Association between anxiety and mortality in patients with congestive heart failure after implantation of cardiac electronic devices.

OBJECTIVE: Several studies suggest that psychological factors including anxiety are associated with negative outcomes and in particular higher mortality rates among heart failure (HF) patients. However, the impact of anxiety on mortality in patients with implanted cardiac devices has not been fully appreciated. The aim of this study was to assess the association between state (SA) and trait (TA) anxiety and all-cause mortality in patients with HF after cardiac electronic devices implantation. METHODS: The monocentric prospective study enrolled 265 patients (215 men and 50 women) aged 23 to 84 years (mean age 57.1 ± 10.0), who received cardiac resynchronization therapy or cardioverter-defibrillator implantation. Mean duration of prospective follow-up was 62.3 ± 36.6 months. State-Trait Anxiety Inventory (STAI) was used to measure anxiety symptoms. Cox proportional hazards multivariate regression model was used to calculate hazard ratio (HR) of all-cause mortality with 95% confidence interval (95% CI). RESULTS: During the prospective follow-up period, 45 (17.0%) patients died due to all causes. According to quantitative analysis, HR for death used for SA scale was 1.04 (95% CI 1.00-1.07, p = 0.07) and for the TA scale 1.02 (95% CI 0.99-1.05, p = 0.21). Analysis of categorical indicators found statistically significant higher HR of mortality in patients with severe SA (2.35, 95% CI 1.17-4.71, p = 0.02), and TA (2.02, 95% CI 1.04-3.94, p = 0.04). CONCLUSION: High levels of SA and TA was significantly and independently associated with a high risk of all-cause mortality in patients, who underwent implantation of cardiac electronic devices.

Depression and all-cause mortality in patients with congestive heart failure and an implanted cardiac device.

OBJECTIVE: The purpose of this study was to assess the association between depression and all-cause mortality in patients with congestive heart failure (CHF) and an implanted cardiac device. METHODS: The study enrolled 260 patients (mean age 56.8±10.0 years; 83.1% male) with CHF and an implanted cardiac device (156 patients with a resynchronization therapy cardiac device, 104 patients with an implantable cardioverter defibrillator). The mean duration of follow-up was 48.6±32.2 months. The Beck Depression Inventory was used to measure depressive symptoms. Depression was considered absent for a score between 0 and 9, mild to moderate for a score between 10 and 18, and severe if the score was 19 or greater. The Cox proportional hazards regression model was used to estimate hazard ratios (HR) with a 95% confidence interval (CI) for the impact of depression on all-cause mortality. The HR was calculated after adjustment for the following confounders: age, gender, smoking status, hypertension, diabetes mellitus, body mass index, hypercholesterolemia, left ventricular ejection fraction, number of hemodynamically significant lesions of the coronary arteries, and the type of implanted cardiac device. RESULTS: During the follow-up period, 37 patients died (14.2%). The adjusted HR of depression for all-cause mortality was 1.05, with a 95% CI of 1.01-1.09. Patients without depression were accepted as a reference group with HR=1.0 for analysis of the categorical indicator. The HR was 1.32, with a 95% CI of 0.57-3.03, in patients with mild depressive symptoms, and the HR was 3.18 with a 95% CI of 1.31-7.73 in patients with severe depressive symptoms. CONCLUSION: Increased depressive symptoms were independently associated with all-cause mortality in patients with CHF and an implanted cardiac device.

Real-world geographic variations in the use of cardiac implantable electronic devices-The PANORAMA 2 observational cohort study.

BACKGROUND: Currently, several geographies around the world remain underrepresented in medical device trials. The PANORAMA 2 study was designed to assess contemporary region-specific differences in clinical practice patterns of patients with cardiac implantable electronic devices (CIEDs). METHODS: In this prospective, multicenter, observational, multinational study, baseline and implant data of 4,706 patients receiving Medtronic CIEDs (Medtronic plc, Minneapolis, MN, USA; either de novo device implants, replacements, or upgrades) were analyzed, consisting of: 54% implantable pulse generators (IPGs), 20.3% implantable cardiac defibrillators (ICDs), 15% cardiac resynchronization therapy -defibrillators, and 5.1% cardiac resynchronization therapy -pacemakers, from 117 hospitals in 23 countries across four geographical regions between 2012 and 2016. RESULTS: For all device types, in all regions, there were fewer females than males enrolled, and women were less likely to have ischemic cardiomyopathy. Implant procedure duration differed significantly across the geographies for all device types. Subjects from emerging countries, women, and older patients were less likely to receive a magnetic resonance imaging-compatible device. Defibrillation testing differed significantly between the regions. European patients had the highest rates of atrial fibrillation (AF), and the lowest number of implanted single-chamber IPGs. Evaluation of stroke history suggested that the general embolic risk is more strongly associated with stroke than AF. CONCLUSIONS: We provide comprehensive descriptive data on patients receiving Medtronic CIEDs from several geographies, some of which are understudied in randomized controlled trials. We found significant variations in patient characteristics. Several medical decisions appear to be affected by socioeconomic factors. Long-term follow-up data will help evaluate if these variations require adjustments to outcome expectations.

Gender in cardiac resynchronisation therapy.

Introduction: Gender differences in cardiac resynchronisation therapy (CRT) response are not clear enough. This study aimed to assess gender influence on systemic inflammation, neurohormonal activation, fibrosis in patients with congestive heart failure (CHF) and CRT. Methods: We compared group I (61 men) and group II (16 women) of patients undergoing CRT. Plasma levels of Nt-proBNP, interleukin (IL)-1ß, IL-6, IL-10, tumor necrosis factor alpha (TNF-α), C-reactive protein, galectin-3 (Gal-3), metalloproteinase-9 (MMP-9), tissue inhibitors of metalloproteinase 1 and 4 (TIMP-1, TIMP-4), ratio MMP-9/TIMP-1, MMP-9/TIMP-4 were measured. According to dynamics of left ventricular end-systolic volume patients were classified into non-responders, responders, super-responders. Results: Women more likely had left bundle branch block (81.3 vs 47.5%, P = 0.016), were more super-responders (66.7 vs 30.5%). Both groups showed decrease of IL-6 (P < 0.05), TNF-α (P < 0.001; P < 0.05), NT-proBNP (P = 0.001; P < 0.05), Gal-3 (P < 0.05). In women there was decrease of IL-6 by 44.4 vs 23.5% in men (PP = 0.029), TNF-α by 41.4 vs 30.9%, NT-proBNP by 73.3 vs 46% (P = 0.002), Gal-3 by 82.3 vs 64.9% (P < 0.05). Group I also showed decrease of IL-10 by 34.2% (P < 0.05). Group dynamics of TIMP-1 was opposite: men showed tendency to reduction of TIMP-1 (P = 0.054), women showed increase of TIMP-1 (P < 0.05). Besides, men showed decrease of MMP-9 (P < 0.05) and ratio MMP-9/TIMP-4 (P < 0.05). Conclusion: The best response to CRT is associated with female gender explained by greater decrease of neurohormonal activation, systemic inflammation and fibrosis. The revealed opposite dynamics of TIMP-1 in the groups can demonstrate the existence of gender features of matrix metalloproteinase system activity and their tissue inhibitors.

Comparison of squatting stress echocardiography and dobutamine stress echocardiography for the diagnosis of coronary artery disease.

BACKGROUND: Dobutamine stress echocardiography (DSE) is commonly used for the diagnosis for coronary artery disease (CAD). We previously demonstrated that squatting induces wall motion abnormalities (WMA) in areas subtended by stenotic coronary arteries. OBJECTIVE: This study was designed to test the hypothesis that dobutamine and squatting stress echocardiography are equally useful for the diagnosis of CAD. METHODS: We studied 39 patients who were scheduled to have coronary angiography for the evaluation of chest pain. Each patient had squatting stress echocardiography followed by DSE. For squatting stress echocardiography the echocardiogram in standard views was recorded in the standing position. The procedure was repeated during squatting for 2 minutes. Dobutamine echocardiography was performed using standard protocol. The squatting and dobutamine stress echocardiograms were interpreted by an observer blinded to the results of coronary angiography. RESULTS: During squatting, new or worsening WMA developed in 20 patients. Six patients developed WMA in the left anterior descending artery territory, three in circumflex territory, three in the right coronary artery territory, and eight in multiple coronary territories. The sensitivity, specificity, and accuracy of squatting echocardiography for diagnosis of CAD were 95%, 94%, and 94%, respectively. For DSE, the sensitivity, specificity, and accuracy for the diagnosis of CAD were 85%, 94%, and 90%, respectively. There was no significant difference between squatting and dobutamine stress echocardiography for the diagnosis of CAD (P = 0.702). CONCLUSION: These data indicate that squatting and dobutamine echocardiography are equally useful in the diagnosis of CAD. In selected patients, squatting echocardiography may be used in place of dobutamine echocardiography for the diagnosis of CAD.

Clinical manifestations and risk factors of coronary artery disease in patients with diabetes mellitus in western Siberia.

OBJECTIVE: To compare the prevalence of cardiovascular risk factors and clinical manifestations of coronary artery disease (CAD) between patients with type 2 diabetes mellitus (DM) and CAD who lived at northern latitudes vs. those who resided at southern latitudes in the Tyumen region, western Siberia. STUDY DESIGN: This retrospective study involved 382 patients with type 2 DM selected from 8,573 patients with angiographic CAD (>50% stenosis). Out of the total, 243 patients were permanent residents at the high latitudes of the Tyumen region ("northern patients"), and 139 patients were permanent residents in areas south of the Tyumen region ("southern patients"). RESULTS: On average, northern patients were younger than southern patients (53 vs. 57 years, respectively). The odds ratio (OR) for living in the north was 2.1 (95% CI 0.99-4.53) for obesity (BMI>or=30 kg/m2), 1.87 (95% CI 1.05-3.31) for smoking, 0.93 (95% CI 0.89-0.96) per 1 year increase in age, 0.84 (95% CI 0.76-0.94) per 1 mmol/L increase of fasting plasma glucose, and 1.15 (95% CI 1.04-1.28) per 1 mm increase of right ventricular end-diastolic diameter. The proportion of patients with 3 or more CAD risk factors was higher in the north. Most patients in both groups had a history of myocardial infarction, severe angina in class III/IV as defined by the Canadian Cardiovascular System (CCS), heart failure in class II/IV as defined by the New York Heart Association (NYHA) and hypertension. CONCLUSIONS: A north-south gradient was observed in cardiovascular risk factors among patients with DM and CAD in the Tyumen region. The clinical manifestations of CAD in DM patients at high latitudes were comparable with those of patients who reside south of the Tyumen region of western Siberia, despite the younger age of northern patients.

Asymmetric septal hypertrophy in patients with coronary artery disease.

AIMS: To assess the relationship between asymmetric septal hypertrophy (ASH) and manifestations of coronary artery disease (CAD). METHODS AND RESULTS: A total of 5128 consecutive patients with proven diagnosis of CAD were examined. There were 2469 patients with left ventricular (LV) hypertrophy (LVH) (48.2%), among whom 297 (5.8%) had ASH (echocardiographic ventricular septum thickness to LV posterior wall thickness ratio > or =1.3). There were more male patients with ASH than patients with symmetric LVH (SLVH). ASH patients were significantly older and more obese, more of them were in NYHA class III/IV compared with SLVH patients. The prevalence of prior myocardial infarction (MI), systemic hypertension, heart rhythm disorders were higher in patients with ASH compared with SLVH patients. The groups differed significantly in echocardiographic parameters: LV and right ventricular (RV) end-diastolic dimensions, LV ejection fraction, left atrial dimension, extent of LV wall motion abnormalities, wall motion score index, LV mass/body surface area, signs of prior MI, and frequency of moderate mitral regurgitation. The frequency of stenosis and more severe (>90% stenosis) lesion of right coronary artery (RCA) and left circumflex artery (LCA) were higher in patients with ASH. Multivariate analysis identified that heart rhythm disorder, LV and RV end-diastolic dimensions, aortic root diameter, impaired LV ejection fraction, echocardiographic signs of previous MI, LV mass, and severe lesions of RCA were independently associated with ASH. CONCLUSION: In patients with CAD, ASH is associated with significant atherosclerosis of RCA and LCA, and more severe clinical manifestations of CAD and impaired LV function.