ECG as a risk stratification tool in patients with wearable cardioverter-defibrillator.

BACKGROUND: The wearable cardioverter defibrillator (WCD) is increasingly used in patients at elevated risk for ventricular arrhythmias but not fulfilling the indications for an implantable cardioverter defibrillator (ICD). Currently, there is an insufficient risk prediction of fatal arrhythmias in patients at risk. In this study, we assessed the prognostic role of baseline electrocardiogram (ECG) in WCD patients. METHODS: WCD patients from diverse clinical institutions in Germany (n = 227) were retrospectively enrolled and investigated for the incidences of death or ventricular arrhythmias during WCD wearing. In addition, the widely accepted ECG predictors of adverse outcome were analyzed in patients with arrhythmic events. RESULTS: Life-threatening arrhythmias occurred in 22 (9.7 %) patients, mostly in subjects with ischemic heart disease (15 of 22). There was no difference in baseline left ventricular ejection fraction (LVEF) in subjects with and without arrhythmic events (31.3 ±â€¯7.9 % vs. 32.6 ±â€¯8.3 %; p = 0,24). Patients with arrhythmia exhibited significantly longer QRS duration (109.5 ±â€¯23.1 ms vs. 100.6 ±â€¯22.3 ms, p = 0,04), Tpeak-Tend (Tp-e) (103.1 ±â€¯15.6 ms vs. 93.2 ±â€¯19.2 ms, p = 0,01) and QTc (475.0 ±â€¯60.0 ms vs. 429.6 ±â€¯59.4 ms, p < 0,001) intervals. In contrast, no significant differences were found for incidences of fragmented QRS (27.3 % vs. 24 %, p = 0.79) and inverted/biphasic T-waves (16.6 % vs. 22.7 %, p = 0,55). In multivariate regression analysis both Tp-e (HR 1.03; 95 % CI 1.001-1.057; p = 0.02) and QTc (HR 1.02; 95 % CI 1.006-1.026; p < 0.001) were identified as independent predictors of ventricular arrhythmias. After WCD use, the prophylactic ICD was indicated in 76 patients (33 %) with uneventful clinical course but persistent LVEF ≤35 %. The ECG analysis in these subjects did not reveal any relevant changes in arrhythmogenesis markers. CONCLUSIONS: ECG repolarization markers Tp-e and QTc are associated with malignant arrhythmias in WCD patients and may be used - in addition to other established risk markers - to identify appropriate patients for ICD implantation.

Device fracture as a potential complication of a left ventricular microaxial pump catheter: a case report.

Background: The use of an Impella pump catheter has advanced substantially in the last few years due to the simple insertion procedure and smaller device size. However, its use is still associated with some risks and complications. Here, we report a device fracture as a rare complication that occurred during the device extraction a few days after the initial insertion. Case summary: A 74-year-old man with cardiogenic shock due to acute non-ST-segment elevation myocardial infarction presented to our hospital, and he was transferred to the cath lab for emergency percutaneous coronary intervention (PCI). An Impella CP pump was inserted without any complication prior to PCI. After successful PCI, the patient was transferred to the intensive care unit with device left for continued haemodynamic support. After 3 days, as the patient's condition remarkably improved, we tried to remove the device. However, a persistent mechanical resistance hindered the further catheter retraction; therefore, a decision was made to remove the catheter under fluoroscopy. Indeed, the fluoroscopy revealed a broken distal part of the pump at the level of the ascending aorta. The retained catheter tip was eventually snared with a snare catheter and removed without any complication. Discussion: An Impella microaxial pump may improve the overall outcome by providing haemodynamic support in critically ill patients. However, its application is not without complications. Intravascular device tip fracture, as demonstrated in this case report, is a rarely reported complication. The use of a snare catheter can be an option in retrieving a broken pump.

[Aspirin in primary prevention of cardiovascular and cerebrovascular diseases]. / Stellenwert der ASS-Therapie in der kardio- und zerebrovaskulären Prävention.

Acetylsalicylic acid (aspirin) is one of the most used medications worldwide. The antithrombotic agent acts mainly through inhibition of cyclooxygenase-1 and consequently thromboxane A2 synthesis, causing an irreversible suppression of platelet function. Despite of its proven benefit in the treatment and secondary prevention of atherosclerotic diseases, its use for the primary prevention remains controversial due to an unclear balance between the benefits and risks of aspirin. Moreover, the recent evidence indicates that the risk of major bleeding outweighs the potential to reduce ischemic events in patients without atherosclerotic diseases, thus, precluding the general use of aspirin for the primary prevention.

[Right heart catheter examination: step by step]. / Rechtsherzkatheteruntersuchung ­ Schritt für Schritt.

Right heart catheterisation is a frequently used procedure in cardiology and intensive care medicine, especially for the differential diagnosis of pulmonary hypertension, shunt diagnostics and accurate calculation of the important haemodynamic parameters. Various catheters are available for the examination; the most common and safest is the use of a Swan-Ganz catheter. The complete examination includes probing of the right atrium, right ventricle, pulmonary artery and pulmonary capillary bed. In this "step-by-step" article, the authors discuss the practical aspects of this method.

Heart rate at discharge in patients with acute decompensated heart failure is a predictor of mortality.

AIMS: Heart failure is a syndrome with increasing prevalence in concordance with the aging population and better survival rates from myocardial infarction. Morbidity and mortality are high in chronic heart failure patients, particularly in those with hospital admission for acute decompensation. Several risk stratification tools and score systems have been established to predict mortality in chronic heart failure patients. However, identification of patients at risk with easy obtainable clinical factors that can predict mortality in acute decompensated heart failure (ADHF) are needed to optimize the care-path. METHODS AND RESULTS: We retrospectively analyzed electronic medical records of 78 patients with HFrEF and HFmrEF who were hospitalized with ADHF in the Heart Center of the University Hospital Cologne in the year 2011 and discharged from the ward after successful treatment. 37.6 ± 16.4 months after index hospitalization 30 (38.5%) patients had died. This mortality rate correlated well with the calculated predicted survival with the Seattle Heart Failure Model (SHFM) for each individual patient. In our cohort, we identified elevated heart rate at discharge as an independent predictor for mortality (p = 0.016). The mean heart rate at discharge was lower in survived patients compared to patients who died (72.5 ± 11.9 vs. 79.1 ± 11.2 bpm. Heart rate of 77 bpm or higher was associated with an almost doubled mortality risk (p = 0.015). Heart rate elevation of 5 bpm was associated with an increase of mortality of 25% (p = 0.022). CONCLUSIONS: Patients hospitalized for ADHF seem to have a better prognosis, when heart rate at discharge is < 77 bpm. Heart rate at discharge is an easily obtainable biomarker for risk prediction of mortality in HFrEF and HFmrEF patients treated for acute cardiac decompensation. Taking into account this parameter could be useful for guiding treatment strategies in these high-risk patients. Prospective data for validation of this biomarker and specific intervention are needed.

Early intravenous beta-blockers in patients undergoing primary percutaneous coronary intervention for ST-segment elevation myocardial infarction: A patient-pooled meta-analysis of randomized clinical trials.

BACKGROUND: Conflicting evidence is available on the efficacy and safety of early intravenous beta-blockers before primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. We performed a patient-pooled meta-analysis of trials comparing early intravenous beta-blockers with placebo or routine care in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. AIM: The aim of this study was to evaluate the clinical and safety outcomes of intravenous beta-blockers in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention. METHODS: Four randomized trials with a total of 1150 patients were included. The main outcome was one-year death or myocardial infarction. Secondary outcomes included biomarker-based infarct size, left ventricular ejection fraction during follow-up, ventricular tachycardia, and a composite safety outcome (cardiogenic shock, symptomatic bradycardia, or hypotension) during hospitalization. RESULTS: One-year death or myocardial infarction was similar among beta-blocker (4.2%) and control patients (4.4%) (hazard ratio: 0.96 (95% confidence interval: 0.53-1.75, p=0.90, I2=0%). No difference was observed in biomarker-based infarct size. One-month left ventricular ejection fraction was similar, but left ventricular ejection fraction at six months was significantly higher in patients treated with early intravenous beta-blockade (52.8% versus 50.0% in the control group, p=0.03). No difference was observed in the composite safety outcome or ventricular tachycardia during hospitalization. CONCLUSION: In ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention, the administration of early intravenous beta-blockers was safe. However, there was no difference in the main outcome of one-year death or myocardial infarction with early intravenous beta-blockers. A larger clinical trial is warranted to confirm the definitive efficacy of early intravenous beta-blockers.

[The Role of Ultrarapid Acting Betablocker Esmolol and Landiolol in Critically Ill Patients]. / Ultraschnell wirksame Betablocker Esmolol und Landiolol: Aktuelle Rolle in der Intensiv- und Notfallmedizin.

Supraventricular tachyarrhythmias, especially atrial fibrillation, are common in cardiac and non-cardiac patients with or without surgery. Prolonged rhythm disturbances may impair cardiac function and worsen the clinical outcome and prognosis. Therefore, heart rate control may be necessary to prevent cardiovascular events.Esmolol and landiolol as ultrashort and rapid acting highly selective ß 1 -adrenergic blockers are of particular interest in the prevention and management of cardiac arrhythmias. This review gives an update on both betablockers and their role in the management of arrhythmias in emergency medicine and perioperative setting.

Novel ECG-based scoring tool for prediction of takotsubo syndrome.

BACKGROUND: Takotsubo syndrome (TS) usually involves ECG changes mimicking acute myocardial infarction (AMI). The differentiation of both disorders is crucial for selection of appropriate treatment. The aim of this study was to assess ECG parameters in patients with TS and AMI, and try to establish a scoring tool for TS prediction. METHODS: The study consisted of two study parts: evaluation and validation cohorts. Overall, the study included 82 patients with TS and 141 subjects with AMI. In addition to the major demographic characteristics and comorbidities, the following ECG parameters were analyzed: heart rate, QRS duration, QTc, QRS amplitudes in frontal and precordial leads, frequencies for ST-segment elevation, combined sign of positive ST-segment elevation in -aVR and absent in V1, negative T-wave in lead I and positive in III, inverted or biphasic T-waves in V2-V5, T-wave inversions in frontal and precordial leads. All significant variables were identified in univariate regression analysis and further included for multivariate logistic regression analysis predicting TS. RESULTS: TS was frequently diagnosed in women and in elderly patients. Presence of ST-segment elevation, inverted/biphasic T-waves in V2-V5, QRS amplitudes in frontal and precordial leads were significantly different in evaluation group. By multivariate regression analysis sex, QRS amplitudes in frontal, inverted or biphasic T-waves in septal leads and QTc were identified as powerful variables to calculate TS probability. The diagnostic accuracy of the developed 6-points-TS-score was then evaluated in the validation group. Thus, no subject with a TS-score of ≥ 5 had AMI (specificity 99%, sensitivity > 92%). CONCLUSION: The developed ECG-based TS-score model may be a useful complimentary tool for TS prediction in acute clinical setting.

[Transesophageal Echocardiography - Step by Step]. / Transösophageale Echokardiografie ­ Schritt für Schritt.

A practical step-by-step approach of transesophageal echocardiography.

Landiolol for rate control management of atrial fibrillation in patients with cardiac dysfunction.

Atrial fibrillation (AFib) is frequently associated with heart failure. Guidelines for AFib management have been recently updated and include an algorithm for acute heart rate control based on left ventricular ejection fraction and haemodynamics. Landiolol is an injectable ultra-short beta-blocker with very high beta-1 selectivity, listed in Japanese Guidelines for AFib management as potential option for rate control of patient with heart failure. Landiolol is now available in Europe with indication of controlling heart rate in AFib and supraventricular tachycardia. This review discusses existing clinical data in Japan and perspectives of landiolol use for acute rate control of AFib patients with cardiac dysfunction.

Randomized Control of Sympathetic Drive With Continuous Intravenous Esmolol in Patients With Acute ST-Segment Elevation Myocardial Infarction: The BEtA-Blocker Therapy in Acute Myocardial Infarction (BEAT-AMI) Trial.

OBJECTIVES: This study sought to evaluate the role of esmolol-induced tight sympathetic control in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Elevated sympathetic drive has a detrimental effect on patients with acute STEMI. The effect of beta-blocker-induced heart rate mediated sympathetic control on myocardial damage is unknown. METHODS: The authors conducted a prospective, randomized, single-blind trial involving patients with STEMI and successful percutaneous intervention (Killip class I and II). Patients were randomly allocated to heart rate control with intravenous esmolol for 24 h or placebo. The primary outcome was the maximum change in troponin T release as a prognostic surrogate marker for myocardial damage. A total of 101 patients were enrolled in the study. RESULTS: There was a significant difference between patients allocated to placebo and those who received sympathetic control with esmolol in terms of maximum change in troponin T release: the median serum troponin T concentration increased from 0.2 ng/ml (interquartile range [IQR] 0.1 to 0.7 ng/ml) to 1.3 ng/ml (IQR: 0.6 to 4.7 ng/ml) in the esmolol group and from 0.3 ng/ml (IQR: 0.1 to 1.2 ng/ml) to 3.2 ng/ml (IQR: 1.5 to 5.3 ng/ml) in the placebo group (p = 0.010). The levels of peak creatine kinase (CK), CK subunit MB (CK-MB), and n-terminal brain natriuretic peptide (NT-proBNP) were lower in the esmolol group compared with placebo (CK 619 U/l [IQR: 250-1,701 U/l] vs. 1,308 U/l [IQR: 610 to 2,324 U/l]; p = 0.013; CKMB: 73.5 U/l [IQR: 30 to 192 U/l] vs. 158.5 U/l [IQR: 74 to 281 U/l]; p = 0.005; NT-proBNP: 1,048 pg/ml (IQR: 623 to 2,062 pg/ml] vs. 1,497 pg/ml [IQR: 739 to 3,318 pg/ml]; p = 0.059). Cardiogenic shock occurred in three patients in the placebo group and in none in the esmolol group. CONCLUSIONS: Esmolol treatment statistically significantly decreased troponin T, CK, CK-MB and NT-proBNP release as surrogate markers for myocardial injury in patients with STEMI. (Heart Rate Control After Acute Myocardial Infarction; DRKS00000766).

Pioglitazone alleviates cardiac and vascular remodelling and improves survival in monocrotaline induced pulmonary arterial hypertension.

Pulmonary arterial hypertension (PAH) is a fatal disease with limited therapeutic options. Pathophysiological changes comprise obliterative vascular remodelling of small pulmonary arteries, elevated mean pulmonary arterial systolic pressure (PASP) due to elevated resistance of pulmonary vasculature, adverse right ventricular remodelling, and heart failure. Recent findings also indicate a role of increased inflammation and insulin resistance underlying the development of PAH. We hypothesized that treatment of this condition with the peroxisome proliferator-activated receptor-γ (PPARγ) activator pioglitazone, known to regulate the expression of different genes addressing insulin resistance, inflammatory changes, and vascular remodelling, could be a beneficial approach. PAH was induced in adult rats by a single subcutaneous injection of monocrotaline (MCT). Pioglitazone was administered for 2 weeks starting 3 weeks after MCT-injection. At day 35, hemodynamics, organ weights, and -indices were measured. We performed morphological and molecular characterization of the pulmonary vasculature, including analysis of the degree of muscularization, proliferation rates, and medial wall thickness of the small pulmonary arteries. Furthermore, markers of cardiac injury, collagen content, and cardiomyocyte size were analyzed. Survival rates were monitored throughout the experimental period. Pioglitazone treatment improved survival, reduced PASP, muscularization of small pulmonary arteries, and medial wall thickness. Further, MCT-induced right ventricular hypertrophy and fibrosis were attenuated. This was accompanied with reduced cardiac expression of brain natriuretic peptide, as well as decreased cardiomyocyte size. Finally, pulmonary macrophage content and osteopontin gene expression were attenuated. Based on the beneficial impact of pioglitazone, activation of PPARγ might be a promising treatment option in PAH.

Comparison of Conventional versus Steerable-Catheter Guided Coronary Sinus Lead Positioning in Patients Undergoing Cardiac Resynchronization Device Implantation.

OBJECTIVES: The aim of this study was to compare conventional versus steerable catheter guided coronary sinus (CS) cannulation in patients with advanced heart failure undergoing cardiac resynchronization therapy (CRT). BACKGROUND: Steerable catheter guided coronary sinus cannulation could reduce fluoroscopy time and contrast medium use during CRT implantation. METHODS: 176 consecutive patients with ischemic and non-ischemic heart failure undergoing CRT implantation from January 2008 to December 2012 at the University Hospital of Cologne were identified. During the study period two concurrent CS cannulation techniques were used: standard CS cannulation technique (standard-group, n = 113) and CS cannulation using a steerable electrophysiology (EP) catheter (EPCath-group, n = 63). Propensity-score matched pairs of conventional and EP-catheter guided CS cannulation made up the study population (n = 59 pairs). Primary endpoints were total fluoroscopy time and contrast medium amount used during procedure. RESULTS: The total fluoroscopy time was 30.9 min (interquartile range (IQR), 19.9-44.0 min) in the standard-group and 23.4 min (IQR, 14.2-34-2 min) in the EPCath-group (p = 0.011). More contrast medium was used in the standard-group (60.0 ml, IQR, 30.0-100 ml) compared to 25.0 ml (IQR, 20.0-50.0 ml) in the EPCath-group (P<0.001). CONCLUSIONS: Use of steerable EP catheter was associated with significant reduction of fluoroscopy time and contrast medium use in patients undergoing CRT implantation.

Cirrhotic cardiomyopathy: a cardiologist's perspective.

Cardiac dysfunction is frequently observed in patients with cirrhosis, and has long been linked to the direct toxic effect of alcohol. Cirrhotic cardiomyopathy (CCM) has recently been identified as an entity regardless of the cirrhosis etiology. Increased cardiac output due to hyperdynamic circulation is a pathophysiological hallmark of the disease. The underlying mechanisms involved in pathogenesis of CCM are complex and involve various neurohumoral and cellular pathways, including the impaired ß-receptor and calcium signaling, altered cardiomyocyte membrane physiology, elevated sympathetic nervous tone and increased activity of vasodilatory pathways predominantly through the actions of nitric oxide, carbon monoxide and endocannabinoids. The main clinical features of CCM include attenuated systolic contractility in response to physiologic or pharmacologic strain, diastolic dysfunction, electrical conductance abnormalities and chronotropic incompetence. Particularly the diastolic dysfunction with impaired ventricular relaxation and ventricular filling is a prominent feature of CCM. The underlying mechanism of diastolic dysfunction in cirrhosis is likely due to the increased myocardial wall stiffness caused by myocardial hypertrophy, fibrosis and subendothelial edema, subsequently resulting in high filling pressures of the left ventricle and atrium. Currently, no specific treatment exists for CCM. The liver transplantation is the only established effective therapy for patients with end-stage liver disease and associated cardiac failure. Liver transplantation has been shown to reverse systolic and diastolic dysfunction and the prolonged QT interval after transplantation. Here, we review the pathophysiological basis and clinical features of cirrhotic cardiomyopathy, and discuss currently available limited therapeutic options.

Remote ischemic preconditioning and renoprotection: from myth to a novel therapeutic option?

There is currently no effective prophylactic regimen available to prevent contrast-induced AKI (CI-AKI), a frequent and life-threatening complication after cardiac catheterization. Therefore, novel treatment strategies are required to decrease CI-AKI incidence and to improve clinical outcomes in these patients. Remote ischemic preconditioning (rIPC), defined as transient brief episodes of ischemia at a remote site before a subsequent prolonged ischemia/reperfusion injury of the target organ, is an adaptational response that protects against ischemic and reperfusion insult. Indeed, several studies demonstrated the tissue-protective effects of rIPC in various target organs, including the kidneys. In this regard, rIPC may offer a novel noninvasive and virtually cost-free treatment strategy for decreasing CI-AKI incidence. This review evaluates the current experimental and clinical evidence for rIPC as a potential renoprotective strategy, and discusses the underlying mechanisms and key areas for future research.