Abdominal Aortic Calcifications Influences the Systemic and Renal Hemodynamic Response to Renal Denervation in the DENERHTN (Renal Denervation for Hypertension) Trial.

BACKGROUND: The DENERHTN (Renal Denervation for Hypertension) trial confirmed the efficacy of renal denervation (RDN) in lowering daytime ambulatory systolic blood pressure when added to standardized stepped-care antihypertensive treatment (SSAHT) for resistant hypertension at 6 months. METHODS AND RESULTS: This post hoc exploratory analysis assessed the impact of abdominal aortic calcifications (AAC) on the hemodynamic and renal response to RDN at 6 months. In total, 106 patients with resistant hypertension were randomly assigned to RDN plus SSAHT or to the same SSAHT alone (control group). Total AAC volume was measured, with semiautomatic software and blind to randomization, from the aortic hiatus to the iliac bifurcation using the prerandomization noncontrast abdominal computed tomography scans of 90 patients. Measurements were expressed as tertiles. The baseline-adjusted difference in the change in daytime ambulatory systolic blood pressure from baseline to 6 months between the RDN and control groups was -10.1 mm Hg (P=0.0462) in the lowest tertile and -2.5 mm Hg (P=0.4987) in the 2 highest tertiles of AAC volume. Estimated glomerular filtration rate remained stable at 6 months for the patients in the lowest tertile of AAC volume who underwent RDN (+2.5 mL/min per 1.73 m2) but decreased in the control group (-8.0 mL/min per 1.73 m2, P=0.0148). In the 2 highest tertiles of AAC volume, estimated glomerular filtration rate decreased similarly in the RDN and control groups (P=0.2640). CONCLUSIONS: RDN plus SSAHT resulted in a larger decrease in daytime ambulatory systolic blood pressure than SSAHT alone in patients with a lower AAC burden than in those with a higher AAC burden. This larger decrease in daytime ambulatory systolic blood pressure was not associated with a decrease in estimated glomerular filtration rate. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01570777.

Twenty-Four-Hour Blood Pressure Monitoring to Predict and Assess Impact of Renal Denervation: The DENERHTN Study (Renal Denervation for Hypertension).

The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure (BP) lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for resistant hypertension at 6 months. We report here the effect of denervation on 24-hour BP and its variability and look for parameters that predicted the BP response. Patients with resistant hypertension were randomly assigned to denervation plus stepped-care treatment or treatment alone (control). Average and standard deviation of 24-hour, daytime, and nighttime BP and the smoothness index were calculated on recordings performed at randomization and 6 months. Responders were defined as a 6-month 24-hour systolic BP reduction ≥20 mm Hg. Analyses were performed on the per-protocol population. The significantly greater BP reduction in the denervation group was associated with a higher smoothness index (P=0.02). Variability of 24-hour, daytime, and nighttime BP did not change significantly from baseline to 6 months in both groups. The number of responders was greater in the denervation (20/44, 44.5%) than in the control group (11/53, 20.8%; P=0.01). In the discriminant analysis, baseline average nighttime systolic BP and standard deviation were significant predictors of the systolic BP response in the denervation group only, allowing adequate responder classification of 70% of the patients. Our results show that denervation lowers ambulatory BP homogeneously over 24 hours in patients with resistant hypertension and suggest that nighttime systolic BP and variability are predictors of the BP response to denervation. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01570777.

Adherence to Antihypertensive Treatment and the Blood Pressure-Lowering Effects of Renal Denervation in the Renal Denervation for Hypertension (DENERHTN) Trial.

BACKGROUND: The DENERHTN trial (Renal Denervation for Hypertension) confirmed the blood pressure-lowering efficacy of renal denervation added to a standardized stepped-care antihypertensive treatment for resistant hypertension at 6 months. We report the influence of adherence to antihypertensive treatment on blood pressure control. METHODS: One hundred six patients with hypertension resistant to 4 weeks of treatment with indapamide 1.5 mg/d, ramipril 10 mg/d (or irbesartan 300 mg/d), and amlodipine 10 mg/d were randomly assigned to renal denervation plus standardized stepped-care antihypertensive treatment, or the same antihypertensive treatment alone. For standardized stepped-care antihypertensive treatment, spironolactone 25 mg/d, bisoprolol 10 mg/d, prazosin 5 mg/d, and rilmenidine 1 mg/d were sequentially added at monthly visits if home blood pressure was ≥135/85 mm Hg after randomization. We assessed adherence to antihypertensive treatment at 6 months by drug screening in urine/plasma samples from 85 patients. RESULTS: The numbers of fully adherent (20/40 versus 21/45), partially nonadherent (13/40 versus 20/45), or completely nonadherent patients (7/40 versus 4/45) to antihypertensive treatment were not different in the renal denervation and the control groups, respectively (P=0.3605). The difference in the change in daytime ambulatory systolic blood pressure from baseline to 6 months between the 2 groups was -6.7 mm Hg (P=0.0461) in fully adherent and -7.8 mm Hg (P=0.0996) in nonadherent (partially nonadherent plus completely nonadherent) patients. The between-patient variability of daytime ambulatory systolic blood pressure was greater for nonadherent than for fully adherent patients. CONCLUSIONS: In the DENERHTN trial, the prevalence of nonadherence to antihypertensive drugs at 6 months was high (≈50%) but not different in the renal denervation and control groups. Regardless of adherence to treatment, renal denervation plus standardized stepped-care antihypertensive treatment resulted in a greater decrease in blood pressure than standardized stepped-care antihypertensive treatment alone. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01570777.

SFE/SFHTA/AFCE primary aldosteronism consensus: Introduction and handbook.

The French Endocrinology Society (SFE) French Hypertension Society (SFHTA) and Francophone Endocrine Surgery Association (AFCE) have drawn up recommendations for the management of primary aldosteronism (PA), based on an analysis of the literature by 27 experts in 7 work-groups. PA is suspected in case of hypertension associated with one of the following characteristics: severity, resistance, associated hypokalemia, disproportionate target organ lesions, or adrenal incidentaloma with hypertension or hypokalemia. Diagnosis is founded on aldosterone/renin ratio (ARR) measured under standardized conditions. Diagnostic thresholds are expressed according to the measurement units employed. Diagnosis is established for suprathreshold ARR associated with aldosterone concentrations >550pmol/L (200pg/mL) on 2 measurements, and rejected for aldosterone concentration<240pmol/L (90pg/mL) and/or subthreshold ARR. The diagnostic threshold applied is different if certain medication cannot be interrupted. In intermediate situations, dynamic testing is performed. Genetic forms of PA are screened for in young subjects and/or in case of familial history. The patient should be informed of the results expected from medical and surgical treatment of PA before exploration for lateralization is proposed. Lateralization is explored by adrenal vein sampling (AVS), except in patients under 35 years of age with unilateral adenoma on imaging. If PA proves to be lateralized, unilateral adrenalectomy may be performed, with adaptation of medical treatment pre- and postoperatively. If PA is non-lateralized or the patient refuses surgery, spironolactone is administered as first-line treatment, replaced by amiloride, eplerenone or calcium-channel blockers if insufficiently effective or poorly tolerated.

SFE/SFHTA/AFCE consensus on primary aldosteronism, part 7: Medical treatment of primary aldosteronism.

Spironolactone, which is a potent mineralocorticoid receptor antagonist, represents the first line medical treatment of primary aldosteronism (PA). As spironolactone is also an antagonist of the androgen and progesterone receptor, it may present side effects, especially in male patients. In case of intolerance to spironolactone, amiloride may be used to control hypokaliemia and we suggest that eplerenone, which is a more selective but less powerful antagonist of the mineralocorticoid receptor, be used in case of intolerance to spironolactone and insufficient control of hypertension by amiloride. Specific calcic inhibitors and thiazide diuretics may be used as second or third line therapy. Medical treatment of bilateral forms of PA seem to be as efficient as surgical treatment of lateralized PA for the control of hypertension and the prevention of cardiovascular and renal morbidities. This allows to propose medical treatment of PA to patients with lateralized forms of PA who refuse surgery or to patients with PA who do not want to be explored by adrenal venous sampling to determine whether they have a bilateral or lateralized form.

Net Blood Pressure Reduction Following 9 Months of Lifestyle and High-Intensity Interval Training Intervention in Individuals With Abdominal Obesity.

The authors aimed to study the impact of a combined 9-month lifestyle program (Mediterranean diet nutritional counselling, and high-intensity interval training twice a week) on blood pressure (BP) in individuals with abdominal obesity, taking into account the regression-to-the-mean phenomena. A total of 115 participants (53±9 years; 84 women; waist circumference [WC]: 111±13 cm; systolic/diastolic BP [SBP/DBP]: 133±13/82±8 mm Hg; 13% diabetics; 12% smokers; and 30% taking antihypertensive therapy) were retrospectively analyzed before and after the program. After 9 months, we observed an improvement in weight (-5.2±5.6 kg) and WC (-6.3±6.0 cm), and an average SBP/DBP net decrease of -5.1±13.7/-2.8±8.7 mm Hg. These changes were not uniform: 67 participants (58%) decreased their SBP by 2 mm Hg or more. The characteristics of responders included a higher baseline BP than nonresponders (SBP/DBP: 137.2±13.7/83.1±7.3 mm Hg vs 127.0±10.3/80.0±7.3 mm Hg, P<.05) and a higher proportion of participants with a baseline BP ≥130/85 mm Hg (81% vs 52%, P=.001) or with the metabolic syndrome (75% vs 54%, P=.02).

Prevalence and management of hypertensive patients in clinical practice: Cross-sectional registry in five countries outside the European Union.

Inadequate blood pressure (BP) control may be linked with poor adherence to guidelines by the treating physician. This study aimed at assessing the rates of controlled hypertension as per the 2009 Reappraisal of the 2007 European Society of Cardiology/European Society of Hypertension (ESC/ESH) guidelines in 2185 hypertensive adults across five countries (Algeria, Pakistan, Ukraine, Egypt and Venezuela). The rates of controlled hypertension according to physician perception, type of therapy and risk factors were evaluated. Overall, 40% of patients had controlled hypertension according to the guidelines. A marked divergence in the rates of controlled hypertension as assessed by physicians and guidelines was observed (72% vs 40%). The presence of high/very high risks was linked to poor BP control. High salt intake [29%; odds ratio (OR) 9.94, 95% confidence interval (CI) 6.72;14.69], treatment non-adherence (27%; OR 7.32, 95% CI 4.82;11.13), lack of understanding of the treatment's importance (25%; OR 4.95, 95% CI 3.16;7.75), comorbidity (13%) and depression (9%; OR 10.50, 95% CI 5.37;20.54) were major reasons for not achieving hypertension control. Addition of another drug was the most frequent medication change prescribed. Poor rates of BP control warrant repeated promotion of guidelines while identifying potential contributing factors and implementing strategies that re-establish BP control.

Cardiovascular prognosis in patients with type 2 diabetes: contribution of heart and kidney subclinical damage.

BACKGROUND: Left ventricular hypertrophy (LVH) and kidney damage (abnormal urinary albumin-to-creatinine ratio [uACR] or estimated glomerular filtration rate [eGFR]) are predictive of major cardiovascular events (MACE) in patients with type 2 diabetes (T2D) but are rarely used in cardiovascular score calculators. Our study aimed to assess their respective prognostic values for MACE and the additive information they provide to score calculators. METHODS: A total of 1298 T2D (43% women) aged 65 (SD 11) years were followed up for a median of 65 months, with MACE as a primary composite end point: cardiovascular death, nonfatal myocardial infarction, or stroke. Electrocardiogram (ECG)-derived LVH was defined using Sokolow, Gubner, and Cornell product indexes; uACR was considered as abnormal if >2.5 mg/mmol in men or >3.5 mg/mmol in women and eGFR if <60 mL/min per 1.73 m(2). RESULTS: Urinary albumin-to-creatinine ratio was higher in subjects with electrocardiographic LVH (ECG-LVH) than in subjects without (median [interquartile range] 7.61 [43.48] and 2.56 [10.53], respectively; P < .0001). After adjustment for age, history of myocardial infarction, and peripheral artery disease, ECG-LVH and kidney damage were strong predictors for MACE (adjusted hazard ratio [1.64; 95% CI 1.23-2.20], [1.90; 95% CI 1.43-2.53], and [1.85; 95% CI 1.42-2.41] for ECG-LVH, uACR, and eGFR, respectively). Net reclassification improvement was higher with the model including both ECG-LVH and uACR than models with ECG-LVH alone (P < .0001) or uACR alone (P < .0001). In addition, using cardiovascular risk calculators (Framingham score and others), we observed an additional prognostic value of ECG-LVH for each one of them. CONCLUSIONS: Electrocardiographic LVH is complementary to kidney damage for MACE prediction in T2D.

[Management of resistant hypertension. Expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology]. / Prise en charge de l'hypertension artérielle résistante. Consensus d'experts de la Société française d'hypertension artérielle, filiale de la Société française de cardiologie.

To improve the management of resistant hypertension, the French Society of Hypertension, an affiliate of the French Society of Cardiology, has published a set of eleven recommendations. The primary objective is to provide the most up-to-date information, based on the strongest scientific rationale and which is easily applicable to daily clinical practice for health professionals working within the French health system. Resistant hypertension is defined as uncontrolled blood pressure (BP) both on office measurements and confirmed by out-of-office measurements despite a therapeutic strategy comprising appropriate lifestyle and dietary measures and the concurrent use of three antihypertensive agents including a thiazide diuretic, a renin-angiotensin system blocker (ARB or ACEI) and a calcium channel blocker, for at least four weeks, at optimal doses. Treatment compliance must be closely monitored, as most factors that are likely to affect treatment resistance (excessive dietary salt intake, alcohol, depression and drug interactions, or vasopressors). If the diagnosis of resistant hypertension is confirmed, the patient should be referred to a hypertension specialist to screen for potential target organ damage and secondary causes of hypertension. The recommended treatment regimen is a combination therapy comprising four treatment classes, including spironolactone (12.5 to 25mg/day). In the event of a contraindication or a non-response to spironolactone, or if adverse effects occur, a ß-blocker, an α-blocker, or a centrally acting antihypertensive drug should be prescribed. Because renal denervation is still undergoing assessment for the treatment of hypertension, this technique should only be prescribed by a specialist hypertension clinic.

Heart failure care in low- and middle-income countries: a systematic review and meta-analysis.

BACKGROUND: Heart failure places a significant burden on patients and health systems in high-income countries. However, information about its burden in low- and middle-income countries (LMICs) is scant. We thus set out to review both published and unpublished information on the presentation, causes, management, and outcomes of heart failure in LMICs. METHODS AND FINDINGS: Medline, Embase, Global Health Database, and World Health Organization regional databases were searched for studies from LMICs published between 1 January 1995 and 30 March 2014. Additional unpublished data were requested from investigators and international heart failure experts. We identified 42 studies that provided relevant information on acute hospital care (25 LMICs; 232,550 patients) and 11 studies on the management of chronic heart failure in primary care or outpatient settings (14 LMICs; 5,358 patients). The mean age of patients studied ranged from 42 y in Cameroon and Ghana to 75 y in Argentina, and mean age in studies largely correlated with the human development index of the country in which they were conducted (r = 0.71, p<0.001). Overall, ischaemic heart disease was the main reported cause of heart failure in all regions except Africa and the Americas, where hypertension was predominant. Taking both those managed acutely in hospital and those in non-acute outpatient or community settings together, 57% (95% confidence interval [CI]: 49%-64%) of patients were treated with angiotensin-converting enzyme inhibitors, 34% (95% CI: 28%-41%) with beta-blockers, and 32% (95% CI: 25%-39%) with mineralocorticoid receptor antagonists. Mean inpatient stay was 10 d, ranging from 3 d in India to 23 d in China. Acute heart failure accounted for 2.2% (range: 0.3%-7.7%) of total hospital admissions, and mean in-hospital mortality was 8% (95% CI: 6%-10%). There was substantial variation between studies (p<0.001 across all variables), and most data were from urban tertiary referral centres. Only one population-based study assessing incidence and/or prevalence of heart failure was identified. CONCLUSIONS: The presentation, underlying causes, management, and outcomes of heart failure vary substantially across LMICs. On average, the use of evidence-based medications tends to be suboptimal. Better strategies for heart failure surveillance and management in LMICs are needed. Please see later in the article for the Editors' Summary.

Prevalence and management of uncontrolled hypertension in French patients aged over 80 years.

BACKGROUND: The rate of uncontrolled hypertensives aged >80 years is not well known. The available literature on this topic has used the threshold <140/90 mmHg, whereas there is now a consensus for a different target: systolic blood pressure (SBP)<150 mmHg. AIMS: This prospective observational population-based study sought to assess the frequency and management of uncontrolled hypertension in French patients aged ≥80 years. METHODS: Nine hundred and seventy-one treated hypertensive outpatients were evaluable (204 recruited by cardiologists, 767 by general practitioners [GPs]; mean age 84.8 ± 3.8 years; 57.8% women). RESULTS: The frequency of SBP ≥ 150 mmHg was 36.6% (44.6% in cardiologists' patients and 34.4% in GPs' patients). The frequency of satisfaction with SBP ≥ 150 mmHg was 22.0% for cardiologists (32.6% if diastolic blood pressure [DBP] <90 mmHg and 9.5% if ≥90 mmHg; P=0.008) and 30.4% for GPs (51.7% if DBP <90 mmHg and 13.2% if ≥90 mmHg; P<0.0001). Non-diabetic status (for cardiologists) and DBP <90 mmHg (for cardiologists and GPs) were independent determinants of SBP being considered acceptable. Accordingly, in patients with an SBP level ≥ 150 mmHg that was considered too high, treatment was reinforced more often if DBP was ≥90 mmHg (82.3%) than <90 mmHg (68.5%). CONCLUSION: In France, hypertension is uncontrolled in more than one in three elderly hypertensives. Physicians are aware that SBP should be lowered to <150 mmHg in patients aged>80 years, but when the target is not reached they are less likely to increase treatment if DBP is <90 mmHg.

How are physicians prescribing the direct renin inhibitor aliskiren in the management of essential hypertension? A French observational study.

OBJECTIVES: The aim of this French observational study was to evaluate how the direct renin inhibitor aliskiren is being prescribed to treat hypertension by primary care providers (PCPs) and office-based cardiologists. METHODS: Each participating physician included the first three consecutive hypertensive patients who had been prescribed aliskiren at least 4 weeks beforehand and noted whether aliskiren was prescribed: alone or as part of a combination; as first-line therapy, to replace another drug or as an add-on therapy. RESULTS: Five thousand, four hundred and eleven patients were analyzed [mean age, 63; 58% men; 24% diabetic; mean blood pressure (BP) 148/85 mmHg]. A total of 23.6% of patients had a controlled BP. Aliskiren was prescribed alone in 49.4% patients and as part of a combination in 50.6% (bitherapy 28.3%, tritherapy 14.7%, and quadri+therapy 7.6%), at the higher recommended dosage (300 mg daily) to two-thirds of cases. Aliskiren replaced another drug in 71.9% [mainly an angiotensin receptor blocker (ARB) or an angiotensin-converting enzyme inhibitor (ACEi)] and was added to an existing regimen in 22.5%. For bitherapy, aliskiren was combined with a diuretic (D; 39%) or a calcium channel blocker (CCB; 32%). For tritherapy, it was prescribed with CCB and D in 28% and ß-blocker and D in 26%. In 8.9% of patients, aliskiren was prescribed with an ACEi or an ARB. CONCLUSION: French physicians are generally following the current prescribing recommendations for aliskiren, but the place of this new class of antihypertensive in the management of essential hypertension will become clearer with longer experience, especially concerning effective doses and combinations.

Prevalence of heart failure with preserved ejection fraction in Latin American, Middle Eastern, and North African Regions in the I PREFER study (Identification of Patients With Heart Failure and PREserved Systolic Function: an epidemiological regional study).

The aims of the present study were to estimate the prevalence of heart failure (HF) with preserved ejection fraction (HF-PEF) in patients with HF and to compare their clinical characteristics with those with reduced ejection fraction in non-Western countries. The left ventricular ejection fraction ≥ 45% if measured < 1 year before the visit was used to qualify the patients as having HF-PEF. Of the 2,536 consecutive outpatients with HF, 1990 (79%) had the EF values recorded. Of these patients, 1291 had HF-PEF, leading to an overall prevalence of 65% (95% confidence interval 63% to 67%). Compared to the patients with HF and a reduced ejection fraction, those with HF-PEF were more likely to be older (65 vs 62 years, p < 0.001), female (50% vs 28%, p < 0.001), and obese (39% vs 27%, p < 0.001). They more frequently had a history of hypertension (78% vs 53%, p < 0.001) and atrial fibrillation (29% vs 24%, p = 0.03) and less frequently had a history of myocardial infarction (21% vs 44%, p < 0.001). Only 29% of patients with HF-PEF and hypertension had optimal blood pressure control. Left ventricular hypertrophy was less frequent in those with HF-PEF (58% vs 69%, p < 0.001). The prevalence of HF-PEF was lower in the Middle East (41%), where coronary artery disease was more often found than in Latin America (69%) and North Africa (75%), where the rate of hypertension was greater. In conclusion, in the present diverse non-Western study, HF-PEF represented almost 2/3 of all HF cases in outpatients. HF-PEF mostly affects older patients, women, and the obese. Hypertension was the most frequently associated risk factor, highlighting the need for optimal blood pressure control.

[Hypertensive emergencies in adults: a practical review]. / Urgences hypertensives de l'adulte.

Hypertensive emergencies must be distinguished from severe blood pressure elevations without acute target organ damage. Clinical examination (chest pain, dyspnoea, neurological disorders, ECG, retinal examination) and laboratory tests (blood and urine tests, cerebral imaging in case of neurological disorders) have to be immediately performed. Immediate referral to an intensive care unit is indicated, and an intravenous antihypertensive therapy has to be implemented. Blood pressure objectives depend on the associated acute pathology (myocardial infarction, pulmonary oedema, aortic dissection, severe pre-eclampsia and eclampsia of pregnancy, hypertensive encephalopathy, retinopathy, subarachnoid hemorrhage, cerebral hemorrhage, ischemic stroke treated or not with thrombolysis).

Real three-dimensional assessment of left atrial and left atrial appendage volumes by 64-slice spiral computed tomography in individuals with or without cardiovascular disease.

CONTEXT: Left atrial (LA) volume is a prognosis factor of cardiovascular morbidity in patients with cardiovascular disease (CD). Recent developments of multislice computed tomography (MSCT) have made non invasive coronary angiography reliable for selected patients and new software facilitates truly volume measurements without geometrical assumptions. OBJECTIVE: To define, by using MSCT, LA and left atrial appendage (LAA) volumes in patients with or without CD. METHODS AND RESULTS: In the population of patients referred to our laboratory for a conventional MSCT coronary angiography, 40 individuals without CD (Normal group) and 80 patients with CD (CD group) were prospectively selected. The CD group was constituted from 4 subgroups of patients with either coronary artery disease (n=20), idiopathic dilated cardiomyopathy (n=20), left ventricular hypertrophy (n=20) or severe mitral regurgitation (MR group, n=20). LAA and LA volumes were measured on a commercially available workstation. LA maximal and minimal volumes were lower in Normal group than in CD group, as LA ejection fraction (54+/-10 versus 67+/-20 ml/m(2), p<0.0001; 31+/-8 versus 46+/-20 ml/m(2), p<0.0001; 43+/-8% versus 33+/- 14%, p<0.001). LAA volume was larger in MR group than in Normal group (15+/-7 ml versus 9+/-3 ml, p<0.0001). CONCLUSION: This MSCT study provides normal values of LA and LAA volumes for patients who underwent MSCT coronary angiography and suggests that MSCT is helpful to assess the changes of LA volumes related to various CD.

A new method for measurement of left atrial volumes using 64-slice spiral computed tomography: comparison with two-dimensional echocardiographic techniques.

BACKGROUND: Left atrial (LA) volume, is related to cardiovascular morbidity. LA enlargement is usually assessed using trans-thoracic echocardiography (TTE). The association of modern multislice computed tomography (MSCT) imaging and new 3D reconstruction software, allows direct cardiac chamber volume measurement without geometrical assumptions. This study was designed to evaluate the maximal (LAmax) and minimal (LAmin) LA volumes during the cardiac cycle using MSCT and TTE approaches. METHODS: We screened 26 consecutive patients referred for coronary imaging using a 64-MSCT scanner and a TTE within 12 h. Contiguous multiphase images were generated from axial MSCT data and semi-automated 3D segmentation technique was applied to generate LA volumes. Using TTE, LA volumes and LA ejection fraction (LAEF) were obtained using five assumptions methods: cubing equation, diameter-length formula, area-length formula, ellipsoidal formula and biplane Simpson rule. RESULTS: Five patients were excluded for inadequate TTE visualization and one for ectopic beats during MSCT. The sample consisted in 20 patients (11 men, age: 56+/-14 years). Using MSCT, LA volumes indexed to body surface area were: LAmax=74+/-27 ml/m(2), LAmin=49+/-26 ml/m(2), with close correlations with TTE measurements and a significant underestimation by all TTE approaches. A close correlation was observed between LAEF using MSCT and TTE Simpson's method: 36+/-14% vs. 37+/-14%, r=0.99, p<0.0001. CONCLUSION: Theses results suggest that the assessment of LA volumes and ejection fraction was reliable using 64-MSCT in patients referred for coronary computed tomography imaging.

Heart transplantation in systemic (AL) amyloidosis: a retrospective study of eight French patients.

BACKGROUND: Immunoglobulinic (AL) amyloidosis is a complication of plasma cell dyscrasia, characterized by widespread deposition of amyloid fibrils derived from monoclonal light chains. Cardiac amyloid is the main prognostic factor, with a median survival of six months. Cardiac transplantation in AL amyloidosis is associated with high mortality, due to disease recurrence in the allograft and systemic progression. Suppression of light chain (LC) production with chemotherapy by melphalan plus dexamethasone (MD) or high dose melphalan followed by autologous stem cell transplantation (HDM/ASCT) improves survival. However, both the indications and results of chemotherapy in patients transplanted for cardiac AL amyloidosis remain unclear. AIMS: To assess the outcome of cardiac transplantation and haematological therapy in patients with cardiac AL amyloidosis. METHODS: Eight French patients, who underwent heart transplantation for cardiac AL amyloidosis between 2001 and 2006 were studied retrospectively. RESULTS: Before transplantation, six patients received MD (n=5) or HDM/ASCT (n=1). Haematological remission was obtained in three patients treated with MD. In the three remaining patients, postoperative HDM/ASCT (n=2) or allogeneic bone marrow transplantation (n=1) resulted in haematological remission in one patient. In 2 patients not treated before transplantation, post-operative treatment with MD resulted in complete hematological remission in one. After a median follow-up of 26 months from cardiac transplantation, six patients were alive and four had sustained haematological remission, as indicated by normal serum free LC levels. CONCLUSION: Appropriate haematological therapy, including MD, may result in a survival benefit in AL amyloidosis patients with advanced heart failure requiring transplantation.

Successful heart transplantation following melphalan plus dexamethasone therapy in systemic AL amyloidosis.

Recurrence in the allograft and progression in other organs increase mortality after cardiac transplantation in AL amyloidosis. Survival may be improved after suppression of monoclonal light chain (LC) production following high dose melphalan and autologous stem cell transplantation (HDM/ASCT). However, because of high treatment related mortality, this tandem approach is restricted to few patients without significant extra-cardiac involvement. A diagnosis of systemic AL amyloidosis was established in a 45-year old patient with congestive heart failure related to restrictive cardiomyopathy, nephrotic syndrome, peripheral neuropathy, postural hypotension, macroglossia, and lambda LC monoclonal gammopathy. After melphalan and dexamethasone (M-Dex) therapy, which resulted in 80% reduction of serum free lambda LC, he underwent orthotopic cardiac transplantation. Two years later, he remains in a sustained hematologic remission, with no evidence of allograft or extra-cardiac amyloid accumulation. M-Dex should be considered as an alternative therapy in AL amyloid heart transplant recipients ineligible for HDM/ASCT.