Excellent suppression of physiological myocardial FDG activity in patients with cardiac sarcoidosis.

INTRODUCTION: Suppression of physiological myocardial FDG activity is vital in patients undergoing PET/CT for assessment of known or suspected cardiac sarcoidosis. This study aims to evaluate the efficacy of physiological myocardial FDG suppression following a protocol change to a 24-h high fat very low carbohydrate (HFVLC) diet and prolonged fast. METHODS: A retrospective review of patients undergoing FDG PET/CT for the evaluation of cardiac sarcoidosis was performed. Prior to June-2018, patients were prepared with a single very high-fat low carbohydrate meal followed by a 12-18 h fast (group 1). After June-2018, a protocol change was initiated with patients prepared with a HFVLC diet for 24-h followed by a 12-18 h fast (group 2). Focal myocardial activity was classified as positive, absent activity as negative and diffuse/focal on diffuse activity as indeterminate. RESULTS: A total of 94 FDG PET/CT scans were included with 46 scans in group 1 and 48 scans in group 2. Studies were classified as positive, negative or indeterminate in 25 (54%), 7 (15%) and 14 (30%) scans in group 1 and in 13 (27%), 33 (69%) and 2 (4%) scans in group 2, respectively. In scans classified as negative, myocardial FDG activity was less than mediastinal blood pool activity in 5/7 (71%) scans in group 1 and 33/33 (100%) scans in group 2. CONCLUSION: Excellent myocardial FDG suppression can be achieved using a 24-h HFVLC diet and prolonged fast, resulting in a very low indeterminate scan rate in patients with known or suspected cardiac sarcoidosis.

Impact of Individual Patient Profiles on Adherence to Guideline Directed Medical Therapy in Heart Failure With Reduced Ejection Fraction: VCOR-HF Study.

BACKGROUND: Multiple co-morbidities complicate initiation of medical therapy in patients with heart failure with reduced ejection fraction (HFrEF). Adherence to guidelines based on individual patient profiles is not well described. This paper examines the effect of individual patient profiles on guideline recommended therapies for HFrEF. METHODS: This was a prospective, observational, non-randomised study of hospitalised HFrEF patients over 30 days, from 2014 to 2017 in 16 hospitals. A previously developed algorithm-based guideline adherence score was used to determine adherence to key performance indicators: prescribing of beta blockers, angiotensin converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), mineralocorticoid-receptor antagonist (MRAs) for HFrEF patients and early outpatient and heart failure (HF) disease management program review. Patients were classified as low, moderate and excellent adherence to medical therapy. RESULTS: Of the 696 HFrEF patients, 69.1% (n=481) were male with an average age of 73.15 years (SD±14.5 years). At discharge, 64.6% (n=427) were prescribed an ACEI/ARB, 78.7% (n=525) a beta blocker and 45.3% (n=302) prescribed MRA. Based on individual patient profiles, 18.2% (n=107) of eligible patients received an outpatient clinic and HF disease management program review within 30 days and 41.5% (n=71) were prescribed triple therapy. Based on individual profiles, 13% (n=21) of patients received an excellent guideline adherence score. CONCLUSION: Individual patient profiles impact on adherence to guideline recommendations. Review in transitional care and prescribing of triple pharmacotherapy is suboptimal. Translational strategies to facilitate the implementation of guideline recommended therapies is warranted.

Heart Failure in Minority Populations - Impediments to Optimal Treatment in Australian Aborigines.

Chronic heart failure (CHF) among Aboriginal/Indigenous Australians is endemic. There are also grave concerns for outcomes once acquired. This point is compounded by a lack of prospective and objective studies to plan care. To capture the essence of the presented topic it is essential to broadly understand Indigenous health. Key words such as 'worsening', 'gaps', 'need to do more', 'poorly studied', or 'future studies should inform' occur frequently in contrast to CHF research for almost all other groups. This narrative styled opinion piece attempts to discuss future directions for CHF care for Indigenous Australians. We provide a synopsis of the problem, highlight the treatment gaps, and define the impediments that present hurdles in optimising CHF care for Indigenous Australians.

Short- and long-term outcomes of intracoronary and endogenously mobilized bone marrow stem cells in the treatment of ST-segment elevation myocardial infarction: a meta-analysis of randomized control trials.

AIMS: Bone marrow stem cell (BMSC) treatment of ST-segment elevation myocardial infarction (STEMI) has been primarily via the intracoronary route or via endogenous mobilization using granulocyte colony-stimulating factor (G-CSF). Studies have provided conflicting results. We therefore performed a meta-analysis of these treatments, examining short- and long-term efficacy and safety. METHODS AND RESULTS: Randomized controlled trials (RCTs) of BMSC-based therapy for STEMI, delivered within 9 days of reperfusion, were identified by systematic search. Random effects models were used to calculate pooled effects of clinical outcomes, with meta-regression to assess dependence of the magnitude of effect sizes on study characteristics. Twenty-nine RCTs enrolling 1830 patients were included. Intracoronary BMSC therapy resulted in an overall improvement in left ventricular ejection fraction (LVEF) of 2.70% [95% confidence interval (CI) 1.48-3.92; P < 0.001] in the short term and 3.31% (95% CI 1.87-4.75; P < 0.001) longer term. Meta-regression suggested a dose-response relationship between quantity of CD34(+) cells delivered and increase in LVEF (P = 0.007). G-CSF treatment resulted in a trend towards similar benefits (P = 0.20). No significant differences were observed in pooled adverse outcome rates between intervention and control groups of either treatment approach, except for lower revascularization rates with intracoronary BMSC vs. control (odds ratio 0.68, 95% CI 0.47-0.97; P = 0.03). CONCLUSIONS: Intracoronary BMSC therapy post-STEMI improves LVEF beyond standard medical treatment, in both the short and longer term. G-CSF treatment shows positive but non-significant trends. Both treatments demonstrate safety comparable with conventional medical treatment.

B-type natriuretic peptide-guided heart failure therapy: A meta-analysis.

BACKGROUND: The use of plasma levels of B-type natriuretic peptides (BNPs) to guide treatment of patients with chronic heart failure (HF) has been investigated in a number of randomized controlled trials (RCTs). However, the benefits of this treatment approach have been uncertain. We therefore performed a meta-analysis to examine the overall effect of BNP-guided drug therapy on cardiovascular outcomes in patients with chronic HF. METHODS: We identified RCTs by systematic search of manuscripts, abstracts, and databases. Eligible RCTs were those that enrolled more than 20 patients and involved comparison of BNP-guided drug therapy vs usual clinical care of the patient with chronic HF in an outpatient setting. RESULTS: Eight RCTs with a total of 1726 patients and with a mean duration of 16 months (range, 3-24 months) were included in the meta-analysis. Overall, there was a significantly lower risk of all-cause mortality (relative risk [RR], 0.76; 95% confidence interval [CI], 0.63-0.91; P = .003) in the BNP-guided therapy group compared with the control group. In the subgroup of patients younger than 75 years, all-cause mortality was also significantly lower in the BNP-guided group (RR, 0.52; 95% CI, 0.33-0.82; P = .005). However, there was no reduction in mortality with BNP-guided therapy in patients 75 years or older (RR, 0.94; 95% CI, 0.71-1.25; P = .70). The risk of all-cause hospitalization and survival free of any hospitalization was not significantly different between groups (RR, 0.82; 95% CI, 0.64-1.05; P = .12 and RR, 1.07; 95% CI, 0.85-1.34; P = .58, respectively). The additional percentage of patients achieving target doses of angiotensin-converting enzyme inhibitors and beta-blockers during the course of these trials averaged 21% and 22% in the BNP group and 11.7% and 12.5% in the control group, respectively. CONCLUSIONS: B-type natriuretic peptide-guided therapy reduces all-cause mortality in patients with chronic HF compared with usual clinical care, especially in patients younger than 75 years. A component of this survival benefit may be due to increased use of agents proven to decrease mortality in chronic HF. However, there does not seem to be a reduction in all-cause hospitalization or an increase in survival free of hospitalization using this approach.

Using adult stem cells to treat heart failure--fact or fiction?

Heart failure is a major health problem on a global scale. Current therapies include drug treatments, lifestyle modification, device therapy and heart transplantation. However, the "holy grail" of heart failure treatment would be to achieve widespread regeneration of diseased cardiac tissue. Examples of regeneration of living tissue are present in nature and involve stem cells. The two key defining properties of stem cells are their ability to renew themselves through cell division and to differentiate into various cell types. Generally, stem cells can be classified into embryonic or adult forms. Human adult stem cells are ethically appealing and have already been used in clinical trials in a variety of disease states. Bone marrow derived stem cells, skeletal myoblasts and resident adult cardiac stem cells are being explored as potential cell types for heart failure treatment. These cells can be delivered to the heart via a number of routes. Several clinical trials using adult stem cell have shown improvements in cardiac function, however, the mechanism of their action is unclear and widespread tissue regeneration is not evident. A more comprehensive understanding of regenerative physiology at the "benchside" combined with ongoing investigations at the bedside, will be paramount in achieving the ultimate goal of stem cell treatment-complete regeneration and repair of tissue.

Chronic heart failure--optimising care in general practice.

BACKGROUND: Chronic heart failure (CHF) is a significant cause of mortality and morbidity in developed countries where it predominantly affects elderly persons with a range of other comorbid conditions requiring polypharmacy. In Australia, over 300 000 people are affected by CHF. Quality general practice forms the cornerstone for early diagnosis and evidence based integrated care. OBJECTIVE: This article examines the epidemiology of CHF, its clinical diagnosis, contemporary management and future treatment possibilities, as well as current barriers to optimal care. DISCUSSION: The global prevalence of CHF is rising. Optimal treatment requires a coordinated interdisciplinary approach using a biopsychosocial model of care in order to maximise compliance with therapy. Pharmacological treatment is essential and should include an angiotensin converting enzyme inhibitor and beta blocker where possible. Device based treatment and cardiac surgery may benefit selected cases.

The twilight zone of troponins.

Since its introduction into the clinical environment in the early nineties, the cardiac enzyme troponin has significantly changed the way we diagnose and manage acute coronary syndromes. Troponin I is a biochemical marker of myocardial injury with a high level of specificity and sensitivity. It has been demonstrated that as ischaemia progresses, troponin I is degraded predictably into smaller and smaller fragments that can be detected in the blood-stream. This may eventually allow more accurate determination of the duration of ischaemia and the likelihood of myocardial salvage and recovery.