Markers of cardiac dysfunction associated with inflammation in a cohort of patients with acute decompensation of cirrhosis.

BACKGROUND AND AIMS: Inflammation underpinning acute decompensation (AD) of liver disease is an important driver for the development of acute-on-chronic liver failure or death. We aimed to investigate associations between inflammatory biomarkers and impaired cardiac function in patients admitted for AD of cirrhosis. METHODS: This is a retrospective analysis of a well-characterized prospective cohort of patients with AD of liver disease admitted to a tertiary referral center. All patients had echocardiographic assessment of cardiac function and serum samples at admission. We reclassified patients according to the CLIF-C AD score, measured inflammatory (IL-6, IL-8, TNF-ɑ, CD206) and cardiac-specific (NT-proBNP, troponin T) biomarkers and tested for associations with echocardiographic parameters of cardiac function. We explored the impact on outcome of these factors in multivariate analysis. RESULTS: We included 70 patients (58 ±â€…10 years, 28 women), with a mean CLIF-C AD score of 47 ±â€…7. Thirty-nine patients (56%) fulfilled the echocardiographic criteria for cardiac dysfunction. We found associations between parameters of diastolic dysfunction and serum concentrations of IL-6 and CD206. Echocardiographic parameters of cardiac function were not associated with markers of liver dysfunction such as the CLIF-C AD score. In multivariate analysis higher MELD, higher NT-proBNP, and IL-8 concentrations as well as the absence of echocardiographic criteria for cardiac dysfunction significantly associated with death during follow-up. CONCLUSION: We found evidence in favor of a clinically relevant link between serum biomarkers of inflammation (IL-6, CD206) and echocardiographic signals of cardiac dysfunction in patients with acutely decompensated cirrhosis.

The complex interplay between right ventricular dysfunction and atrial fibrillation - a narrative review.

Atrial fibrillation (AF) is one of the most common sustained arrhythmias in clinical practice, associated with multiple comorbidities and complication. The potential predictors of AF onset and perpetuation or specific drivers of complications need future investigation. Right ventricular (RV) dysfunction plays an important role in the development of new-onset AF warranting in-depth analysis in relation to AF. RV may play a significant role in a better characterization of the cardiac substrate of AF patients. The relation between RV dysfunction and AF is bidirectional as AF may be one of the causes of RV dysfunction and their coexistence worsens the overall patient prognosis. Our aim is to present in a narrative review the most relevant data regarding the complex relationship between AF and RV dysfunction.

Prognostic Impact of Severe Atrial Functional Tricuspid Regurgitation in Atrial Fibrillation Patients.

Background and Aim: Atrial fibrillation (AF) is an epidemic disease with a significant global health impact. Atrial functional tricuspid regurgitation (AF-TR) is a more recently acknowledged complication of AF. The main purpose of this study was to determine the prognostic value of severe AF-TR in patients with AF, and its determinants. Methods: In this retrospective, observational study, we included AF patients admitted consecutively to a tertiary clinical hospital between January 2018 and February 2020, irrespective of cause of hospitalization. Patients with organic TR, significant pulmonary hypertension, left ventricular ejection fraction < 50%, those with implanted cardiac devices and those with in-hospital mortality were excluded. Severe TR was defined according to current guidelines. Median follow-up time was 34 (28−39) months. Primary endpoint was all-cause mortality. Results: We included 246 AF patients, with a mean age of 71.5 ± 9.4 years. 86.2% had AF-TR, while 8.1% had severe AF-TR. Mortality rate was 8.5%. Right atrial diameter (p = 0.005), systolic pulmonary artery pressure (sPAP) (p = 0.015) and NT-proBNP (p = 0.026) were independent predictors for the presence of severe valvular dysfunction. In multivariable survival analysis, severe AF-TR, was an independent predictor of all-cause mortality (HR 5.4, 95% CI 1.1−26.2, p = 0.035). Conclusion: Severe AF-TR was an independent predictor of mortality in AF patients, while mild/moderate AF-TR apparently had no impact on prognosis.

The Physical Activity Levels and Sitting Time of Adults Living With Atrial Fibrillation: The CHAMPLAIN-AF Study.

Background: The primary goal of this study was to determine the time spent completing moderate-to-vigorous intensity physical activity (MVPA) among adults with atrial fibrillation (AF). Secondary aims examined MVPA and sitting time (ST) by AF subtypes (ie, paroxysmal, persistent, long-standing persistent, and permanent) and associations between MVPA or ST and knowledge, task self-efficacy, and outcome expectations. Methods: An observational study was conducted in the Champlain region of Ontario, Canada. AF patients completed a survey to determine MVPA and ST using the Short-Form International Physical Activity Questionnaire. Results: A total of 619 patients (66% male; median age 65 years [95% CI 64-67 years]) completed the survey. Median MVPA and ST were 100 (60-120) min/wk and 6 (5-6) h/d; 56% of patients were not meeting the Canadian 24H Movement Guidelines. Most patients (54%) did not know/were unsure of the MVPA recommendations, yet 72% thought physical activity should be part of AF management. Positive correlations were found between higher MVPA levels and the following: (i) speaking to a healthcare professional about engaging in physical activity for managing AF (ρ = 0.108, P = 0.017); (ii) greater confidence regarding ability to perform physical activity and muscle-strengthening exercise (ρ = 0.421, P < 0.01); and (iii) patient agreement that AF would be better managed if they were active (ρ = 0.205, P < 0.01). Conclusions: Many AF patients do not meet the MVPA recommendations, which may be due to lack of physical activity knowledge. Exercise professionals may help educate patients on the benefits of physical activity, improve task-self efficacy, and integrate MVPA into patient lifestyles.

Introduction: Le principal objectif de la présente étude était de déterminer le temps consacré à faire de l'activité physique modérée à vigoureuse (APMV) chez les adultes atteints de fibrillation auriculaire (FA). Les objectifs secondaires visaient à examiner l'APMV et le temps en position assise (TA) selon les sous-types de FA (c.-à-d. paroxystique, persistante, persistante de longue durée et permanente) et les associations entre l'APMV ou le TA et les connaissances, le sentiment d'auto-efficacité et les attentes de résultats. Méthodes: Nous avons réalisé une étude observationnelle dans la région de Champlain, en Ontario, au Canada. Les patients atteints de FA ont rempli une enquête pour déterminer l'APMV et le TA à l'aide du questionnaire court International Physical Activity Questionnaire (IPAQ). Résultats: Un total de 619 patients (66 % d'hommes; âge médian de 65 ans [IC à 95 % 64-67 ans]) a rempli l'enquête. L'APMV et le TPA médians étaient de 100 (60-120) min/sem et de 6 (5-6) h/j; 56 % des patients ne répondaient pas aux Directives canadiennes en matière de mouvement sur 24 heures. La plupart des patients (54 %) ne connaissaient pas les recommandations d'APMV ou n'étaient pas certains de les connaître, mais 72 % pensaient que l'activité physique devrait faire partie de la prise en charge de la FA. Nous avons observé des corrélations positives entre les degrés plus élevés d'APMV et ce qui suit : (i) le fait de parler à un professionnel de la santé de la pratique de l'activité physique pour prendre en charge la FA (ρ = 0,108, P = 0,017); (ii) la confiance accrue quant à la capacité de faire de l'activité physique et les exercices de renforcement musculaire (ρ = 0,421, P < 0,01); (iii) l'accord du patient sur le fait que la pratique de l'activité physique contribuerait à une meilleure prise en charge de la FA (ρ = 0,205, P < 0,01). Conclusions: Plusieurs patients atteints de FA ne répondaient pas aux recommandations d'APMV, possiblement en raison du manque de connaissances concernant l'activité physique. Les professionnels de l'activité physique peuvent contribuer à l'éducation des patients afin de leur faire connaître les avantages de l'activité physique, améliorer leur auto-efficacité et intégrer l'APMV à leur mode de vie.

Determinants of Prolonged Length of Hospital Stay of Patients with Atrial Fibrillation.

BACKGROUND AND AIM: The increasing prevalence and high hospitalization rates make atrial fibrillation (AF) a significant healthcare strain. However, there are limited data regarding the length of hospital stay (LOS) of AF patients. Our purpose was to determine the main drivers of extended LOS of AF patients. METHODS: All AF patients, hospitalized consecutively in a tertiary cardiology center, from January 2018 to February 2020 were included in this retrospective cohort study. Readmissions were excluded. Prolonged LOS was defined as more than seven days (the upper limit of the third quartile). RESULTS: Our study included 949 AF patients, 52.9% females. The mean age was 72.5 ± 10.3 years. The median LOS was 4 days. A total of 28.7% had an extended LOS. Further, 82.9% patients had heart failure (HF). In multivariable analysis, the independent predictors of extended LOS were: acute coronary syndromes (ACS) (HR 4.60, 95% CI 1.66-12.69), infections (HR 2.61, 95% CI 1.44-3.23), NT-proBNP > 1986 ng/mL (HR 1.96, 95% CI 1.37-2.82), acute decompensated HF (ADHF) (HR 1.76, 95% CI 1.23-2.51), HF with reduced ejection fraction (HFrEF) (HR 1.69, 95% CI 1.15-2.47) and the HAS-BLED score (HR 1.42, 95% CI 1.14-1.78). CONCLUSION: ACS, ADHF, HFrEF, increased NT-proBNP levels, infections and elevated HAS-BLED were independent predictors of extended LOS, while specific clinical or therapeutical AF characteristics were not.

Characteristics of shared decision making in Romania from the patient perspective: A cross-sectional multicentric study.

BACKGROUND: Shared decision making (SDM) is very important from patients' perspective. This process has not yet been evaluated in Romania. The study aims to evaluate SDM from the patients' perspective and to evaluate patients' characteristics that associate with SDM. MATERIAL AND METHODS: A cross-sectional multicentric study comprising eight recruitment centres was performed. Inpatients and outpatients who referred to Hospital Units treating autoimmune diseases or atrial fibrillation were included. Another sample consisted of members of the Autoimmune Disease Patient Society, who completed an online anonymous questionnaire. All participants completed the Romanian translated version of the 9-item Shared Decision Making Questionnaire (SDM-Q-9), as these samples were used for the validation of this questionnaire, too. Patients had to refer to the visit in which the decision concerning the antithrombotic treatment was taken (atrial fibrillation patients), or the immunosuppressive treatment was last time changed (autoimmune disease patients). Ordinal regression having the total SDM score as dependent variable was used. RESULTS: A total of 665 questionnaires were filled in within the hospital setting (n = 324; 48.7%) and online (n = 341; 51.3%). The median score for SDM was 34 of 45, but it differed between hospital completion -39/45 and online completion (anonymous) -20/45 (P < .001). Patients with higher education were influenced most by the setting, giving the best marks in hospital and low marks online, while those with lower education gave lower marks in both settings. In ordinal regression with SDM score as dependent variable, hospital completion of the questionnaire (OR = 9.5, 95% confidence interval, 5.69-16), collagen disease diagnosis (OR = 2.4, 95% confidence interval, 1.39-4.14), and immunosuppressive treatment (OR = 2.16, 95% confidence interval, 1.43-3.26) were independent predictors. CONCLUSION: In our study, full anonymity was associated with significantly lower scores for the SDM process. The patients with higher education were most influenced by this condition, while those with the lowest education were the most critical.

Romanian version of SDM-Q-9 validation in Internal Medicine and Cardiology setting: a multicentric cross-sectional study.

BACKGROUND: Shared decision making (SDM) is becoming more and more important for the patient-physician interaction. There has not been a study in Romania evaluating patients' point of view in the SDM process yet. Therefore, the present study aims to evaluate the psychometric parameters of the translated Romanian version of SDM-Q-9. MATERIAL AND METHODS: A multicentric cross-sectional study was performed comprising eight recruitment centers. The sample consisted of in- and outpatients who referred to Hospital Units for treatment for atrial fibrillation or collagen diseases. Furthermore, patients who were members of Autoimmune Disease Patient Society were able to participate via an online survey. All participants completed the Romanian translated SDM-Q-9. RESULTS: Altogether, 665 questionnaires were filled in within the hospital setting (n = 324; 48.7%) and online (n = 341; 51.3%). The Romanian version had good internal consistency (Cronbach α coefficient of 0.96.) Corrected item correlations were good ranging from 0.64 to 0.89 with low corrected item correlations for item 1 and item 7. PCA found a one-factorial solution (similar with previous reports) but the first item had the lowest loading. CONCLUSION: SDM-Q-9 is a useful tool for evaluation and improvement in health care that was validated in Romania and can be used in clinical setting in this country.

The diagnostic and prognostic value of serum endocan in patients with cirrhotic cardiomyopathy.

BACKGROUND: We aimed to determine the relationship between endocan and cirrhotic cardiomyopathy. MATERIALS AND METHODS: Patients with liver cirrhosis and no heart disease were included in a prospective observational study with liver disease decompensation and death as primary outcomes. RESULTS: 83 cirrhotic patients were included and 32 had cirrhotic cardiomyopathy. Endocan levels were significantly lower in patients with cirrhotic cardiomyopathy (5.6 vs. 7 ng/mL, p = 0.034). Endocan correlated with severity of cirrhosis, time to decompensation or death from liver disease (OR 4.5 95% CI 1.06-31.1). CONCLUSION: Endocan is a promising biomarker of severity of cirrhosis and may help in the diagnosis of cardiac dysfunction in this population.

Psychosocial interventions for smoking cessation in patients with coronary heart disease.

BACKGROUND: This is an update of a Cochrane review previously published in 2008. Smoking increases the risk of developing atherosclerosis but also acute thrombotic events. Quitting smoking is potentially the most effective secondary prevention measure and improves prognosis after a cardiac event, but more than half of the patients continue to smoke, and improved cessation aids are urgently required. OBJECTIVES: This review aimed to examine the efficacy of psychosocial interventions for smoking cessation in patients with coronary heart disease in short-term (6 to 12 month follow-up) and long-term (more than 12 months). Moderators of treatment effects (i.e. intervention types, treatment dose, methodological criteria) were used for stratification. SEARCH METHODS: The Cochrane Central Register of Controlled Trials (Issue 12, 2012), MEDLINE, EMBASE, PsycINFO and PSYNDEX were searched from the start of the database to January 2013. This is an update of the initial search in 2003. Results were supplemented by cross-checking references, and handsearches in selected journals and systematic reviews. No language restrictions were applied. SELECTION CRITERIA: Randomised controlled trials (RCTs) in patients with CHD with a minimum follow-up of 6 months. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial eligibility and risk of bias. Abstinence rates were computed according to an intention to treat analysis if possible, or if not according to completer analysis results only. Subgroups of specific intervention strategies were analysed separately. The impact of study quality on efficacy was studied in a moderator analysis. Risk ratios (RR) were pooled using the Mantel-Haenszel and random-effects model with 95% confidence intervals (CI). MAIN RESULTS: We found 40 RCTs meeting inclusion criteria in total (21 trials were new in this update, 5 new trials contributed to long-term results (more than 12 months)). Interventions consist of behavioural therapeutic approaches, telephone support and self-help material and were either focused on smoking cessation alone or addressed several risk factors (eg. obesity, inactivity and smoking). The trials mostly included older male patients with CHD, predominantly myocardial infarction (MI). After an initial selection of studies three trials with implausible large effects of RR > 5 which contributed to substantial heterogeneity were excluded. Overall there was a positive effect of interventions on abstinence after 6 to 12 months (risk ratio (RR) 1.22, 95% confidence interval (CI) 1.13 to 1.32, I² 54%; abstinence rate treatment group = 46%, abstinence rate control group 37.4%), but heterogeneity between trials was substantial. Studies with validated assessment of smoking status at follow-up had similar efficacy (RR 1.22, 95% CI 1.07 to 1.39) to non-validated trials (RR 1.23, 95% CI 1.12 to 1.35). Studies were stratified by intervention strategy and intensity of the intervention. Clustering reduced heterogeneity, although many trials used more than one type of intervention. The RRs for different strategies were similar (behavioural therapies RR 1.23, 95% CI 1.12 to 1.34, I² 40%; telephone support RR 1.21, 95% CI 1.12 to 1.30, I² 44%; self-help RR 1.22, 95% CI 1.12 to 1.33, I² 40%). More intense interventions (any initial contact plus follow-up over one month) showed increased quit rates (RR 1.28, 95% CI 1.17 to 1.40, I² 58%) whereas brief interventions (either one single initial contact lasting less than an hour with no follow-up, one or more contacts in total over an hour with no follow-up or any initial contact plus follow-up of less than one months) did not appear effective (RR 1.01, 95% CI 0.91 to 1.12, I² 0%). Seven trials had long-term follow-up (over 12 months), and did not show any benefits. Adverse side effects were not reported in any trial. These findings are based on studies with rather low risk of selection bias but high risk of detection bias (namely unblinded or non validated assessment of smoking status). AUTHORS' CONCLUSIONS: Psychosocial smoking cessation interventions are effective in promoting abstinence up to 1 year, provided they are of sufficient duration. After one year, the studies showed favourable effects of smoking cessation intervention, but more studies including cost-effectiveness analyses are needed. Further studies should also analyse the additional benefit of a psychosocial intervention strategy to pharmacological therapy (e.g. nicotine replacement therapy) compared with pharmacological treatment alone and investigate economic outcomes.

Prevalence and impact on survival of hepatopulmonary syndrome and cirrhotic cardiomyopathy in a cohort of cirrhotic patients.

BACKGROUND & AIMS: Extrahepatic complications of cirrhosis increase the risk for decompensation of the liver disease and death. Previous studies show common pathogenetic mechanisms involved in the development of hepatopulmonary syndrome and cirrhotic cardiomyopathy. We aimed to assess the link between these entities and their effect on disease-related patient morbidity and mortality. METHODS: Seventy-four consecutive cirrhotic patients without prior history of cardiovascular and pulmonary disease were included in a prospective observational study. Routine blood work, arterial blood gas analysis, pulse oximetry measurements, N-terminal pro-brain natriuretic peptide levels and contrast enhanced echocardiography examination with tissue Doppler imaging were performed in all patients. Patients were followed up for a median of 6 months and disease-related adverse events and death were the main outcomes tested. Statistical analysis was conducted according to the presence of hepatopulmonary syndrome or cirrhotic cardiomyopathy. RESULTS: Hepatopulmonary syndrome was diagnosed in 17 patients (23%) and cirrhotic cardiomyopathy in 30 patients (40.5%). There was no association between the presence of cirrhotic cardiomyopathy and the existence of mild or moderate hepatopulmonary syndrome. No echocardiographic parameters were useful in predicting the presence of hepatopulmonary syndrome. N-terminal pro-brain natriuretic peptide levels and length of QT interval did not aid in diagnosis of cirrhotic cardiomyopathy. Neither entity had significant influence on disease-related outcomes in the follow-up period. CONCLUSIONS: Hepatopulmonary syndrome and cirrhotic cardiomyopathy are independent complications arising in cirrhosis and have a limited influence on morbidity and mortality on a pre-liver transplantation population.

A debate on the certainty of etiology in a case of syncope.

We present the case of a 47-year-old woman with reccurent syncope. The investigations for establishing the etiology of syncope were extended over 4 years and multiple possible mecahisms for the syncope were identified. Even if the guidelines mention a good diagnostic yield for history and initial evaluation, for some selected cases the initial diagnostic supposition should be revised.