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Gantzel RH, Meyer M, Mazgareanu S, Aagaard NK, Jepsen P, Holzmeister J, Watson H, Grønbæk H. Ularitide as treatment of refractory ascites in cirrhosis- a study protocol for a randomised trial. Dan Med J 2021; 68:A07210610. [PMID: 34851251] [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] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
INTRODUCTION Ascites is a frequent complication to cirrhosis. When ascites becomes refractory to standard diuretic pharmacotherapy, patients are facing a median survival of less than one year and most likely a need for frequent hospitalisations due to large-volume paracentesis or complications. An unmet need exists for new and improved treatments of refractory ascites and the present study investigates the potential of the natriuretic peptide ularitide for this indication. METHODS We aim to investigate the effects, safety and tolerability of ularitide as treatment of refractory ascites in cirrhosis patients in a randomised, double-blind, placebo-controlled trial. Participants receive ularitide or placebo as a continuous intravenous infusion during hospitalisation as an add-on to any diuretic treatment. Clinical end points include increase in diuresis and natriuresis, reduction in body weight and waist circumference, safety end points, as well as changes in plasma concentrations of renal and systemic response biomarkers and hormones. CONCLUSION This study will provide evidence concerning the potential of ularitide in treating cirrhosis patients with refractory ascites. FUNDING This investigator-initiated trial is supported by ADS AIPHIA Development Services AG. TRIAL REGISTRATION Clinicaltrials.gov (NCT04311489) and EU Drug Regulating Authorities Clinical Trials (EudraCT: 2019-002268-28). The trial will be conducted in accordance with good clinical practice, the Declaration of Helsinki and applicable demands from Danish authorities.
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2
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Maack C, Eschenhagen T, Hamdani N, Heinzel FR, Lyon AR, Manstein DJ, Metzger J, Papp Z, Tocchetti CG, Yilmaz MB, Anker SD, Balligand JL, Bauersachs J, Brutsaert D, Carrier L, Chlopicki S, Cleland JG, de Boer RA, Dietl A, Fischmeister R, Harjola VP, Heymans S, Hilfiker-Kleiner D, Holzmeister J, de Keulenaer G, Limongelli G, Linke WA, Lund LH, Masip J, Metra M, Mueller C, Pieske B, Ponikowski P, Ristić A, Ruschitzka F, Seferović PM, Skouri H, Zimmermann WH, Mebazaa A. Treatments targeting inotropy. Eur Heart J 2020; 40:3626-3644. [PMID: 30295807 DOI: 10.1093/eurheartj/ehy600] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [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: 05/25/2018] [Revised: 08/06/2018] [Accepted: 09/14/2018] [Indexed: 02/06/2023] Open
Abstract
Acute heart failure (HF) and in particular, cardiogenic shock are associated with high morbidity and mortality. A therapeutic dilemma is that the use of positive inotropic agents, such as catecholamines or phosphodiesterase-inhibitors, is associated with increased mortality. Newer drugs, such as levosimendan or omecamtiv mecarbil, target sarcomeres to improve systolic function putatively without elevating intracellular Ca2+. Although meta-analyses of smaller trials suggested that levosimendan is associated with a better outcome than dobutamine, larger comparative trials failed to confirm this observation. For omecamtiv mecarbil, Phase II clinical trials suggest a favourable haemodynamic profile in patients with acute and chronic HF, and a Phase III morbidity/mortality trial in patients with chronic HF has recently begun. Here, we review the pathophysiological basis of systolic dysfunction in patients with HF and the mechanisms through which different inotropic agents improve cardiac function. Since adenosine triphosphate and reactive oxygen species production in mitochondria are intimately linked to the processes of excitation-contraction coupling, we also discuss the impact of inotropic agents on mitochondrial bioenergetics and redox regulation. Therefore, this position paper should help identify novel targets for treatments that could not only safely improve systolic and diastolic function acutely, but potentially also myocardial structure and function over a longer-term.
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Affiliation(s)
- Christoph Maack
- Comprehensive Heart Failure Center, University Clinic Würzburg, Am Schwarzenberg 15, Würzburg, Germany
| | - Thomas Eschenhagen
- Department of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany.,Partner site Hamburg/Kiel/Lübeck, DZHK (German Centre for Cardiovascular Research), Hamburg, Germany
| | - Nazha Hamdani
- Department of Cardiovascular Physiology, Ruhr University Bochum, Bochum, Germany
| | - Frank R Heinzel
- Department of Cardiology, Charité University Medicine, Berlin, Germany
| | - Alexander R Lyon
- NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital and National Heart and Lung Institute, Imperial College, London, UK
| | - Dietmar J Manstein
- Institute for Biophysical Chemistry, Hannover Medical School, Hannover, Germany.,Division for Structural Biochemistry, Hannover Medical School, Hannover, Germany
| | - Joseph Metzger
- Department of Integrative Biology & Physiology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Carlo G Tocchetti
- Department of Translational Medical Sciences, Federico II University, Naples, Italy
| | - M Birhan Yilmaz
- Department of Cardiology, Cumhuriyet University, Sivas, Turkey
| | - Stefan D Anker
- Department of Cardiology and Pneumology, University Medical Center Göttingen and DZHK (German Center for Cardiovascular Research), Göttingen, Germany.,Division of Cardiology and Metabolism - Heart Failure, Cachexia and Sarcopenia, Department of Internal Medicine and Cardiology, Berlin-Brandenburg Center for Regenerative Therapies (BCRT) at Charité University Medicine, Berlin, Germany
| | - Jean-Luc Balligand
- Institut de Recherche Expérimentale et Clinique (IREC), Pole of Pharmacology and Therapeutics (FATH), Universite Catholique de Louvain and Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, Hannover D-30625, Germany
| | | | - Lucie Carrier
- Department of Experimental Pharmacology and Toxicology, Cardiovascular Research Center, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany.,Partner site Hamburg/Kiel/Lübeck, DZHK (German Centre for Cardiovascular Research), Hamburg, Germany
| | - Stefan Chlopicki
- Department of Pharmacology, Medical College, Jagiellonian University, Krakow, Poland
| | - John G Cleland
- University of Hull, Kingston upon Hull, UK.,National Heart and Lung Institute, Royal Brompton and Harefield Hospitals NHS Trust, Imperial College, London, UK
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Alexander Dietl
- Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Rodolphe Fischmeister
- Inserm UMR-S 1180, Univ. Paris-Sud, Université Paris-Saclay, Châtenay-Malabry, France
| | | | | | | | | | - Gilles de Keulenaer
- Laboratory of Physiopharmacology (University of Antwerp) and Department of Cardiology, ZNA Hospital, Antwerp, Belgium
| | - Giuseppe Limongelli
- Department of Cardiothoracic Sciences, Second University of Naples, Naples, Italy
| | | | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari Integral, University of Barcelona, Spain
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Switzerland
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany.,Department of Internal Medicine and Cardiology, German Heart Center Berlin, and German Centre for Cardiovascular Research (DZHK), Partner site Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Piotr Ponikowski
- Department of Cardiology, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | - Arsen Ristić
- Department of Cardiology of the Clinical Center of Serbia and Belgrade University School of Medicine, Belgrade, Serbia
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Centre, University Hospital Zurich, Switzerland
| | | | - Hadi Skouri
- Division of Cardiology, American University of Beirut Medical Centre, Beirut, Lebanon
| | - Wolfram H Zimmermann
- Institute of Pharmacology and Toxicology, University Medical Center Göttingen, Göttingen, Germany.,German Center for Cardiovascular Research (DZHK), Partner siteGöttingen, Göttingen, Germany
| | - Alexandre Mebazaa
- Hôpital Lariboisière, Université Paris Diderot, Inserm U 942, Paris, France
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Bax JJ, Delgado V, Sogaard P, Singh JP, Abraham WT, Borer JS, Dickstein K, Gras D, Brugada J, Robertson M, Ford I, Krum H, Holzmeister J, Ruschitzka F, Gorcsan J. Prognostic implications of left ventricular global longitudinal strain in heart failure patients with narrow QRS complex treated with cardiac resynchronization therapy: a subanalysis of the randomized EchoCRT trial. Eur Heart J 2018; 38:720-726. [PMID: 28426885 DOI: 10.1093/eurheartj/ehw506] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 07/15/2016] [Accepted: 09/29/2016] [Indexed: 11/13/2022] Open
Abstract
Aim Left ventricular (LV) global longitudinal strain (GLS) reflects LV systolic function and correlates inversely with the extent of LV myocardial scar and fibrosis. The present subanalysis of the Echocardiography Guided CRT trial investigated the prognostic value of LV GLS in patients with narrow QRS complex. Methods and results Left ventricular (LV) global longitudinal strain (GLS) was measured on the apical 2-, 4- and 3-chamber views using speckle tracking analysis. Measurement of baseline LV GLS was feasible in 755 patients (374 with cardiac resynchronization therapy (CRT)-ON and 381 with CRT-OFF). The median value of LV GLS in the overall population was 7.9%, interquartile range 6.2-10.1%. After a mean follow-up period of 19.4 months, 95 patients in the CRT-OFF group and 111 in the CRT-ON group reached the combined primary endpoint of all-cause mortality and heart failure hospitalization. Each 1% absolute unit decrease in LV GLS was independently associated with 11% increase in the risk to reach the primary endpoint (Hazard ratio 1.11; 95% confidence interval 95% 1.04-1.17, P < 0.001), after adjusting for ischaemic cardiomyopathy and randomization treatment among other clinically relevant variables. When categorizing patients according to quartiles of LV GLS, the primary endpoint occurred more frequently in patients in the lowest quartile (<6.2%) treated with CRT-ON vs. CRT-OFF (45.6% vs. 28.7%, P = 0.009) whereas, no differences were observed in patients with LV GLS ≥6.2% treated with CRT-OFF vs. CRT-ON (23.7% vs. 24.5%, respectively; P = 0.62). Conclusion Low LV GLS is associated with poor outcome in heart failure patients with QRS width <130 ms, independent of randomization to CRT or not. Importantly, in the group of patients with the lowest LV GLS quartile, CRT may have a detrimental effect on clinical outcomes.
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Affiliation(s)
- Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2300 RC Leiden, The Netherlands
| | - Peter Sogaard
- Aalborg University, Fredrik Bajers Vej 7-D3, Aalborg 9220, Denmark
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Corrigan Minehan Heart Center, 55 Fruit Street, Boston, MA 02114, USA
| | - William T Abraham
- The Division of Cardiovascular Medicine, Ohio State University Medical Center, Davis Heart and Lung Research Institute, 473 West 12th Avenue, Room 110P, Columbus, OH 43210-1252, USA
| | - Jeffrey S Borer
- The Division of Cardiovascular Medicine and Howard Gilman and Ron and Jean Schiavone Institutes, State University of New York Downstate College of Medicine, 450 Clarkson Avenue, Division of Cardiovascular Medicine, Sixth Floor, Brooklyn, NY, New York, USA
| | - Kenneth Dickstein
- University of Bergen, Stavanger University Hospital, Postboks 8600 Forus, 4036 Stavanger, Norway
| | - Daniel Gras
- Nouvelles Cliniques Nantaises, 2 - 4 Rue Eric Tabarly, 44200 Nantes, France
| | - Josep Brugada
- Cardiology Department, Thorax Institute, Hospital Clinic, University of Barcelona, Villarroel 170, 08036 Barcelona, Spain
| | - Michele Robertson
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Henry Krum
- Monash Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Victoria 3800, Australia
| | - Johannes Holzmeister
- Clinic for Cardiology, University Hospital Zurich, Moussonstrasse 4, CH 8091 Zürich, Switzerland
| | - Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Moussonstrasse 4, CH 8091 Zürich, Switzerland
| | - John Gorcsan
- The University of Pittsburgh, 4200 Fifth Ave, Pittsburgh, PA 15260, USA
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Varma N, Sogaard P, Bax JJ, Abraham WT, Borer JS, Dickstein K, Singh JP, Gras D, Holzmeister J, Brugada J, Ruschitzka F. Interaction of Left Ventricular Size and Sex on Outcome of Cardiac Resynchronization Therapy Among Patients With a Narrow QRS Duration in the EchoCRT Trial. J Am Heart Assoc 2018; 7:JAHA.118.009592. [PMID: 29807890 PMCID: PMC6015380 DOI: 10.1161/jaha.118.009592] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Longer QRS duration (QRSd) improves, but increased left ventricular (LV) end-diastolic volume (LVEDV) reduces, efficacy of cardiac resynchronization therapy (CRT). QRSd/LVEDV ratios differ between sexes. We hypothesized that in the EchoCRT (Echocardiography Guided Cardiac Resynchronization Therapy) trial enrolling patients with heart failure with QRSd <130 ms, those with larger LVEDV would deteriorate but those with the highest QRSd/LVEDV would improve with CRT. METHODS AND RESULTS Primary outcome in patients (n=787, 72% men, 93% New York Heart Association class III, QRSd <130 ms, LV ejection fraction ≤35%, LV dilation and dyssynchrony) randomized to CRT-ON or CRT-OFF and followed up for 19 months was compared according to LVEDV (height indexed) or QRSd/LVEDV ratio, in multivariable analysis. Structural remodeling was assessed echocardiographically 6 months after implantation. Patients with baseline LVEDV higher than or equal to median worsened with CRT (death/heart failure hospitalization: CRT-ON versus CRT-OFF, 35.2% versus 24.5% [hazard ratio, 1.64; 95% confidence interval, 1.11-2.42; P=0.012]), but those with LVEDV lower than median remained unaffected. Patients with the highest QRSd/LVEDV ratio improved with CRT (death/heart failure hospitalization in top quartile: 20.9% in CRT-ON [n=91] versus 28.3% in CRT-OFF [n=106] [hazard ratio, 0.64; 95% confidence interval, 0.34-1.24; P=0.188], versus the remaining quartiles: 31.7% in CRT-ON [n=300] versus 24.8% in CRT-OFF [n=290] [hazard ratio, 1.47; 95% confidence interval, 1.07-2.02; P=0.016], test for interaction P=0.046). QRSd and dyssynchrony were similar between groups. The 3-way test for interaction indicated no sex-specific effects. However, numerically, men with LVEDV higher than or equal to median accounted for worse outcomes of CRT-ON. Women, with the highest QRSd/LVEDV ratio exhibited significant reverse remodeling. CONCLUSION CRT has opposite effects among patients with heart failure with QRSd <130 ms according to LV size: worsening outcomes in patients with larger LV, but inducing beneficial effects in those with smaller LV. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00683696.
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Affiliation(s)
- Niraj Varma
- Cleveland Clinic, Heart and Vascular Institute, Cleveland, OH
| | | | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - William T Abraham
- Division of Cardiovascular Medicine, Ohio State University Medical Center, Davis Heart and Lung Research Institute, Columbus, OH
| | - Jeffrey S Borer
- Division of Cardiovascular Medicine and Howard Gilman and Ron and Jean Schiavone Institutes, State University of New York Downstate College of Medicine, Brooklyn, NY
| | - Kenneth Dickstein
- University of Bergen Stavanger University Hospital, Stavanger, Norway
| | - Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Corrigan Minehan Heart Center, Boston, MA
| | - Daniel Gras
- Nouvelles Cliniques Nantaises, Nantes, France
| | | | - Josep Brugada
- Cardiology Department, Thorax Institute, Hospital Clinic, University of Barcelona, Spain
| | - Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
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5
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Tayal B, Gorcsan J, Bax JJ, Risum N, Olsen NT, Singh JP, Abraham WT, Borer JS, Dickstein K, Gras D, Krum H, Brugada J, Robertson M, Ford I, Holzmeister J, Ruschitzka F, Sogaard P. Cardiac Resynchronization Therapy in Patients With Heart Failure and Narrow QRS Complexes. J Am Coll Cardiol 2018; 71:1325-1333. [DOI: 10.1016/j.jacc.2018.01.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2017] [Revised: 01/11/2018] [Accepted: 01/16/2018] [Indexed: 10/17/2022]
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Packer M, O'Connor C, McMurray JJV, Wittes J, Abraham WT, Anker SD, Dickstein K, Filippatos G, Holcomb R, Krum H, Maggioni AP, Mebazaa A, Peacock WF, Petrie MC, Ponikowski P, Ruschitzka F, van Veldhuisen DJ, Kowarski LS, Schactman M, Holzmeister J. Effect of Ularitide on Cardiovascular Mortality in Acute Heart Failure. N Engl J Med 2017; 376:1956-1964. [PMID: 28402745 DOI: 10.1056/nejmoa1601895] [Citation(s) in RCA: 226] [Impact Index Per Article: 32.3] [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: 11/19/2022]
Abstract
BACKGROUND In patients with acute heart failure, early intervention with an intravenous vasodilator has been proposed as a therapeutic goal to reduce cardiac-wall stress and, potentially, myocardial injury, thereby favorably affecting patients' long-term prognosis. METHODS In this double-blind trial, we randomly assigned 2157 patients with acute heart failure to receive a continuous intravenous infusion of either ularitide at a dose of 15 ng per kilogram of body weight per minute or matching placebo for 48 hours, in addition to accepted therapy. Treatment was initiated a median of 6 hours after the initial clinical evaluation. The coprimary outcomes were death from cardiovascular causes during a median follow-up of 15 months and a hierarchical composite end point that evaluated the initial 48-hour clinical course. RESULTS Death from cardiovascular causes occurred in 236 patients in the ularitide group and 225 patients in the placebo group (21.7% vs. 21.0%; hazard ratio, 1.03; 96% confidence interval, 0.85 to 1.25; P=0.75). In the intention-to-treat analysis, there was no significant between-group difference with respect to the hierarchical composite outcome. The ularitide group had greater reductions in systolic blood pressure and in levels of N-terminal pro-brain natriuretic peptide than the placebo group. However, changes in cardiac troponin T levels during the infusion did not differ between the two groups in the 55% of patients with paired data. CONCLUSIONS In patients with acute heart failure, ularitide exerted favorable physiological effects (without affecting cardiac troponin levels), but short-term treatment did not affect a clinical composite end point or reduce long-term cardiovascular mortality. (Funded by Cardiorentis; TRUE-AHF ClinicalTrials.gov number, NCT01661634 .).
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Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Christopher O'Connor
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - John J V McMurray
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Janet Wittes
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - William T Abraham
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Stefan D Anker
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Kenneth Dickstein
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Gerasimos Filippatos
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Richard Holcomb
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Henry Krum
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Aldo P Maggioni
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Alexandre Mebazaa
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - W Frank Peacock
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Mark C Petrie
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Piotr Ponikowski
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Frank Ruschitzka
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Dirk J van Veldhuisen
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Lisa S Kowarski
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Mark Schactman
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
| | - Johannes Holzmeister
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.), and Baylor College of Medicine, Houston (F.P.) - both in Texas; Inova Heart and Vascular Institute, Falls Church, VA (C.O.); the Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (J.J.V.M., M.C.P.); Statistics Collaborative, Washington, DC (J.W., L.S.K., M.S.); Ohio State University Heart and Vascular Center, Columbus (W.T.A.); Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany (S.A.); the Division of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway (K.D.); Faculty of Medicine, National and Kapodistrian University of Athens, Athens (G.F.); private consultant, Wayzata, MN (R.H.); Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, VIC, Australia (H.K.); Centro Studi, Associazione Nazionale Medici Cardiologi Ospedalieri, Fondazione Per il Tuo Cuore HCF ONLUS, Florence, Italy (A.P.M.); University Paris 7 Diderot, Assistance Publique-Hôpitaux de Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint-Louis Lariboisière, U 942 INSERM, Paris (A.M.); Wroclaw Medical University, Wroclaw, Poland (P.P.); the Department of Cardiology, University Hospital Zurich, Zurich (F.R., J.H.), and Cardiorentis, Zug (J.H.) - both in Switzerland; and the University Medical Center Groningen, Groningen, the Netherlands (D.J.V.)
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Packer M, Holcomb R, Abraham WT, Anker S, Dickstein K, Filippatos G, Krum H, Maggioni AP, McMurray JJV, Mebazaa A, O'Connor C, Peacock F, Ponikowski P, Ruschitzka F, van Veldhuisen DJ, Holzmeister J. Rationale for and design of the TRUE-AHF trial: the effects of ularitide on the short-term clinical course and long-term mortality of patients with acute heart failure. Eur J Heart Fail 2016; 19:673-681. [PMID: 27862700 DOI: 10.1002/ejhf.698] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [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: 03/11/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 12/16/2022] Open
Abstract
The TRUE-AHF is a randomized, double-blind, parallel-group, placebo-controlled trial which is evaluating the effects of a 48-h infusion of ularitide (15 ng/kg/min) on the short- and long-term clinical course of patients with acute heart failure. Noteworthy features of the study include the early enrolment of patients following their initial clinical presentation (within 12 h), and entry blood pressure criteria and thresholds for the adjustment of drug infusion rates, which aim to minimize the risk of hypotension. The trial has two primary endpoints: (i) cardiovascular mortality during long-term follow-up; and (ii) the clinical course of patients during their index hospitalization. Cardiovascular mortality is evaluated in this event-driven trial by following all randomized patients for the occurrence of death until the end of the entire study without truncation at an arbitrarily determined early time point. The clinical course during the index hospitalization is evaluated using the hierarchical clinical composite endpoint, which combines information regarding changes in symptoms and the occurrence of in-hospital worsening heart failure events and death into a single ranked metric that captures interval clinical events and minimizes the likelihood of missing data and confounding due to intensification of background therapy. The design of the TRUE-AHF trial capitalizes on lessons learned from earlier trials and aims to evaluate definitively the potential benefit of ularitide in patients with acute heart failure. TRIAL REGISTRATION NCT01661634.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | | | - Stefan Anker
- Innovative Clinical Trials, Department of Cardiology & Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon Athens University Hospital, Department of Cardiology, Athens, Greece
| | - Henry Krum
- Monash University, Centre of Cardiovascular Research & Education in Therapeutics, Melbourne, Australia
| | - Aldo P Maggioni
- Centro Studi ANMCO, Fondazione 'per il Tuo cuore' HCF ONLUS, Firenze, Italy
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Alexandre Mebazaa
- University of Paris, Department of Anesthesia and Critical Care, Hôpitaux Universitaire Saint Louis Lariboisière, Paris, France
| | | | | | | | | | | | - Johannes Holzmeister
- Cardiology, University Hospital Zurich, Zurich, Switzerland.,Cardiorentis AG, Zug, Switzerland
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Nägele MP, Steffel J, Robertson M, Singh JP, Flammer AJ, Bax JJ, Borer JS, Dickstein K, Ford I, Gorcsan J, Gras D, Krum H, Sogaard P, Holzmeister J, Abraham WT, Brugada J, Ruschitzka F. Effect of cardiac resynchronization therapy in patients with diabetes randomized in
EchoCRT. Eur J Heart Fail 2016; 19:80-87. [DOI: 10.1002/ejhf.655] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Revised: 06/20/2016] [Accepted: 08/03/2016] [Indexed: 12/28/2022] Open
Affiliation(s)
- Matthias P. Nägele
- Department of Cardiology University Heart Centre Zurich Zurich Switzerland
| | - Jan Steffel
- Department of Cardiology University Heart Centre Zurich Zurich Switzerland
| | - Michele Robertson
- Robertson Centre for Biostatistics University of Glasgow Glasgow United Kingdom
| | - Jagmeet P. Singh
- Cardiac Arrhythmia Service Massachusetts General Hospital, Harvard Medical School Boston MA USA
| | - Andreas J. Flammer
- Department of Cardiology University Heart Centre Zurich Zurich Switzerland
| | - Jeroen J. Bax
- Department of Cardiology Leiden University Medical Centre Leiden the Netherlands
| | - Jeffrey S. Borer
- Division of Cardiovascular Medicine and Howard Gilman and Ron and Jean Schiavone Institutes State University of New York Downstate College of Medicine New York NY USA
| | - Kenneth Dickstein
- University of Bergen Bergen Norway
- Stavanger University Hospital Stavanger Norway
| | - Ian Ford
- Robertson Centre for Biostatistics University of Glasgow Glasgow United Kingdom
| | | | | | - Henry Krum
- Monash Centre of Cardiovascular Research and Education in Therapeutics Melbourne VIC Australia
| | - Peter Sogaard
- Department of Cardiology and Clinical Institute Aalborg University Hospital Aalborg Denmark
| | | | - William T. Abraham
- Division of Cardiovascular Medicine Ohio State University Medical Center Columbus OH USA
| | - Josep Brugada
- Cardiology Department, Thorax Institute, Hospital Clinic University of Barcelona Spain
| | - Frank Ruschitzka
- Department of Cardiology University Heart Centre Zurich Zurich Switzerland
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Varma N, Steffel J, Robertson M, Singh J, Bax JJ, Borer J, Dickstein K, Ford I, Gorscan J, Gras D, Krum H, Sogaard P, Holzmeister J, Brugada J, Abraham WT, Ruschitzka F. 89-04: Gender Effects of CRT in Patients with QRS Duration <130 ms in EchoCRT. Europace 2016. [DOI: 10.1093/europace/18.suppl_1.i58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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Gorcsan J, Sogaard P, Bax JJ, Singh JP, Abraham WT, Borer JS, Dickstein K, Gras D, Krum H, Brugada J, Robertson M, Ford I, Holzmeister J, Ruschitzka F. Association of persistent or worsened echocardiographic dyssynchrony with unfavourable clinical outcomes in heart failure patients with narrow QRS width: a subgroup analysis of the EchoCRT trial. Eur Heart J 2015; 37:49-59. [DOI: 10.1093/eurheartj/ehv418] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 07/29/2015] [Indexed: 01/09/2023] Open
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11
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Emani S, Meyer M, Palm D, Holzmeister J, Haas GJ. Ularitide: a natriuretic peptide candidate for the treatment of acutely decompensated heart failure. Future Cardiol 2015; 11:531-46. [PMID: 26278236 DOI: 10.2217/fca.15.53] [Citation(s) in RCA: 6] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Treatment for acutely decompensated heart failure (ADHF) has not changed much in the last two decades. Currently available therapies have variable efficacy and can be associated with adverse outcomes. Natriuretic peptides properties include diuresis, natriuresis, vasorelaxation, inhibition of renin-angiotensin-aldosterone system, and are thus chosen in the treatment of ADHF. Two forms of natriuretic peptides are currently available for the treatment of ADHF. Urodilatin (INN: ularitide) represents another member of the natriuretic peptide family with a unique molecular structure that may provide distinct benefits in the treatment of ADHF. Early clinical exploratory and Phase II studies have demonstrated that ularitide has potential cardiovascular and renal benefits. Ularitide is currently being tested in the Phase III TRUE-AHF clinical study. TRUE-AHF has features that may be different when compared with other recent outcome studies in ADHF. These distinct differences aim to maximize clinical effects and minimize potential adverse events of ularitide. However, whether this rationale translates into a better outcome needs to be awaited.
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Affiliation(s)
- Sitaramesh Emani
- Division of Cardiology, The Ohio State University, 473 W 12th Ave, Suite 200 DHLRI, Columbus, OH 43210, USA
| | - Markus Meyer
- Cardiorentis Ltd, Steinhauserstrasse 74, Zug 6300, Switzerland
| | - Denada Palm
- Department of Internal Medicine, University of Cincinnati, Medical Sciences Building, 231 Albert Sabin Way #6065, Cincinnati, OH 45267, USA
| | | | - Garrie J Haas
- Division of Cardiology, The Ohio State University, 473 W 12th Ave, Suite 200 DHLRI, Columbus, OH 43210, USA
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12
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Mebazaa A, Longrois D, Metra M, Mueller C, Richards AM, Roessig L, Seronde MF, Sato N, Stockbridge NL, Gattis Stough W, Alonso A, Cody RJ, Cook Bruns N, Gheorghiade M, Holzmeister J, Laribi S, Zannad F. Agents with vasodilator properties in acute heart failure: how to design successful trials. Eur J Heart Fail 2015; 17:652-64. [PMID: 26040488 DOI: 10.1002/ejhf.294] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [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: 02/12/2015] [Revised: 04/17/2015] [Accepted: 04/22/2015] [Indexed: 01/08/2023] Open
Abstract
Agents with vasodilator properties (AVDs) are frequently used in the treatment of acute heart failure (AHF). AVDs rapidly reduce preload and afterload, improve left ventricle to aorta and right ventricle to pulmonary artery coupling, and may improve symptoms. Early biomarker changes after AVD administration have suggested potentially beneficial effects on cardiac stretch, vascular tone, and renal function. AVDs that reduce haemodynamic congestion without causing hypoperfusion might be effective in preventing worsening organ dysfunction. Existing AVDs have been associated with different results on outcomes in randomized clinical trials, and observational studies have suggested that AVDs may be associated with a clinical outcome benefit. Lessons have been learned from past AVD trials in AHF regarding preventing hypotension, selecting the optimal endpoint, refining dyspnoea measurements, and achieving early randomization and treatment initiation. These lessons have been applied to the design of ongoing pivotal clinical trials, which aim to ascertain if AVDs improve clinical outcomes. The developing body of evidence suggests that AVDs may be a clinically effective therapy to reduce symptoms, but more importantly to prevent end-organ damage and improve clinical outcomes for specific patients with AHF. The results of ongoing trials will provide more clarity on the role of AVDs in the treatment of AHF.
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Affiliation(s)
- Alexandre Mebazaa
- University Paris Diderot, Sorbonne Paris Cité, Paris, France.,U942 INSERM, AP-HP, Paris, France.,APHP, Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis-Lariboisière, Paris, France
| | - Dan Longrois
- Département d'Anesthésie-Réanimation, Hôpital Bichat-Claude Bernard, University Paris Diderot, Sorbonne Paris Cité, Paris, U1148 INSERM, Paris, France
| | - Marco Metra
- Cardiology, University of Brescia, Brescia, Italy
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | - Arthur Mark Richards
- Cardiovascular Research Institute, National University of Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lothar Roessig
- Global Clinical Development, Bayer Pharma AG, Berlin, Germany
| | - Marie France Seronde
- Department of Cardiology, University Hospital of Besançon, U942 INSERM, Besançon, France
| | - Naoki Sato
- Internal Medicine, Cardiology, and Intensive Care Medicine, Nippon Medical School Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Norman L Stockbridge
- Division of Cardiovascular and Renal Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD, USA
| | | | - Angeles Alonso
- Scientific Advice Working Party European Medicines Agency, Madrid, Spain
| | | | | | - Mihai Gheorghiade
- Department of Medicine, Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Said Laribi
- APHP, Department of Emergency Medicine, Hôpitaux Universitaires Saint Louis-Lariboisière, INSERM U942, Paris, France
| | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 9501 and Unité 961, Centre Hospitalier Universitaire, and the Department of Cardiology, Nancy University, Université de Lorraine, Nancy, France
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13
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Steffel J, Robertson M, Singh JP, Abraham WT, Bax JJ, Borer JS, Dickstein K, Ford I, Gorcsan J, Gras D, Krum H, Sogaard P, Holzmeister J, Brugada J, Ruschitzka F. The effect of QRS duration on cardiac resynchronization therapy in patients with a narrow QRS complex: a subgroup analysis of the EchoCRT trial. Eur Heart J 2015; 36:1983-9. [DOI: 10.1093/eurheartj/ehv242] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/14/2015] [Indexed: 11/14/2022] Open
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14
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15
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Affiliation(s)
- Jagmeet P Singh
- Cardiac Arrhythmia Service, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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16
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Hai OY, Mentz RJ, Zannad F, Gasparini M, De Ferrari GM, Daubert JC, Holzmeister J, Lam CS, Pochet T, Vincent A, Linde C. Cardiac resynchronization therapy in heart failure patients with less severe left ventricular dysfunction. Eur J Heart Fail 2014; 17:135-43. [DOI: 10.1002/ejhf.208] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 10/20/2014] [Accepted: 10/24/2014] [Indexed: 01/14/2023] Open
Affiliation(s)
- Ofek Y. Hai
- Division of Cardiovascular Medicine, Department of Medicine; State University of New York (SUNY) Downstate Medical Center; Brooklyn NY USA
| | - Robert J. Mentz
- Division of Cardiology, Department of Medicine; Duke University Medical Center; Durham NC USA
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques; Université de Lorraine and CHU de Nancy; Nancy France
| | | | - Gaetano M. De Ferrari
- Department of Cardiology and Cardiovascular Clinical Research Center; Fondaizone IRCCS Policlinico San Matteo; Pavia Italy
| | - Jean-Claude Daubert
- Cardiology Department and CIC-IT U804; Centre Hospitalier Universitaire; Rennes France
| | - Johannes Holzmeister
- Cardiovascular Center, Cardiology; University Hospital Zurich; Zurich Switzerland
| | | | - Thierry Pochet
- Global Clinical Trials; Rhythm Management, Boston Scientific; Diegem Belgium
| | | | - Cecilia Linde
- Karolinska Institutet, Department of Medicine, and Karolinska University Hospital; Department of Cardiology; Stockholm Sweden
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17
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Steffel J, Hurlimann A, Starck C, Krasniqi N, Schmidt S, Luscher TF, Duru F, Ruschitzka F, Holzmeister J, Hurlimann D. Long-term performance of modern coronary sinus leads in cardiac resynchronization therapy. Indian Pacing Electrophysiol J 2014; 14:112-20. [PMID: 24948850 PMCID: PMC4032778 DOI: 10.1016/s0972-6292(16)30752-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) has become an important pillar of contemporary heart failure therapy. The efficacy of CRT, however, critically relies on proper LV lead placement and performance, which is why data regarding the long-term performance of CS leads are of considerable interest. Available studies are limited by a restricted variety of lead vendors, earlier lead models and / or very short follow-up periods. In the current study, we therefore investigated the long-term performance of modern LV leads in a large "real world" cohort of patients undergoing CRT implantation. METHODS AND RESULTS All 193 patients who had successfullyundergone CRT implantation at the University Hospital Zurich between September 2003 and January 2010 were included in the study. An overall stable course of stimulation energy was observed over time; neither ischemic etiology, lead configuration, or severely reduced EF had an influence on the evolution of energy thresholds over time. Interestingly, patients with a high energy threshold at baseline experienced a significant reduction during follow-up. In contrast, a significant drop in impedance was seen following implantation, followed by a steady course for the rest of the observation period. Only 15 patients (9.7%) showed an impedance > 1000 Ohm at any time during their follow-up. Seven lead dislocations were observed during follow up. CONCLUSION The current comprehensive analysis of long-term performance of modern coronary sinus leads demonstrates excellent stability, performance and safety. These data may have important implications for physicians involved in biventricular pacemaker implantations and in the follow-up care of these patients.
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Hospital Zurich
| | | | | | | | | | | | - Firat Duru
- Department of Cardiology, University Hospital Zurich
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18
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Holzmeister J, Gorcsan J, Ruschitzka F. Cardiac-resynchronization therapy in heart failure with a narrow QRS complex. N Engl J Med 2014; 370:579-80. [PMID: 24499223 DOI: 10.1056/nejmc1315288] [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: 11/19/2022]
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19
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Ruschitzka F, Abraham WT, Singh JP, Bax JJ, Borer JS, Brugada J, Dickstein K, Ford I, Gorcsan J, Gras D, Krum H, Sogaard P, Holzmeister J. Cardiac-resynchronization therapy in heart failure with a narrow QRS complex. N Engl J Med 2013; 369:1395-405. [PMID: 23998714 DOI: 10.1056/nejmoa1306687] [Citation(s) in RCA: 576] [Impact Index Per Article: 52.4] [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: 01/17/2023]
Abstract
BACKGROUND Cardiac-resynchronization therapy (CRT) reduces morbidity and mortality in chronic systolic heart failure with a wide QRS complex. Mechanical dyssynchrony also occurs in patients with a narrow QRS complex, which suggests the potential usefulness of CRT in such patients. METHODS We conducted a randomized trial involving 115 centers to evaluate the effect of CRT in patients with New York Heart Association class III or IV heart failure, a left ventricular ejection fraction of 35% or less, a QRS duration of less than 130 msec, and echocardiographic evidence of left ventricular dyssynchrony. All patients underwent device implantation and were randomly assigned to have CRT capability turned on or off. The primary efficacy outcome was the composite of death from any cause or first hospitalization for worsening heart failure. RESULTS On March 13, 2013, the study was stopped for futility on the recommendation of the data and safety monitoring board. At study closure, the 809 patients who had undergone randomization had been followed for a mean of 19.4 months. The primary outcome occurred in 116 of 404 patients in the CRT group, as compared with 102 of 405 in the control group (28.7% vs. 25.2%; hazard ratio, 1.20; 95% confidence interval [CI], 0.92 to 1.57; P=0.15). There were 45 deaths in the CRT group and 26 in the control group (11.1% vs. 6.4%; hazard ratio, 1.81; 95% CI, 1.11 to 2.93; P=0.02). CONCLUSIONS In patients with systolic heart failure and a QRS duration of less than 130 msec, CRT does not reduce the rate of death or hospitalization for heart failure and may increase mortality. (Funded by Biotronik and GE Healthcare; EchoCRT ClinicalTrials.gov number, NCT00683696.).
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Affiliation(s)
- Frank Ruschitzka
- Clinic for Cardiology, University Hospital Zurich, Zurich, Switzerland
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20
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Steffel J, Rempel H, Breitenstein A, Schmidt S, Namdar M, Krasniqi N, Holzmeister J, Lüscher TF, Ruschitzka F, Hürlimann D. Comprehensive cardiac resynchronization therapy optimization in the real world. Cardiol J 2013; 21:316-24. [PMID: 23990194 DOI: 10.5603/cj.a2013.0123] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Revised: 07/20/2013] [Accepted: 08/13/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in patients suffering from chronic heart failure (CHF). Optimal device programming is crucial for maximum patient benefit. The goal of the present study was to assess device settings from CHF patients undergoing CRT optimization in a "real world" setting, and to delineate parameters most frequently requiring adjustment. METHODS All patients who underwent CRT device implantation in the Cardiology Clinicat the University Hospital Zurich between January 2011 and September 2012 and in whom follow-up was available were included in this analysis. RESULTS A total of 170 CHF patients were included in this analysis. True biventricular pacing was present in 44% of all patients, while QRS fusion was detected in 49.9%. The majority of the patients presented with suboptimal atrioventricular (AV) delays requiring adjustment. AV delays were therefore shortened due to the presence of QRS fusion in 53.3% and 38.1% of patients (sAV and pAV, respectively) or prolonged because of truncation of the A wave in the left ventricular inflow pulse wave Doppler measurement (17.5% and 28.4% for sAV and pAV, respectively). In contrast, interventricular delay (VV delay) was rarely changed (11.9%). CONCLUSIONS In our "real world" cohort, a substantial proportion of patients presented to their first post-operative consultation with suboptimal device settings. Our data indicate that the opportunity to optimize device settings is frequently wasted in the "real world", underlining the necessity for expert device follow-up to deliver optimal care to this challenging group of heart failure patients.
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, Cardiovascular Center, University Hospital Zurich, Switzerland.
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21
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Fröhlich GM, Holzmeister J, Hübler M, Hübler S, Wolfrum M, Enseleit F, Seifert B, Hürlimann D, Lehmkuhl HB, Noll G, Steffel J, Falk V, Lüscher TF, Hetzer R, Ruschitzka F. Prophylactic implantable cardioverter defibrillator treatment in patients with end-stage heart failure awaiting heart transplantation. Heart 2013; 99:1158-65. [DOI: 10.1136/heartjnl-2013-304185] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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22
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Fröhlich GM, Enseleit F, Wolfrum M, von Babo M, Frank M, Berli R, Hermann M, Holzmeister J, Noll G, Lüscher TF, Ruschitzka F, Rufibach K, Wilhelm M, Falk V. Response to letters regarding article, “statins and the risk of cancer after heart transplantation”. Circulation 2013; 127:e442. [PMID: 23505639 DOI: 10.1161/circulationaha.112.147595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/16/2022]
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23
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Fröhlich GM, Rufibach K, Enseleit F, Wolfrum M, von Babo M, Frank M, Berli R, Hermann M, Holzmeister J, Wilhelm M, Falk V, Noll G, Lüscher TF, Ruschitzka F. Statins and the risk of cancer after heart transplantation. Circulation 2012; 126:440-7. [PMID: 22761452 DOI: 10.1161/circulationaha.111.081059] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [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: 01/20/2023]
Abstract
BACKGROUND Although newer immunosuppressive agents, such as mTOR (mammalian target of rapamycin) inhibitors, have lowered the occurrence of malignancies after transplantation, cancer is still a leading cause of death late after heart transplantation. Statins may have an impact on clinical outcomes beyond their lipid-lowering effects. The aim of the present study was to delineate whether statin therapy has an impact on cancer risk and total mortality after heart transplantation. METHODS AND RESULTS A total of 255 patients who underwent heart transplantation at the University Hospital Zurich between 1985 and 2007 and survived the first year were included in the present study. The primary outcome measure was the occurrence of any malignancy; the secondary end point was overall survival. During follow-up, a malignancy was diagnosed in 108 patients (42%). The cumulative incidence of tumors 8 years after transplantation was reduced in patients receiving a statin (34% versus 13%; 95% confidence interval, 0.25-0.43 versus 0.07-0.18; P<0.003). Statin use was associated with improved cancer-free and overall survival (both P<0.0001). A Cox regression model that analyzed the time to tumor formation with or without statin therapy, adjusted for age, male sex, type of cardiomyopathy, and immunosuppressive therapy (including switch to mTOR inhibitors or tacrolimus), demonstrated a superior survival in the statin group. Statins reduced the hazard of occurrence of any malignancy by 67% (hazard ratio, 0.33; 95% confidence interval, 0.21-0.51; P<0.0001). CONCLUSIONS Although it is not possible to adjust for all potential confounders because of the very long follow-up period, this registry suggests that statin use is associated with improved cancer-free and overall survival after cardiac transplantation. These data will need to be confirmed in a prospective trial.
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Affiliation(s)
- Georg Marcus Fröhlich
- Cardiovascular Center Cardiology, Heart Failure/Transplantation Clinic, University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland.
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Starck C, Salzberg S, Grünenfelder J, Hürlimann D, Holzmeister J, Falk V. Transvenous pacemaker and ICD lead extractions using a staged approach. Thorac Cardiovasc Surg 2012. [DOI: 10.1055/s-0031-1297772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
Implantable cardioverter defibrillators and cardiac resynchronisation therapy (CRT) have become standard of care in modern treatment for heart failure. Results from trials have provided ample evidence that CRT, in addition to its proven benefits in patients with symptomatic heart failure (New York Heart Association [NYHA] class III), might also reduce morbidity and mortality in those with mildly symptomatic heart failure (NYHA class II). As a result, the 2010 European Society of Cardiology guidelines now recommend CRT for both patient populations. In this review we summarise and critically assess the landmark randomised clinical trials REVERSE, MADIT-CRT, and RAFT. Furthermore, we discuss the rationale and available evidence for other emerging indications of CRT, including its use in patients with a mildly reduced left ventricular ejection fraction (>35%), in those with a narrow QRS complex (≤120 ms), and in those with concomitant bradyarrhythmic pacemaker indications. We also focus on patients who do not respond to CRT, and on CRT optimisation.
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Affiliation(s)
- Johannes Holzmeister
- Department of Cardiology and Cardiac Surgery, University Hospital Zurich, Zurich, Switzerland.
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Steffel J, Milosevic G, Hurlimann A, Krasniqi N, Namdar M, Ruschitzka F, Luscher TF, Duru F, Holzmeister J, Hurlimann D. Characteristics and long-term outcome of echocardiographic super-responders to cardiac resynchronisation therapy: 'real world' experience from a single tertiary care centre. Heart 2011; 97:1668-74. [DOI: 10.1136/heartjnl-2011-300222] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Steffel J, Hürlimann D, Namdar M, Despotovic D, Kobza R, Wolber T, Holzmeister J, Haegeli L, Brunckhorst C, Lüscher TF, Jenni R, Duru F. Long-term follow-up of patients with isolated left ventricular noncompaction: role of electrocardiography in predicting poor outcome. Circ J 2011; 75:1728-34. [PMID: 21617326 DOI: 10.1253/circj.cj-10-1217] [Citation(s) in RCA: 16] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Abnormal baseline electrocardiograms (ECGs) are common in patients with isolated left ventricular noncompaction (IVNC). Whether certain electrocardiographic parameters are associated with a poor clinical outcome, however, remains elusive. The present study was therefore designed to comprehensively assess the predictive value of baseline ECG findings in patients newly diagnosed with IVNC. METHODS AND RESULTS 74 patients diagnosed with IVNC were included in the analysis. During follow-up, 8 patients (11%) died of a cardiovascular cause or underwent heart transplantation (primary outcome measure). On univariate analysis, several variables, including repolarization abnormalities (ST segment elevation/depression, T-wave inversion) in the inferior leads (5-year estimator: 67.1 ± 10.7% vs. 98 ± 2.2%; P = 0.001), an increase in PQ- (hazard ratio (HR) 1.032, P=0.004) and QTc-duration (HR 1.037, P=0.001), were predictive of cardiovascular death or heart transplantation. On multivariate analysis, only PQ- and QTc-duration and the presence of repolarization abnormalities in the inferior leads remained significantly predictive of a poor outcome. CONCLUSIONS PQ duration, QTc duration, and repolarization abnormalities in the inferior leads are independently predictive of a poor prognosis in IVNC. Further prospective studies are required to conclusively investigate the usefulness of baseline ECG parameters for risk stratification in patients with IVNC.
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Affiliation(s)
- Jan Steffel
- Clinic for Cardiology, Cardiovascular Center, University Hospital Zurich, Zurich, Switzerland
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28
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Namdar M, Steffel J, Vidovic M, Brunckhorst CB, Holzmeister J, Lüscher TF, Jenni R, Duru F. Electrocardiographic changes in early recognition of Fabry disease. Heart 2011; 97:485-90. [PMID: 21270075 DOI: 10.1136/hrt.2010.211789] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [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: 12/15/2022] Open
Abstract
BACKGROUND Fabry disease (FD) is an inherited X-chromosomal lysosomal storage disease resulting in intracellular storage of globotriaosylceramide. Cardiac involvement is most frequently manifested as left ventricular hypertrophy (LVH). However, patients with FD may also have various conduction abnormalities before LVH develops. The present study was designed to analyse early conduction abnormalities on baseline ECG of patients with FD and to investigate their diagnostic value. METHODS AND RESULTS Baseline electrocardiographic (ECG) and echocardiographic measurements of patients with FD (n = 30) were compared with those of heart rate and age-matched healthy individuals (n = 50). The PQ-interval (131 ± 18 vs 155 ± 20 ms, p < 0.000001) and the QRS width (83 ± 11 vs 90 ± 9 ms, p < 0.05) were significantly shorter and repolarisation dispersion was more pronounced in patients with FD (QTc dispersion: 66 ± 32 vs 40 ± 24 ms, p < 0.001, T(peak)-T(end) dispersion: 56 ± 20 vs 37 ± 16 ms, p < 0.0005). Moreover, P-wave duration was significantly shorter (74 ± 16 vs 105 ± 14 ms, p < 0.000001) in FD and accounted predominantly for the shortening of the PQ-interval. P-wave duration showed a 92% sensitivity and 80% specificity for the diagnosis of FD. CONCLUSIONS P-wave duration, PQ-interval and QRS width are shorter and repolarisation dispersion more pronounced in patients with FD compared with heart rate and age-matched controls. The significant shortening of the PQ-interval in FD occurs because of a marked shortening of the P-wave duration, which in itself demonstrated a high sensitivity and specificity for early detection and treatment of this disease.
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Affiliation(s)
- Mehdi Namdar
- Heart Rhythm Management Centre, University Hospital Brussels - UZB, Brussels, Belgium.
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29
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Sudano I, Flammer AJ, Périat D, Enseleit F, Hermann M, Wolfrum M, Hirt A, Kaiser P, Hurlimann D, Neidhart M, Gay S, Holzmeister J, Nussberger J, Mocharla P, Landmesser U, Haile SR, Corti R, Vanhoutte PM, Lüscher TF, Noll G, Ruschitzka F. Acetaminophen increases blood pressure in patients with coronary artery disease. Circulation 2010; 122:1789-96. [PMID: 20956208 DOI: 10.1161/circulationaha.110.956490] [Citation(s) in RCA: 128] [Impact Index Per Article: 9.1] [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: 11/16/2022]
Abstract
BACKGROUND Because traditional nonsteroidal antiinflammatory drugs are associated with increased risk for acute cardiovascular events, current guidelines recommend acetaminophen as the first-line analgesic of choice on the assumption of its greater cardiovascular safety. Data from randomized clinical trials prospectively addressing cardiovascular safety of acetaminophen, however, are still lacking, particularly in patients at increased cardiovascular risk. Hence, the aim of this study was to evaluate the safety of acetaminophen in patients with coronary artery disease. METHODS AND RESULTS The 33 patients with coronary artery disease included in this randomized, double-blind, placebo-controlled, crossover study received acetaminophen (1 g TID) on top of standard cardiovascular therapy for 2 weeks. Ambulatory blood pressure, heart rate, endothelium-dependent and -independent vasodilatation, platelet function, endothelial progenitor cells, markers of the renin-angiotensin system, inflammation, and oxidative stress were determined at baseline and after each treatment period. Treatment with acetaminophen resulted in a significant increase in mean systolic (from 122.4±11.9 to 125.3±12.0 mm Hg P=0.02 versus placebo) and diastolic (from 73.2±6.9 to 75.4±7.9 mm Hg P=0.02 versus placebo) ambulatory blood pressures. On the other hand, heart rate, endothelial function, early endothelial progenitor cells, and platelet function did not change. CONCLUSIONS This study demonstrates for the first time that acetaminophen induces a significant increase in ambulatory blood pressure in patients with coronary artery disease. Thus, the use of acetaminophen should be evaluated as rigorously as traditional nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors, particularly in patients at increased cardiovascular risk. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00534651.
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Affiliation(s)
- Isabella Sudano
- Cardiovascular Center Cardiology University Hospital Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
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van Bommel RJ, Tanaka H, Delgado V, Bertini M, Borleffs CJW, Ajmone Marsan N, Holzmeister J, Ruschitzka F, Schalij MJ, Bax JJ, Gorcsan J. Association of intraventricular mechanical dyssynchrony with response to cardiac resynchronization therapy in heart failure patients with a narrow QRS complex. Eur Heart J 2010; 31:3054-62. [PMID: 20864484 PMCID: PMC3001589 DOI: 10.1093/eurheartj/ehq334] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS current criteria for cardiac resynchronization therapy (CRT) are restricted to patients with a wide QRS complex (>120 ms). Overall, only 30% of heart failure patients demonstrate a wide QRS complex, leaving the majority of heart failure patients without this treatment option. However, patients with a narrow QRS complex exhibit left ventricular (LV) mechanical dyssynchrony, as assessed with echocardiography. To further elucidate the possible beneficial effect of CRT in heart failure patients with a narrow QRS complex, this two-centre, non-randomized observational study focused on different echocardiographic parameters of LV mechanical dyssynchrony reflecting atrioventricular, interventricular and intraventricular dyssynchrony, and the response to CRT in these patients. METHODS AND RESULTS a total of 123 consecutive heart failure patients with a narrow QRS complex (<120 ms) undergoing CRT was included at two centres. Several widely accepted measures of mechanical dyssynchrony were evaluated: LV filling ratio (LVFT/RR), LV pre-ejection time (LPEI), interventricular mechanical dyssynchrony (IVMD), opposing wall delay (OWD), and anteroseptal posterior wall delay with speckle tracking (ASPWD). Response to CRT was defined as a reduction ≥15% in left ventricular end-systolic volume at 6 months follow-up. Measures of dyssynchrony can frequently be observed in patients with a narrow QRS complex. Nonetheless, for LVFT/RR, LPEI, and IVMD, presence of predefined significant dyssynchrony is <20%. Significant intraventricular dyssynchrony is more widely observed in these patients. With receiver operator characteristic curve analyses, both OWD and ASPWD demonstrated usefulness in predicting response to CRT in narrow QRS patients with a cut-off value of 75 and 107 ms, respectively. CONCLUSION mechanical dyssynchrony can be widely observed in heart failure patients with a narrow QRS complex. In particular, intraventricular measures of mechanical dyssynchrony may be useful in predicting LV reverse remodelling at 6 months follow-up in heart failure patients with a narrow QRS complex, but with more stringent cut-off values than currently used in 'wide' QRS patients.
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Affiliation(s)
- Rutger J van Bommel
- Department of Cardiology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, The Netherlands
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Fröhlich G, Steffel J, Hürlimann D, Enseleit F, Lüscher TF, Ruschitzka F, Abraham WT, Holzmeister J. Upgrading to resynchronization therapy after chronic right ventricular pacing improves left ventricular remodelling. Eur Heart J 2010; 31:1477-85. [PMID: 20233792 DOI: 10.1093/eurheartj/ehq065] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [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: 02/07/2023] Open
Abstract
AIMS Chronic right ventricular (RV) pacing may impose ventricular dyssynchrony leading to LV remodelling and is associated with increased morbidity and mortality. Upgrading patients with chronic RV pacing to cardiac resynchronization therapy (CRT) may be considered to restore synchronicity and prevent these deleterious effects. METHODS AND RESULTS A total of 172 patients from two tertiary centres were analysed over a mean follow-up of 21.7 and 23.5 months after primary CRT implantation (n = 102) and CRT upgrade (n = 70), respectively. In the latter group, mean duration of RV pacing before CRT upgrade was 80.3 months, and ventricular stimulation was >95%. A significant improvement in left ventricular (LV) ejection fraction (10 and 11% absolute increase in primary CRT vs. upgrades, respectively), LV end-diastolic diameter index (-0.15 cm/m(2) vs. -0.2 cm/m(2)), and LV end-systolic diameter (-6.0 vs. -7.0 mm) was observed in both groups, which did not differ between primary CRT recipients and CRT upgrades. Response to CRT upgrade was independent of the underlying rhythm, QRS duration, duration of prior RV pacing, or LV function and size at baseline. Of note, even seven of nine patients with RV pacing >12 years responded favourably to CRT. CONCLUSION The current study demonstrates that CRT reverses LV remodelling in heart failure patients with chronic RV pacing in a similar way as in primary CRT recipients, even after very long periods of RV pacing. Our data, therefore, may have important implications for the treatment of pacemaker-dependent patients with heart failure, and support the use of CRT in this setting.
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Affiliation(s)
- Georg Fröhlich
- Cardiovascular Center, Cardiology, University Hospital Zurich, Raemistrasse 100, Zurich CH-8091, Switzerland
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32
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Namdar M, Kampmann C, Steffel J, Walder D, Holzmeister J, Lüscher TF, Jenni R, Duru F. PQ interval in patients with Fabry disease. Am J Cardiol 2010; 105:753-6. [PMID: 20185028 DOI: 10.1016/j.amjcard.2009.10.056] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 10/25/2009] [Accepted: 10/25/2009] [Indexed: 11/24/2022]
Abstract
Fabry disease (FD) is an X-chromosomal inherited lysosomal storage disease resulting in intracellular storage of globotriaosylceramide. Cardiac involvement is most frequently manifested as left ventricular hypertrophy. However, patients with FD may also have from various conduction abnormalities particularly affecting atrioventricular (AV) conduction. The present study was designed to analyze primarily AV conduction abnormalities on baseline electrocardiograms of patients with FD and to investigate the correlation with echocardiographic findings. Electrocardiograms at rest of 207 patients with FD were compared to echocardiograms. PQ-interval shortening and first-degree AV block could be found in only 29 cases (14%) and 3 cases (1.4%), respectively. No echocardiographic differences could be found in patients with and without PQ-interval shortening, including left ventricular hypertrophy, atrial size, and diastolic parameters. Furthermore, no correlation of the PQ interval with any echocardiographic parameters was detected. There was no difference between men and women in baseline clinical and electrocardiographic parameters. In conclusion, shortening of the PQ interval was not a common electrocardiographic finding in patients newly diagnosed with FD. Furthermore, no correlation with typical echocardiographic findings or disease stage in FD at baseline could be found.
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33
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Holzmeister J. Time to RethinQ PROSPECT? Eur Heart J 2009; 30:2436-7. [DOI: 10.1093/eurheartj/ehp367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Sankaranarayanan R, James MA, Burtchaell S, Holloway R, Hoyt RH, Mchenry B, Fedewa MM, Penot JP, Jacquot C, Bonet JF, Pochet H, Jean S, Fressonnet R, Penot MP, Weiss A, Abecasis JA, Leal S, Monge J, Fartouce S, Santos JM, Silva A, Costa R, Leao MIP, Mori RF, Giannini G, Costa SPL, Silva KR, Penteado IM, Palka P, Lange A, Donnelly JE, Adsett M, Hayes JR, Stafford WJ, Hirayama Y, Kawamura Y, Sato N, Saito T, Hotta D, Kikuchi K, Ohori K, Hasebe N, Cabrera Bueno F, Alzueta J, Fernandez-Pastor J, Pena-Hernandez JL, Molina-Mora MJ, Barrera A, De Teresa E, Ayala Paredes F, Roux JF, Scazzuso F, Lavallee L, Poirier M, Chaumont J, Iorgulescu C, Vasile A, Dorobantu M, Vatasescu RG, Lefflerova K, Lupinek P, Bytesnik J, Cihak R, Krausova R, Vancura V, Kautzner J, Blich M, Suleiman M, Zeidan Shwiri T, Marai I, Boulos M, Amikam S, Lilli A, Magnacca M, Svetlich C, D'addario S, Baratto MT, Ghidini Ottonelli A, Savino K, Casolo G, Wolber T, On C, Binggeli C, Holzmeister J, Brunckhorst C, Duru F. Poster Session 2: Results (pacing), indications (pacing). Europace 2009. [DOI: 10.1093/europace/euq204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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35
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Affiliation(s)
- Johannes Holzmeister
- Cardiovascular Center, University Hospital Zurich, Rämistrasse 100, Zurich, Switzerland.
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36
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Blumer J, Wolber T, Hellermann J, Holzmeister J, Binggeli C, Duru F, Brunckhorst C. Predictors of Appropriate Implantable Cardioverter-Defibrillator Therapy During Long-Term Follow-up of Patients With Coronary Artery Disease. Int Heart J 2009; 50:313-21. [DOI: 10.1536/ihj.50.313] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [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: 11/18/2022]
Affiliation(s)
- Johannes Blumer
- Arrhythmia Service, Cardiovascular Division, University Hospital Zurich
| | - Thomas Wolber
- Arrhythmia Service, Cardiovascular Division, University Hospital Zurich
| | | | | | | | - Firat Duru
- Arrhythmia Service, Cardiovascular Division, University Hospital Zurich
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Schefer T, Wolber T, Binggeli C, Holzmeister J, Brunckhorst C, Duru F. Long-term predictors of mortality in ICD patients with non-ischaemic cardiac disease: impact of renal function. Europace 2008; 10:1052-9. [DOI: 10.1093/europace/eun186] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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38
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Siegrist PT, Comte N, Holzmeister J, Sütsch G, Koepfli P, Namdar M, Duru F, Brunckhorst C, Scharf C, Kaufmann PA. Effects of AV delay programming on ventricular resynchronisation: role of radionuclide ventriculography. Eur J Nucl Med Mol Imaging 2008; 35:1516-22. [PMID: 18350288 DOI: 10.1007/s00259-008-0750-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2007] [Revised: 01/31/2008] [Accepted: 02/15/2008] [Indexed: 11/24/2022]
Abstract
PURPOSE Optimal atrioventricular delay (AVD) setting for cardiac resynchronisation therapy, i.e. biventricular pacing in patients with heart failure, remains a formidable challenge. Thus, the purpose of this study was to evaluate the effects of different AVD on inter- and intra-ventricular resynchronisation using phase histograms of radionuclide ventriculography (RNV). METHODS In 17 consecutive patients (mean age 64 +/- 6 years), RNV was performed 236 +/- 350 days after pacemaker implantation for cardiac resynchronisation therapy. Images were acquired during atrial pacing at 80 bpm and during biventricular pacing with AVD ranging from 80 to 160 ms. Inter-ventricular dyssynchrony was measured by the delay between the mean phase angles of the left and right ventricles. Intra-ventricular dyssynchrony was measured by the standard deviation (SD) of left ventricular phase histograms. RESULTS Left ventricular (LV) ejection fraction (EF) was inversely correlated to LV dyssynchrony (SD of LV phase histogram, R = -0.82, p < 0.0001). However, the increase in LVEF by biventricular pacing (mean +4.4 +/- 4%) showed only modest correlation to the resulting resynchronisation effect (characterised by a -13 +/- 8 degrees decrease in LV phase histogram SD, R = -0.38, p < 0.0001). CONCLUSION RNV is helpful in optimising pacing parameters for resynchronisation therapy. Varying AVD did not have a major impact on intra- or inter-ventricular resynchronisation. Thus, the benefit of AVD-based LVEF optimisation seems to result from atrioventricular resynchronisation.
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Affiliation(s)
- Patrick T Siegrist
- Cardiovascular Center, Universitiy Hospital Zurich NUK C 32, Raemistrasse 100, CH-8091, Zurich, Switzerland
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Wolber T, Binggeli C, Holzmeister J, Brunckhorst C, Strobel U, Boes C, Moser R, Becker D, Duru F. Wavelet-Based Tachycardia Discrimination in ICDs: Impact of Posture and Electrogram Configuration. Pacing Clin Electro 2006; 29:1255-60. [PMID: 17100680 DOI: 10.1111/j.1540-8159.2006.00521.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Inappropriate therapy delivery is an important concern in the management of patients with implantable cardioverter defibrillators (ICDs). Recently, a morphology-based algorithm (wavelet feature) has been introduced for differentiation of ventricular and supraventricular tachycardia. In this study, we evaluated the performance of the wavelet algorithm using various electrogram (EGM) configurations during different body positions. METHODS Patients with a single-chamber Medtronic model 7230 ICD (Minneapolis, MN, USA) and a double-coil lead were included. EGM templates were collected during baseline rhythm in supine position for different EGM sources (right ventricular [RV] coil-can, RV coil-superior vena cava [SVC] coil, tip-ring, SVC coil-can). For each EGM configuration, morphologic similarity (match percentage) of EGMs obtained during different body positions (supine, left and right lateral, sitting, standing, walking) were compared with the templates. RESULTS Twenty-eight patients (24 males; age 58 +/- 17 years) were studied. A total of 9,775 intracardiac EGMs were analyzed. Median match percentage (interquartile range) was 88% (85-94), 88% (82-94), 82% (76-88), and 73 (58-85) for the RV coil-can, RV coil-SVC coil, tip-ring, and SVC coil-can configurations, respectively. Correct classification rates, as defined by match percentage of 70% or higher, were significantly higher with the RV coil-can, RV coil-SVC coil, and tip-ring EGM configurations, as compared to the SVC coil-can configuration (95, 91, and 91 vs 58% > or =70% match percent, P < 0.001). CONCLUSION Wavelet-based morphology scores in ICDs may change with various body positions. These variations are relatively minor using the nominal configuration (RV coil-can), as well as by using RV coil-SVC coil and tip-ring. However, morphology scores can vary considerably when SVC coil-can is used; therefore, this configuration should be avoided while using the wavelet algorithm.
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Affiliation(s)
- Thomas Wolber
- Cardiovascular Center, Cardiology, University Hospital Zurich, Zurich, Switzerland.
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40
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Wolber T, Ryf S, Binggeli C, Holzmeister J, Brunckhorst C, Luechinger R, Duru F. Potential interference of small neodymium magnets with cardiac pacemakers and implantable cardioverter-defibrillators. Heart Rhythm 2006; 4:1-4. [PMID: 17198980 DOI: 10.1016/j.hrthm.2006.09.012] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [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] [Received: 08/31/2006] [Accepted: 09/08/2006] [Indexed: 01/11/2023]
Abstract
BACKGROUND Magnetic fields may interfere with the function of cardiac pacemakers and implantable cardioverter-defibrillators (ICDs). Neodymium-iron-boron (NdFeB) magnets, which are small in size but produce strong magnetic fields, have become widely available in recent years. Therefore, NdFeB magnets may be associated with an emerging risk of device interference. OBJECTIVE We conducted a clinical study to evaluate the potential of small NdFeB magnets to interfere with cardiac pacemakers and ICDs. METHODS The effect of four NdFeB magnets (two spherical magnets 8 and 10 mm in diameter, a necklace made of 45 spherical magnets, and a magnetic name tag) was tested in forty-one ambulatory patients with a pacemaker and 29 patients with an ICD. The maximum distance at which the magnetic switch of a device was influenced was observed. RESULTS Magnetic interference was observed in all patients. The maximum distance resulting in device interference was 3 cm. No significant differences were found with respect to device manufacturer and device types. CONCLUSION Small NdFeB magnets may cause interference with cardiac pacemakers and ICDs. Patients should be cautioned about the interference risk associated with NdFeB magnets during daily life.
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Affiliation(s)
- Thomas Wolber
- Cardiovascular Center, Cardiology, University Hospital, Zurich.
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41
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Rolf S, Holzmeister J, Fruehwirth M, Haverkamp W. Idiopathic left ventricular tachycardia: procedural and fluoroscopy time saving ablation using LocaLisa navigation system. J Cardiovasc Electrophysiol 2006; 17:214-5. [PMID: 16533262 DOI: 10.1111/j.1540-8167.2005.00304.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 11/28/2022]
Affiliation(s)
- Sascha Rolf
- Department of Cardiology, Charité- University Medicine Berlin, Campus Virchow-Klinikum, Berlin, Germany.
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Brunckhorst CB, Lemola K, Holzmeister J, Scharf C, Altwegg S, Binggeli C, Hellermann JP, Enseleit F, Duru F. [Diagnostic yield of the implantable loop recorder to detect the mechanism of syncope--a single center long term experience of a tertiary care center]. Praxis (Bern 1994) 2005; 94:105-112. [PMID: 15732804 DOI: 10.1024/0369-8394.94.4.105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
AIM The aim of this study was to investigate the usefulness in providing diagnostic information about syncope by implantation of a loop recorder (ILR). METHODS AND RESULTS The study population consisted of 48 consecutive patients (23 male, 25 female, mean age 42 +/- 17) with unexplained syncope who presented between 1998 and 2002 and underwent extensive cardiological screening and were followed with an implantable loop recorder (Reveal or Reveal Plus). The mean follow-up duration was 9 +/- 6 months. During this follow-up in 17 (35%) patients syncope recurred. Arrhythmia correlating with syncope was documented in 15 (88%) of these patients, in 2 (12%) patients an arrhythmia could be excluded. Of these 15 patients with arrhythmogenic cause of syncope 5 (33%) patients revealed higher degree AV-Block, 7 (47%) patients sinus bradycardia or sinus pauses, 4 (27%) due to sick sinus syndrome and 3 (20%) due to neurally mediated syncope, 3 (20%) patients had atrial tachycardias or atrial fibrillation with rapid AV-conduction. As a result of ILR findings 12 pacemakers were implanted and 2 radiofrequency ablations were performed. CONCLUSION The ILR is a valuable and effective tool to establish an arrhythmic cause for unexplained syncope. In these cases they have an impact on subsequent clinical decision making. ILR can also be useful in ruling out arrhythmias as cause of syncope and presyncope.
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Brunckhorst CB, Holzmeister J, Scharf C, Binggeli C, Hellermann JP, Duru F. [Atrila fibrillation: a review]. Praxis (Bern 1994) 2004; 93:803-815. [PMID: 15185487 DOI: 10.1024/0369-8394.93.19.803] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
Atrial fibrillation (AF) is the most common sustained arrhythmia and increases exponentially with age. The physiologic basis are certain triggers initiating multiple micro-reentry circuits, which require a certain amount of "myocardial mass" to be sustained. There are numerous predisposing factors for AF, mostly leading to dilatation or hypertrophy of the atrial myocardium. Lone AF, however, occurs in structurally normal hearts. In the management of AF it is mandatory to decide between medical or electrical cardioversion in persistent AF and rate control in permanent AF. Medical cardioversion or prophylaxis of recurrence can be performed with Class IA, IC or Class III antiarrhythmic drugs. The choice of drugs depends on the underlying cardiac pathology of the individual patient. Patients with long duration of poor rate control during AF are at risk for tachycardia-induced cardiomyopathy. Cardioversion is safe to be performed within 48 hours after the onset of AF without prior and--if there is no risk of recurrence--without consecutive anticoagulation. When AF persists longer than 48 hours, anticoagulation for three weeks is mandatory prior to attempted cardioversion, or alternatively, transesophageal echocardiography can be performed to exclude the presence of an intraatrial thrombus. Anticoagulation has to be maintained for a minimum of four weeks after the restoration of sinus rhythm. Anticoagulation is required for paroxysmal, persistent and permanent AF. Lone atrial fibrillation in patients under the age of 60 years is an exception to these rules and does not require anticoagulation. In case of refractory AF with poor rate control, catheter ablation of the AV node with pacemaker implantation is the treatment of last choice. Early attempts to provide a cure for AF included the surgical "Maze" procedure, followed by linear catheter ablation with the goal of reducing the atrial mass. Catheter ablation of the triggers of AF, which mainly originate at the pulmonary veins and the "substrate modification" have been introduced in the last couple of years and is performed increasingly in specialized EP centers.
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Affiliation(s)
- C B Brunckhorst
- Abteilung Kardiologie, Departement Innere Medizin, Universitätsspital Zürich
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Brunckhorst C, Binggeli C, Hellermann JP, Scharf C, Holzmeister J, Duru F. ICD-Therapie bei Patienten mit koronarer Herzkrankheit – Inzidenz adäquater Interventionen. Therapeutische Umschau 2004; 61:271-8. [PMID: 15139319 DOI: 10.1024/0040-5930.61.4.271] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Hintergrund: Implantierbare Cardioverter/Defibrillatoren (ICD) stellen eine etablierte Therapieform für Risikopatienten hinsichtlich maligner ventrikulärer Arrhythmien dar. Der Überlebensvorteil der ICD- Therapie bei Patienten mit koronarer Herzkrankheit und ventrikulären Tachykardien gegenüber einer antiarrhythmischen Therapie ist erwiesen. Auch in der Primärprävention setzt sich bei Hochrisikopatienten zunehmend die ICD-Therapie durch. Wir berichten über die Inzidenz adäquater ICD-Therapien bei Patienten mit koronarer Herzkrankheit, bei denen im UniversitätsSpital Zürich ein ICD implantiert wurde. Methoden: 104 konsekutive Patienten (97 Männer, 7 Frauen, mittleres Alter 67 ± 10 Jahre) mit koronarer Herzkrankheit, bei denen nach AHA/ACC/NASPE Richtlinien eine Indikation zur ICD-Implantation gestellt wurde und im UniversitätsSpital Zürich im Zeitraum von Januar 2000 bis Juli 2003 erstmals mit einem ICD versorgt wurden, sind in die Studie eingeschlossen. Eine Nachkontrolle erfolgte alle drei bis sechs Monate, wobei alle ICD-Therapien dokumentiert wurden. Diese Dokumentationen wurden zur Analyse adäquater und nicht-adäquater ICD-Therapien verwendet. Resultate: Der Nachbeobachtungszeitraum dauerte 383 ± 195 Tage. Die Zeit bis zur ersten adäquaten Therapie betrug 201 ± 283 Tage. Die kumulative Inzidenz für die erste adäquate Therapieabgabe betrug nach sechs Monaten 21%, nach zwei Jahren 39% und nach vier Jahren 59%. Bei 64% der Patienten, die eine ICD-Therapie erfuhren, wurde primär eine ATP-Therapie, bei 36% primär eine Schock-Therapie abgegeben. ATP war in 83% der Fälle erfolgreich. Im Nachbeobachtungszeitraum sind zwölf Patienten verstorben. Schlussfolgerung: In unserer Studie zeigte sich der Nutzen der ICD-Therapie bei Risikopatienten mit koronarer Herzkrankheit nach einem relativ kurzen Zeitraum und bestätigt damit den Stellenwert der ICD-Therapie bei der primären und sekundären Prävention.
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Abstract
Stress und Depressionen verändern die elektrophysiologischen Eigenschaften des Myokards insbesondere durch den Einfluss des autonomen Nervensystems und können somit Herzrhythmusstörungen auslösen. Durch die asymmetrische autonome Innervation des Herzens wirkt sich die Interaktion von Sympathikus und Parasympathikus auf die verschiedenen Lokalisationen des Reizleitungssystems unterschiedlich aus. Bei einer Arrhythmie handelt es sich um ein komplexes Zusammenspiel aus einem elektrophysiologischen Substrat und einem auslösenden Trigger, der auf einer autonomen Stimulation oder anderen Einflussfaktoren beruht, was einen spezifischen Arrhythmie-Mechanismus auslösen kann. Die Korrelation zwischen dem Auftreten von Arrhythmien und einer gestörten autonomen Balance im Sinne eines reduzierten parasympathischen und gesteigerten sympathischen Tonus ist in der Literatur gut dokumentiert. Die Patienten zeichnen sich klinisch durch eine reduzierte Herzfrequenzvariabilität, verstärkte QT-Dispersion und verminderte Barorezeptorsensitivität aus.Kasuistiken bestätigen, dass autonome Innervationszustände unter bestimmten Umständen Rhythmusstörungen bis hin zu lebensbedrohlichen ventrikulären Arrhythmien triggern können.
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Bruemmer D, Riggers U, Holzmeister J, Grill M, Lippek F, Settmacher U, Regitz-Zagrosek V, Fleck E, Graf K. Expression of CD40 in vascular smooth muscle cells and macrophages is associated with early development of human atherosclerotic lesions. Am J Cardiol 2001; 87:21-7. [PMID: 11137828 DOI: 10.1016/s0002-9149(00)01266-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [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: 01/07/2023]
Abstract
CD40-CD154-mediated signaling has recently been described as playing a role in cellular functions involved in atherosclerotic processes. CD40 is expressed in macrophages, lymphocytes, endothelial cells, and vascular smooth muscle cells. However, cross-sectional studies investigating the expression of CD40 in atherosclerotic lesions are lacking. In the present study the expression of CD40 was studied in atherosclerotic lesions from 43 patients classified according to the World Health Organization criteria. Serial immunohistologic stainings of human iliac arteries from 43 patients were performed using monoclonal antibodies. Lesions were classified according to World Health Organization criteria, and CD40 expression was analyzed with regard to cell morphology and cellular markers by 2 independent observers. Human atherosclerotic lesions revealed a significant increase in intimal thickness, number of inflammatory infiltrates, and CD40-positive macrophages and vascular smooth muscle cells with progression of the lesions. This increase was most prominent from stage 0 to stage I. A significant correlation between intimal thickness and CD40-positive macrophages (r = 0.75, p <0.0005) and CD40-positive vascular smooth muscle cells (r = 0.81, p <0.0005) was observed. Ligation of the cellular CD40 receptor contributes to inflammatory cellular events in human vascular smooth muscle cells. These data suggest a direct association of CD40 expression in atherosclerotic lesions with early plaque development.
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Affiliation(s)
- D Bruemmer
- Department of Medicine/Cardiology, Virchow Klinikum Humboldt Universität Berlin, Germany
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Warnecke C, Willich T, Holzmeister J, Bottari SP, Fleck E, Regitz-Zagrosek V. Efficient transcription of the human angiotensin II type 2 receptor gene requires intronic sequence elements. Biochem J 1999; 340 ( Pt 1):17-24. [PMID: 10229654 PMCID: PMC1220217] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
To investigate mechanisms of human angiotensin II type 2 receptor (hAT2) gene regulation we functionally characterized the promoter and downstream regions of the gene. 5'-Terminal deletion mutants from -1417/+100 to -46/+100 elicited significant but low functional activity in luciferase reporter gene assays with PC12W cells. Inclusion into the promoter constructs of intron 1 and the transcribed region of the hAT2 gene up to the translation start enhanced luciferase activity 6.7+/-1.6-fold and 11.6+/-1.7-fold (means+/-S.E.M.) respectively, whereas fusion of the promoter to the spliced 5' untranslated region of hAT2 cDNA did not, which indicated an enhancement caused by intronic sequence elements. Reverse transcriptase-mediated PCR confirmed that the chimaeric hAT2-luciferase mRNA was regularly spliced in PC12W cells. A Northern blot analysis of transfected cells showed levels of luciferase mRNA expression consistent with the respective enzyme activities. Mapping of intron 1 revealed that a 12 bp sequence in the centre of the intron was required for the increase in promoter activity, whereas the 5' adjacent intronic region mediated a decrease in luciferase activity. Mutation of the 12 bp region led to altered protein binding and markedly decreased luciferase activity. Cloned into a promoterless luciferase vector, a 123 bp intron 1 fragment was able to direct reporter gene expression to the same activity as occurred in conjunction with the 5' flanking region. These results indicate that sequence elements in intron 1 are necessary for efficient transcription of hAT2. In reporter gene assays, intron 1 might by itself function as a promoter and initiate transcription from an alternative start point.
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MESH Headings
- 5' Untranslated Regions/genetics
- Animals
- Base Sequence
- Binding Sites
- Cloning, Molecular
- Codon, Initiator/genetics
- DNA-Binding Proteins/metabolism
- Enhancer Elements, Genetic/genetics
- Gene Expression Regulation
- Genes, Reporter
- Humans
- Introns/genetics
- Molecular Sequence Data
- Mutation
- PC12 Cells
- Promoter Regions, Genetic/genetics
- RNA Splicing
- RNA, Messenger/analysis
- RNA, Messenger/genetics
- Rats
- Receptor, Angiotensin, Type 2
- Receptors, Angiotensin/genetics
- TATA Box/genetics
- Transcription, Genetic/genetics
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Affiliation(s)
- C Warnecke
- Department of Internal Medicine/Cardiology, Charité, Campus Virchow Clinic, Humboldt University Berlin and Deutsches Herzzentrum Berlin, Augustenburger Platz 1, 13353 Berlin, Germany.
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Holzmeister J, Graf K, Warnecke C, Fleck E, Regitz-Zagrosek V. Protein kinase C-dependent regulation of the human AT1 promoter in vascular smooth muscle cells. Am J Physiol 1997; 273:H655-64. [PMID: 9277481 DOI: 10.1152/ajpheart.1997.273.2.h655] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The expression level of angiotensin II (ANG II) type 1 receptors (AT1) determines the magnitude of ANG II signaling in vascular smooth muscle cells (VSMC). AT1 mRNA expression in cultured bovine VSMC increased twofold after 8 h of protein kinase C (PKC) activation with phorbol 12-myristate 13-acetate (PMA), whereas stimulation with forskolin did not alter the AT1 mRNA level. The expression of AT1 promoter/exon 1 [-513/+92 base pairs (bp)] luciferase constructs transfected into VSMC increased 2.4-fold with PMA stimulation. In-gel kinase assays demonstrated rapid phosphorylation of mitogen-activating protein kinases (MAPK) ERK1 and ERK2 by PMA. Electrophoretic gel mobility shift assays showed sequence-specific binding of nuclear proteins from PMA-activated VSMC, identified as activator protein 1 (AP-1) complex in competition assays, to a radiolabeled AT1-promoter fragment (-368/-399 bp). Recombinant AP-1 binds in a sequence-specific manner to the -386/-399-bp region. Site-specific mutagenesis destroying the AP-1 site, the adjacent polyoma enhancer activator 3 element, or both sites simultaneously indicated that both sites together are necessary and sufficient to control basal and PMA-induced activation of the human AT1 promoter in transfected VSMC. The capability of the phorbol ester PMA to activate the human AT1 promoter in VSMC via an AP-1 element suggests a prominent role for PKC/MAPK and Ets proteins in AT1 regulation.
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MESH Headings
- Animals
- Calcium-Calmodulin-Dependent Protein Kinases/metabolism
- Cattle
- Cells, Cultured
- Cyclic AMP-Dependent Protein Kinases/pharmacology
- HeLa Cells
- Humans
- Mitogen-Activated Protein Kinase 1
- Mitogen-Activated Protein Kinase 3
- Mitogen-Activated Protein Kinases
- Muscle, Smooth, Vascular/cytology
- Muscle, Smooth, Vascular/drug effects
- Muscle, Smooth, Vascular/physiology
- Mutagenesis, Site-Directed
- Promoter Regions, Genetic/drug effects
- Protein Kinase C/pharmacology
- RNA, Messenger/metabolism
- Receptors, Angiotensin/genetics
- Receptors, Angiotensin/metabolism
- Tetradecanoylphorbol Acetate/pharmacology
- Transcription Factor AP-1/metabolism
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Affiliation(s)
- J Holzmeister
- Department of Internal Medicine, Cardiology, Virchow Klinikum of the Humboldt University, Berlin, Germany
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Regitz-Zagrosek V, Neuss M, Holzmeister J, Warnecke C, Fleck E. Molecular biology of angiotensin receptors and their role in human cardiovascular disease. J Mol Med (Berl) 1996; 74:233-51. [PMID: 8773261 DOI: 10.1007/bf00196577] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The actions of angiotensin II in the cardiovascular system are transmitted by two known and possibly some unknown angiotensin receptor types. AT1 and AT2 both correspond to G-protein-coupled receptors with seven hydrophobic transmembrane domains, several N-glycosylation sites and a potential G-protein binding site. Cloning of coding regions and promoter sequences contributed to the understanding of receptor protein function and regulation. Angiotensin receptors with atypical binding properties for the known AT1- and AT2-specific ligands are expressed on human cardiac fibroblasts and in the human ulcrus. In several animal models, receptors with high affinity for angiotensin (1-7) have been described. AT1 stimulation is mediated by the generation of phospholipid-derived second messengers, activation of protein kinase C, the MAPkinase pathway and of immediate early genes. Recently, phosphorylation and dephosphorylation of tyrosine kinases have been associated with AT1- and AT2-mediated signal transduction. ATR are regulated by phosphorylation, internalization, modification of transcription rate and mRNA stability. Regulation is highly cell and organ specific and includes upregulation of ATR in some pathophysiological situations where the renin angiotensin system is activated. Whereas the function of AT1 in the cardiovascular system is relatively well established, there is little information regarding the role of AT2. Recent hypotheses suggest an antagonism between AT1 and AT2 at the signal transduction and the functional level. Transgenic animal models, particularly with targeted disruption of the AT1 and AT2 genes, suggest the contribution of both genes to blood pressure regulation. Genetic polymorphisms have been described in the AT1 and AT2 gene or neighbored regions and are used to analyze the association between gene defects and cardiovascular diseases. AT1 antagonists are now being introduced into the treatment of hypertension and potentially heart failure, and more interesting pharmacological developments are expected from the ongoing basic studies.
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Affiliation(s)
- V Regitz-Zagrosek
- Department of Internal Medicine/Cardiology, Virchow-Klinikum, Humboldt Universität, Berlin, Germany
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Abstract
Angiotensin receptors have been described in the human heart and are suspected to play a central role in remodeling after myocardial infarction and in cardiac hypertrophy. Two subtypes, AT1 and AT2, have so far been described in humans, with AT2 being the dominant subtype in human atria. We have now determined subtype numbers and distribution by binding in ventricular myocardium from patients with end-stage heart failure. We found about 50-80% of subtype AT2 in the right and left ventricles from patients with end-stage heart failure due to coronary artery disease and cardiomyopathy, indicating that AT2 is the dominant angiotensin receptor subtype in the whole human heart. To determine the cellular localization of angiotensin receptors in human myocardium in addition to the known localization on myocytes, smooth muscle cells and endothelial cells, we investigated cardiac fibroblasts. They express an angiotensin receptor with yet incompletely understood binding characteristics which is coupled to proliferation and DNA synthesis. As AT2 is the dominant angiotensin receptor subtype in human heart, we cloned the complete mRNA sequence by a rapid amplification of cDNA ends (RACE) procedure and thereafter the promoter sequence from a human genomic library. Once the sequence of the mRNA and thus exon 1 was obtained by the RACE-PCR, a probe was constructed for the most 5' region of exon 1 and used for screening of a human genomic DNA bank. After cutting of the positive clones with EcoR1 and Not1, a 4000 bp fragment hybridized with the probe and was further sequenced. A functional AT2 promoter, with > 90% homology with the mouse promoter and 35% homology with the human AT1 promoter containing numerous cis-acting sequences for basal (TFIID) and inducible (AP-1, PEA-3, CBF) transcription factors in the first 1000 bp was identified.
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