Discharge heart rate and 1-year clinical outcomes in heart failure patients with atrial fibrillation.

BACKGROUND: The association between heart rate and 1-year clinical outcomes in heart failure (HF) patients with atrial fibrillation (AF), and whether this association depends on left ventricular ejection fraction (LVEF), are unclear. We investigated the relationship between discharge heart rate and 1-year clinical outcomes after discharge among hospitalized HF patients with AF, and further explored this association that differ by LVEF level. METHODS: In this analysis, we enrolled 1760 hospitalized HF patients with AF from the China Patient-centered Evaluative Assessment of Cardiac Events Prospective Heart Failure study from August 2016 to May 2018. Patients were categorized into three groups with low (<65 beats per minute [bpm]), moderate (65-85 bpm), and high (≥86 bpm) heart rate measured at discharge. Cox proportional hazard models were employed to explore the association between heart rate and 1-year primary outcome, which was defined as a composite outcome of all-cause death and HF rehospitalization. RESULTS: Among 1760 patients, 723 (41.1%) were women, the median age was 69 (interquartile range [IQR]: 60-77) years, median discharge heart rate was 75 (IQR: 69-84) bpm, and 934 (53.1%) had an LVEF <50%. During 1-year follow-up, a total of 792 (45.0%) individuals died or had at least one HF hospitalization. After adjusting for demographic characteristics, smoking status, medical history, anthropometric characteristics, and medications used at discharge, the groups with low (hazard ratio [HR]: 1.32, 95% confidence interval [CI]: 1.05-1.68, P = 0.020) and high (HR: 1.34, 95% CI: 1.07-1.67, P = 0.009) heart rate were associated with a higher risk of 1-year primary outcome compared with the moderate group. A significant interaction between discharge heart rate and LVEF for the primary outcome was observed (P for interaction was 0.045). Among the patients with LVEF ≥50%, only those with high heart rate were associated with a higher risk of primary outcome compared with the group with moderate heart rate (HR: 1.38, 95% CI: 1.01-1.89, P = 0.046), whereas there was no difference between the groups with low and moderate heart rate. Among the patients with LVEF <50%, only those with low heart rate were associated with a higher risk of primary outcome compared with the group with moderate heart rate (HR: 1.46, 95% CI: 1.09-1.96, P = 0.012), whereas there was no difference between the groups with high and moderate heart rate. CONCLUSIONS: Among the overall HF patients with AF, both low (<65 bpm) and high (≥86 bpm) heart rates were associated with poorer outcomes as compared with moderate (65-85 bpm) heart rate. Among patients with LVEF ≥50%, only a high heart rate was associated with higher risk; while among those with LVEF <50%, only a low heart rate was associated with higher risk as compared with the group with moderate heart rate. TRAIL REGISTRATION: Clinicaltrials.gov; NCT02878811.

Beta-blockers and 1-year clinical outcomes in hospitalized heart failure patients with atrial fibrillation.

OBJECTIVE: To assess the association between beta-blockers and 1-year clinical outcomes in heart failure (HF) patients with atrial fibrillation (AF), and further explore this association that differs by left ventricular ejection fraction (LVEF) level. METHODS: We enrolled hospitalized HF patients with AF from China Patient-centered Evaluative Assessment of Cardiac Events Prospective Heart Failure Study. COX proportional hazard regression models were employed to calculate hazard ratio of beta-blockers. The primary outcome was all-cause death. RESULTS: Among 1762 HF patients with AF (756 women [41.4%]), 1041 (56%) received beta-blockers at discharge and 1272 (72.2%) had an LVEF > 40%. During one year follow up, all-cause death occurred in 305 (17.3%), cardiovascular death occurred in 203 patients (11.5%), and rehospitalizations for HF occurred in 622 patients (35.2%). After adjusting for demographic characteristics, social economic status, smoking status, medical history, anthropometric characteristics, and medications used at discharge, the use of beta-blockers at discharge was not associated with all-cause death [hazard ratio (HR): 0.86; 95% Confidence Interval (CI): 0.65-1.12; P = 0.256], cardiovascular death (HR: 0.76, 95% CI: 0.52-1.11; P = 0.160), or the composite outcome of all-cause death and HF rehospitalization (HR: 0.97, 95% CI: 0.82-1.14; P = 0.687) in the entire cohort. There were no significant interactions between use of beta-blockers at discharge and LVEF with respect to all-cause death, cardiovascular death, or composite outcome. In the adjusted models, the use of beta-blockers at discharge was not associated with all-cause death, cardiovascular death, or composite outcome across the different levels of LVEF: reduced (< 40%), mid-range (40%-49%), or preserved LVEF (≥ 50%). CONCLUSION: Among HF patients with AF, the use of beta-blockers at discharge was not associated with 1-year clinical outcomes, regardless of LVEF.

Association between paced QRS duration and atrial fibrillation after permanent pacemaker implantation: A retrospective observational cohort study.

Right ventricular pacing often results in prolonged QRS duration (QRSd) as the result of right ventricular stimulation, and atrial fibrillation (AF) may result. The association of pacing-induced prolonged QRSd and AF in patients with permanent pacemakers is unknown.We selected 180 consecutive patients who underwent pacemaker implantation for complete/advanced atrioventricular block. All of the patients were paced from the right ventricular septum. Electrocardiography recordings were obtained at the beginning and the end of pacemaker implantation. QRSd was measured in all 12 leads. The QRSd variation was calculated by subtracting the preimplantation QRSd from the postimplantation QRSd.The occurrence of AF was observed in 64 (35.56%) patients (follow-up 33.62 ±â€Š21.47 mo). No significant differences in preimplantation QRSd were observed between the AF occurrence and nonoccurrence groups. The QRSd variation in leads V4 (54.22 ±â€Š29.03 vs 42.66 ±â€Š33.79 ms, P = .022), and V6 (64.62 ±â€Š23.16 vs 48.45 ±â€Š34.40 ms, P = .001) differed significantly between the occurrence and nonoccurrence groups. More QRSd variation in lead V6 (P = .005, HR = 1.822, 95% CI 1.174-2.718, interval scale of QRSd was 40 ms) and left atrial diameter (P = .045, HR = 1.042, 95% CI 1.001-1.086) were independent risk factors for AF occurrence. Receiver operating characteristic curve suggested that QRSd variation in lead V6 could predict AF occurrence, especially for patients with long preimplantation QRSd (≥120 ms, area under the curve was 0.826, 95% CI 0.685-0.967).QRSd variation in lead V6 might be positively correlated with postimplantation AF occurrence. In patients with pacemaker implantation, QRSd could be a complementary criterion for optimizing the right ventricular septal pacing site, and smallest QRSd might be worth pursuing.

AMPK attenuates ventricular remodeling and dysfunction following aortic banding in mice via the Sirt3/Oxidative stress pathway.

Although recent findings have suggested that AMP-activated protein kinase (AMPK) exerts inhibitory effects on cardiac remodeling secondary to hypertension, the mechanism and optimal duration of treatment remain unknown. Mice with descending aortic banding (AB) or subjected to sham operation received subcutaneous injection of either AICAR (0.5mgg-1day-1) or vehicle over 4 week periods. At the end of 4 week treatment, left ventricular (LV) remodeling and function were evaluated with histological analysis and echocardiography. Collagen deposition within the LV myocardium was detected with Masson's trichrome staining. Collagen I, Collagen III, Smad 2, Smad 3, NOX2, NOX4 and Sirt3 (an important antioxidant factor) within the LV tissue were also evaluated. Compared with the sham group, the vehicle-treated AB group exhibited significant elevations in cardiac remodeling and heart failure, characterized by an increase in LV weight relative to body weight, an increase in the area of collagen deposition, an increase in LV end-diastolic diameter, an increase in mitral E inflow velocity to mitral A inflow velocity and increases in the gene expressions of the fibrosis markers Collagen I, III and Smad 2, 3 mRNA and decreases in EF and fractional shortening. AMPK attenuate the cardiac remodeling parameters and improve cardiac function. Moreover, the expressions of NOX2, NOX4 were significantly elevated in vehicle-treated AB group. AMPK was able to significantly inhibit NOX2, NOX4 expression, while activate Sirt3 expression. AMPK significantly attenuated hypertension-induced Ventricular remodeling and dysfunction, which may be mediated by the Sirt3/Oxidative stress signaling pathway.

Real role of ß-blockers in regression of left ventricular mass in hypertension patients: Bayesian network meta-analysis.

BACKGROUND: Left ventricular hypertrophy (LVH) is commonly present in patients with hypertension (HT). According to the expert consensus document from American, angiotensin-converting enzyme inhibitor (ACEI) and angiotensin receptor blockers (ARBs) were recommended as 1st-line therapeutic drugs. However, none noticed the different efficacy between fat-soluble and selective ß1-receptor blockers (FS-ß-B) and other ß-blockers on regression of LVH before. The aim of this analysis was to compare the efficacy of FS-ß-B with the other 4 different classes of antihypertensive drugs (ACEI, ARBs, calcium channel blockers [CCBs], and diuretics) on regression of LVH. METHODS: Relative trials were identified in the PubMed, Web of Science, OVID EBM Reviews and Cochrane databases, and the relevant papers were examined. We performed both traditional and Bayesian meta-analysis of randomized controlled trials (RCTs) about the regression of LVH. Sensitivity analysis and regression analysis were performed to explore possible sources of heterogeneity. Inconsistency analysis was performed to check whether the analysis of the trials in the network was indeed consistent. RESULTS: A total of 41 RCTs involving 2566 patients with HT and LVH were included in this analysis. Bayesian network meta-analysis indicated no statistically significant differences between these groups: FS-ß-B and ACEI (MD, -7.09; 95% CI, -14.99, 1.27); FS-ß-B and ARB (MD, -2.66; 95% Cl, -12.02, 6.31). Although FS-ß-B showed greater efficacy when compared with diuretic (MD, 13.04; 95% CI, 3.38, 22.59) or CCB (MD, 10.90; 95% CI, 1.98, 19.49). The probabilities of being among the most efficacious treatments were: FS-ß-B (72%), ARB (27%), ACEI (0.01%), CCB (0.00%), and diuretic (0.00%). CONCLUSION: Evidence from our analysis reveals that FS-ß-B have potential to become 1st-line therapeutic drugs in HT and LVH patients. However, the real efficacy of FS-ß-B on regression of LVH should be confirmed by further large, high quality trials considering the limitation of the study number.

A meta-analysis of low-dose dopamine in heart failure.

BACKGROUND: Heart failure (HF) is a major health problem worldwide with no proven therapy. Low-dose dopamine (LDD) has been applied to patients with HF to enhance diuresis and preserve renal function since the last century. However, the efficacy of LDD in HF has been questioned by several studies recently. The purpose of this meta-analysis is to appraise the effects of the LDD to HF. METHODS: Relative trials were identified in the PubMed, The Web of Science, OVID EBM Reviews and Cochrane databases, and the relevant papers were examined. Pooled mean difference (MD) and 95% confidence interval (95% CI) were estimated by random effects models. The primary endpoints in our meta-analysis were renal function, determined by blood urea, creatinine levels, eGFR and urine output. Secondary endpoints were rates of all-cause mortality and readmission after treatment. RESULTS: Six randomized controlled trials (RCTs) and one retrospective study involving 587 patients were included in this analysis. LDD enhanced eGFR (MD, 7.44; 95% CI, 1.92-12.95; P=0.008), urine output (SMD, 0.58; 95% CI, 0.15-1.01; P=0.008) and decrease creatinine levels (MD, -0.36; 95% CI, -0.64/-0.08; P=0.004), blood urea (MD, -6.97; 95% CI, -13.12/-0.81; P=0.03). No statistically significant differences in the rates of mortality (RR, 0.86; 95% CI, 0.62-1.20, P=0.37) and readmission (RR: 0.86; 95% CI 0.47-1.56, P=0.62) were noted. CONCLUSIONS: LDD indeed brought benefits in terms of promoting diuresis and preserving renal function for HF patients. It did not demonstrate statistical significance in rates of readmission nor mortality. The efficacy of LDD to HF patients should be confirmed by further large, high quality clinical trials.