Nebivolol versus Carvedilol or Metoprolol in Patients Presenting with Acute Myocardial Infarction Complicated by Left Ventricular Dysfunction

OBJECTIVE

The aim of this study was to evaluate the efficacy of nebivolol, carvedilol or metoprolol succinate on the outcome of patients presenting with acute myocardial infarction (AMI) complicated by left ventricular dysfunction.

SUBJECTS AND METHODS

Patients (n = 172, aged 28-87 years) with AMI and left ventricular ejection fraction ≤0.45 were randomized to the nebivolol (n = 55), carvedilol (n = 60) and metoprolol succinate (n = 57) groups. Baseline demographic and clinical characteristics and composite event rates of nonfatal MI, cardiovascular mortality, hospitalization due to unstable angina pectoris or heart failure, stroke or revascularization during the 12-month follow-up were compared among the groups using the x03C7;2 test, t test or log-rank test as appropriate.

RESULTS

Baseline demographic and clinical characteristics were similar in the three groups. The composite end point during follow-up was lower in the patients treated with nebivolol than those treated with metoprolol (14.5 vs. 31.5%; p = 0.03). However, event rates were similar between the patients treated with carvedilol and those treated with the metoprolol (20.3 vs. 31.5%, p > 0.05) and between the patients treated with nebivolol and carvedilol (14.5 vs. 20.3%, p > 0.05).

CONCLUSION

The patients treated with nebivolol experienced 12-month cardiovascular events at a lower rate than those treated with metoprolol succinate. However, event rates were similar between the carvedilol and the metoprolol succinate groups and between the nebivolol and the carvedilol groups.

Preoperative N-terminal pro-B-type natriuretic peptide and myocardial injury after stopping or continuing renin-angiotensin system inhibitors in noncardiac surgery: a prespecified analysis of a phase 2 randomised controlled multicentre trial

BACKGROUND

Patients with elevated preoperative plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP >100 pg ml-1) experience more complications after noncardiac surgery. Individuals prescribed renin-angiotensin system (RAS) inhibitors for cardiometabolic disease are at particular risk of perioperative myocardial injury and complications. We hypothesised that stopping RAS inhibitors before surgery increases the risk of perioperative myocardial injury, depending on preoperative risk stratified by plasma NT-proBNP concentrations.

METHODS

In a preplanned analysis of a phase 2a trial in six UK centres, patients ≥60 yr old undergoing elective noncardiac surgery were randomly assigned either to stop or continue RAS inhibitors before surgery. The pharmacokinetic profile of individual RAS inhibitors determined for how long they were stopped before surgery. The primary outcome, masked to investigators, clinicians, and patients, was myocardial injury (plasma high-sensitivity troponin-T ≥15 ng L-1 or a ≥5 ng L-1 increase, when preoperative high-sensitivity troponin-T ≥15 ng L-1) within 48 h after surgery. The co-exposures of interest were preoperative plasma NT-proBNP (< or >100 pg ml -1) and stopping or continuing RAS inhibitors.

RESULTS

Of 241 participants, 101 (41.9%; mean age 71 [7] yr; 48% females) had preoperative NT-proBNP >100 pg ml -1 (median 339 [160-833] pg ml-1), of whom 9/101 (8.9%) had a formal diagnosis of cardiac failure. Myocardial injury occurred in 63/101 (62.4%) subjects with NT-proBNP >100 pg ml-1, compared with 45/140 (32.1%) subjects with NT-proBNP <100 pg ml -1 {odds ratio (OR) 3.50 (95% confidence interval [CI] 2.05-5.99); P<0.0001}. For subjects with preoperative NT-proBNP <100 pg ml-1, 30/75 (40%) who stopped RAS inhibitors had myocardial injury, compared with 15/65 (23.1%) who continued RAS inhibitors (OR for stopping 2.22 [95% CI 1.06-4.65]; P=0.03). For preoperative NT-proBNP >100 pg ml-1, myocardial injury rates were similar regardless of stopping (62.2%) or continuing (62.5%) RAS inhibitors (OR for stopping 0.98 [95% CI 0.44-2.22]).

CONCLUSIONS

Stopping renin-angiotensin system inhibitors in lower-risk patients (preoperative NT-proBNP <100 pg ml -1) increased the likelihood of myocardial injury before noncardiac surgery.

Metabolic Syndrome and Physical Inactivity May Be Shared Etiological Agents of Prostate Cancer and Coronary Heart Diseases

Simple Summary

As metabolic syndrome (MetS) and a sedentary lifestyle are associated with an increased risk of prostate cancer (PCa) and cardiovascular diseases (CVDs), the 2 conditions may share common causes. We investigated the association between CVDs and PCa. Clinical data from patients undergone prostate biopsy were collected, physical activity (PA) was assessed and coronary heart diseases (CHDs) recorded. PCa was diagnosed in 395/955 men and 238 were aggressive tumors. Although CHDs were more common among PCa-patients (9.4% vs. 7.5%) the difference was not statistically significant and no difference was observed between low- and high-grade subgroups (9.5% vs. 9.2%). PA significantly reduced the risk of PCa diagnosis and aggressiveness while MetS only increased the risk of being diagnosed with cancer. CHDs were associated neither with tumor diagnosis nor aggressiveness. MetS and PA are strong predictors of PCa. We failed to prove a significant association between PCa and CHDs.

Abstract

As metabolic syndrome (MetS) and a sedentary lifestyle have been associated with an increased risk of developing both prostate cancer (PCa) and cardiovascular diseases (CVDs), the 2 conditions may share a common etiology. We aimed at investigating the association between CVDs and PCa. A retrospective analysis was performed. Our dataset on patients undergone systematic prostate biopsy was searched for histopathologic and clinical data. The physical activity (PA) scale for the elderly (PASE) was collected. Coronary heart diseases (CHDs) were recorded. Prognostic Grade Group ≥3 tumors were defined as high-grade (HG). The association between MetS, PA, CHDs and PCa was assessed using logistic regression analyses. Data on 955 patients were collected; 209 (22%) presented with MetS, 79 (8%) with CHDs. PCa was diagnosed in 395 (41.3%) men and 60% (n = 238) presented with an high-grade tumor. CHDs were more common among PCa-patients (9.4% vs. 7.5%; p = 0.302) but the difference was not statistically significant. No difference was observed between low- and high-grade subgroups (9.5% vs. 9.2%; p = 0.874). PASE independently predicted PCa diagnosis (OR: 0.287; p = 0.001) and HG-PCa (OR: 0.165; p = 0.001). MetS was an independent predictor of HG-PCa only (OR: 1.50; 95% CI: 1.100–2.560; p = 0.023). CHDs were not associated with tumor diagnosis and aggressiveness.

Association Between Serial B-Type Natriuretic Peptide Levels, Vasoactive Drug Weaning, and Adverse Cardiovascular Outcomes in Pediatric Heart Failure

BACKGROUND

Children hospitalized with acute decompensated heart failure (ADHF) frequently require intravenous vasoactive (IVV) support drugs and are at risk for adverse cardiovascular (ACV) outcomes. We wished to assess whether serial changes in B-type natriuretic peptide (BNP) levels are associated with successful weaning off IVV support and/or prespecified ACV outcomes in children hospitalized with ADHF.

METHODS AND RESULTS

Children hospitalized with ADHF from 2005 to 2021 at our institution were assessed for serial changes in BNP, weaning off of IVV support, and ACV outcomes. Changes in BNP level were evaluated using linear mixed-effects modeling. Bonferroni correction was used to adjust for multiple hypothesis testing. In 131 hospitalizations of children with ADHF, the median age was 4.8 years, with 74% receiving IVV support. ACV outcomes occurred in 62 children. IVV support was associated with lower admission left ventricular ejection fraction (26.7% versus 32%, P=0.002), more severe left ventricular dilation (left ventricular internal diastolic dimension Z score 5.9 versus 3.1, P=0.021) moderate or more mitral regurgitation (41.3% versus 20.6%, P=0.038), and qualitative right ventricular systolic dysfunction (in 45.4% versus 11.8%, P<0.001). Decline in BNP levels was more rapid in patients who were successfully weaned from IVV support (-0.20 versus -0.03 2log pg/mL per day, P<0.001) and in the non-ACV group (-0.17 versus -0.03 2log pg/mL per day, P<0.001). Right ventricular systolic dysfunction was an independent risk factor for ACV (odds ratio, 2.49; P=0.045).

CONCLUSIONS

The declining rate of serial BNP levels was associated with weaning from IVV support and no ACV outcomes in children hospitalized with ADHF. Right ventricular systolic dysfunction was associated with ACV outcomes.

Predicting mortality for patients with heart failure beyond oxygen consumption: a prognostic risk score

Cardiopulmonary exercise test (CPET) is a crucial tool for the functional evaluation of cardiac patients. We hypothesized that maximal oxygen consumption (V̇o_2max) and ventilatory efficiency-minute ventilation to carbon dioxide production (V̇e/V̇co₂) slope are not the only parameters of CPET able to predict major cardiac events (mortality or cardiac transplantation urgently or elective). We aimed to identify the best CPET predictors of major cardiac events in patients with severe chronic heart failure and to propose an integrated score that could be applied for their prognostic evaluation. We evaluated 140 patients with chronic heart failure who underwent CPET between 2011 and 2019. Major cardiac events were evaluated during follow-up. Univariate and multivariate logistic regression analyses were applied to study the predictive value of different clinical, echocardiographic, and CPET parameters in relation to the major cardiac events. A score was generated, and c-statistic was used for the comparisons. Thirty-nine patients (27.9%) died or underwent cardiac transplantation over a median follow-up of 48 mo. Five parameters (maximal workload, breathing reserve, left ventricular ejection fraction, diastolic dysfunction, and nonidiopathic cardiomyopathy) were used to generate a risk score that had better risk discrimination than the New York Heart Association dyspnea scale, V̇o_2max, V̇e/V̇co₂ slope > 35 alone, and combined V̇o_2max and V̇e/V̇co₂ slope (P = 0.009, 0.004, <0.001, and 0.005, respectively) in predicting major cardiac events. A composite score of CPET and clinical/echocardiographic data is more reliable than the single use of V̇o_2max or combined with V̇e/V̇co₂ slope to predict major cardiac events.NEW & NOTEWORTHY This is a cohort study with a follow-up of maximum of 8 years of patients with chronic heart failure that demonstrates a simple integrated score consisting of CPET (breathing reserve, workload at maximal exercise), echocardiographic (LVEF, diastolic dysfunction), and clinical (etiology of cardiac disease) data. The generated score was a better predictor of major cardiac events (mortality or cardiac transplantation) than Weber classification (V̇o_2max classification) or NYHA functional class as single factors.

Preoperative activation of the renin-angiotensin system and myocardial injury in noncardiac surgery: exploratory mechanistic analysis of the SPACE randomised controlled trial

BACKGROUND

Hypertension therapy in older adults is often suboptimal, in part because of inadequate suppression of the renin-angiotensin-aldosterone system (RAAS). We hypothesised that distinct endotypes of RAAS activation before noncardiac surgery are associated with increased risk of myocardial injury.

METHODS

This was a prespecified exploratory analysis of a multicentre randomised controlled trial (ISRCTN17251494) which randomised patients ≥60 yr old undergoing elective noncardiac surgery to either continue or stop RAAS inhibitors (determined by pharmacokinetic profiles). Unsupervised hierarchical cluster analysis identified distinct groups of patients with similar RAAS activation from samples obtained before induction of anaesthesia, quantified by enzyme-linked immunoassays for plasma renin, aldosterone, angiotensin-converting enzyme 2, and dipeptidyl peptidase-3. The primary outcome, masked to investigators and participants, was myocardial injury (plasma high-sensitivity troponin-T).

RESULTS

We identified three clusters, with similar proportions of RAAS inhibitors randomised to stop or continue. Cluster 1 (n=52; mean age [standard deviation], 75 yr [8 yr]; 54% female) and cluster 3 (n=25; 75 yr [6 yr]; 44% female) had higher rates of myocardial injury (23/52 [44%] and 13/25 [52%], respectively), compared with cluster 2 with 51/164 (31.1%; n=153; 70 yr [6] yr; 46% female; odds ratio: 1.95, 95% confidence interval (CI) 1.12-3.39, P=0.018). Cluster 2 was characterised by lower N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentration (mean difference 698 pg ml-1, 95% CI 576-820 pg ml-1) and higher renin concentration (mean difference 350 pg ml-1, 95% CI 123-577 pg ml-1), compared with clusters 1 and 3 which had higher rates of myocardial injury.

CONCLUSIONS

This mechanistic exploratory analysis suggests that effective preoperative RAAS inhibition is associated with lower risk of myocardial injury after noncardiac surgery, independent of stopping or continuing RAAS inhibitors before surgery.

CLINICAL TRIAL REGISTRATION

ISRCTN17251494.

Increased Diastolic Energy Loss Associated with Cardiac Events in Adults with Pulmonary Atresia Suffering from Intact Ventricular Septum

PURPOSE

To assess right heart diastolic energy loss (EL) as a cardiac workload and evaluate its association with major cardiac events (MACE) in adult patients with pulmonary atresia with an intact ventricular septum (PAIVS).

METHODS

We retrospectively enrolled and compared 30 consecutive adult patients (18 with PAIVS and 12 with pulmonary stenosis [PS] as controls) who underwent right ventricular (RV) outflow tract reconstruction and 4D flow MRI. EL, conventional parameters on MRI, and the severity of tricuspid regurgitation (TR) on echocardiography were assessed. We also evaluated the association between MACE including arrhythmias, heart failure, surgical intervention, and imaging parameters in adults with PAIVS.

RESULTS

Patients with PAIVS were younger, had a higher diastolic EL/cardiac output (CO) ratio, and had a more significant TR than those with PS (controls). However, RV volume, ejection fraction (EF), and pulmonary regurgitation (PR) severity did not differ between the two groups. Higher RV end-diastolic pressure (EDP) and lower cardiac index (CI) correlated with the diastolic EL/CO in patients with PAIVS. Univariate logistic analysis demonstrated that older age and a higher diastolic EL/CO ratio were important factors for MACE in adults with PAIVS (P = 0.048, 0.049).

CONCLUSION

A higher diastolic EL/CO ratio was associated with a higher RV EDP and lower CI. A high diastolic EL/CO ratio is also associated with MACE in adults with PAIVS. Even in adults with normal RV volume and EF, the right heart EL was elevated, suggesting an excessive right-sided cardiac workload that integrated both afterload and preload beyond the RV size in adult patients with PAIVS.