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JACC : Heart Failure
   Full-text available via subscription Subscription journal
     ISSN (Online) 2213-1779
     Published by American College of Cardiology Foundation Homepage  [1 journal]
  • Correction
    • Abstract: Zile MR, Gaasch WH, Patel K, Aban I, Ahmed A
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Polymorphic Variation in the G-Protein Beta-3 Subunit Gene and Response to
           BiDil in A-HeFT Basis for an African-American Pharmacogenetic Advantage to
           Nitric Oxide Donor Therapy? ∗
    • Authors: Bristow MR.
      Abstract: Guanine nucleotide-binding proteins, or G-proteins, typically provide the major signal transducing step between agonist occupancy of a 7-transmembrane receptor and effector mechanisms. G-proteins consist of 3 subunits (α, β, and γ); the β and γ subunits are tightly bound and typically function as a “βγ” subunit. Both the α and βγ subunits serve signal transduction functions. G-protein–coupled receptor (GPCR) activation catalyzes guanosine diphosphate (GDP)–guanosine triphosphate (GTP) exchange that results in temporary dissociation of α and βγ subunits, and each is then free to effect downstream signaling via protein-protein interactions. Signal transduction via free/activated α subunits is well known (e.g., stimulation and inhibition of adenylyl cyclase). βγ−subunit–mediated signal transduction was appreciated later but is also important and includes muscarinic activation of cardiac Kir3.1 channels (1), β-adrenergic activation of G-protein–coupled receptor kinase-2 (GRK2) (2), and GPCR responses known to be operative in vascular smooth muscle (3–5).
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Race, Common Genetic Variation, and Therapeutic Response Disparities in
           Heart Failure
    • Authors: Taylor MR; Sun AY, Davis G, et al.
      Abstract: Because of its comparatively recent evolution, Homo sapiens exhibit relatively little within-species genomic diversity. However, because of genome size, a proportionately small amount of variation creates ample opportunities for both rare mutations that may cause disease as well as more common genetic variations that may be important in disease modification or pharmacogenetics. Primarily because of the East African origin of modern humans, individuals of African ancestry (AA) exhibit greater degrees of genetic diversity than more recently established populations, such as those of European ancestry (EA) or Asian ancestry. Those population effects extend to differences in frequency of common gene variants that may be important in heart failure natural history or therapy. For cell-signaling mechanisms important in heart failure, we review and present new data for genetic variation between AA and EA populations. Data indicate that: 1) neurohormonal signaling mechanisms frequently (16 of the 19 investigated polymorphisms) exhibit racial differences in the allele frequencies of variants comprising key constituents; 2) some of these differences in allele frequency may differentially affect the natural history of heart failure in AA compared with EA individuals; and 3) in many cases, these differences likely play a role in observed racial differences in drug or device response.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Inside This Issue
    • PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • G-Protein Beta-3 Subunit Genotype Predicts Enhanced Benefit of Fixed-Dose
           Isosorbide Dinitrate and Hydralazine Results of A-HeFT
    • Authors: McNamara DM; Taylor AL, Tam S, et al.
      Abstract: ObjectivesThe purpose of this study was to evaluate the influence of the guanine nucleotide-binding proteins (G-proteins), beta-3 subunit (GNB3) genotype on the effectiveness of a fixed-dose combination of isosorbide dinitrate and hydralazine (FDC I/H) in A-HeFT (African American Heart Failure Trial).BackgroundGNB3 plays a role in alpha2-adrenergic signaling. A polymorphism (C825T) exists, and the T allele is linked to enhanced alpha-adrenergic tone and is more prevalent in African Americans.MethodsA total of 350 subjects enrolled in the genetic substudy (GRAHF [Genetic Risk Assessment of Heart Failure in African Americans]) were genotyped for the C825T polymorphism. The impact of FDC I/H on a composite score (CS) that incorporated death, hospital stay for heart failure, and change in quality of life (QoL) and on event-free survival were assessed in GNB3 genotype subsets.ResultsThe GRAHF cohort was 60% male, 25% ischemic, 97% New York Heart Association functional class III, age 57 ± 13 years, with a mean qualifying left ventricular ejection fraction of 0.24 ± 0.06. For GNB3 genotype, 184 subjects were TT (53%), 137 (39%) CT, and 29 (8%) were CC. In GNB3 TT subjects, FDC I/H improved the CS (FDC I/H = 0.50 ± 1.6; placebo = −0.11 ± 1.8, p = 0.02), QoL (FDC I/H = 0.69 ± 1.4; placebo = 0.24 ± 1.5, p = 0.04), and event-free survival (hazard ratio: 0.51, p = 0.047), but not in subjects with the C allele (for CS, FDC I/H = −0.05 ± 1.7; placebo = −0.09 ± 1.7, p = 0.87; for QoL, FDC I/H = 0.28 ± 1.5; placebo = 0.14 ± 1.5, p = 0.56; and for event-free survival, p = 0.35).ConclusionsThe GNB3 TT genotype was associated with greater therapeutic effect of FDC I/H in A-HeFT. The role of the GNB3 genotype for targeting therapy with FDC I/H deserves further study.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Reply BAG3 Protein in Advanced-Stage Heart Failure
    • Authors: Storrow AB; Jenkins CA, Self WH, et al.
      Abstract: We appreciate the interest of Dr. De Marco and colleagues in our report (1) and their interesting observations on the potential use of serum BAG3, possibly in combination with other tests, in monitoring progression of heart failure. We agree that a multiple biomarker approach may add unique diagnostic and prognostic information (2). In our study, we were not focused on chronic heart failure or long-term outcomes but rather the burden of acute heart failure on our nation’s emergency departments. The high hospital admission rate and significant resource consumption suggest that strategies to safely reduce admissions, or alternatives to hospital stays, may have profound implications. We believe this challenge could be addressed with better methods to identify patients at low risk for short-term adverse outcomes and readmissions, including assessment of self-care behaviors such as symptom monitoring, medication taking, and exercise. We have previously suggested that combining physician judgment, physiological risk predictors, strategies to address barriers to ideal self-care, and shared decision making may provide this critical inertia (3,4). Unfortunately, there are currently no validated tools to identify low-risk patients with acute heart failure in the emergency department suitable for discharge or perhaps a brief period of observation (4). We suggest that previous biomarker and risk stratification efforts have not significantly affected emergency department decision making; those with no high-risk features do not necessarily equate with low risk (5). Although novel biomarkers likely will play an important role, we suggest that a more comprehensive methodology is needed to address the burden before it becomes overwhelming.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • The Effects of Dose Reduction of Furosemide on Glomerular Filtration Rate
           in Stable Systolic Heart Failure
    • Authors: McKie PM; Schirger JA, Benike SL, et al.
      Abstract: Loop diuretics are effective and necessary to improve hemodynamics and relieve congestion in subjects with systolic heart failure (HF) and fluid overload. In contrast, in compensated/noncongested patients with left ventricular systolic dysfunction, reports suggest negative consequences of chronic loop diuretic therapy on the progression of HF (1,2). Others and we have also reported that in patients with compensated HF, loop diuretic therapy has deleterious neurohumoral and renal hemodynamic effects such as renal vasoconstriction and activation of the renin-angiotensin-aldosterone system (1,3). The adverse renal effects of chronic loop diuretic therapy are significant because renal function is one of the most important predictors of prognosis in HF (4). Therefore, interventions aimed at improving or avoiding deterioration in renal function are critically important. The objective of the current study was to define the effects of decreasing the dose of furosemide, the most commonly prescribed loop diuretic, on renal function in patients with compensated systolic HF with and without underlying renal insufficiency. We hypothesized that dose reduction of furosemide would improve glomerular filtration rate (GFR) and decrease neurohumoral activation without adverse effects or a deterioration in functional status.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Reply Predicting Sudden Cardiac Death in Heart Failure
    • Authors: Ahmad T; Felker G.
      Abstract: We thank Dr. Weir for the insightful comments in regard to our recent report (1). We wholeheartedly agree with the assertion that biomarkers may play a role in prediction of risk of sudden cardiac death in combination with electrical and structural assessments of the heart.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • BAG3 Protein in Advanced-Stage Heart Failure
    • Authors: De Marco M; D’Auria R, Rosati A, et al.
      Abstract: We read with interest the report by Storrow et al. (1), which shows that a high proportion of patients with acute heart failure (HF) are admitted to emergency departments annually, with high readmission rates and costs. Accurate monitoring is critical to guide clinical management of HF and identify high-risk patients who may be considered for advanced therapy. It is increasingly evident that analysis of multiple biomarkers reflecting various pathophysiologies in HF may add unique information to gauge the severity and/or progression of the disease, assist in stratifying risk, and ultimately improve the care of patients with HF, resulting in better outcomes and lower health care costs (2,3). In this respect, novel identification of molecules released by failing cardiomyocytes may contribute to the available apparatus of diagnostic and prognostic tools while simultaneously extending our understanding of biological processes in HF.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Predicting Sudden Cardiac Death in Heart Failure
    • Authors: Weir RP.
      Abstract: Ahmad et al. (1) suggest that biomarkers related to myocardial stress and fibrosis add some weight to the prediction of mode of death in patients with heart failure–reduced ejection fraction (HF-REF), particularly pump failure as opposed to sudden cardiac death (SCD). A variety of biomarkers have been shown to predict adverse ventricular remodeling/progressive pump failure, including natriuretic peptides and various markers of matrix turnover, but the holy grail of outcome prediction in HF-REF is the discovery of a robust predictor of SCD at the point of diagnosis. The decision as to whether to implant a defibrillator early after diagnosis of de novo HF-REF is one of the most challenging, balancing the potential for recovery of left ventricular function with evidence-based pharmacotherapy against the risk of SCD while awaiting possible functional recovery. Although certain biomarkers may provide some information to this effect, none are particularly powerful predictors, including galectin-3 and ST2, which were investigated in the study by Ahmad et al. (1). This may be because risk of SCD in HF-REF is more appropriately predicted by electrical and structural data than by biomarkers, but perhaps there is a role for biomarkers in combination with electrical and structural abnormalities in the prediction of SCD.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Combined Neprilysin and Renin-Angiotensin System Inhibition for the
           Treatment of Heart Failure
    • Authors: Vardeny O; Miller R, Solomon SD.
      Abstract: Neprilysin is an enzyme that contributes to the breakdown of the biologically active natriuretic peptides and several other vasoactive compounds. Inhibiting neprilysin has been a therapeutic target for several compounds that have been tested in cardiovascular disease, including ecadotril, candoxatril, omapatrilat, and LCZ696. Although ecadotril, candoxatril, and omapatrilat were initially tested in hypertension and/or heart failure, lack of efficacy and side effects led to discontinuation of their development. LCZ696 (sacubitril valsartan) is a first-in-class angiotensin receptor neprilysin inhibitor that has been developed for use in heart failure. This compound is composed of 2 molecular moieties in a single crystalline complex—the angiotensin receptor blocker valsartan and a neprilysin inhibitor prodrug—and has now been tested in hypertension, in a phase 2 trial in heart failure with preserved ejection fraction, and has demonstrated greater efficacy than enalapril in a phase 3 trial in heart failure with reduced ejection fraction. Its ability to inhibit the renin-angiotensin-aldosterone axis and augment the endogenous natriuretic peptide system provides a distinctive mechanism of action in cardiovascular disease.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Precision and Predictive Medicine: Lessons Learned From Our Oncology
    • Authors: O’Connor CM.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Cardiac Rehabilitation in Left Ventricular Assist Device Recipients Can it
           Bolster the Benefits of Restored Flow? ∗
    • Authors: Reeves GR; Whellan DJ.
      Abstract: In appropriately selected advanced heart failure (HF) patients, treatment with a left ventricular assist device (LVAD) is associated with significant improvements in physical function and quality of life (QOL) (1). However, despite these improvements, impairments persist, with functional capacity frequently ≤50% of predicted (2–6) and gains in both physical function and QOL lagging behind those of heart transplantation recipients (2,6,7). Cardiac rehabilitation (CR) has been shown to increase exercise capacity, reduce HF symptoms, and improve the health status in patients with chronic stable HF who have a reduced ejection fraction (HFREF) (8,9), prompting the Centers for Medicare and Medicaid Services to recently expand CR coverage to this patient population. However, it has not been established if conventional CR provides additional benefit to LVAD recipients.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Cardiac Rehabilitation Improves Functional Capacity and Patient-Reported
           Health Status in Patients With Continuous-Flow Left Ventricular Assist
           Devices The Rehab-VAD Randomized Controlled Trial
    • Authors: Kerrigan DJ; Williams CT, Ehrman JK, et al.
      Abstract: ObjectivesThis study examined the effects of a cardiac rehabilitation (CR) program on functional capacity and health status (HS) in patients with newly implanted left ventricular assist devices (LVADs).BackgroundReduced functional capacity and HS are independent predictors of mortality in patients with heart failure. CR improves both, and is related to improved outcomes in patients with heart failure; however, there is a paucity of data that describe the effects of CR in patients with LVADs.MethodsEnrolled subjects (n = 26; 7 women; age 55 ± 13 years; ejection fraction 21 ± 8%) completed a symptom-limited cardiopulmonary exercise test, the Kansas City Cardiomyopathy Questionnaire (KCCQ), a 6-min walk test (6MW), and single-leg isokinetic strength test before 2:1 randomization to CR versus usual care. Subjects in the CR group underwent 18 visits of aerobic exercise at 60% to 80% of heart rate reserve. Within-group changes from baseline to follow-up were analyzed with a paired t-test, whereas an independent t-test was used to determine differences in the change between groups.ResultsWithin-group improvements were observed in the CR group for peak oxygen uptake (10%), treadmill time (3.1 min), KCCQ score (14.4 points), 6MW distance (52.3 m), and leg strength (17%). Significant differences among groups were observed for KCCQ, leg strength, and total treadmill time.ConclusionsIndicators of functional capacity and HS are improved in patients with continuous-flow LVADs who attend CR. Future trials should examine the mechanisms responsible for these improvements, and if such improvements translate into improved clinical outcomes. (Cardiac Rehabilitation in Patients With Continuous Flow Left Ventricular Assist Devices:Rehab VAD Trial [RehabVAD]; NCT01584895)
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • A New Direction for Albuminuria An Enigmatic Multibiomarker ∗
    • Authors: Ghali JK.
      Abstract: The past 2 decades have witnessed a rising interest in biomarkers, as reflected by close to 6,500 publications in the past decade alone (1). Several definitions of biomarkers have been suggested; I prefer to use the following: “A characteristic that is objectively measured and evaluated as an indicator of normal biological processes, pathogenic processes, or pharmacologic responses to a therapeutic intervention” (2).
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Albuminuria Is Independently Associated With Cardiac Remodeling, Abnormal
           Right and Left Ventricular Function, and Worse Outcomes in Heart Failure
           With Preserved Ejection Fraction
    • Authors: Katz DH; Burns JA, Aguilar FG, et al.
      Abstract: ObjectivesThe purpose of this study was to determine the relationship between albuminuria and cardiac structure/function in heart failure with preserved ejection fraction (HFpEF).BackgroundAlbuminuria, a marker of endothelial dysfunction, has been associated with adverse cardiovascular outcomes in HFpEF. However, the relationship between albuminuria and cardiac structure/function in HFpEF has not been well studied.MethodsWe measured urinary albumin-to-creatinine ratio (UACR) and performed comprehensive echocardiography, including tissue Doppler imaging and right ventricular (RV) evaluation, in a prospective study of 144 patients with HFpEF. Multivariable-adjusted linear regression was used to determine the association between UACR and echocardiographic parameters. Cox proportional hazards analyses were used to determine the association between UACR and outcomes.ResultsThe mean age was 66 ± 11 years, 62% were female, and 42% were African American. Higher UACR was associated with greater left ventricular mass, lower preload-recruitable stroke work, and lower global longitudinal strain. Higher UACR was also significantly associated with RV remodeling (for each doubling of UACR, RV wall thickness was 0.9 mm higher [95% confidence interval: 0.05 to 0.14 mm; p = 0.001, adjusted p = 0.01]) and worse RV systolic function (for each doubling of UACR, RV fractional area change was 0.56% lower [95% confidence interval: 0.14 to 0.98%; p = 0.01, adjusted p = 0.03]. The association between UACR and RV parameters persisted after the exclusion of patients with macroalbuminuria (UACR >300 mg/g). Increased UACR was also independently associated with worse outcomes.ConclusionsIn HFpEF, increased UACR is a prognostic marker and is associated with increased RV and left ventricular remodeling and longitudinal systolic dysfunction. (Classification of Heart Failure With Preserved Ejection Fraction; NCT01030991)
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Do Dipeptidyl Peptidase-4 Inhibitors Increase the Risk of Heart
           Failure? ∗
    • Authors: Bhatt DL; Cavender MA.
      Abstract: An association between diabetes and the risk of heart failure has been seen in observational studies. The mechanism is undefined, and it remains unclear whether dipeptidyl peptidase (DPP)-4 this association is related to concomitant medical problems associated with diabetes (e.g., ischemic heart disease, renal dysfunction, hypertension) or the direct effect of poorly controlled blood glucose. Current American Diabetes Association guidelines recommend that commonly used antihyperglycemic agents (e.g., thiazolidinedione agents) should be used with caution in patients with heart failure (1,2).
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Sitagliptin Use in Patients With Diabetes and Heart Failure A
           Population-Based Retrospective Cohort Study
    • Authors: Weir DL; McAlister FA, Senthilselvan A, et al.
      Abstract: ObjectivesThe study objective was to evaluate the effects of sitagliptin in patients with type 2 diabetes (T2D) and heart failure (HF).BackgroundThere is uncertainty in the literature about whether dipeptidyl peptidase (DPP)-4 inhibitors cause harm in patients with HF and T2D.MethodsWe analyzed data from a national commercially insured U.S. claims database. Patients with incident HF were identified from individuals with T2D initially treated with metformin or sulfonylurea and followed over time. Subjects subsequently using sitagliptin were compared with those not using sitagliptin in the 90 days before our primary outcome of all-cause hospital admission or death using a nested case-control analysis after adjustment for demographics and clinical and laboratory data. HF-specific hospital admission or death also was assessed.ResultsA total of 7,620 patients with diabetes and incident HF met our inclusion criteria. Mean (SD) age was 54 years (9), and 58% (3,180) were male. Overall, 887 patients (12%) were exposed to sitagliptin therapy (521 patient years of exposure) after incident HF. Our primary composite endpoint occurred in 4,137 patients (54%). After adjustment, sitagliptin users were not at an increased risk for the primary endpoint (7.1% vs. 9.2%, adjusted odds ratio [aOR]: 0.84, 95% confidence interval [CI]: 0.69 to 1.03) or each component (hospital admission 7.5% vs. 9.2%, aOR: 0.93, 95% CI: 0.76 to 1.14; death 6.9% vs. 9.3%, aOR: 1.16, 95% CI: 0.68 to 1.97). However, sitagliptin use was associated with an increased risk of HF hospitalizations (12.5% vs. 9.0%, aOR: 1.84, 95% CI: 1.16 to 2.92).ConclusionsSitagliptin use was not associated with an increased risk of all-cause hospitalizations or death, but was associated with an increased risk of HF-related hospitalizations among patients with T2D with pre-existing HF.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Time to Energize Coenzyme Q 10 for Patients With Heart Failure?
    • Authors: Ezekowitz JA.
      Abstract: Nobody realizes that some people expend tremendous energy merely to be normal.Albert Camus, Notebooks, 1942–1951 (1)
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • The Effect of Coenzyme Q 10 on Morbidity and Mortality in Chronic Heart
           Failure Results From Q-SYMBIO: A Randomized Double-Blind Trial
    • Authors: Mortensen SA; Rosenfeldt F, Kumar A, et al.
      Abstract: ObjectivesThis randomized controlled multicenter trial evaluated coenzyme Q10 (CoQ10) as adjunctive treatment in chronic heart failure (HF).BackgroundCoQ10 is an essential cofactor for energy production and is also a powerful antioxidant. A low level of myocardial CoQ10 is related to the severity of HF. Previous randomized controlled trials of CoQ10 in HF were underpowered to address major clinical endpoints.MethodsPatients with moderate to severe HF were randomly assigned in a 2-year prospective trial to either CoQ10 100 mg 3 times daily or placebo, in addition to standard therapy. The primary short-term endpoints at 16 weeks were changes in New York Heart Association (NYHA) functional classification, 6-min walk test, and levels of N-terminal pro–B type natriuretic peptide. The primary long-term endpoint at 2 years was composite major adverse cardiovascular events as determined by a time to first event analysis.ResultsA total of 420 patients were enrolled. There were no significant changes in short-term endpoints. The primary long-term endpoint was reached by 15% of the patients in the CoQ10 group versus 26% in the placebo group (hazard ratio: 0.50; 95% confidence interval: 0.32 to 0.80; p = 0.003) by intention-to-treat analysis. The following secondary endpoints were significantly lower in the CoQ10 group compared with the placebo group: cardiovascular mortality (9% vs. 16%, p = 0.026), all-cause mortality (10% vs. 18%, p = 0.018), and incidence of hospital stays for HF (p = 0.033). In addition, a significant improvement of NYHA class was found in the CoQ10 group after 2 years (p = 0.028).ConclusionsLong-term CoQ10 treatment of patients with chronic HF is safe, improves symptoms, and reduces major adverse cardiovascular events. (Coenzyme Q10 as adjunctive treatment of chronic heart failure: a randomised, double-blind, multicentre trial with focus on SYMptoms, BIomarker status [Brain-Natriuretic Peptide (BNP)], and long-term Outcome [hospitalisations/mortality]; ISRCTN94506234)
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Revisiting Arrhythmic Risk After Alcohol Septal Ablation Is the
           Pendulum Finally Swinging…Back to Myectomy? ∗
    • Authors: Maron BJ; Nishimura RA.
      Abstract: For the past 10 years, a debate has raged within the international cardiovascular medicine community regarding treatment options for severely symptomatic and drug-refractory patients with obstructive hypertrophic cardiomyopathy (HCM) (1–21). Surgical myectomy has been the gold-standard treatment for this relatively small HCM subset since the early 1960s, with proven efficacy in abolishing left ventricular (LV) outflow gradients and heart failure symptoms, enhancing quality of life associated with long-term survival equivalent to the general population, and recently with low operative mortality (
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Long-Term Outcomes After Medical and Invasive Treatment in Patients With
           Hypertrophic Cardiomyopathy
    • Authors: Vriesendorp PA; Liebregts M, Steggerda RC, et al.
      Abstract: ObjectivesThe aim of this study was to determine the long-term outcomes (all-cause mortality and sudden cardiac death [SCD]) after medical therapy, alcohol septal ablation (ASA), and myectomy in patients with hypertrophic cardiomyopathy (HCM).BackgroundTherapy-resistant obstructive HCM can be treated both surgically and percutaneously. But there is no consensus on the long-term effects of ASA, especially on SCD.MethodsThis study included 1,047 consecutive patients with HCM (mean age 52 ± 16 years, 61% men) from 3 tertiary referral centers. A total of 690 patients (66%) had left ventricular outflow tract gradients ≥ 30 mm Hg, of whom 124 (12%) were treated medically, 316 (30%) underwent ASA, and 250 (24%) underwent myectomy. Primary endpoints were all-cause mortality and SCD. Kaplan-Meier graphs and Cox regression models were used for statistical analyses.ResultsThe mean follow-up period was 7.6 ± 5.3 years. Ten-year survival was similar in medically treated patients (84%), ASA patients (82%), myectomy patients (85%), and patients with nonobstructive HCM (85%) (log-rank p = 0.50). The annual rate of SCD was low after invasive therapy: 1.0%/year in the ASA group and 0.8%/year in the myectomy group. Multivariate analysis demonstrated that the risk for SCD was lower after myectomy compared with the ASA group (hazard ratio: 2.1; 95% confidence interval: 1.0 to 4.4; p = 0.04) and the medical group (hazard ratio: 2.3; 95% confidence interval: 1.0 to 5.2; p = 0.04).ConclusionsPatients with obstructive HCM who are treated at referral centers for HCM care have good survival and low SCD risk, similar to that of patients with nonobstructive HCM. The SCD risk of patients after myectomy was lower than after ASA or in the medical group.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Outcomes of Implantable Cardioverter-Defibrillator Use in Patients With
           Comorbidities Results From a Combined Analysis of 4 Randomized Clinical
    • Authors: Steinberg BA; Al-Khatib SM, Edwards R, et al.
      Abstract: ObjectivesThe aim of this study was to determine if the benefit of implantable cardioverter-defibrillators (ICDs) is modulated by medical comorbidity.BackgroundPrimary prevention ICDs improve survival in patients at risk for sudden cardiac death. Their benefit in patients with significant comorbid illness has not been demonstrated.MethodsOriginal, patient-level datasets from MADIT I (Multicenter Automatic Defibrillator Implantation Trial I), MADIT II, DEFINITE (Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation), and SCD-HeFT (Sudden Cardiac Death in Heart Failure Trial) were combined. Patients in the combined population (N = 3,348) were assessed with respect to the following comorbidities: smoking, pulmonary disease, diabetes, peripheral vascular disease, atrial fibrillation, ischemic heart disease, and chronic kidney disease. The primary outcome was overall mortality, using the hazard ratio (HR) of time to death for patients receiving an ICD versus no ICD by extent of medical comorbidity, and adjusted for age, sex, race, left ventricular ejection fraction, use of antiarrhythmic drugs, beta-blockers, and angiotensin-converting enzyme inhibitors.ResultsOverall, 25% of patients (n = 830) had 
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Insights Into Defibrillator Shocks What OPTION Teaches Us ∗
    • Authors: Ellenbogen KA; Kalahasty G.
      Abstract: The mortality benefits of implantable cardioverter-defibrillators (ICD) are well established and accepted (1,2). It is equally well accepted that inappropriate therapy due to arrhythmia misclassification is associated with increased morbidity and mortality (3). It is intuitive to think that the use of an atrial lead will result in a lower likelihood of inappropriate shocks. However, this assertion has proved difficult to validate. Although it is not the objective of this editorial to provide a comprehensive review of the published research, that cited is representative of the contradictory findings among studies showing both beneficial and detrimental impacts of dual-chamber devices with respect to risk for inappropriate shocks and morbidity.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Is Subclinical Myocardial Injury the Smoking Gun Linking Obesity
           With Heart Failure? ∗
    • Authors: de Lemos JA; Neeland IJ.
      Abstract: Although rates of atherosclerotic cardiovascular disease are on the decline, heart failure (HF) is slowly becoming a global epidemic. Recent projections suggest that the prevalence of HF will increase almost 50% from 2012 to 2030 and that 1 in 5 adults will develop HF over their lifetime (1). This emergent HF burden is in part attributable to aging of the population and improved survival from atherosclerotic cardiovascular disease and other chronic cardiovascular diseases. In addition, obesity is increasingly recognized as a key driver of the increase in HF prevalence, due to both staggering increases in rates of obesity and better understanding of the direct and indirect mechanisms through which obesity contributes to HF risk.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Reduced Risk for Inappropriate Implantable Cardioverter-Defibrillator
           Shocks With Dual-Chamber Therapy Compared With Single-Chamber Therapy
           Results of the Randomized OPTION Study
    • Authors: Kolb C; Sturmer M, Sick P, et al.
      Abstract: ObjectivesThe OPTION (Optimal Anti-Tachycardia Therapy in Implantable Cardioverter-Defibrillator Patients Without Pacing Indications) trial sought to compare long-term rates of inappropriate shocks, mortality, and morbidity between dual-chamber and single-chamber settings in implantable cardioverter-defibrillators (ICDs) patients.BackgroundThe use of dual-chamber ICDs potentially allows better discrimination of supraventricular arrhythmias and thereby reduces inappropriate shocks. However, it may lead to detrimental ventricular pacing.MethodsThis prospective multicenter, single-blinded trial enrolled 462 patients with de novo primary or secondary prevention indications for ICD placement and with left ventricular ejection fractions ≤40% despite optimal tolerated pharmacotherapy. All patients received atrial leads and dual-chamber defibrillators that were randomized to be programmed either with dual-chamber or single-chamber settings. In the dual-chamber setting arm, the PARAD+ algorithm, which differentiates supraventricular from ventricular arrhythmias, and SafeR mode, to minimize ventricular pacing, were activated. In the single-chamber setting arm, the acceleration, stability, and long cycle search discrimination criteria were activated, and pacing was set to VVI 40 beats/min. Ventricular tachycardia detection was required at rates between 170 and 200 beats/min, and ventricular fibrillation detection was activated above 200 beats/min.ResultsDuring a follow-up period of 27 months, the time to the first inappropriate shock was significantly longer in the dual-chamber setting arm (p = 0.012, log-rank test), and 4.3% of patients in the dual-chamber setting group compared with 10.3% in the single-chamber setting group experienced inappropriate shocks (p = 0.015). Rates of all-cause death or cardiovascular hospitalization were 20% for the dual-chamber setting group and 22.4% for the single-chamber setting group and satisfied the pre-defined margin for equivalence (p < 0.001).ConclusionsTherapy with dual-chamber settings for ICD discrimination combined with algorithms for minimizing ventricular pacing was associated with reduced risk for inappropriate shock compared with single-chamber settings, without increases in mortality and morbidity. (Optimal Anti-Tachycardia Therapy in Implantable Cardioverter-Defibrillator [ICD] Patients Without Pacing Indications [OPTION]; NCT00729703)
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
  • Obesity, Subclinical Myocardial Injury, and Incident Heart Failure
    • Authors: Ndumele CE; Coresh J, Lazo M, et al.
      Abstract: ObjectivesThe study sought to evaluate the association of obesity with a novel biomarker of subclinical myocardial injury, cardiac troponin T measured with a new high-sensitivity assay (hs-cTnT), among adults without clinical cardiovascular disease (CVD).BackgroundLaboratory evidence suggests a relationship between obesity and myocardial injury that may play a role in the development of heart failure (HF), but there is limited clinical data regarding this association.MethodsWe evaluated 9,507 participants in the ARIC (Atherosclerosis Risk in Communities) study without baseline CVD (Visit 4, 1996 to 1999). We assessed the cross-sectional association of body mass index (BMI) with high (≥14 ng/l) and measurable (≥3 ng/l) hs-cTnT levels after multivariable regression. We further evaluated the independent and combined associations of BMI and hs-cTnT with incident HF.ResultsHigher BMI was independently associated with a positive, linear increase in the likelihood of high hs-cTnT, with severe obesity (BMI >35 kg/m2) associated with an odds ratio of 2.20 (95% confidence interval: 1.59 to 3.06) for high hs-cTnT after adjustment. Over 12 years of follow-up, there were 869 incident HF events. Obesity and hs-cTnT were both independently associated with incident HF, and individuals with severe obesity and high hs-cTnT had a greater than 9-fold higher risk of incident HF (hazard ratio: 9.20 [95% confidence interval: 5.67 to 14.93]) than individuals with normal weight and undetectable hs-cTnT.ConclusionsAmong individuals without CVD, higher BMI has an independent, linear association with subclinical myocardial injury, as assessed by hs-cTnT levels. Obesity and hs-cTnT provide independent and complementary prognostic information regarding the risk of incident HF.
      PubDate: Mon, 01 Dec 2014 00:00:00 GMT
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