Clinical and prognostic association of total atrial conduction time in patients with heart failure: a report from Studies Investigating Co-morbidities Aggravating Heart Failure.

BACKGROUND: The total atrial conduction time can be measured as the time from the onset of the P wave on the ECG to the peak of the A wave recorded at the mitral annulus using tissue Doppler imaging (A'; P-A'TDI); when prolonged, it might predict incident atrial fibrillation. METHODS: We measured P-A'TDI in outpatients with heart failure and sinus rhythm enrolled in the SICA-HF programme. RESULTS: P-A'TDI measured at the lateral mitral annulus was longer in patients with HF with reduced [LVEF<50%, N = 141; 126 (112-146) ms; P = 0.005] or preserved left ventricular ejection fraction [LVEF>50% and NT-proBNP > 125 ng/l, N = 71; 128 (108-145) ms; P = 0.026] compared to controls [N = 117; 120 (106-135) ms]. Increasing age, left atrial volume and PR interval were independently associated with prolonged P-A'TDI. During a median follow-up of 1251 (956-1602) days, 73 patients with heart failure died (N = 42) or developed atrial fibrillation (N = 31). In univariable analysis, P-A'TDI was associated with an increased risk of the composite outcome of death or atrial fibrillation, but only increasing log [NT-proBNP], age and more severe symptoms (NYHA III vs. I/II) were independently related to this outcome. Patients in whom both P-A'TDI and left atrial volume were above the median (127 ms and 64 ml, respectively) had the highest incidence of atrial fibrillation (hazard ratio 6.61, 95% CI 2.27-19.31; P < 0.001 compared with those with both P-A'TDI and LA volume below the median). CONCLUSION: Measuring P-A'TDI interval identifies patients with chronic heart failure at higher risk of dying or developing atrial fibrillation during follow-up.

This patient is not breathing properly: is this COPD, heart failure, or neither?

INTRODUCTION: Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are two common, heterogeneous, long-term illnesses which cause significant morbidity and mortality. Although they both present with breathlessness, they are treated differently. Treatment of COPD focuses mainly on relieving short-term breathlessness, whilst treatment of HF has focused on long term morbidity and mortality. Areas covered: In this review, we aim to highlight the diagnostic challenges in distinguishing COPD from HF. We also explore the implications of their overlap, and the use of biomarkers and treatments for HF in patients with COPD to improve long-term outcomes. Expert commentary: Cardiovascular morbidity and mortality amongst patients with COPD is substantial. Approaches which identify patients with COPD at highest cardiovascular risk may therefore be helpful. A trial targeting those patients with COPD and raised natriuretic peptide levels might be the way to test whether cardiovascular medication has anything to offer the respiratory patient.

Effect of beta-adrenergic blockade with carvedilol on cachexia in severe chronic heart failure: results from the COPERNICUS trial.

BACKGROUND: Cardiac cachexia frequently accompanies the progression of heart failure despite the use of effective therapies for left ventricular dysfunction. Activation of the sympathetic nervous system has been implicated in the pathogenesis of weight loss, but the effects of sympathetic antagonism on cachexia are not well defined. METHODS: We prospectively evaluated changes in body weight in 2289 patients with heart failure who had dyspnoea at rest or on minimal exertion and a left ventricular ejection fraction <25%. Patients were randomly assigned (double-blind) to receive either placebo (n = 1133) or carvedilol (n = 1156) and were followed for the occurrence of major clinical events for up to 29 months (COPERNICUS trial). Patients were not enrolled if they had signs of clinically significant fluid retention due to heart failure. RESULTS: Patients in the carvedilol group were 33% less likely than patients in the placebo group to experience a further significant loss of weight (>6%) (95% confidence interval: 14-48%, P = 0.002) and were 37% more likely to experience a significant gain in weight (≥5%) (95% confidence interval: 12-66%, P = 0.002). Carvedilol's ability to prevent weight loss was most marked in patients with increased body mass index at baseline, whereas its ability to promote weight gain was most marked in patients with decreased body mass index at baseline. Increases in weight were not accompanied by evidence of fluid retention. Baseline values for body mass index and change in body weight were significant predictors of survival regardless of treatment. CONCLUSIONS: Carvedilol attenuated the development and promoted a partial reversal of cachexia in patients with severe chronic heart failure, supporting a role for prolonged sympathetic activation in the genesis of weight loss.