oedema as part of this pathogenic process.
Purpose
To assess the presence of inflammation in patients with FD using T2 mapping (for oedema/inflammation) supported by blood troponin levels (showing myocyte death and by inference inflammation).
Methods
A multi-centre international study in gene positive FD patients using CMR and blood biomarkers. All participants underwent CMR at 1.5 T. Native T1 and T2 mapping were performed. The T1 mapping sequence was MOLLI with sampling scheme in seconds. LGE used a phase sensitive inversion recovery sequence. Global longitudinal 2D strain (GLS) values were obtained using feature tracking analysis. Blood high-sensitivity troponin T (hsTnT) was measured on the same day.
Results
100 FD patients (age 43.8±1.3 years, 42% male) were included. 45% had LVH, 35% LGE. Low T1 mapping (normal <943ms) was found in 49% and 33% had high hsTnT values (normal <15ng/L). Mean T2 mapping values were 52.6±0.6ms in the BIFL wall and 49.5±0.3ms in the remote myocardium/septum (p<0.001, normal <53ms). T2 values in the BIFL wall were significantly higher among patients with LGE (58.2±6.1ms vs 49.2±3.1ms, p<0.001, Figure 1). In a per-segment analysis of 1600 segments, higher T2 values correlated positively with percentage of LGE per segment (r=0,262, p<0.001), T1 values (r=0,205, p<0.001), maximum wall thickness (r=0,253, p<0.001) and GLS values (r=0,212, p<0.001). HsTnT values were higher among patients with LGE (median of 31 vs 3ng/L in patients without LGE, p<0.001). There was a strong positive correlation between T2 values in the BIFL wall and ln(hsTnT) (r=0.776, p<0.001, Figure 2). The strongest predictor of increased hsTnT in multivariate analysis (age, sex, LVH, septum T1, T2 in the BIFL, GLS, LGE) was T2 in the BIFL wall (β=0.4, p=0.001).
Conclusions
Cardiac involvement in FD goes beyond storage (low T1 values). When LGE is present, this is almost always associated with a high T2 and troponin elevation supporting FD as a chronic inflammatory cardiomyopathy. Initial reports of LGE being fibrosis are too simplistic – LGE in FD appears to have a significant chronic inflammation/oedema component.
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Affiliation(s)
| | - S Nordin
- Barts Health NHS Trust, London, United Kingdom
| | - R Kozor
- University of Sydney, Sydney Medical School, Sydney, Australia
| | - R Vijapurapu
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom
| | - K Knott
- University College London, London, United Kingdom
| | - U Ramaswami
- Royal Free Hospital, Lysosomal Storage Disorder Unit, London, United Kingdom
| | - T D Geberhiwot
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom
| | - R P Steeds
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom
| | - S Baig
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom
| | - D Hughes
- Royal Free Hospital, Lysosomal Storage Disorder Unit, London, United Kingdom
| | - J C Moon
- Barts Health NHS Trust, London, United Kingdom
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22
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Rudolph TK, Messika-Zeitoun D, Frey N, Lutz M, Krapf L, Passefort S, Fryearson J, Simpson H, Mortensen K, Rehse S, Tiroke A, Dodos F, Mies F, Pohlmann C, Kurucova J, Thoenes M, Bramlage P, Steeds RP. Caseload management and outcome of patients with aortic stenosis in primary/secondary versus tertiary care settings-design of the IMPULSE enhanced registry. Open Heart 2019; 6:e001019. [PMID: 31413844 PMCID: PMC6667938 DOI: 10.1136/openhrt-2019-001019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 05/31/2019] [Accepted: 06/13/2019] [Indexed: 01/14/2023] Open
Abstract
Background Severe aortic stenosis (AS) is one of the most common and most serious valve diseases. Without timely intervention with surgical aortic valve replacement or transcatheter aortic valve replacement, patients have an estimated survival of 2–3 years. Guidelines for the treatment of AS have been developed, but studies suggest that as many as 42% of patients with AS are not treated according to these recommendations. The aims of this registry are to delineate the caseload of patients with AS, outline the management of these patients and determine appropriateness of treatments in participating centres with and without onsite access to surgery and percutaneous treatments. Methods/design The IMPULSE enhanced registry is an international, multicentre, prospective, observational cohort registry conducted at four central full access centres (tertiary care hospitals) and at least two satellite centres per hub (primary/secondary care hospitals). An estimated 800 patients will be enrolled in the registry and patient follow-up will last for 12 months. Discussion In addition to the primary aims determining the caseload management and outcome of patients with AS in primary, secondary and tertiary care settings, the registry will also determine a time course for the transition from asymptomatic to symptomatic status and the diagnostic steps, treatment decisions and the identification of decision-makers in tertiary versus primary/secondary care hospitals. The last patient will be enrolled in the registry in 2018 and results of the registry are anticipated in 2019. Registration number NCT03112629.
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Affiliation(s)
- Tanja K Rudolph
- Department of Cardiology, University of Cologne Heart Center, Cologne, Germany
| | - David Messika-Zeitoun
- Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Norbert Frey
- Department of Cardiology and Angiology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Matthias Lutz
- Department of Cardiology and Angiology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | - Laura Krapf
- Department of Cardiology, Hopital Max Fourestier, Nanterre, France
| | | | - John Fryearson
- Department of Cardiology, South Warwickshire NHS Foundation Trust, Warwick, UK
| | - Helen Simpson
- Department of Cardiology, Birmingham Heartlands Hospital, Birmingham, UK
| | | | - Sebastian Rehse
- Department of Internal Medicine, Hospital Preetz, Preetz, Germany
| | | | - Fotini Dodos
- Practice for Internal Medicine, Cardiology, Pneumology / Practice for Cardiology Hohenlind, Cologne, Germany
| | - Florian Mies
- Practice for Internal Medicine, Cardiology, Pneumology / Practice for Cardiology Hohenlind, Cologne, Germany
| | | | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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23
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Frey N, Steeds RP, Rudolph TK, Thambyrajah J, Serra A, Schulz E, Maly J, Aiello M, Lloyd G, Bortone AS, Hauptmann KE, Clerici A, Delle Karth G, Rieber J, Indorfi C, Mancone M, Belle L, Lauten A, Arnold M, Bouma BJ, Lutz M, Pohlmann C, Kurucova J, Thoenes M, Bramlage P, Messika-Zeitoun D. Symptoms, disease severity and treatment of adults with a new diagnosis of severe aortic stenosis. Heart 2019; 105:1709-1716. [PMID: 31302639 DOI: 10.1136/heartjnl-2019-314940] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/18/2019] [Accepted: 06/21/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Contemporary data on patients with previously undiagnosed severe aortic stenosis (AS) are scarce. We aimed to address this gap by gathering data from consecutive patients diagnosed with severe AS on echocardiography. METHODS This was a prospective, multicentre, multinational, registry in 23 tertiary care hospitals across 9 European countries. Patients with a diagnosis of severe AS were included using echocardiography (aortic valve area (AVA) <1 cm2, indexed AVA <0.6 cm2/m2, maximum jet-velocity (Vmax) >4 m/s and/or mean transvalvular gradient >40 mm Hg). RESULTS The 2171 participants had a mean age of 77.9 years and 48.0% were female. The mean AVA was 0.73 cm2, Vmax4.3 m/s and mean gradient 47.1 mm Hg; 62.1% had left ventricular hypertrophy and 27.3% an ejection fraction (EF) <50%. 1743 patients (80.3%) were symptomatic (shortness-of-breath 91.0%; dizziness 30.2%, chest pain 28.9%). Patients had a EuroSCORE II of 4.0; 25.3% had a creatinine clearance <50 mL/min, and 3.2% had an EF <30%. Symptomatic patients were older and had more comorbidities than asymptomatic patients. Despite European Society of Cardiology 2017 valvular heart disease guideline class I recommendation, in only 76.2% a decision was made for an intervention (transcatheter 50.4%, surgical aortic valve replacement 25.8%). In asymptomatic patients, 57.7% with a class I/IIa indication were scheduled for a procedure, while 36.3% patients without an indication had their valve replaced. CONCLUSIONS The majority of patients with severe AS presented at an advanced disease stage. Management of severe AS remained suboptimal in a significant proportion of contemporary patients with severe AS. TRIAL REGISTRATION NUMBER NCT02241447;Results.
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Affiliation(s)
- Norbert Frey
- Department of Cardiology and Angiology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | | | | | - Antonio Serra
- Department of Cardiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Eberhard Schulz
- Kardiologie I, Universitätsmedizin der Johannes Gutenberg Universität Mainz, Mainz, Germany
| | - Jiri Maly
- Department of Cardiovascular Surgery, Second Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Marco Aiello
- Cardiothoracic Surgery, Pavia University School of Medicine, Foundation IRCCS Policlinico S.Matteo, Pavia, Italy
| | - Guy Lloyd
- Cardiology/Cardiac Imaging, St Bartholomews Hospital, London, UK
| | | | - Karl Eugen Hauptmann
- Abteilung für Innere Medizin 3, Krankenhaus der Barmherzigen Brüder, Trier, Germany
| | - Alberto Clerici
- Department of Cardiac Surgery, University of Turin, Turin, Italy
| | - Georg Delle Karth
- Department of Internal Medicine/Cardiology, Hietzing Hospital, Vienna, Austria
| | - Johannes Rieber
- Department of Cardiology and Intensive Care Medicine, Heart Center Bogenhausen, Munich, Germany
| | - Ciro Indorfi
- Department of Cardiology, Magna Graecia University, Catanzaro, Italy
| | - Massimo Mancone
- Department of Cardiovascular and Respiratory Disease, University of Rome La Sapienza, Rome, Italy
| | - Loic Belle
- Department of Cardiology, Annecy Hospital, Annecy, France
| | - Alexander Lauten
- Department of Cardiology, University Heart Center Berlin and Charite University Medicine Berlin, Campus Benjamin-Franklin, Berlin, Germany
| | - Martin Arnold
- Cardiology Department, University of Erlangen, Erlangen, Germany
| | - Berto J Bouma
- AMC Heart Center, Academical Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Matthias Lutz
- Department of Cardiology and Angiology, University Medical Center Schleswig-Holstein, Kiel, Germany
| | | | | | | | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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24
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Bicho Augusto JA, Nordon S, Kozor R, Vijapurapu R, Knott K, Hughes R, Rosmini S, Ramaswami U, Geberhiwot T, Steeds RP, Baig S, Hughes D, Moon JC. 323Inflammatory cardiomyopathy in Fabry disease. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez102.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- J A Bicho Augusto
- Barts Health NHS Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - S Nordon
- Barts Health NHS Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - R Kozor
- University of Sydney, Sydney Medical School, Sydney, Australia
| | - R Vijapurapu
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - K Knott
- Barts Health NHS Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - R Hughes
- Barts Health NHS Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - S Rosmini
- Barts Health NHS Trust, London, United Kingdom of Great Britain & Northern Ireland
| | - U Ramaswami
- Royal Free Hospital, Lysosomal Storage Disorder Unit, London, United Kingdom of Great Britain & Northern Ireland
| | - T Geberhiwot
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - R P Steeds
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - S Baig
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - D Hughes
- Royal Free Hospital, Lysosomal Storage Disorder Unit, London, United Kingdom of Great Britain & Northern Ireland
| | - J C Moon
- Barts Health NHS Trust, London, United Kingdom of Great Britain & Northern Ireland
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25
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Nickander J, Cole BR, Nordin S, Vijapurapu R, Steeds RP, Moon JC, Kellman P, Ugander M, Kozor R. P171Blood correction of native T1 increases detection of cardiac involvement in patients with fabry disease. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez117.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Nickander
- Karolinska Institute, Clinical Physiology, Stockholm, Sweden
| | - B R Cole
- University of Sydney, Sydney Medical School, Sydney, Australia
| | - S Nordin
- University College London, Institute of Cardiovascular Science, London, United Kingdom of Great Britain & Northern Ireland
| | - R Vijapurapu
- University of Birmingham, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - R P Steeds
- University of Birmingham, Institute of Cardiovascular Sciences, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - J C Moon
- University College London, Institute of Cardiovascular Science, London, United Kingdom of Great Britain & Northern Ireland
| | - P Kellman
- National Institute of Health (Home), National Heart, Lung, and Blood Institute, Washington, United States of America
| | - M Ugander
- Karolinska Institute, Clinical Physiology, Stockholm, Sweden
| | - R Kozor
- University of Sydney, Sydney Medical School, Sydney, Australia
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26
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Moody WE, Holloway B, Gill S, Boivin C, Wahid Y, Ferguson J, Steeds RP. 248Prognostic value of single photon emission computed tomography among liver transplantation candidates. Eur Heart J Cardiovasc Imaging 2019. [DOI: 10.1093/ehjci/jez150.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- W E Moody
- Royal Brompton Hospital, London, United Kingdom of Great Britain & Northern Ireland
| | - B Holloway
- University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - S Gill
- University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - C Boivin
- University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - Y Wahid
- University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - J Ferguson
- University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - R P Steeds
- University of Birmingham, Queen Elizabeth Hospital, Birmingham, United Kingdom of Great Britain & Northern Ireland
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27
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Baig S, Vijapurapu R, Alharbi F, Nordin S, Kozor R, Moon J, Bembi B, Geberhiwot T, Steeds RP. Diagnosis and treatment of the cardiovascular consequences of Fabry disease. QJM 2019; 112:3-9. [PMID: 29878206 DOI: 10.1093/qjmed/hcy120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Fabry disease (FD) has been a diagnostic challenge since it was first recognized in 1898, with patients traditionally suffering from considerable delay before a diagnosis is made. Cardiac involvement is the current leading cause of death in FD. A combination of improved enzyme assays, availability of genetic profiling, together with more organized clinical services for rare diseases, has led to a rapid growth in the prevalence of FD. The earlier and more frequent diagnosis of asymptomatic individuals before development of the phenotype has focussed attention on early detection of organ involvement and closer monitoring of disease progression. The high cost of enzyme replacement therapy at a time of constraint within many health economies, moreover, has challenged clinicians to target treatment effectively. This article provides an outline of FD for the general physician and summarizes the aetiology and pathology of FD, the cardiovascular consequences thereof, modalities used in diagnosis and then discusses current indications for treatment, including pharmacotherapy and device implantation.
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Affiliation(s)
- S Baig
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - R Vijapurapu
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
| | - F Alharbi
- Central Military Laboratory and Blood Bank, Riyadh, Saudi Arabia
| | - S Nordin
- Institute of Cardiovascular Science, University College London, London, UK
| | - R Kozor
- Sydney Medical School, University of Sydney, Camperdown, Australia
| | - J Moon
- Institute of Cardiovascular Science, University College London, London, UK
| | - B Bembi
- Centre for Rare Diseases, AMC Hospital of Udine, Udine, Italy
| | - T Geberhiwot
- Centre for Rare Diseases, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - R P Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
- Institute of Cardiovascular Science, University of Birmingham, Birmingham, UK
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28
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Vijapurapu R, Nordin S, Baig S, Liu B, Rosmini S, Augusto J, Tchan M, Hughes DA, Geberhiwot T, Moon JC, Steeds RP, Kozor R. Global longitudinal strain, myocardial storage and hypertrophy in Fabry disease. Heart 2018; 105:470-476. [PMID: 30282640 DOI: 10.1136/heartjnl-2018-313699] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/28/2018] [Accepted: 08/30/2018] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Detecting early cardiac involvement in Fabry disease (FD) is important because therapy may alter disease progression. Cardiovascular magnetic resonance (CMR) can detect T1 lowering, representing myocardial sphingolipid storage. In many diseases, early mechanical dysfunction may be detected by abnormal global longitudinal strain (GLS). We explored the relationship of early mechanical dysfunction and sphingolipid deposition in FD. METHODS An observational study of 221 FD and 77 healthy volunteers (HVs) who underwent CMR (LV volumes, mass, native T1, GLS, late gadolinium enhancement), ECG and blood biomarkers, as part of the prospective multicentre Fabry400 study. RESULTS All FD had normal LV ejection fraction (EF 73%±8%). Mean indexed LV mass (LVMi) was 89±39 g/m2 in FD and 55.6±10 g/m2 in HV. 102 (46%) FD participants had left ventricular hypertrophy (LVH). There was a negative correlation between GLS and native T1 in FD patients (r=-0.515, p<0.001). In FD patients without LVH (early disease), as native T1 reduced there was impairment in GLS (r=-0.285, p<0.002). In the total FD cohort, ECG abnormalities were associated with a significant impairment in GLS compared with those without ECG abnormalities (abnormal: -16.7±3.5 vs normal: -20.2±2.4, p<0.001). CONCLUSIONS GLS in FD correlates with an increase in LVMi, storage and the presence of ECG abnormalities. In LVH-negative FD (early disease), impairment in GLS is associated with a reduction in native T1, suggesting that mechanical dysfunction occurs before evidence of sphingolipid deposition (low T1). TRIAL REGISTRATION NUMBER NCT03199001; Results.
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Affiliation(s)
- Ravi Vijapurapu
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Sabrina Nordin
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Shanat Baig
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Boyang Liu
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | | | - Joao Augusto
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Michel Tchan
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | | | - Tarekegn Geberhiwot
- Department of Inherited Metabolic Disorders, Queen Elizabeth Hospital, Birmingham, UK
| | - James C Moon
- Department of Cardiology, Barts Heart Centre, London, UK
| | - Richard Paul Steeds
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Rebecca Kozor
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Abstract
A 30 year old asymptomatic male with stage 3 chronic kidney disease (CKD) secondary to Focal Segmental Glomerulosclerosis was found to have features of CKD associated cardiomyopathy including left ventricular hypertrophy (LVH) and focal sub-endocardial scarring on cardiac magnetic resonance imaging. There was also a significantly raised CT coronary calcium score and evidence of non-flow limiting coronary artery disease (CAD) on a CT coronary angiogram. Early stage CKD is a major risk factor for cardiovascular risk causing myocardial hypertrophy and fibrosis and coronary artery atheroma. Cardiovascular risk begins to increase from an eGFR of around 75ml/min/1.73m2. The pathophysiology of cardiovascular disease in CKD is under investigation but to date, treatment options are limited. Blood pressure control and statins have the strongest supportive evidence.
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Affiliation(s)
- A M Price
- Department of Nephrology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Science, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, UK
- Address correspondence to Dr Anna M. Price, Department of Nephrology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Science, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, UK.
| | - C J Ferro
- Department of Nephrology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Science, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, UK
| | - M K Hayer
- Department of Nephrology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Science, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, UK
| | - R P Steeds
- Department of Cardiology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Science, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, UK
| | - N C Edwards
- Department of Cardiology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Science, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, UK
| | - J N Townend
- Department of Cardiology, Birmingham Cardio-Renal Group, Institute of Cardiovascular Science, Queen Elizabeth Hospital Birmingham and University of Birmingham, Edgbaston, UK
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Stiles CE, Tetteh-Wayoe ET, Bestwick J, Steeds RP, Drake WM. A meta-analysis of the prevalence of cardiac valvulopathy in hyperprolactinemic patients treated with Cabergoline. J Clin Endocrinol Metab 2018; 104:5094016. [PMID: 30215804 DOI: 10.1210/jc.2018-01071] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Accepted: 09/04/2018] [Indexed: 01/08/2023]
Abstract
CONTEXT Cabergoline is first line treatment for most patients with lactotrope pituitary tumors and hyperprolactinemia. Its use at high-dose in Parkinson's disease has largely been abandoned, because of its association with the development of a characteristic restrictive cardiac valvulopathy. Whether similar valvular changes occur in patients receiving lower doses for treatment of hyperprolactinemia is unclear, although stringent regulatory recommendations for echocardiographic screening exist. OBJECTIVE To conduct a meta-analysis exploring any link between the use of cabergoline for the treatment of hyperprolactinemia and clinically-significant cardiac valvulopathy. DATA SOURCES Full-text papers published up to and including January 2017 were found via PubMed and selected according to strict inclusion criteria. STUDY SELECTION All case-control studies were included where patients had received ≥6 months cabergoline treatment for hyperprolactinemia. Single case reports, previous meta-analyses, review papers and papers pertaining solely to Parkinson's disease were excluded. 13/76 originally selected studies met inclusion criteria. DATA EXTRACTION A list of desired data were compiled and extracted from papers by independent observers. Each also independently graded for paper quality (bias) and met to reach consensus. DATA SYNTHESIS More tricuspid regurgitation was observed (OR 3.74; 95% CI 1.79-7.8 p<0.001) in the cabergoline treated patients compared to controls. In no patient was tricuspid valve dysfunction diagnosed as a result of clinical symptoms. There was no significant increase in any other valvulopathy. CONCLUSIONS Treatment with low dose cabergoline in hyperprolactinemia appears to be associated with an increased prevalence of tricuspid regurgitation. The clinical significance of this is unclear and requires further investigation. 51.
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Affiliation(s)
- C E Stiles
- Queen Mary University of London, Department of Endocrinology, London
- Department of Endocrinology, St Bartholomew's Hospital, London
| | - E T Tetteh-Wayoe
- Queen Mary University of London, Department of Endocrinology, London
| | - J Bestwick
- Queen Mary University of London, Centre for Environmental and Preventive Medicine, London
| | - R P Steeds
- Department of Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham
| | - W M Drake
- Department of Endocrinology, St Bartholomew's Hospital, London
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Hayer MK, Price AM, Liu B, Baig S, Ferro CJ, Townend JN, Steeds RP, Edwards NC. Diffuse Myocardial Interstitial Fibrosis and Dysfunction in Early Chronic Kidney Disease. Am J Cardiol 2018; 121:656-660. [PMID: 29366457 PMCID: PMC5810844 DOI: 10.1016/j.amjcard.2017.11.041] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 11/16/2017] [Accepted: 11/20/2017] [Indexed: 01/23/2023]
Abstract
Patients with chronic kidney disease (CKD) have a disproportionately high risk of cardiovascular (CV) morbidity and mortality from the very early stages of CKD. This excess risk is believed to be the result of myocardial disease commonly termed uremic cardiomyopathy (UC). It has been suggested that interstitial myocardial fibrosis progresses with advancing kidney disease and may be the key mediator of UC. This longitudinal study reports data on the myocardial structure and function of 30 patients with CKD with no known cardiovascular disease and healthy controls. All patients underwent cardiac magnetic resonance imaging including T1 mapping and late gadolinium enhancement (if estimated glomerular filtration rate > 30 ml/min/1.73 m2). Over a mean follow-up period of 2.7 ± 0.8 years, there was no change in left ventricular mass, volumes, ejection fraction, native myocardial T1 times, or extracellular volume with CKD or in healthy controls. Global longitudinal strain (20.6 ± 2.9 s−1 vs 19.8 ± 2.9 s−1, p = 0.03) and mitral annular planar systolic excursion (13 ± 2 mm vs 12 ± 2 mm, p = 0.009) decreased in CKD but were clinically insignificant. Midwall late gadolinium enhancement was present in 4 patients at baseline and was unchanged at follow-up. Renal function was stable in this cohort over follow-up (change in estimated glomerular filtration rate was −3 ml/min/1.73 m2) with no adverse clinical CV events. In conclusion, this study demonstrates that in a cohort of patients with stable CKD, left ventricular mass, native T1 times, and extracellular volume do not increase over a period of 2.7 years.
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Hayer MK, Ferro CJ, Townend JN, Steeds RP, Edwards NC. Re: assessment of myocardial fibrosis with T1 mapping MRI. Clin Radiol 2016; 71:1309-1310. [PMID: 27733276 DOI: 10.1016/j.crad.2016.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 09/16/2016] [Accepted: 08/18/2016] [Indexed: 12/01/2022]
Affiliation(s)
- M K Hayer
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK.
| | - C J Ferro
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - J N Townend
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - R P Steeds
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
| | - N C Edwards
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, UK
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Edwards NC, Yuan M, Nolan O, Pawade TA, Oelofse T, Singh H, Mehrzad H, Zia Z, Geh JI, Palmer DH, May CJH, Ayuk J, Shah T, Rooney SJ, Steeds RP. Effect of Valvular Surgery in Carcinoid Heart Disease: An Observational Cohort Study. J Clin Endocrinol Metab 2016; 101:183-90. [PMID: 26580239 DOI: 10.1210/jc.2015-3295] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
CONTEXT Carcinoid heart disease (NET-CHD) is associated with the development of symptom-limited exercise capacity and high rates of morbidity and mortality. OBJECTIVE This study sought to determine the survival, cardiac function, and functional class following surgery. DESIGN AND SETTING, AND PATIENTS This was a retrospective observational cohort study between 2005 and 2015 at a European Centre of Excellence for Neuroendocrine Tumours, Queen Elizabeth Hospital Birmingham. England consisting of 62 consecutive patients referred to the NET-Cardiology Service. INTERVENTIONS Subjects were assessed at referral using transthoracic echocardiography (with saline contrast) and transesophageal echocardiography, and 77% with confirmed NET-CHD underwent cardiovascular magnetic resonance imaging. Symptomatic patients with concomitant severe valvular dysfunction were referred for surgery with stable NET disease. MAIN OUTCOME MEASURE Survival of patients with proven NET-CHD following medical and surgical treatments was measure. RESULTS In total, 47/62 patients were diagnosed with NET-CHD. Thirty-two patients (68%) underwent surgery with bioprosthetic valve replacements in all subjects; tricuspid, n = 31; pulmonary, n = 30; mitral, n = 3; and aortic, n = 3. Four patients underwent concomitant coronary artery bypass grafting. There were 4 (13%) early post-operative deaths. One- and 2-y survival rates after surgery were 75 and 69% compared with 45 and 15% in un-operated patients. Post-operatively, functional class was improved (pre-New York Heart Association Classification [NYHA], 2.6 [0.5] vs post-NYHA, 1.7 [1.1]), P < .05, right-ventricular (RV) size was reduced (136 ml/m(2) [25] vs 71 ml/m(2) [7]; P < .01) with preserved RV ejection fraction (61% ± 9 vs 55% ± 10; P = .26). CONCLUSION Valve surgery improved functional class and resulted in RV reverse remodelling with improved survival rates at 2 y compared with those not proceeding to operation. These data highlight the importance of close collaboration between NET clinicians, cardiology, and cardiothoracic surgery teams. Early referral can improve functional capacity but more research is needed to define the selection of appropriate candidates and randomized data are needed to define the effect of surgery on prognosis.
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Affiliation(s)
- N C Edwards
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - M Yuan
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - O Nolan
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - T A Pawade
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - T Oelofse
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - H Singh
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - H Mehrzad
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - Z Zia
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - J I Geh
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - D H Palmer
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - C J H May
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - J Ayuk
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - T Shah
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - S J Rooney
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
| | - R P Steeds
- Departments of Cardiology (N.C.E., M.Y., O.N., T.A.P., R.P.S.), Anaesthesia (T.O., H.S.), Radiology (H.M., Z.Z.), Oncology (J.I.G.), Endocrinology (C.J.H.M., J.A.), Hepatology (T.S.), and Cardiothoracic Surgery (S.J.R.), Queen Elizabeth Hospital Birmingham, Birmingham B15 2TT, United Kingdom; and Department of Molecular and Clinical Cancer Medicine (D.H.P.), University of Liverpool, Liverpool L69 3BX, United Kingdom
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Moody WE, Edwards NC, Chue CD, Taylor RJ, Ferro CJ, Townend JN, Steeds RP. Variability in cardiac MR measurement of left ventricular ejection fraction, volumes and mass in healthy adults: defining a significant change at 1 year. Br J Radiol 2015; 88:20140831. [PMID: 25710361 DOI: 10.1259/bjr.20140831] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Variability in the measurement of left ventricular (LV) parameters in cardiovascular imaging has typically been assessed over a short time interval, but clinicians most commonly compare results from studies performed a year apart. To account for variation in technical, procedural and biological factors over this time frame, we quantified the within-subject changes in LV volumes, LV mass (LVM) and LV ejection fraction (EF) in a well-defined cohort of healthy adults at 12 months. METHODS Cardiac MR (CMR) was performed in 42 healthy control subjects at baseline and at 1 year (1.5 T Magnetom® Avanto; Siemens Healthcare, Erlangen, Germany). Analysis of steady-state free precession images was performed manually offline (Argus software; Siemens Healthcare) for assessment of LV volumes, LVM and EF by a single blinded observer. A random subset of 10 participants also underwent repeat imaging within 7 days to determine short-term interstudy reproducibility. RESULTS There were no significant changes in any LV parameter on repeat CMR at 12 months. The short-term interstudy biases were not significantly different from the long-term changes observed at 1 year. The smallest detectable change (SDC) for LVEF, end-diastolic volume, end-systolic volume and LVM that could be recognized with 95% confidence were 6%, 13 ml, 7 ml and 6 g, respectively. CONCLUSION The variability in CMR-derived LV measures arising from technical, procedural and biological factors remains minimal at 12 months. Thus, for patients undergoing repeat annual assessment by CMR, even small differences in LV function, size and LVM (which are greater than the SDC) may be attributed to disease-related factors. ADVANCES IN KNOWLEDGE The reproducibility and reliability of CMR data at 12 months is excellent allowing clinicians to be confident that even small changes in LV structure and function over this time frame are real.
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Affiliation(s)
- W E Moody
- 1 Birmingham CardioRenal Group, Centre for Clinical Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham, UK
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Teoh JK, Steeds RP, Warfield AT. Not all myocardium that sparkles is amyloid. QJM 2014; 107:933-4. [PMID: 24694548 DOI: 10.1093/qjmed/hcu071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- J K Teoh
- Department of Cardiology, University Hospital Birmingham, UK
| | - R P Steeds
- Department of Cardiology, University Hospital Birmingham, UK
| | - A T Warfield
- Department of Pathology, University Hospital Birmingham, UK
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Leithead JA, Kandiah K, Steed H, Gunson BK, Steeds RP, Ferguson JW. Tricuspid regurgitation on echocardiography may not be a predictor of patient survival after liver transplantation. Am J Transplant 2014; 14:2192-3. [PMID: 24985366 DOI: 10.1111/ajt.12821] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- J A Leithead
- Liver Unit, Queen Elizabeth Hospital, Birmingham, UK; NIHR Biomedical Research Unit and Centre for Liver Research, University of Birmingham, Birmingham, UK
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Drake WM, Stiles CE, Howlett TA, Toogood AA, Bevan JS, Steeds RP. A cross-sectional study of the prevalence of cardiac valvular abnormalities in hyperprolactinemic patients treated with ergot-derived dopamine agonists. J Clin Endocrinol Metab 2014; 99:90-6. [PMID: 24187407 PMCID: PMC5137780 DOI: 10.1210/jc.2013-2254] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Concern exists in the literature that the long-term use of ergot-derived dopamine agonist drugs for the treatment of hyperprolactinemia may be associated with clinically significant valvular heart disease. OBJECTIVE The aim of the study was to determine the prevalence of valvular heart abnormalities in patients taking dopamine agonists as treatment for lactotrope pituitary tumors and to explore any associations with the cumulative dose of drug used. DESIGN A cross-sectional echocardiographic study was performed in a large group of patients who were receiving dopamine agonist therapy for hyperprolactinemia. Studies were performed in accordance with the British Society of Echocardiography minimum dataset for a standard adult transthoracic echocardiogram. Poisson regression was used to calculate relative risks according to quartiles of dopamine agonist cumulative dose using the lowest cumulative dose quartile as the reference group. SETTING Twenty-eight centers of secondary/tertiary endocrine care across the United Kingdom participated in the study. RESULTS Data from 747 patients (251 males; median age, 42 y; interquartile range [IQR], 34-52 y) were collected. A total of 601 patients had taken cabergoline alone; 36 had been treated with bromocriptine alone; and 110 had received both drugs at some stage. The median cumulative dose for cabergoline was 152 mg (IQR, 50-348 mg), and for bromocriptine it was 7815 mg (IQR, 1764-20 477 mg). A total of 28 cases of moderate valvular stenosis or regurgitation were observed in 24 (3.2%) patients. No associations were observed between cumulative doses of dopamine agonist used and the age-corrected prevalence of any valvular abnormality. CONCLUSION This large UK cross-sectional study does not support a clinically concerning association between the use of dopamine agonists for the treatment of hyperprolactinemia and cardiac valvulopathy.
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Affiliation(s)
- WM Drake
- St Bartholomew’s Hospital, W Smithfield, London, UK, EC1A 7BE
| | - CE Stiles
- St Bartholomew’s Hospital, W Smithfield, London, UK, EC1A 7BE
| | - TA Howlett
- Leicester Royal Infirmary, Infirmary Square, Leicester, Leicestershire, UK, LE1 5WW
| | - AA Toogood
- Queen Elizabeth Hospital, Birmingham, Mindelsohn Way Edgbaston Birmingham, UK, B15 2WB
| | - JS Bevan
- Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK AB25 2ZN
| | - RP Steeds
- Queen Elizabeth Hospital, Birmingham, Mindelsohn Way Edgbaston Birmingham, UK, B15 2WB
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Meijer A, Conradi HJ, Bos EH, Anselmino M, Carney RM, Denollet J, Doyle F, Freedland KE, Grace SL, Hosseini SH, Lane DA, Pilote L, Parakh K, Rafanelli C, Sato H, Steeds RP, Welin C, de Jonge P. Adjusted prognostic association of depression following myocardial infarction with mortality and cardiovascular events: individual patient data meta-analysis. Br J Psychiatry 2013; 203:90-102. [PMID: 23908341 DOI: 10.1192/bjp.bp.112.111195] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The association between depression after myocardial infarction and increased risk of mortality and cardiac morbidity may be due to cardiac disease severity. AIMS To combine original data from studies on the association between post-infarction depression and prognosis into one database, and to investigate to what extent such depression predicts prognosis independently of disease severity. METHOD An individual patient data meta-analysis of studies was conducted using multilevel, multivariable Cox regression analyses. RESULTS Sixteen studies participated, creating a database of 10 175 post-infarction cases. Hazard ratios for post-infarction depression were 1.32 (95% CI 1.26-1.38, P<0.001) for all-cause mortality and 1.19 (95% CI 1.14-1.24, P<0.001) for cardiovascular events. Hazard ratios adjusted for disease severity were attenuated by 28% and 25% respectively. CONCLUSIONS The association between depression following myocardial infarction and prognosis is attenuated after adjustment for cardiac disease severity. Still, depression remains independently associated with prognosis, with a 22% increased risk of all-cause mortality and a 13% increased risk of cardiovascular events per standard deviation in depression z-score.
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Affiliation(s)
- A Meijer
- Interdisciplinary Centre for Psychiatric Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
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Edwards NC, Griffiths M, Steeds RP. Intra-cardiac echocardiography in mitral valve repair: a novel use of a complimentary imaging modality in a difficult scenario. Heart 2013; 99:1791-2. [PMID: 23813848 DOI: 10.1136/heartjnl-2013-304165] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- N C Edwards
- Department of Cardiovascular Medicine, University of Birmingham, , Birmingham, UK
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Taylor RJ, Umar F, Moody WE, Townend J, Steeds RP, Leyva F. 102 THE REPRODUCIBILITY AND ANALYSIS TIME OF CARDIAC MAGNETIC RESONANCE FEATURE TRACKING: POTENTIAL FOR CLINICAL APPLICATION. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Edwards NC, Moody WE, Springthorpe E, Weale PJ, Paisey RB, Martin U, Geberhiwot T, Steeds RP. 160 DIFFUSE FIBROSIS IN ALSTRöM SYNDROME: A MARKER OF DISEASE PROGRESSION. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Moody WE, Taylor RJ, Edwards NC, Chue CD, Umar F, Ferro CJ, Townend JN, Leyva F, Steeds RP. 101 VALIDATION OF MAGNETIC RESONANCE FEATURE TRACKING FOR LONGITUDINAL SYSTOLIC AND DIASTOLIC STRAIN CALCULATION WITH SPATIAL MODULATION OF MAGNETISATION IMAGING ANALYSIS. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Edwards NC, Nundlall N, Moody WE, Davies N, Ferro CJ, Townend JN, Steeds RP. 085 MYOCARDIAL SEGMENTAL ANALYSIS FOR T1-MAPPING IMAGING: A NOVEL SEMI-AUTOMATED METHOD. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chue CD, Moody WE, Steeds RP, Townend JN, Ferro CJ. Unexpected benefits of participation in a clinical trial: abdominal aortic aneurysms in patients with chronic kidney disease. QJM 2012; 105:1213-6. [PMID: 21930664 DOI: 10.1093/qjmed/hcr172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C D Chue
- Department of Cardiovascular Medicine, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Birmingham B15 2TT, UK.
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Abstract
The aim of this article is to provide a perspective on the relative importance and contribution of different imaging modalities in patients with valvular heart disease. Valvular heart disease is increasing in prevalence across Europe, at a time when the clinical ability of physicians to diagnose and assess severity is declining. Increasing reliance is placed on echocardiography, which is the mainstay of cardiac imaging in valvular heart disease. This article outlines the techniques used in this context and their limitations, identifying areas in which dynamic imaging with cardiovascular magnetic resonance and multislice CT are expanding.
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Affiliation(s)
- W S Choo
- Penang Medical College, Georgetown, Malaysia
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Abstract
This article reviews the recent developments in echocardiography that have maintained this technology at the forefront of day-to-day imaging in clinical cardiology. The primary reason for most requests for imaging in cardiovascular medicine is to assess left ventricular structure and function. As our understanding of left ventricular mechanics has become more intricate, tissue Doppler and speckle tracking modalities have been developed that deliver greater insights into diagnosis of cardiomyopathy and earlier warning of ventricular dysfunction. Increased accuracy has been achieved with the dissemination of real-time three-dimensional echocardiography, which has also acquired a central role in the pre-operative assessment of patients prior to reparative valvular surgery. The use of contrast has broadened the indications for transthoracic echocardiography and has increased the accuracy of stress echocardiography, while reducing the number of patients who cannot be scanned because of a limited acoustic window. Finally, echocardiography will be seen in the future not only as a diagnostic tool in those affected by cardiovascular disease but also as a method for prediction of risk and perhaps activation of targeted treatment.
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Affiliation(s)
- R P Steeds
- Queen Elizabeth Hospital, Edgbaston, Birmingham, UK.
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Kanagala P, Bradley C, Hoffman P, Steeds RP. Guidelines for transoesophageal echocardiographic probe cleaning and disinfection from the British Society of Echocardiography. Eur J Echocardiogr 2012; 12:i17-23. [PMID: 21998464 DOI: 10.1093/ejechocard/jer095] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The clinical utility of transoesophageal echocardiography (TOE) is well established. Being a semi-invasive procedure, however, the potential for transmission of infection between sequential patients exists. This has implications for the protection of both patients and medical staff. Guidelines for disinfection during gastrointestinal endoscopy (GIE) have been in place for many years.(1,2) Unfortunately, similar guidance is lacking with respect to TOE. Although traversing the same body cavities and sharing many similarities with upper GIE, there are fundamental structural and procedural differences with TOE which merit special consideration in establishing a decontamination protocol. This document provides recommendations for TOE probe decontamination based on the available evidence, expert opinion, and modification of the current British Society of Gastroenterology guidelines.
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Affiliation(s)
- C J Ferro
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, B15 2TH, UK.
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Moody WE, Chue CD, Inston NG, Edwards NC, Steeds RP, Ferro CJ, Townend JN. Understanding the effects of chronic kidney disease on cardiovascular risk: are there lessons to be learnt from healthy kidney donors? J Hum Hypertens 2011; 26:141-8. [PMID: 21593781 DOI: 10.1038/jhh.2011.46] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic kidney disease (CKD) is now a recognized global public health problem. It is highly prevalent and strongly associated with hypertension and cardiovascular disease (CVD); far more patients with a glomerular filtration rate below 60 ml min(-1) per 1.73 m(2) will die from cardiovascular causes than progress to end-stage renal disease. A better understanding of the complex mechanisms underlying the development of CVD among CKD patients is required if we are to begin devising therapy to prevent or reverse this process. Observational studies of CVD in CKD are difficult to interpret because renal impairment is almost always accompanied by confounding factors. These include the underlying disease process itself (for example, diabetes mellitus and systemic vasculitis) and the complications of CKD, such as hypertension, anaemia and inflammation. Kidney donors provide an ideal opportunity to study healthy subjects without manifest vascular disease who experience an acute change from having normal to modestly impaired renal function at the time of uninephrectomy. Prospectively examining the cardiovascular consequences of uninephrectomy using donors as a model of CKD may provide useful insight into the pathophysiology of CVD in CKD and, therefore, into how the CVD risk associated with renal impairment might eventually be reduced.
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Affiliation(s)
- W E Moody
- Department of Cardiovascular Medicine, Queen Elizabeth Hospital, University of Birmingham, Birmingham, UK.
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Chue CD, Edwards NC, Ferro CJ, Steeds RP, Townend JN. Reduction of blood pressure already in the normal range further regresses left ventricular mass. Heart 2010; 96:1080; author reply 1080. [PMID: 20483900 DOI: 10.1136/hrt.2009.191619] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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