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Background A thorough analysis of noncardiac determinants of mortality in heart failure (HF) is missing. Furthermore, evidence conflicts on the outcome of patients with HF and no or mild systolic dysfunction. We aimed to investigate the prevalence of noncardiac and cardiac causes of death in a cohort of chronic HF patients, covering the whole spectrum of systolic function. Methods and Results We enrolled 2791 stable HF patients, classified into HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction [EF] <40%), HR with midrange EF (HFmrEF; left ventricular EF 41-49%), or HF with preserved EF (HFpEF; left ventricular EF ≥50%), and followed up for all-cause, cardiac, and noncardiac mortality (adjudicated as due to cancer, sepsis, respiratory disease, renal disease, or other causes). Over follow-up of 39 months, adjusted mortality was lower in HFpEF and HFmrEF versus HFrEF (hazard ratio: 0.75 [95% CI, 0.67-0.84], P<0.001 for HFpEF; hazard ratio: 0.78 [95% CI, 0.63-0.96], P=0.017 for HFmrEF). HFrEF had the highest rates of cardiac death, whereas noncardiac mortality was similar across left ventricular EF categories. Noncardiac causes accounted for 62% of deaths in HFpEF, 54% in HFmrEF and 35% in HFrEF; cancer was twice as frequent as a cause of death in HFpEF and HFmrEF versus HFrEF. Yearly rates of noncardiac death exceeded those of cardiac death since the beginning of follow-up in HFpEF and HFmrEF. Conclusions Noncardiac death is a major determinant of outcome in stable HF, exceeding cardiac-related mortality in HFpEF and HFmrHF. Comorbidities should be regarded as main therapeutic targets and objects of dedicated quality improvement initiatives, especially in patients with no or mild systolic dysfunction.
Assuntos
Insuficiência Cardíaca/mortalidade , Ventrículos do Coração/diagnóstico por imagem , Volume Sistólico/fisiologia , Função Ventricular Esquerda/fisiologia , Idoso , Causas de Morte/tendências , Ecocardiografia , Feminino , Seguimentos , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/fisiopatologia , Humanos , Itália/epidemiologia , Masculino , Prognóstico , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida/tendênciasRESUMO
BACKGROUND: Previous studies have investigated the role of intrinsic conduction in optimizing cardiac resynchronization therapy. We investigated the role of fusing pacing-induced activation and intrinsic conduction in cardiac resynchronization therapy by evaluating the acute hemodynamic effects of simultaneous His-bundle (HIS) and left ventricular (LV) pacing. METHODS AND RESULTS: We studied 11 patients with systolic heart failure and left bundle-branch block scheduled for cardiac resynchronization therapy implantation. On implantation, LV pressure-volume data were determined via conductance catheter. Standard leads were placed in the right atrium, at the right ventricular apex, and in a coronary vein. An additional electrode was temporarily positioned in the HIS. The following pacing configurations were systematically assessed: standard biventricular (right ventricular apex+LV), LV-only, HIS, simultaneous HIS and LV (HIS+LV). Each configuration was compared with the AAI mode at multiple atrioventricular delays (AVD). In comparison with the AAI, right ventricular apex+LV and LV-only pacing resulted in improved stroke volume (85±32 mL and 86±33 mL versus 58±23 mL; P<0.001), stroke work, maximum pressure derivative, and systolic dyssynchrony at individually optimized AVD. The optimal AVD was close to the P-H interval in the majority of patients. By contrast, HIS-LV pacing improved hemodynamic indexes at all AVD (stroke volume >76 mL at all fixed intervals and 88±31 mL at optimal interval; all P<0.001). CONCLUSIONS: Standard right ventricular apex+LV and LV-only pacing enhanced systolic function and LV synchrony at individually optimized AVD close to the measured intrinsic P-H interval. By contrast, HIS+LV pacing yielded improvements, regardless of AVD setting. These findings support the hypothesis of the crucial role of intrinsic right ventricular conduction in optimal cardiac resynchronization therapy delivery.
Assuntos
Fascículo Atrioventricular/fisiopatologia , Bloqueio de Ramo/terapia , Terapia de Ressincronização Cardíaca/métodos , Insuficiência Cardíaca/terapia , Hemodinâmica/fisiologia , Idoso , Idoso de 80 Anos ou mais , Bloqueio de Ramo/fisiopatologia , Eletrocardiografia , Feminino , Seguimentos , Insuficiência Cardíaca/fisiopatologia , Ventrículos do Coração/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento , Pressão VentricularRESUMO
BACKGROUND: The use of cardiac resynchronization therapy (CRT) and implantable cardioverter- defibrillator (ICD) for advanced heart failure (HF) is increasing. Renal dysfunction is a common condition in HF which is associated with a worse survival. The study aims at identifying in patients with advanced HF treated with CRT the effect of baseline glomerular filtration rate (GFR), GFR improvement and left ventricular ejection fraction (LVEF) change, after 6-months of CRT implant, on survival. METHODS: The study population consisted of 375 advanced HF patients who received a CRT between 1999 and 2009, of these 277 received also an ICD implant. Clinical characteristics (New York Heart Association [NYHA] functional class, ischemic vs. non-ischemic etiology, atrial fibrillation, diabetes, hypertension, LVEF, QRS duration and GFR were recorded. The use of common used drugs was evaluated. Cox proportional hazards analysis was calculated in order to evaluate variables associated to mortality. RESULTS: During a median follow-up of 43.0 months, 93 (24.8%) patients died. Patients deceased during the study had at baseline higher NYHA class and lower LVEF and GFR. In Cox regression analysis, GFR predicts long-term mortality (hazard ratio [HR] 0.983; 95% confidence interval [CI] 0.969-0.998; p = 0.023) independently from the effect of others covariates. In addition, a positive GFR improvement 6 months after CRT implant is significantly associated with a lower hazard of mortality (for each 10 mL/min of GFR improvement HR 0.86; 95% CI 0.75-0.99; p = 0.038). CONCLUSIONS: GFR is a significant predictor of mortality in advanced HF patients who received CRT. A GFR improvement 6 months after CRT implant is significantly associated with a lower hazard of mortality.
Assuntos
Terapia de Ressincronização Cardíaca , Cardioversão Elétrica , Insuficiência Cardíaca/terapia , Nefropatias/fisiopatologia , Rim/fisiopatologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia de Ressincronização Cardíaca/efeitos adversos , Terapia de Ressincronização Cardíaca/mortalidade , Dispositivos de Terapia de Ressincronização Cardíaca , Distribuição de Qui-Quadrado , Doença Crônica , Desfibriladores Implantáveis , Cardioversão Elétrica/efeitos adversos , Cardioversão Elétrica/instrumentação , Cardioversão Elétrica/mortalidade , Feminino , Taxa de Filtração Glomerular , Insuficiência Cardíaca/diagnóstico , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/fisiopatologia , Humanos , Nefropatias/diagnóstico , Nefropatias/mortalidade , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Recuperação de Função Fisiológica , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Volume Sistólico , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda , Adulto JovemRESUMO
Patients' response to dual antiplatelet therapy (DAPT) is subject to variations and its monitoring allows to individualize this therapy. In this study, we evaluated if a strategy of tailored DAPT after platelet function testing could reduce high on-treatment platelet reactivity (HPR) and improve outcome of patients treated with stent implantation. In 257 patients undergoing percutaneous angioplasty, platelet function was measured by light transmittance aggregometry (LTA) using 10 µM/L adenosine-diphosphate (ADP) and 1 mM arachidonic acid (AA) as agonists. Patients with HPR by ADP (≥70%) were switched to double-dose clopidogrel, ticlopidine, prasugrel or ticagrelor; in patients with HPR by AA (≥20%) acetylsalicylic acid dose was increased if not contraindicated. Platelet function analysis was repeated 48 hours after therapy variation. At 20-month follow-up major adverse cardiovascular events (MACE) and bleedings were assessed. HPR was detected in 97/257 (37.7%) patients: 69/257 (26.8%) had HPR by ADP and 71/257 (27.6%) had HPR by AA. In patients with HPR by ADP or by AA, tailored DAPT determined a significant reduction in residual platelet reactivity. No significant difference in MACE or bleeding occurrence was documented in HPR patients treated with tailored DAPT vs. those without HPR. HPR patients treated with tailored DAPT had significant lower follow-up MACE and deaths vs. 139 HPR patients not switched, even after propensity score analysis. These results suggest that a DAPT tailored on platelet testing can improve antiplatelet response in HPR patients, possibly reducing their thrombotic events to a level similar to non-HPR patients, without increasing the risk of bleeding.
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Síndrome Coronariana Aguda/tratamento farmacológico , Quimioterapia Combinada/métodos , Inibidores da Agregação Plaquetária/uso terapêutico , Testes de Função Plaquetária , Stents/efeitos adversos , Síndrome Coronariana Aguda/cirurgia , Idoso , Aspirina/uso terapêutico , Plaquetas/efeitos dos fármacos , Clopidogrel , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Stents/tendências , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêuticoRESUMO
We present a very rare case of paraneoplastic syndrome characterized by the unusual coexistence of a left ventricular apical thrombus and pulmonary embolism as the first manifestation of an unrecognized lung adenocarcinoma.
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Guidelines stated that extracorporeal membrane oxygenation (ECMO) may improve outcomes after refractory cardiac arrest (CA) in cases of cardiogenic shock and witnessed arrest, where there is an underlying circulatory disease amenable to immediate corrective intervention. Due to the lack of randomized trials, available data are supported by small series and observational studies, being therefore characterized by heterogeneity and controversial results. In clinical practice, using ECMO involves quite a challenging medical decision in a setting where the patient is extremely vulnerable and completely dependent on the medical team's judgment. The present review focuses on examining existing evidence concerning inclusion and exclusion criteria, and outcomes (in-hospital and long-term mortality rates and neurological recovery) in studies performed in patients with refractory CA treated with ECMO. Discrepancies can be related to heterogeneity in study population, to differences in local health system organization in respect of the management of patients with CA, as well as to the fact that most investigations are retrospective. In the real world, patient selection occurs individually within each center based on their previous experience and expertise with a specific patient population and disease spectrum. Available evidence strongly suggests that in CA patients, ECMO is a highly costly intervention and optimal utilization requires a dedicated local health-care organization and expertise in the field (both for the technical implementation of the device and for the intensive care management of these patients). A careful selection of patients guarantees optimal utilization of resources and a better outcome.
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Oxigenação por Membrana Extracorpórea/métodos , Parada Cardíaca/terapia , Adolescente , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/metabolismo , Reanimação Cardiopulmonar/métodos , Criança , Hospitalização , Humanos , Pessoa de Meia-Idade , Parada Cardíaca Extra-Hospitalar/terapia , Medição de Risco , Taxa de Sobrevida , Resultado do Tratamento , Adulto JovemAssuntos
Oxigenação por Membrana Extracorpórea/métodos , Parada Cardíaca/mortalidade , Parada Cardíaca/terapia , Terapia de Substituição Renal/métodos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/mortalidade , Injúria Renal Aguda/terapia , Estudos de Coortes , Cuidados Críticos/métodos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Seguimentos , Parada Cardíaca/diagnóstico , Mortalidade Hospitalar , Humanos , Unidades de Terapia Intensiva , Masculino , Terapia de Substituição Renal/mortalidade , Estudos Retrospectivos , Medição de Risco , Análise de Sobrevida , Fatores de Tempo , Resultado do TratamentoAssuntos
Hemorragia Cerebral/mortalidade , Oxigenação por Membrana Extracorpórea/métodos , Hemorragia Gastrointestinal/mortalidade , Parada Cardíaca/terapia , Reanimação Cardiopulmonar/métodos , Reanimação Cardiopulmonar/mortalidade , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/terapia , Estudos de Coortes , Cuidados Críticos/métodos , Transfusão de Eritrócitos/métodos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Feminino , Seguimentos , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/terapia , Parada Cardíaca/mortalidade , Humanos , Unidades de Terapia Intensiva , Masculino , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Análise de Sobrevida , Resultado do TratamentoRESUMO
In this paper, two different aspects of the relationship between chronic kidney disease and sudden cardiac death (SCD) have been reviewed. In end-stage renal disease patients, SCD risk is increased, and among patients implanted with a cardioverter defibrillator (ICD), dialysed ones carry a superior relative risk compared to non-dialysed ones. Cardiorenal syndrome patients have increase in SCD risk, and when receiving ICD implantation, survival improves.