Non-thyroidal Illness in Children with Congestive Heart Failure

Objective: To estimate the proportion and risk factors of non-thyroidal illness (NTI) in children with congenital heart disease (CHD) with congestive heart failure (CHF). Methods: This study enrolled children (6 weeks to 60 months age) with CHD and CHF. The clinical profile and disease severity, derived from the Pediatric Early Warning Score (PEWS) was recorded. Baseline blood samples were taken within 24 hours of hospitalization and evaluated for free tri-iodothyronine (fT3), free thyroxine (fT4), thyroid stimulating hormone (TSH), N-terminal pro-brain natriuretic peptide (NT pro-BNP) and reverse T3. Results: A total of 80 (64 acyanotic CHD) children of median (interquartile range) age 5 (2.5, 8.0) months were enrolled. NTI was seen in 37 (46%) of whom 27 had low fT3 levels. The proportion of NTI was highest in children with severe disease (20/30), than moderate (4/9) or mild disease (13/41) (p=0.018). Ten (27%) patients with NTI died compared to 2 (4.7%) without NTI with unadjusted odds ratio (OR) [95% confidence interval (CI)] 7.593 (1.54, 37.38); p=0.006. After adjusting for NTI, shock and NT-pro-BNP levels, PEWS was the only significant predictor of mortality (OR: 1.41, 95% CI: 1.03, 1.92; p=0.032). Linear regression for fT3 identified a significant relationship with log NT-BNP [beta -3.541, (95% CI: -1.387, -0.388)] and with TSH [beta 2.652 (95% CI: 0.054, 0.383)]. The cutoff (area under the curve, 95% CI) that predicted mortality were fT4 <14.5 pmol/L (0.737, 0.60, 0.88), fT3/rT3 index <1.86 pg/ng (0.284, 0.129, 0.438) and NT pro-BNP >3725 pg/mL (0.702; 0.53, 0.88). Conclusion: NTI was present in a significant proportion of children with CHD and CHF. fT3 level was significantly associated with NTBNP levels and thus severity of CHF.

Effect of ivabradine vs atenolol on heart rate and effort tolerance in patients with mild to moderate mitral stenosis and normal sinus rhythm.

BACKGROUND: Patients with mitral stenosis become symptomatic at a higher heart rate. We studied the comparative efficacy of heart rate control with ivabradine or atenolol and its effect on effort tolerance in patients with mild-moderate mitral stenosis in normal sinus rhythm. METHODS AND RESULTS: Fifty patients with mild-moderate mitral stenosis in sinus rhythm were randomized to receive ivabradine or atenolol for 4 weeks each in an open-label, randomized, crossover design trial. A 24-hour Holter and treadmill test was performed at baseline and after each active treatment period. In the first treatment period, 23 patients were allocated to ivabradine (22 analyzed), and 27 were allocated to atenolol (26 analyzed). In the second period, all 48 patients were analyzed. Ivabradine increased the mean total exercise time to 500.7 seconds (SD 99.7) from a baseline of 410.3 seconds (SD 115.4), and atenolol increased it to 463.7 seconds (SD 113.1). The point estimate (absolute difference between ivabradine and atenolol) was 35.27 seconds (95% CI 15.24-55.20; P = .0009). The point estimate for decrease in the maximum exercise heart rate and mean heart rate were 7.64/min (95% CI 0.37-15.9; P = .04) and 5.61/min (95% CI 2.51-8.71; P = .0007), respectively. CONCLUSIONS: Ivabradine is more effective than atenolol for effort related symptoms in patients with mild-moderate mitral stenosis and normal sinus rhythm.