The 6-minute walk test and fall risk in patients with heart failure: A cross-sectional study

BACKGROUND

Given the increased risk of falls in patients with heart failure (HF), there is limited information in the literature about the possible relationship between fall risk and functional capacity.

OBJECTIVE

To investigate the relationship between functional capacity and fall risk in patients with HF and to determine whether there are differences in clinical parameters between patients with and without fall risk.

METHODS

The study included 64 patients with HF. The Activity-Specific Balance Confidence Scale (ABC) determined the fall risk. Functional capacity was assessed with the 6-minute walk test (6MWT). The Berg Balance Scale (BBS), the timed up-and-go test (TUG), and the five times sit-to-stand (5-STS) test were used to evaluate functional balance and mobility. Comorbidities and dyspnea perception were assessed with the Charlson Comorbidity Index (CCI) and modified Medical Research Council (mMRC), respectively.

RESULTS

The 6MWT was associated with fall risk in logistic regression with an odds ratio of 0.979 (0.970-0.989, p < 0.001). Furthermore, the 6MWT had a discriminative value for increased fall risk in patients with HF, with a cutoff value of 248 m. Patients with increased fall risk had lower 6MWT distance, BBS, and gait speed, and higher CCI and mMRC, number of falls, duration of TUG and 5STS compared to patients with no increased fall risk (p < 0.05).

CONCLUSIONS

The study results demonstrated that 6MWT may be a clinically useful tool in quickly identifying potential balance problems and increased fall risk by providing insight into fall risk/balance confidence in addition to assessing functional capacity.

Trends in heart failure between 2016 and 2022 in Türkiye (TRends-HF): a nationwide retrospective cohort study of 85 million individuals across entire population of all ages

Background

Data on the burden of heart failure (HF) outside western countries are limited, but available data suggest it may present differently in other countries. The aim of this study was to examine the incidence, prevalence, and survival rates of HF in Türkiye, with a specific focus on how these rates vary according to age, sex, comorbidities, and socioeconomic status (SES).

Methods

We harnessed the extensive National Electronic Database of the Turkish Ministry of Health, covering Turkey's entire population from January 1, 2016, to December 31, 2022, to identify 2,722,151 cases of HF and their associated comorbidities using ICD-10 codes. Analyzing the primary endpoint of all-cause mortality, our study utilized anonymized data to examine patient demographics, comorbidities, socioeconomic status, and survival patterns, employing statistical techniques to delve into relationships and trends. The data were segmented by gender, socioeconomic status, and age, involving cross-tabulations and statistical metrics to explore connections, odds ratios, and survival rates.

Findings

The estimated prevalence of HF was 2.114% in Türkiye at the end of 2022, with an annual incidence ranging between 3.00 and 6.06 per 1000 person years. Females were older than males (69.8 ± 13.9 years vs. 66.8 ± 13.9 years, respectively). The most common comorbidities were congenital heart diseases and anemia under the age of 20, and hypertension and atherosclerotic cardiovascular disease in the adult population. Only 23.6% (643,159/2,722,151) of patients were treated with any triple guideline-directed medical therapy (GDMT) and 3.6% (96,751/2,722,151) of patients were on quadruple GDMT. The survival rates for patients with HF at 1, 5, and 7 years were 83.3% (95% CI: 83.2-83.3), 61.5% (95% CI: 61.4-61.6), and 57.7% (95% CI: 57.6-57.8) among females, and 82.1% (95% CI: 82.0-82.2), 58.2% (95% CI: 58.1-58.3), and 54.2% (95% CI: 54.0-54.3) among males. Despite a tendency for an increase from the highest to the lowest SES, the prevalence of HF and mortality were paradoxically lowest in the lowest SES region.

Interpretation

The prevalence, incidence, and survival rates of HF in Türkiye were comparable to western countries, despite the notable difference of HF onset occurring 8-10 years earlier in the Turkish population. Drug usage statistics indicate there is a need for effective strategies to improve treatment with GDMT.

Funding

None.

Global survival trends for brain tumors, by histology: analysis of individual records for 556,237 adults diagnosed in 59 countries during 2000-2014 (CONCORD-3)

BACKGROUND

Survival is a key metric of the effectiveness of a health system in managing cancer. We set out to provide a comprehensive examination of worldwide variation and trends in survival from brain tumors in adults, by histology.

METHODS

We analyzed individual data for adults (15-99 years) diagnosed with a brain tumor (ICD-O-3 topography code C71) during 2000-2014, regardless of tumor behavior. Data underwent a 3-phase quality control as part of CONCORD-3. We estimated net survival for 11 histology groups, using the unbiased nonparametric Pohar Perme estimator.

RESULTS

The study included 556,237 adults. In 2010-2014, the global range in age-standardized 5-year net survival for the most common sub-types was broad: in the range 20%-38% for diffuse and anaplastic astrocytoma, from 4% to 17% for glioblastoma, and between 32% and 69% for oligodendroglioma. For patients with glioblastoma, the largest gains in survival occurred between 2000-2004 and 2005-2009. These improvements were more noticeable among adults diagnosed aged 40-70 years than among younger adults.

CONCLUSIONS

To the best of our knowledge, this study provides the largest account to date of global trends in population-based survival for brain tumors by histology in adults. We have highlighted remarkable gains in 5-year survival from glioblastoma since 2005, providing large-scale empirical evidence on the uptake of chemoradiation at population level. Worldwide, survival improvements have been extensive, but some countries still lag behind. Our findings may help clinicians involved in national and international tumor pathway boards to promote initiatives aimed at more extensive implementation of clinical guidelines.

Relationship between left atrial functions and ambulatory blood pressure variability in patients with heart failure and preserved ejection fraction

Aim    The aim of this study was to investigate the relationship between left atrial (LA) abnormalities and ambulatory blood pressure variability (BPV) in heart failure with preserved ejection fraction (HFpEF) patients.Material and methods    In this single-center, prospective study, we included 187 patients with HFpEF. Eighteen patients with poor image quality were excluded from the study. BPV was evaluated using 24-h ambulatory blood pressure (BP) monitoring. The standard deviation of systolic BP (SBP-SD) was calculated to assess BPV. The patients were classified into two groups according to median SBP-SD (10.5 mm Hg).Results    Overall, 169 HFpEF patients (69.2% women, mean age 69.2±11 yrs) were evaluated. There were 98 patients (57.9%) with a SBP-SD greater than 10.5 mm Hg. Patients with higher SPB-SD had significantly higher left atrial stiffness (LASt) and lower LA reservoir strain (LASr) than those with low SPB-SD. LASt was correlated with 24 hr SBP-SD in both sinus rhythm (r= 0.35, p= 0.015) and atrial fibrillation patients (r= 0.32, p= 0.005). There were significant correlations between night-time SBP-SD and LASr (r=-0.23, p=0.045) in HFpEF with sinus rhythm. For all HFpEF patients, multiple regression analyses showed that 24-hr SBP-SD was correlated with LASt (coeff.=0.40, 95%CI= 0.52-5.25, P= 0.017).Conclusions    High BPV is associated with impaired LA function, especially for LASt and LASr. This study may provide insight for larger multicenter studies to evaluate the effects on outcomes in HFpEF.

Immunoadsorption therapy in refractory heart failure patients with dilated cardiomyopathy: a potential therapeutic option

OBJECTIVE

Removal of cardiac autoantibodies by immunoadsorption might confer clinical improvement in dilated cardiomyopathy. In this pilot study, we investigated the efficacy and safety of immunoadsorption therapy in refractory heart failure patients with dilated cardiomyopathy.

METHODS

This study consisted of 9 heart failure patients with dilated cardiomyopathy, NYHA III-IV, left ventricular ejection fraction <30%, unresponsive to heart failure therapy, and with cardiac autoantibodies. Patients underwent immunoadsorption therapy for five consecutive days using a tryptophan column. Changes in cardiac function (left ventricular ejection fraction, left ventricular end-diastolic diameter, left ventricular end-systolic diameter), exercise capacity (6-minute walk distance), neurohormonal (N-terminal pro-brain natriuretic peptide), proinflammatory (high-sensitive C-reactive protein), and myocardial (cardiac troponin-I), biochemical, and hematological variables were obtained at baseline and after 3 and 6 months of immunoadsorption therapy.

RESULTS

Mean left ventricular ejection fraction and 6-minute walk distance significantly increased at 3 months (from 23.27±5.09 to 32.1±1.7%, p=0.01 for left ventricular ejection fraction and from 353±118 to 434±159 m, p=0.04 for 6-minute walk distance) and further increased at 6 months after immunoadsorption therapy (to 34.5±7.7%, p=0.02 for ejection fraction and to 441±136 m, p=0.04 for 6-minute walk distance). NT-proBNP level reduced from 1161(392.8-3034) to 385(116.1-656.5) ng/L (p=0.04), and high-sensitive C-reactive protein decreased from 9.74±0.96 to 4.3±5.8 mg/L (p=0.04) at 6 months. Left ventricular end-diastolic diameter (66.1±5.8 vs. 64.7±8.9 mm) and left ventricular end-systolic diameter (56.1±8.6 vs. 52.3±10.8 mm) tended to decrease but did not reach statistical significance. No significant worsening was observed in creatinine, cardiac troponin-I, and hemoglobin levels after the immunoadsorption procedure.

CONCLUSION

In dilated cardiomyopathy patients with refractory heart failure, immunoadsorption may be considered a potentially useful therapeutic option to improve a patient's clinical status.

Assessment of clinical characteristics of cardiac amyloidosis as a potential underlying etiology in patients diagnosed with heart failure with preserved ejection fraction

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is heterogeneous clinical syndrome. Transthyretin cardiac amyloidosis (CA) is an underdiagnosed cause of HFpEF. Red flags are extremely useful for suspecting CA.

AIMS

We aimed to evaluate the frequency of cardiac and extracardiac manifestations of CA in HFpEF patients based on red flags.

METHODS

Baseline characteristics of 85 patients were recorded during admission. Electrocardiogram and echocardiography were performed. All patients were examined for red flags. Cardiac scintigraphy was performed in 85 patients.

RESULTS

The mean (standard deviation [SD]) age of the study group was 67.9 (9.8) years, and 52 (61.2%) patients were female. At least 1 red flag was observed in 67% of HFpEF patients. Only 4 of the patients had more than 3 red flags. The mean number of red flags in a patient with HFpEF was 1.3. Extracardiac clinical red flags were observed in only 9 (10.5%) patients. Cardiac clinical red flags were extremely rare. An electrocardiographic red flag was detected in 2 out of 10 patients and an echocardiographic red flag in 4 out of 10 patients with HFpEF. Scintigraphy showed that 17.6% of all patients have had a grade 2 or 3 cardiac uptake. The patients with wild-type transthyretin CA had twice as many red flags as those without.

CONCLUSION

The results of the study showed that patients diagnosed with HFpEF had an average of 1.3 red flags suggestive of CA. In real life, extracardiac red flags are rare, while electrocardiographic and echocardiographic red flags are more common in patients with HFpEF.

The mitral inflow E/A ratio before the procedure may predict late recurrence after pulmonary vein isolation using second-generation cryoballoon

Funding Acknowledgements

Type of funding sources: None.

Background

The left ventricular (LV) diastolic dysfunction (DD) increases the risk of atrial fibrillation (AF) development. Some studies investigated whether a relationship between DD and late recurrence after catheter ablation for AF, but they found conflictory results. Such studies had relatively short follow-up duration and they did not have a standard ablation protocol. Some patients were taken to PVI only, while additional linear lesions in localizations such as the left atrial (LA) roof, LA isthmus, and cavotricuspid isthmus were added in others.

Purpose

The mitral inflow E/A ratio is a simple and practical method commonly used to evaluate LV DD. We aimed to investigate whether the E/A ratio before the procedure was predictive for late recurrence in patients with AF undergoing pulmonary vein isolation (PVI) with cryoballoon (CB).

Methods

A total of 100 patients undergoing AF ablation for the first time using second-generation CB were included. Only patients with paroxysmal AF and sinus rhythm the day before the procedure, and with pre-procedural pro-B natriuretic peptide levels within normal limits were included. The patients with and without late recurrence were compared in terms of basal characteristics and procedural features. Any atrial tachyarrhythmia episode longer than 30 s after the blanking period was defined as late recurrence.

Results

The patients [age: 58.0 (50.2-62.0) years, 53 female] were followed up for a median of 44.5 (14.2-62.7) months and late recurrence developed in 25 patients. Female gender (72.0% vs 46.7%), hypertension (72.0% vs 48.0%), and the frequency of early recurrence (20.0% vs 4.0%) were found to be higher in patients with late recurrence than in those without it (p =0.028, 0.037 and 0.022, respectively). The CHA2DS2-Vasc score was higher [2.0 (1.0-3.0) vs 1.0 (0-2.0)], AF duration was longer (27.8 ± 9.4 vs 22.0 ± 8.4 months) and the E/A ratio was lower [0.5 (0.4-1.2) vs 1.4 (0.6-1.7)] in patients with late recurrence than in those without it (p=0.014, 0.006 and 0.001, respectively) (Figure 1). The groups were similar in terms of precedural features. A multivariate analysis showed that female gender (HR: 4.46, 95%CI: 1.24-15.97, p=0.021), early recurrence (HR: 10.22, 95% CI: 2.49-41.99, p=0.001), and E/A ratio (HR: 0.25, 95%CI: 0.11-0.57, p=0.001) were independent predictors for late recurrence (Figure 2). Receiver operating characteristic analysis showed that the optimal cut-off level of the E/A ratio was 0.84. Any ATa free survival rate was significantly lower in patients with E/A ratio &lt;0.84 than in those with ≥0.84 (56.1% vs 88.1%, log-rank p&lt;0.001).

Conclusions

Female gender, early recurrence, and E/A ratio are independent predictors of late recurrence in patients with AF undergoing PVI using second-generation CB. Measuring the E/A ratio in patients with sinus rhythm before AF ablation may help to predict future recurrences.

Clinical characteristics and in-hospital outcomes of COVID-19 patients with history of heart failure: a propensity score-matched study

BACKGROUND

Data on the clinical course and outcomes of COVID-19 disease among patients with a history of heart failure (HF) are scarce. Therefore, the aim of this study was to assess the clinical characteristics, prognostic biomarkers and in-hospital outcomes of patients with a history of HF hospitalised with confirmed COVID-19.

METHODS

A total of 8321 consecutive patients hospitalised with suspected COVID-19 disease were screened. Furthermore, 3849 patients with laboratory-confirmed SARS-CoV-2 infection were included in the study. Two hundred and forty COVID-19 patients with a history of HF and 240 without HF paired with PSM were evaluated.

RESULTS

Mean age was 72.7 ± 9.90 years, and 64.6% were men. Oxygen saturation, systolic and diastolic blood pressure at admission were significantly lower and heart rate was significantly higher in patients with a history of HF compared to those without. Patients with HF, compared to those without, had significantly higher leukocyte count, D-dimer, CRP, procalcitonin, hsTnI, lactate and lower albumin and lymphocyte. Compared with patients without HF, those with previous HF had a longer length of stay at ICU (6.22 d vs. 3.71 d; p < 0.001), increased risk of mechanical ventilation (42.1% vs. 15.4%; p < 0.001), in-hospital death (39.2% vs. 15.4%; p < 0.001) and composite outcomes (52.9% vs. 17.1%; p < 0.001).

CONCLUSION

History of HF is associated with a higher risk of mechanical ventilation, cardiogenic shock, mortality and longer ICU stay in patients hospitalised for COVID-19, therefore the diagnosis of HF alone is important for predicting clinical outcomes.

Inappropriate drug use rates of geriatric patients attending to a university hospital cardiology policlinic

Background

The interest in risks related to inappropriate drug use (IDU) and polypharmacy among the elderly has increased in recent years.

Aims

We aimed to determine the frequency of IDU and multiple drug use in elderly patients in the cardiology outpatient clinic.

Patients and Methods

: In this prospective, cross-sectional study, a total of 513 patients aged 65 years and above who were admitted to the Cardiology Policlinic between December 2017 and January 2018 were included. To determine the prevalence of IDU, we investigated the suitability of the drugs used by the patients (according to the criteria of Beers 2015 and Screening Tool of Older People's Prescriptions [STOPP] version 2), the number of violated criteria in both the guidelines and which criterion was violated by the inappropriate drugs.

Results

: The 513 patients (mean age: 73.18 ± 5.99) in this study included females (n = 235; 45.8%) and males (n = 278; 54.2%). A total of 2,910 drugs were used by the 513 patients (mean per patient: 5.67 ± 2.51); 52.8% of the patients were using more than five drugs. The Beers criteria revealed that 304 IDUs were detected among the drugs and showed that 38.6% (n = 198) of the patients had IDU. According to the STOPP criteria, 366 IDUs were identified among the drugs used, and 45.6% (n = 234) of the patients had IDU.

Conclusion

IDU frequencies of the elderly patients are similar to the world literature in our study. As the number of chronic illnesses the patients had increases, the frequency of IDU increases according to Beers and STOPP criteria in our study.

Prognostic value of D-dimer/fibrinogen ratio on in-hospital outcomes of patients with heart failure and COVID-19

Aim: In the present study, the relationship between D-dimer/fibrinogen ratio (DFR) and in-hospital outcomes was evaluated in patients with COVID-19 and a diagnosis of heart failure (HF). Materials & methods: In-hospital outcomes were compared in patients with high and low DFR values. Results: With regard to in-hospital outcomes, patients in the third tertile of DFR had a higher rate of mechanical ventilation, cardiogenic shock and death (p < 0.001). The length of ICU stay was longer in the third tertile group (p < 0.001). When evaluated together with infection markers, DFR was found to be an independent predictor of outcomes. Conclusion: DFR can be used as a prognostic marker in patients with COVID-19 with a diagnosis of HF, and perhaps more valuable than other infection markers.

Concordance between quantitative and semi-quantitative analysis of Tc-99m-pyrophosphate scintigraphy for the diagnosis of transthyretin cardiac amyloidosis in patients with HFpEF

Background

Transthyretin (TTR) cardiac amyloidosis (CA) is an underdiagnosed cause of heart failure with preserved ejection fraction (HFpEF). Cardiac scintigraphy with 99mTechnetium-pyrophosphate (99mTc-PYP) is referred as a simple, non-invasive and reliable method in the diagnosis of TTR-CA. American Society of Nuclear Cardiology Practice Points recommends two interpretative approaches: the quantitative heart-to-contralateral lung ratio (H/CL) at 1 hour or the semi-quantitative visual assessment at 3 hours after radiotracer injection.

Purpose

In this study, we evaluated the concordance between semi-quantitative and quantitative approaches in the diagnosis of TTR CA in patients with HFpEF.

Methods

This single-center, prospective study included 78 patients who had a diagnosis of HFpEF according to 2016 ESC HF guidelines. 99mTc-PYP cardiac scintigraphy was performed in 43 patients who have ≥2 red flags for TTR-CA including left ventricular hypertrophy (LVH) (wall thickness ≥12 mm), biventricular hypertrophy, sparkling pattern, reduction in longitudinal strain with apical sparing, thickening of the interatrial septum (&gt;6mm), low-voltage, pseudo infarct pattern or atrioventricular block on ECG. In the absence of monoclonal protein in the serum and urine, Grade 2 to 3 myocardial uptake in semi-quantitative analysis at 3 hours or a H/CL ratio of ≥1.5 in quantitative analysis at 1 hour post injection of 99mTc-PYP is considered positive for TTR-CA. Grade 2–3 uptake with a H/CL ratio ≥1.5 or Grade 0–1 uptake with a H/CL ratio &lt;1.5 were considered as concordant results. Grade 2–3 uptake with a H/CL ratio &lt;1.5 or Grade 0–1 uptake with a H/CL ratio ≥1.5 were considered as discordant results.

Results

Mean age of study population was 68.26±9.97 years. 17 (39.5%) of 43 patients who underwent 99mTc-PYP cardiac scintigraphy showed a Grade 2 or 3 cardiac uptake and in these patients with Grade 2–3 uptake, 11 patients (65%) had a H/CL ratio ≥1.5 (concordant results) and 6 patients (35%) had a H/CL ratio &lt;1.5 (discordant results). 26 (60.5%) of 43 patients showed Grade 0–1 cardiac uptake. All patients (100%) with Grade 0–1 uptake had a H/CL ratio &lt;1.5 and therefore, showed concordant results. Overall, 37 (86%) patients had concordant and 6 (14%) patients had discordant results (Table 1).

Conclusion

The results of this study showed that although there was a high agreement between semi-quantitative and quantitative analysis of 99mTc-PYP cardiac scintigraphy, 14% of patients have discordant results and need further workup to confirm TTR-CA in patients with HFpEF.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Pfizer independent grant.

Potantial clinical application of potassium binders in patients with chronic heart failure in real life clinical practice: results from TREAT HF study

Purpose

Hyperkalemia is increasingly prevalent and life-threatening condition in heart failure (HF). In clinical practice, hyperkalemia is also an important barrier to optimal application of RAASi. New potassium binders, sodium zirconium cyclosilicate and patiromer, were developed for the treatment of hyperkalemia. TREAT HF data were analyzed for the evaluation of potential clinical application of potassium binders in real life clinical care in HF patients.

Methods

TREAT HF is a network which undertakes multicenter, national, observational studies designed to evaluate HF patients' clinical characteristics and current treatment modalities. 1028 patients with the diagnosis of chronic HF, median age 64 years and median LVEF 30% who had potassium and GFR data were included in this analysis. In this patient population, 847 patients (82.6%) were receiving beta blockers, 739 (71.9%) were receiving ACE inhibitors or ARBs and 518 (50.4%) were receiving MRA. Patients with hyperkalemia (serum potassium ≥5.1 mEq/L) were considered candidate for potassium binders based on the criteria of HARMONIZE study. According to eGFR (mL/min) level, renal dysfunction was subclassified as: stage-1 (eGFR ≥90) (n=211), stage-2 (eGFR 60-&lt;90) (n=398), stage-3 (eGFR 30-&lt;60) (n=306) and stage 4–5 (eGFR &lt;30) (n=113).

Results

In study population, median potassium level was 4.5 mEq/L, median creatinin level was 1.1 mg/dL and median eGFR was 65.5 mL/min. Overall, 82.9% of patients had normal serum potassium levels (≥3.5–5 mEq/l) and 14.3% of patients (n=147) were found to have hyperkalemia (≥5.1 mEq/L) and, hypokalemia was found in 2.8% of patients (n=30). Hyperkalemia was present in 10.9% (n=23) of patients with stage-1, 12.6% (n=50) of patients with stage-2, 17.0% (n=52) of patients with stage-3 and 19.5% (n=22) of patients with stage 4–5 renal dysfunction. In patients with eGFR &lt;60 ml/min (n=419), hyperkalemia was much more prevalent than those with eGFR ≥60 ml/min (n=609) (17.6% and 11.9% respectively, p=0.011). In patients with stage 4–5 renal dysfunction who were receiving ACEI/ARB or combination of ACEI/ARB and MRA (RAASi), more patients had hyperkalemia than those not receiving RAASi therapy (23.4%, 20.0% and 12.5%, respectively).

Conclusions

This study suggested that in real life clinical practice, 14.3% of HF patients have hyperkalemia and seem to be eligible for the treatment of potassium binders. The risk of hyperkalemia increases with advanced stages of renal dysfunction and the use of RAASi, showing an increased clinical need for potassium binders in HF patients with renal dysfunction and in those receiving RAASi.

Funding Acknowledgement

Type of funding source: None

P4518Cerebral blood flow is lower in heart failure patients with reduced ejection fraction

Purpose

Heart and brain interaction is a well-known entity in heart failure (HF) and left ventricular systolic dysfunction poses an increased risk for stroke and cognitive impairment. Transcranial Doppler (TCD) provides valuable information on cerebral blood flow and detects microembolic signals that can be used to determine the risk of cerebrovascular events. However, less is known about cerebral blood flow in HF patients with reduced EF. So, we aimed to evaluate cerebral blood flow rates by means of TCD in HF patients with reduced ejection fraction (EF).

Methods

This study included 46 HF patients with an EF less than 35% (mean age 65.2±11 years, mean EF 20.1±3.8%) who underwent to TCD examination. In addition, 26 healthy individuals with sinus rhythm and EF >50% (mean age 64.4±9.0 years, mean EF 63.5±2.38%) were included in the study as a control group. Minimum, maximum and mean flow velocities of the both right middle cerebral artery (RMCA) and left middle cerebral artery (LMCA) determined by TCD were analyzed.

Results

The average of RMCA maximum and mean flow velocities were found to be significantly lower in HF patients than those in control group (76,06±23,7 cm/s and 48,49±16,4 cm/s in HF group vs 87,84±14,5 cm/s and 56,41±10,7 cm/s in control group, p=0,025 and p=0,016, respectively). The average of LMCA maximum and mean flow velocities were also significantly lower in HF patients than those in control group (75,1±22,3 cm/s and 47,57±14.8 cm/s in HF group vs 88,73±17,7 cm/s and 57,15±12,4 cm/s in control group, p=0,009 and p=0,007, respectively). However, there was no significant difference in minimum RMCA or LMCA flow velocities between HF group and control groups (33,5±10,6 cm/s and 32,86±9,58 cm/s in HF group vs 36,34±9,2 cm/s and 36,53±10,4 cm/s in control group, p=0,226 and p=0,157, respectively). No significant microembolic signals were detected in HF and control groups.

Conclusions

The results of this study showed that HF patients with reduced EF have lower cerebral blood flow velocities as compared to healthy controls, which might be one of the explanations of the adverse interaction between heart and brain in HF.

P773Initiation of sacubitril/valsartan and optimisation of evidence-based heart failure therapies after hospitalisation for acute decompensated heart failure: An analysis of the TRANSITION study

Background

Optimisation of chronic heart failure (HF) therapy remains the key strategy to improve outcomes after hospitalisation for acute decompensated HF (ADHF) with reduced ejection fraction (HFrEF). Initiation and uptitration of disease-modifying therapies is challenging in this vulnerable patient population. We aimed to describe the patterns of treatment optimisation including sacubitril/valsartan (S/V) in the TRANSITION study.

Methods

TRANSITION (NCT02661217) was a randomised, open-label study comparing S/V initiation pre- vs. post-discharge (1–14 days) in patients admitted for ADHF after haemodynamic stabilisation. The primary endpoint was the proportion of patients achieving 97/103 mg S/V twice daily (bid) at 10 weeks post-randomisation. Up-titration of S/V was as per label. Information on dose of S/V and on the use of concomitant HF medication was collected at each study visit up to week 26.

Results

A total of 493 patients received at least one dose of S/V in the pre-discharge arm and 489 patients in the post-discharge arm. One month after randomisation, 45% of patients in the pre-d/c arm vs. 44% in the post-discharge arm used 24/26 mg bid starting dose and 42% vs. 40% were on 49/51 mg S/V bid, respectively. At week 10, 47% of patients had achieved the target dose in the pre-discharge arm vs. 51% in the post-discharge arm. At the end of the follow-up at 26 weeks, the proportion of patients on S/V target dose further increased to 53% in the pre-discharge and 61% in the post-discharge arm (Figure 1). At week 10, the mean dose of S/V was 132 mg in the pre-discharge arm and 136 mg in the post-discharge arm, and at week 26, it was 140 mg and 147 mg, respectively.

Before hospital admission, 52% and 54% of the patients received a beta-blocker (BB) in the pre-discharge and post-discharge group, respectively, and 42% in both arms received a mineralcorticoid receptor antagonist (MRA). At time of discharge, 68% and 71%% of the patients received a BB and 68% and 65% an MRA, in the pre-discharge and post-discharge groups, respectively. These proportions remained stable to week 10 and week 26.

Uptitration of sacubitril/valsartan

Conclusions

In the vulnerable post-ADHF population, initiation of S/V and up-titration to target dose was feasible within 10 weeks in half of the patients alongside with a 20% increase in the use of other disease-modifying medications that remained stable through the end of the 6-month follow-up.

Acknowledgement/Funding

The TRANSITION study was funded by Novartis

P1637Rehospitalisations during 26 weeks of follow up from initiation of sacubitril/valsartan after acute decompensated heart failure: An analysis of the TRANSITION study

Background

Patients with acute decompensated heart failure (ADHF) are at high risk of recurrent hospitalisations and death. In-hospital initiation of sacubitril/valsartan (S/V) reduced the risk for HF re-hospitalisation by 44% compared to enalapril in the PIONEER-HF study during the 8-week follow-up period. We aimed to describe the pattern of readmissions and their causes in the TRANSITION study, which randomised participants to pre-discharge or post-discharge initation of S/V.

Methods

TRANSITION (NCT02661217) was a randomised, open-label study comparing S/V initiation pre- vs. post-discharge (1–14 days) in haemodynamically stabilised patients with HF with reduced ejection fraction, admitted for ADHF. The primary endpoint was the proportion of patients achieving 97/103 mg S/V twice daily at 10 weeks post-randomisation. Information on rehospitalisation was collected throughout the study up to 26 weeks.

Results

A total of 493 patients received S/V in the pre-discharge arm and 489 patients in the post-discharge arm. Readmissions due to any cause were reported in 9.7% and 18.1% in the pre-discharge arm vs. 10.6% and 21.3% in the post-discharge arm within 30 days, and 10 weeks respectively. During the 26-weeks follow-up, all-cause readmission was reported in 34.5% of patients in the pre-discharge arm vs. 34.6% in the post-discharge arm. Median time to first rehospitalisation was 67 days in the pre-discharge arm (IQR: 26–110 days) and 50 days (IQR: 23–108 days) in the post-discharge arm. At least one HF hospitalisation was reported in 7.5% of patients in the pre-discharge arm and 7.4% in the post-discharge arm during 10 weeks and in 11.8% and 12.3% of patients, respectively, during 26 weeks of follow-up. Median duration of HF readmission was 7 days (IQR: 4–11 days) in the pre-discharge group and 6.5 days (IQR: 6.5–10 days) in the post-discharge arm. In total 2.6% and 5.5% patients in pre-discharge arm and 3.9% and 7% in the post-discharge arm visited an emergency room during 10 weeks and 26 weeks, respectively.

Conclusions

Initiation of S/V in patients hospitalised for ADHF either before or shortly after discharge, results in comparable rates of all cause and HF rehospitalisations, as well as emergency room visits without hospital admission over the 26 week follow-up period. HF re-hospitalisations rates at 10 weeks in TRANSITION are in line with the 8% in S/V arm reported in PIONEER-HF during the 8-weeks follow-up.

Acknowledgement/Funding

The TRANSITION study was funded by Novartis

Initiation of sacubitril/valsartan in haemodynamically stabilised heart failure patients in hospital or early after discharge: primary results of the randomised TRANSITION study

AIMS

To assess tolerability and optimal time point for initiation of sacubitril/valsartan in patients stabilised after acute heart failure (AHF).

METHODS AND RESULTS

TRANSITION was a randomised, multicentre, open-label study comparing two treatment initiation modalities of sacubitril/valsartan. Patients aged ≥ 18 years, hospitalised for AHF were stratified according to pre-admission use of renin-angiotensin-aldosterone system inhibitors and randomised (n = 1002) after stabilisation to initiate sacubitril/valsartan either ≥ 12-h pre-discharge or between Days 1-14 post-discharge. Starting dose (as per label) was 24/26 mg or 49/51 mg bid with up- or down-titration based on tolerability. The primary endpoint was the proportion of patients attaining 97/103 mg bid target dose after 10 weeks. Median time of first dose of sacubitril/valsartan from the day of discharge was Day -1 and Day +1 in the pre-discharge group and the post-discharge group, respectively. Comparable proportions of patients in the pre- and post-discharge initiation groups met the primary endpoint [45.4% vs. 50.7%; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.79-1.02]. The proportion of patients who achieved and maintained for ≥ 2 weeks leading to Week 10, either 49/51 or 97/103 mg bid was 62.1% vs. 68.5% (RR 0.91; 95% CI 0.83-0.99); or any dose was 86.0% vs. 89.6% (RR 0.96; 95% CI 0.92-1.01). Discontinuation due to adverse events occurred in 7.3% vs. 4.9% of patients (RR 1.49; 95% CI 0.90-2.46).

CONCLUSIONS

Initiation of sacubitril/valsartan in a wide range of heart failure with reduced ejection fraction patients stabilised after an AHF event, either in hospital or shortly after discharge, is feasible with about half of the patients achieving target dose within 10 weeks.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02661217.

Heart and brain interaction in patients with heart failure: overview and proposal for a taxonomy. A position paper from the Study Group on Heart and Brain Interaction of the Heart Failure Association

Heart failure (HF) is a complex clinical syndrome with multiple interactions between the failing myocardium and cerebral (dys-)functions. Bi-directional feedback interactions between the heart and the brain are inherent in the pathophysiology of HF: (i) the impaired cardiac function affects cerebral structure and functional capacity, and (ii) neuronal signals impact on the cardiovascular continuum. These interactions contribute to the symptomatic presentation of HF patients and affect many co-morbidities of HF. Moreover, neuro-cardiac feedback signals significantly promote aggravation and further progression of HF and are causal in the poor prognosis of HF. The diversity and complexity of heart and brain interactions make it difficult to develop a comprehensive overview. In this paper a systematic approach is proposed to develop a comprehensive atlas of related conditions, signals and disease mechanisms of the interactions between the heart and the brain in HF. The proposed taxonomy is based on pathophysiological principles. Impaired perfusion of the brain may represent one major category, with acute (cardio-embolic) or chronic (haemodynamic failure) low perfusion being sub-categories with mostly different consequences (i.e. ischaemic stroke or cognitive impairment, respectively). Further categories include impairment of higher cortical function (mood, cognition), of brain stem function (sympathetic over-activation, neuro-cardiac reflexes). Treatment-related interactions could be categorized as medical, interventional and device-related interactions. Also interactions due to specific diseases are categorized. A methodical approach to categorize the interdependency of heart and brain may help to integrate individual research areas into an overall picture.

Ivabradine treatment prevents dobutamine-induced increase in heart rate in patients with acute decompensated heart failure

BACKGROUND

Ivabradine is a heart rate (HR)-lowering agent acting by inhibiting the If-channel. Dobutamine does increase the HR and has some deleterious effects on myocardium. So, we aimed to evaluate whether ivabradine treatment blunts a dobutamine-induced increase in HR.

METHODS

The main study population consisted of 58 acute decompensated heart failure patients requiring inotropic support with left-ventricular ejection fraction below 35%, who were randomized to ivabradine (n = 29) or control (n = 29). All patients underwent Holter recording for 6 h and then dobutamine was administered at incremental doses of 5, 10 and 15 μg/kg/min, with 6-h steps. Holter recording was continued during dobutamine infusion. Ivabradine 7.5 mg was given at the initiation of dobutamine and readministered at 12 h of infusion. Also, a nonrandomized beta-blocker group with 15 patients receiving beta-blocker was included in the analysis. Control and beta-blocker groups did not receive ivabradine.

RESULTS

In the control group, mean HR gradually and significantly increased at each step of dobutamine infusion (81 ± 11, 90 ± 16, 97 ± 14 and 101 ± 16 b.p.m., respectively; P = 0.001), whereas no significant increase in HR was observed in the ivabradine group (82 ± 17, 82 ± 15, 85 ± 14 and 83 ± 12 b.p.m., respectively; P = 0.439). Mean HR was also found to significantly increase during dobutamine infusion in the beta-blocker group (75 ± 13, 82 ± 13, 86 ± 14 and 88 ± 13 b.p.m., respectively; P = 0.001). The median increase in HR from baseline was significantly higher in the control group compared to those in the ivabradine group (5 vs. 2 b.p.m.; P = 0.007 at first step, 13 vs. 5 b.p.m.; P = 0.001 at second step and 18 vs. 6 b.p.m.; P = 0.0001 at third step of dobutamine, respectively).

CONCLUSIONS

Ivabradine treatment prevents dobutamine-induced increase in HR and may be useful in reducing HR-related adverse effects of dobutamine.

Cardiovascular involvement in patients with pseudoexfoliation syndrome

AIM

Pseudoexfoliation (PEX) syndrome, diagnosed by ocular examination, is a common disorder of the extracellular matrix. Previous studies have demonstrated accumulation of PEX material in the walls of blood vessels and myocardium. We aimed to investigate whether PEX is associated with cardiovascular involvement using carotid ultrasound measurements and myocardial tissue Doppler imaging (TDI).

METHODS

Thirty-six PEX patients and 34 age-matched and sex-matched healthy controls who had no PEX material were included. Fasting blood samples were taken and the following data were obtained from all cases: myocardial TDI measurements, the mean carotid intima-media thickness (IMT), total carotid plaque area and number.

RESULTS

There were no significant differences between the groups regarding clinical and biochemical data. The peak systolic TDI velocities at the septal (septal S) and lateral annuli (lateral S), and the isovolumic contraction velocity at the lateral annulus [lateral isovolumic contraction velocity (IVC)] were significantly lower in patients with PEX, than in controls (P = 0.001, <0.001 and 0.016, respectively) whereas IMT, total carotid plaque area and number were significantly higher (P = 0.002, 0.035 and 0.033, respectively). In a logistic regression analysis including age, septal S, lateral S, lateral IVC, IMT, total carotid plaque area and number, septal S, lateral S and IMT were significantly associated with PEX, (P = 0.035, 0.011 and 0.035, respectively).

CONCLUSION

Peak systolic TDI velocities were significantly lower and IMT was significantly increased in patients with PEX. However, PEX was weakly associated with carotid plaque measurements.

Long-term stability of early implant placement with contour augmentation

In this prospective case series study, 20 patients with an implant-borne single crown following early implant placement with simultaneous contour augmentation were followed for 6 years. Clinical, radiologic, and esthetic parameters were assessed. In addition, cone beam computed tomography (CBCT) was used at 6 years to examine the facial bone wall. During the study period, all 20 implants were successfully integrated, and the clinical parameters remained stable over time. Pleasing esthetic outcomes were noted, as assessed by the pink esthetic scores. None of the implants developed mucosal recession of 1 mm or more. The periapical radiographs yielded stable peri-implant bone levels, with a mean DIB of 0.44 mm at 6 years. The CBCT scans showed that all 20 implants had a detectable facial bone wall at 6 years, with a mean thickness of around 1.9 mm. In summary, this prospective case series study demonstrated stable peri-implant hard and soft tissues for all 20 implants, and pleasing esthetic outcomes overall. The follow-up of 6 years confirmed that the risk for mucosal recession is low with early implant placement. In addition, contour augmentation with guided bone regeneration (GBR) was able to establish and maintain a facial bone wall in all 20 patients.

Effectiveness of cardiac simulator on the acquirement of cardiac auscultatory skills of medical students

BACKGROUND

Cardiac simulators have been developed as an alternative training model in order to improve the cardiac auscultation skills of medical students. The effectiveness of the cardiac simulator's use in cardiac auscultatory training is presently not yet well established.

OBJECTIVES

The authors aimed to investigate whether the use of a cardiac simulator can improve the auscultation skills of medical students.

MATERIAL AND METHODS

The students taking the auscultation training on the cardiac simulator were grouped as Group A and the students not taking the auscultation training on the cardiac simulator were grouped as Group B (before). The students in Group B (before) were grouped as Group B (after) after receiving the auscultation training on the cardiac simulator. The percentages of accurate diagnoses for the tested heart murmurs were compared between Group A and Group B (before), and between Group B (before) and Group B (after).

RESULTS

The rate of making correct diagnoses of normal heart sounds was similar in all the groups (Group A, Group B (before), and Group B (after)). By contrast, the percentage of accurate diagnoses for the tested heart murmurs was notably improved among the students in Group A with respect to Group B (before) (p < 0.01). Similarly, the rate of correct diagnoses for the tested heart murmurs was markedly higher among the students in Group B (after) than in Group B (before) (p < 0.01).

CONCLUSIONS

The use of a cardiac simulator as a training tool can improve the auscultation skills of medical students quickly and efficiently.

Statins improve myocardial perfusion in metabolic syndrome patients who have perfusion defects on myocardial perfusion imaging and angiographically normal coronary arteries

OBJECTIVE

Previous studies in hypercholesterolemic patients with coronary artery disease (CAD) have demonstrated that lipid lowering therapy restores coronary endothelium dependent vasodilatation and increases myocardial perfusion. However, there is not enough data showing the effects of statins on myocardial perfusion in metabolic syndrome (MetS) patients who have perfusion abnormalities but not evident CAD, which are attributed to microvascular dysfunction. We aimed to evaluate whether or not statin therapy improves myocardial perfusion, as assessed by Technetium (Tc)-99m single-photon emission computed tomography (SPECT), in patients with MetS and angiographically normal epicardial coronary anatomy.

MATERIALS AND METHODS

The study population consisted of 55 selected patients (mean age: 52, 72% female) with MetS who have perfusion defect on exercise stress Tc-99m SPECT and normal coronary arteries. Patients were treated with 20 mg atorvastatin for six months regardless of baseline lipid levels and SPECT study was repeated after the therapy. The summed stress score (SSS), summed rest score (SRS) and summed difference score (SDS), and left ventricular (LV) volumes and ejection fractions (EF) at rest and stress were obtained.

RESULTS

We found significant improvements in SSS, SRS and SDS after six months of statin therapy (p = 0.001, 0.001 and 0.002, respectively). In addition, end-diastolic volumes at rest and stress, and stroke volume at rest were significantly decreased (p = 0.001, 0.001 and 0.026, respectively). Also, LV EF at stress was significantly increased (p = 0.035).

CONCLUSIONS

Statin therapy in patients with MetS who have perfusion defects on Tc-99m SPECT and normal coronary arteries produces significant improvements in myocardial perfusion abnormalities.

Mode of onset of polymorphic ventricular tachycardia in acute myocardial infarction

BACKGROUND

Polymorphic ventricular tachycardia (PVT) can occur during acute myocardial infarction (MI). In the past, studies investigated the initiation pattern of ventricular tachycardias in different patient populations; however, the mode of onset of PVT in acute MI patients has not been investigated previously.

OBJECTIVE

To retrospectively investigate the electrophysiological features of PVT with different initiation patterns in acute MI patients to assess whether there is a relationship of the initiation patterns of PVT with clinical and electrophysiological characteristics.

METHODS

Sixty-two rhythm strips defined as PVT from 53 patients (mean [± SD] age 63±8 years) with acute ST elevation MI were analyzed. All patients were monitored while they were hospitalized in the coronary care unit, and the electrocardiogram strips were obtained from continuous monitoring. PVT was defined as sudden-onset tachycardia if it was not preceded by ventricular ectopic beats. PVT that was preceded by single or multiple ectopic beats was defined as nonsudden-onset tachycardia.

RESULTS

Nonsudden-onset episodes were more common than suddenonset episodes (40 episodes [64.5%] versus 22 episodes [35.5%]). In the nonsudden-onset group, 25 episodes (62.5%) were initiated after a single ectopic beat, while 15 episodes (37.5%) were initiated after multiple complexes. The mean (± SD) left ventricular ejection fraction of patients with nonsudden-onset PVT was decreased (53±6% versus 65±7%, P<0.01). Nonsudden-onset tachycardias had lower coupling intervals than suddenonset tachycardias. Similarly, the PVT cycle length was shorter in the presence of nonsudden-onset initiation. When nonsudden-onset PVT episodes were further subclassified based on the morphology of the first beat of tachycardia, 26 PVTs (65%) had a first beat of tachycardia similar to the subsequent PVT beats and 14 (35%) did not.

CONCLUSIONS

These results demonstrate that PVT is often preceded by ventricular ectopy in acute MI patients. Nonsudden-onset PVT is usually characterized by a lower coupling interval, shorter PVT cycle length and an associated lower ejection fraction.

Levosimendan is not effective in reducing pulmonary pressures in patients with idiopathic pulmonary arterial hypertension: report of two cases

Currently, prostacyclin, endothelin receptor antagonists and phosphodiesterase inhibitors are recommended therapy in idiopathic pulmonary arterial hypertension. However, each of these drugs has limited efficacy in the improvement of clinical symptoms, pulmonary hemodynamics and long-term survival. Levosimendan, a novel calcium-sensitizing inodilator agent, has been shown to have pulmonary vasodilatory action. However, the potential pulmonary vasodilating effect of levosimendan in patients with idiopathic pulmonary arterial hypertension remains unclear. Levosimendan administered in two patients with nonvasoreactive idiopathic pulmonary arterial hypertension exhibited deterioration in clinical status, and, contrary to what was expected, levosimendan was found to increase pulmonary pressures and did not lead to a substantial improvement of the patient's condition.

Anticoagulant drugs in noncompaction: a mandatory therapy?

BACKGROUND

Noncompaction of left ventricular myocardium is a rare congenital cardiomyopathy resulting from an incomplete myocardial morphogenesis that leads to the persistence of the embryonic myocardium. This condition is characterized by a thin compacted epicardial and an extremely thickened endocardial layer with prominent trabeculations and deep intertrabecular recesses. It is not clear, in noncompaction of myocardium, whether intertrabecular recesses could be responsible for thrombi formation and thromboembolic complications.

METHODS

The prevalence of stroke and echocardiographic finding of thrombus was evaluated in a continuous series of 229 patients (men and women) affected by noncompaction of the left ventricular myocardium, who were included in the SIEC registry. We excluded patients affected by atrial fibrillation.

RESULTS

The mean age of the patients was 49.5 years. Fifty percent of the patients were affected by a ventricular systolic dysfunction. The mean period of follow-up was 7.3 years. Only four patients had a history of ischemic stroke. A large thrombus into the left ventricular chamber was observed in a 1-year-old child affected by Behcet's disease (high risk of thrombi formation).

CONCLUSION

Noncompaction of the left ventricular myocardium, by itself, does not seem to be a risk factor for stroke or embolic results, so there is no indication for oral anticoagulant therapy.

Supraventricular arrhythmias in noncompaction of left ventricle: Is this a frequent complication?

BACKGROUND

Isolated left ventricular noncompaction is the result of incomplete myocardial morphogenesis, leading to persistence of the embryonic myocardium. The condition is recognised by an excessively prominent trabecular meshwork and deep intertrabecular recesses of the left ventricle. Whether these intertrabecular recesses are a favorable substrate for supraventricular arrhythmias is unclear, even if the incidence of chronic heart failure seems to be high.

RESULTS

We evaluated a continuous series of 238 patients affected by noncompaction. In 4 cases the patients reported palpitations and in 4 an episode of syncope. Periodic holter monitoring was performed every 6 months for 4 years. Only 9 patients had documented atrial fibrillation. In no cases we observed supraventricular tachycardia.

CONCLUSIONS

Noncompaction alone does not seem to be a risk factor for supraventricular arrhythmias.

Initiation patterns of monomorphic ventricular tachycardia in acute myocardial infarction: analysis of rhythm strips

OBJECTIVE

Monomorphic ventricular tachycardias (MVT) frequently occur in the acute phase of myocardial infarction (MI). In the past, some studies aimed to investigate the initiation pattern of ventricular tachycardias, although not in acute MI patients. The aim of the present study was to analyse the initiation pattern of MVT in acute MI using rhythm strips.

METHODS

This study utilized data on 255 rhythm strips defined as MVT, from 173 patients with acute ST-segment elevation MI. Monomorphic ventricular tachycardias that were not preceded by ventricular ectopic beats were defined as sudden onset MVT. Monomorphic ventricular tachycardias which were preceded by a single or multiple ectopic beats, including a short-long-short sequence, were defined as non-sudden onset MVT.

RESULTS

Non-sudden onset episodes were more common than sudden onset episodes (172 episodes, 67.4% versus 83 episodes, 32.5%). The morphology of the ventricular ectopic beat initiating tachycardia was similar to the first beat of MVT in 127 episodes (73.8%), but not in the remaining 45 episodes (26.1%). In the non-sudden onset group, 117 episodes (68%) initiated with a single ectopic beat, while 55 episodes (32%) initiated with multiple complexes. The left ventricular ejection fraction of the patients with non-sudden onset MVT was lower (50 +/- 6 versus 56 +/- 5, P < 0.05). Monomorphic ventricular tachycardias with no sudden onset also had shorter coupling intervals (CI) (P < 0.001) and shorter prematurity index (PI) (P < 0.001) than MVT with sudden onset. Similarly, the ventricular tachycardia cycle length was shorter in the group of MVT subjects with non-sudden onset as compared with sudden onset (P < 0.05). In contrast, tachycardias with sudden onset were associated with a shorter preceding RR interval (P < 0.01).

CONCLUSIONS

Analysis of rhythm strips demonstrated that MVT is most often preceded by ventricular ectopic beats in the acute phase of MI.

Both levosimendan and dobutamine treatments result in significant reduction of NT-proBNP levels, but levosimendan has better and prolonged neurohormonal effects than dobutamine

Levosimendan and dobutamine are comparable inotropic drugs as regards their hemodynamic effects and clinical outcomes in decompensated heart failure (HF). The aim of this study was to compare the effects of levosimendan and dobutamine treatment on NT-proBNP levels in patients with decompensated HF. Forty-four patients with decompensated HF and ejection fraction <35% received either a 24-h infusion of levosimendan (n=26) or dobutamine (n=18). NT-proBNP was measured at baseline and 12 h, 24 h and 48 h after the initiation of drug infusion. NT-proBNP levels at baseline, 12 h, 24 h and 48 h were 16,879+/-2437, 16,004+/-2635, 12,881+/-2305 and 11,078+/-2092 pg/ml, respectively, in the levosimendan group and 16,031+/-3463, 15,908+/-3806, 12,271+/-3299 and 14,840+/-4009 pg/ml, respectively, in the dobutamine group. NT-proBNP decreased significantly at 24 h in response to both levosimendan and dobutamine treatment (p<0.01 and p<0.05, respectively) with no significant difference among the treatment groups. In the dobutamine group, NT-proBNP increased at 48 h (p=n.s. vs. baseline), in contrast, NT-proBNP reduction continued for up to 48 h in the levosimendan group (p<0.001 vs. baseline). Although not statistically different, a greater percentage of NT-proBNP reduction was observed with levosimendan treatment at both 24 h (-25+/-7% vs. -20+/-10%) and 48 h (-32+/-7% vs. -20+/-11%) compared to dobutamine. Both levosimendan and dobutamine treatments result in significant reduction of NT-proBNP levels at the end of the 24-h infusion. However, compared to dobutamine, levosimendan has better and prolonged effects on NT-proBNP levels in decompensated HF.