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Rieger AC, Myerburg RJ, Florea V, Tompkins BA, Natsumeda M, Premer C, Khan A, Schulman IH, Vidro-Casiano M, DiFede DL, Heldman AW, Mitrani R, Hare JM. Genetic determinants of responsiveness to mesenchymal stem cell injections in non-ischemic dilated cardiomyopathy. EBioMedicine 2019; 48:377-385. [PMID: 31648988 PMCID: PMC6838383 DOI: 10.1016/j.ebiom.2019.09.043] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 09/20/2019] [Accepted: 09/23/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Non-ischemic dilated cardiomyopathy (NIDCM) responds variably to intramyocardial injection of mesenchymal stem cells (MSCs). We hypothesized that NIDCM genotype may influence responsiveness to MSC therapy and performed genotyping on all patients in the POSEIDON-DCM trial. METHODS POSEIDON-DCM patients (n = 34) underwent genetic sequence analysis and deletion/duplication testing. The results were classified as positive for pathological variants (PV+; n = 8), negative for any variants (V-; n = 6), or as variants of uncertain significance (VUS; n = 20). All outcomes of therapy were analysed for each category of genetic results. FINDINGS The 3 groups were indistinguishable at baseline with regard to ejection fraction (EF), demographics, medication use, or functional parameters. V- patients had an increase in EF at 12 months: +13.6% (IQR = +7.8%; +20.5%; p = 0.002), compared with VUS (+6.5%; IQR = +0.9%, +11.1%; p = 0.005) and PV+(-5.9%; IQR = -12.7%, +1.0; p = 0.2; p = 0.01 between groups). Six-minute walk distance improved in V- patients, but not in VUS and PV+. V- patients improved MLHFQ, compared to the other 2 groups, which did not improve over time. EPCCFUs increased by 9.7 ± 1.9 in V- (p = 0.009) compared to VUS and PV+ patients. V- patients had one-year survival (100%) compared with VUS (85%) and PV+ (40%; p = 0.015 log-rank). Similarly, MACE rates were lower in V- (0%) than PV+ (61.9%) or VUS (42.2%; p = 0.021 log-rank). INTERPRETATION Our findings support the concept that the genetic profile of NIDCM patients plays a role in responsiveness to MSC therapy, with V- patients more likely to benefit and the converse for PV+. This observation emphasizes the need for further genetic studies, because of important implications for the management of NIDCM syndromes.
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Affiliation(s)
- Angela C Rieger
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Robert J Myerburg
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Victoria Florea
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Bryon A Tompkins
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States; Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Makoto Natsumeda
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Courtney Premer
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Aisha Khan
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Ivonne H Schulman
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States; Katz Family Division of Nephrology and Hypertension, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Mayra Vidro-Casiano
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Darcy L DiFede
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Alan W Heldman
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Raul Mitrani
- Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Joshua M Hare
- Interdisciplinary Stem Cell Institute, University of Miami Miller School of Medicine, Miami, FL, United States; Cardiovascular Division, University of Miami Miller School of Medicine, Miami, FL, United States.
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Abstract
The use of antipsychotic medications has now expanded to multiple mental health conditions beyond schizophrenia. This has increased the overall population exposure to these medications, which have been associated with both metabolic changes and adverse cardiovascular effects. QTc prolongation, torsades de pointes, sudden cardiac death, myocarditis, and cardiomyopathy are all very real concerns that clinicians face on a regular basis. One must take these risks into consideration when selecting antipsychotic therapy and also when determining whether therapeutic changes and adjustments are necessary. This review examines a number of cardiac-associated concerns, the role that antipsychotics may play in contributing to these adverse events, and suggested management interventions.
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Affiliation(s)
- Steven C Stoner
- Chair and Clinical Professor, Division of Pharmacy Practice and Administration, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri,
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3
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Merlo M, Gentile P, Naso P, Sinagra G. The natural history of dilated cardiomyopathy. J Cardiovasc Med (Hagerstown) 2017; 18 Suppl 1:e161-e165. [DOI: 10.2459/jcm.0000000000000459] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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4
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Merlo M, Stolfo D, Anzini M, Negri F, Pinamonti B, Barbati G, Ramani F, Lenarda AD, Sinagra G. Persistent recovery of normal left ventricular function and dimension in idiopathic dilated cardiomyopathy during long‐term follow‐up: does real healing exist? J Am Heart Assoc 2015; 4:e001504. [PMID: 25587018 PMCID: PMC4330044 DOI: 10.1161/jaha.114.000570] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
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5
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Merlo M, Stolfo D, Anzini M, Negri F, Pinamonti B, Barbati G, Ramani F, Di Lenarda A, Sinagra G. Persistent recovery of normal left ventricular function and dimension in idiopathic dilated cardiomyopathy during long‐term follow‐up: does real healing exist? J Am Heart Assoc 2015. [PMID: 25587018 PMCID: PMC4330074 DOI: 10.1161/jaha.114.001504] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background An important number of patients with idiopathic dilated cardiomyopathy have dramatically improved left ventricular function with optimal treatment; however, little is known about the evolution and long‐term outcome of this subgroup, which shows apparent healing. This study assesses whether real healing actually exists in dilated cardiomyopathy . Methods and Results Persistent apparent healing was evaluated among 408 patients with dilated cardiomyopathy receiving tailored medical treatment and followed over the very long‐term. Persistent apparent healing was defined as left ventricular ejection fraction ≥50% and indexed left ventricular end‐diastolic diameter ≤33 mm/m2 at both mid‐term (19±4 months) and long‐term (103±9 months) follow‐up. At mid‐term, 63 of 408 patients (15%) were apparently healed; 38 (60%; 9% of the whole population) showed persistent apparent healing at long‐term evaluation. No predictors of persistent apparent healing were found. Patients with persistent apparent healing showed better heart transplant–free survival at very long‐term follow‐up (95% versus 71%; P=0.014) compared with nonpersistently normalized patients. Nevertheless, in the very long term, 37% of this subgroup experienced deterioration of left ventricular systolic function, and 5% died or had heart transplantation. Conclusions Persistent long‐term apparent healing was evident in a remarkable proportion of dilated cardiomyopathy patients receiving optimal medical treatment and was associated with stable normalization of main clinical and laboratory features. This condition can be characterized by a decline of left ventricular function over the very long term, highlighting the relevance of serial and individualized follow‐up in all patients with dilated cardiomyopathy, especially considering the absence of predictors for long‐term apparent healing.
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Affiliation(s)
- Marco Merlo
- Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Italy (M.M., D.S., M.A., F.N., B.P., G.B., F.R., G.S.)
| | - Davide Stolfo
- Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Italy (M.M., D.S., M.A., F.N., B.P., G.B., F.R., G.S.)
| | - Marco Anzini
- Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Italy (M.M., D.S., M.A., F.N., B.P., G.B., F.R., G.S.)
| | - Francesco Negri
- Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Italy (M.M., D.S., M.A., F.N., B.P., G.B., F.R., G.S.)
| | - Bruno Pinamonti
- Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Italy (M.M., D.S., M.A., F.N., B.P., G.B., F.R., G.S.)
| | - Giulia Barbati
- Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Italy (M.M., D.S., M.A., F.N., B.P., G.B., F.R., G.S.)
| | - Federica Ramani
- Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Italy (M.M., D.S., M.A., F.N., B.P., G.B., F.R., G.S.)
| | - Andrea Di Lenarda
- Cardiovascular Center, “Azienda per i Servizi Sanitari” n 1, Trieste, Italy (A.D.L.)
| | - Gianfranco Sinagra
- Cardiovascular Department, “Ospedali Riuniti” and University of Trieste, Italy (M.M., D.S., M.A., F.N., B.P., G.B., F.R., G.S.)
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Mazzanti A, O'Rourke S, Ng K, Miceli C, Borio G, Curcio A, Esposito F, Napolitano C, Priori SG. The usual suspects in sudden cardiac death of the young: a focus on inherited arrhythmogenic diseases. Expert Rev Cardiovasc Ther 2014; 12:499-519. [PMID: 24650315 DOI: 10.1586/14779072.2014.894884] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Up to 14,500 young individuals die suddenly every year in Europe of cardiac pathologies. The majority of these tragic events are related to a group of genetic defects that predispose the development of malignant arrhythmias (inherited arrhythmogenic diseases [IADs]). IADs include both cardiomyopathies (hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy) and channelopathies (long QT syndrome, short QT syndrome, Brugada syndrome and catecholaminergic polymorphic ventricular tachycardia). Every time an IAD is identified in a patient, other individuals in his/her family may be at risk of cardiac events. However; if a timely diagnosis is made, simple preventative measures may be applied. Genetic studies play a pivotal role in the diagnosis of IADs and may help in the management of patients and their relatives.
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Affiliation(s)
- Andrea Mazzanti
- Molecular Cardiology, IRCCS Salvatore Maugeri Foundation, Pavia, Italy
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Moretti M, Merlo M, Barbati G, Di Lenarda A, Brun F, Pinamonti B, Gregori D, Mestroni L, Sinagra G. Prognostic impact of familial screening in dilated cardiomyopathy. Eur J Heart Fail 2014; 12:922-7. [DOI: 10.1093/eurjhf/hfq093] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Michele Moretti
- Cardiovascular Department; Azienda Ospedaliera ‘Ospedali Riuniti’ and University of Trieste; Trieste Italy
| | - Marco Merlo
- Cardiovascular Department; Azienda Ospedaliera ‘Ospedali Riuniti’ and University of Trieste; Trieste Italy
| | - Giulia Barbati
- Cardiovascular Department; Azienda Ospedaliera ‘Ospedali Riuniti’ and University of Trieste; Trieste Italy
| | - Andrea Di Lenarda
- Cardiovascular Center; Azienda per i Servizi Sanitari No. 1; Trieste Italy
| | - Francesca Brun
- Cardiovascular Department; Azienda Ospedaliera ‘Ospedali Riuniti’ and University of Trieste; Trieste Italy
| | - Bruno Pinamonti
- Cardiovascular Department; Azienda Ospedaliera ‘Ospedali Riuniti’ and University of Trieste; Trieste Italy
| | - Dario Gregori
- Department of Environmental Medicine and Public Health; University of Padova; Padova Italy
| | - Luisa Mestroni
- Cardiovascular Institute; University of Colorado; Denver CO USA
| | - Gianfranco Sinagra
- Cardiovascular Department; Azienda Ospedaliera ‘Ospedali Riuniti’ and University of Trieste; Trieste Italy
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Merlo M, Pivetta A, Pinamonti B, Stolfo D, Zecchin M, Barbati G, Di Lenarda A, Sinagra G. Long-term prognostic impact of therapeutic strategies in patients with idiopathic dilated cardiomyopathy: changing mortality over the last 30 years. Eur J Heart Fail 2013; 16:317-24. [PMID: 24464640 DOI: 10.1002/ejhf.16] [Citation(s) in RCA: 151] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 09/27/2013] [Accepted: 10/11/2013] [Indexed: 11/06/2022] Open
Abstract
AIMS ACE-inhibitors, β-blockers, implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy (CRT) improved prognosis of heart failure. We sought to analyse the long-term prognostic impact of evidence-based integrated therapeutic strategies in patients with idiopathic dilated cardiomyopathy (IDCM). METHODS AND RESULTS From 1978 to 2007, 853 IDCM patients (45 ± 15 years, 72% males) were enrolled and classified as follows: Group 1, 110 patients (12.8%) enrolled during 1978-1987; Group 2, 376 patients (44.1%) enrolled during 1988-1997; Group 3, 367 patients (43.1%) enrolled during 1998-2007. ACE-inhibitors/angiotensin receptor blockers were administered in 34%, 93%, and 93% (P <0.001), and β-blockers in 11%, 82%, and 86% (P <0.001) in Groups 1, 2, and 3, respectively; ICDs were implanted in 2%, 14%, and 13% (P = 0.005); mean time to device implantation was lower in Group 3. At 8 years, heart transplant (HTx)-free survival rates were 55%, 71%, and 87% in Groups 1, 2, and 3, respectively (P <0.001). Similar progressive improvement was found for pump-failure death (DHF)/HTx, while survival free from sudden death (SD) was significantly improved only in Group 3. Multivariable models considering competing risk indicated early diagnosis (i.e. a baseline less advanced disease stage) and tailored medical therapy (HR 0.44, CI 95% 0.19-0.98) as independent protectors against DHF/HTx. Concerning SD, lower left ventricular ejection fraction emerged as a predictor, while ICD was the only therapy with a protective role (HR 0.08, CI 95% 0.01-0.61). Treatment with digitalis emerged as a predictor of both DHF/HTx and SD. CONCLUSIONS An effective management and evidence-based integrated therapeutic approach progressively and significantly improved the long-term prognosis of IDCM during the last three decades.
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Affiliation(s)
- Marco Merlo
- Cardiovascular Department, Ospedali Riuniti and University of Trieste, Trieste, 34149, Italy
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9
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Castelli G, Fornaro A, Ciaccheri M, Dolara A, Troiani V, Tomberli B, Olivotto I, Gensini GF. Improving Survival Rates of Patients With Idiopathic Dilated Cardiomyopathy in Tuscany Over 3 Decades. Circ Heart Fail 2013; 6:913-21. [DOI: 10.1161/circheartfailure.112.000120] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Gabriele Castelli
- From the Heart and Vessel Department, Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | - Alessandra Fornaro
- From the Heart and Vessel Department, Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | - Mauro Ciaccheri
- From the Heart and Vessel Department, Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | - Alberto Dolara
- From the Heart and Vessel Department, Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | - Vito Troiani
- From the Heart and Vessel Department, Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | - Benedetta Tomberli
- From the Heart and Vessel Department, Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | - Iacopo Olivotto
- From the Heart and Vessel Department, Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
| | - Gian Franco Gensini
- From the Heart and Vessel Department, Referral Center for Cardiomyopathies, Careggi University Hospital, Florence, Italy
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Novel predictors of left ventricular reverse remodeling in individuals with recent-onset dilated cardiomyopathy. J Am Coll Cardiol 2013; 61:54-63. [PMID: 23287372 DOI: 10.1016/j.jacc.2012.07.072] [Citation(s) in RCA: 113] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 06/25/2012] [Accepted: 07/03/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVES This study aimed to evaluate the performance of cardiac magnetic resonance (CMR), cardiac biomarkers, and endomyocardial biopsy (EMB) results to predict left ventricular reverse remodeling (LVRR) in individuals with recent-onset dilated cardiomyopathy (DCM). BACKGROUND LVRR is a marker of a favorable prognosis in individuals with recent-onset DCM. We used the aforementioned novel methods of prognostication to predict this event. METHODS A total of 44 consecutive patients with recent-onset DCM underwent at baseline CMR, measurement of biomarkers and EMB together with conventional methods, including cardiopulmonary exercise testing and echocardiography. Measurement of B-type natriuretic peptide (BNP) and the cardiological examination were repeated at 3, 6, and 12 months. CMR was repeated at 12 months. LVRR was defined as an absolute increase in left ventricular ejection fraction from ≥10% to a final value of >35% accompanied by a decrease in left ventricular end-diastolic dimension ≥10% at 12 months of follow-up. RESULTS LVRR was observed in 20 individuals (45%) at 12 months. At baseline, a lower extent of late gadolinium enhancement (odds ratio [OR]: 0.67 [95% confidence interval (CI): 0.50 to 0.90]; p = 0.008) and a higher myocardial edema ratio (OR: 1.45 [95% CI: 1.04 to 2.02]; p = 0.027) measured by CMR were independent predictors of LVRR. At 3 months, the latest BNP plasma level (OR: 0.14 [95% CI: 0.02 to 0.94] per log BNP; p = 0.047) was the strongest predictor of LVRR. CONCLUSIONS Both CMR and serial BNP testing provide a better prediction of LVRR in recent-onset DCM than EMB results, other biomarkers, and the conventional methods of follow-up.
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Matsumura Y, Hoshikawa-Nagai E, Kubo T, Yamasaki N, Furuno T, Kitaoka H, Takata J, Sugiura T, Doi Y. Left ventricular reverse remodeling in long-term (>12 years) survivors with idiopathic dilated cardiomyopathy. Am J Cardiol 2013; 111:106-10. [PMID: 23040590 DOI: 10.1016/j.amjcard.2012.08.056] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 08/30/2012] [Accepted: 08/30/2012] [Indexed: 10/27/2022]
Abstract
Little is known about left ventricular (LV) reverse remodeling (LVRR) in long-term survivors with idiopathic dilated cardiomyopathy. We studied 59 patients with idiopathic dilated cardiomyopathy who had a potential clinical and echocardiographic follow-up period of >12 years. LVRR was defined as LV end-diastolic dimension ≤ 55 mm and fractional shortening ≥ 25% on the last echocardiogram. Of the 59 patients, 38 died (heart failure in 20, sudden death in 11, and other causes in 7), 2 underwent transplantation, and 19 survived. In the survivors, the LV size had significantly decreased and LV fractional shortening had significantly increased on the last echocardiogram. LVRR occurred in 37% of the survivors. The remaining 63% of the survivors still had LV dysfunction, but the LV end-systolic dimension had decreased significantly. In patients who died or underwent transplantation, the LV size significantly increased. No patient who died or underwent transplantation had LVRR. In conclusion, >60% of the long-term (>12 years) survivors with idiopathic dilated cardiomyopathy still had LV systolic dysfunction, but the LV end-systolic dimension had decreased significantly. In contrast, patients who died or underwent transplantation had significant LV enlargement. These results suggest that LVRR, even if it is not marked, is associated with a favorable prognosis.
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Khaleghi Y. A man awaiting a double transplant. BMJ Case Rep 2012; 2012:bcr.11.2011.5070. [PMID: 22729343 DOI: 10.1136/bcr.11.2011.5070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 40-year-old gentleman previously fit and well presented to hospital on Christmas day in 2003 with dyspnoea, indigestion and 'pins and needles' down his left arm. Investigations in the emergency department were normal, so the patient was discharged from hospital with a diagnosis of panic attacks. A month later he re-presented to hospital, again with an indigestion-like pain in the chest, worsening dyspnoea, poor exercise tolerance and paroxysmal nocturnal dyspnoea. Myocardial infarction was diagnosed, as well as dilated cardiomyopathy. The patient was subsequently put on the heart transplant register. First he had a pacemaker put in, and 4 months later a defibrillator was inserted which dramatically improved the patient's signs and symptoms. He felt well in himself for 7 years; however began to deteriorate in August 2010. No heart transplants were available at the time, so the patient was offered a ventricular assist device in September 2010. The patient went into kidney failure in December 2010 and haemodialysis was commenced in January 2011. He is currently at home awaiting a double heart and kidney transplant.
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Affiliation(s)
- Yasmin Khaleghi
- Vascular Ultrasound Department, Imperial College London, London, UK.
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Manu P, Kane JM, Correll CU. Sudden deaths in psychiatric patients. J Clin Psychiatry 2011; 72:936-41. [PMID: 21672496 PMCID: PMC3305794 DOI: 10.4088/jcp.10m06244gry] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 12/20/2010] [Indexed: 12/21/2022]
Abstract
BACKGROUND Studies using death certificates have indicated an excess of sudden cardiac deaths among users of antipsychotic drugs compared to the general population, but they may have underestimated the presence of other known causes of sudden and unexpected death. OBJECTIVE To assess the causes and risk factors for sudden death discovered by contemporaneous investigation of all deaths occurring over a 26-year period (1984-2009) in adults (119,500 patient-years) receiving care in one large psychiatric hospital in New York. METHOD Circumstances of death, psychiatric diagnoses, psychotropic drugs, and past medical history were extracted from the root cause analyses of sudden, unexpected deaths. After cases involving suicide, homicide, and drug overdoses were excluded, the remaining explained and unexplained cases of sudden death were compared regarding clinical variables and the utilization of antipsychotics. RESULTS One hundred cases of sudden death were identified. The death remained unexplained in 52 cases. The incidence of unexplained sudden death per 100,000 patient-years increased from 7 (95% CI, 3.7-19.4) in 1984-1998 to 125 (95% CI, 88.9-175.1) in 2005-2009. Explained and unexplained cases were similar regarding psychiatric diagnoses and use of all psychotropic classes, including first- and second-generation antipsychotics. Dyslipidemia (P = .012), diabetes (P = .054), and comorbid dyslipidemia and diabetes (P = .006) were more common in the unexplained group. CONCLUSIONS In a consecutive cohort of psychiatric patients, the unexplained sudden deaths were not associated with higher utilization of first- or second-generation antipsychotics. The role of diabetes and dyslipidemia as risk factors for sudden death in psychiatric patients requires careful longitudinal studies.
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Affiliation(s)
- Peter Manu
- Medical Services, Zucker Hillside Hospital, 75-59 263rd St, Glen Oaks, NY 11004, USA.
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Merlo M, Pyxaras SA, Pinamonti B, Barbati G, Di Lenarda A, Sinagra G. Prevalence and Prognostic Significance of Left Ventricular Reverse Remodeling in Dilated Cardiomyopathy Receiving Tailored Medical Treatment. J Am Coll Cardiol 2011; 57:1468-76. [DOI: 10.1016/j.jacc.2010.11.030] [Citation(s) in RCA: 274] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 11/08/2010] [Accepted: 11/09/2010] [Indexed: 11/27/2022]
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Gregori D, Rosato R, Zecchin M, Baldi I, Di Lenarda A. Heart failure and sudden death in dilated cardiomyopathy: a hidden competition we should not forget about when modelling mortality. J Eval Clin Pract 2008; 14:53-8. [PMID: 18211644 DOI: 10.1111/j.1365-2753.2007.00792.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES This paper discusses the use of bivariate survival curve estimators jointly with a competing risk Cox model to analyse mortality in dilated cardiomyopathy due to heart failure (HF) or sudden death (SD), without assuming independence between outcomes. The goal of the manuscript is to suggest a possible protocol for the analysis of competing risk events, mimicking the common approaches used in the univariate case. METHODS The non-parametric bivariate survival estimators are used to estimate a multivariate proportional hazard model for dealing with SD or HF in a long-term prospective cohort of 235 patients, recruited from 1978 to 1992. Patients have been stratified, among others, by age, severity and treatment. The latter has been considered under two specific protocols of analysis: intention to treat and actual treatment. RESULTS The bivariate survival curves show different survival probabilities for HF and SD. For HF the force of mortality acts early and then slows down as follow-up increases, while for SD the mortality is lower initially and increases later in time. Under competing risk analysis, evidence of treatment effect is shown only in the actual treatment protocol, in contrast with the results provided by standard Cox regression. CONCLUSIONS One of the advantages of non-parametric bivariate survival estimation in the presence of competing risks is that parameters may be interpreted in much the same way as those estimated by the standard Cox regression. Moreover, ignoring the competing risk structure may provide a misleading interpretation of the results.
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Affiliation(s)
- Dario Gregori
- Department of Public Health and Microbiology, University of Torino, Torino, Italy.
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Guías de Práctica Clínica del ACC/AHA/ESC 2006 sobre el manejo de pacientes con arritmias ventriculares y la prevención de la muerte cardiaca súbita.Versión resumida. Rev Esp Cardiol 2006. [DOI: 10.1157/13096582] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247-346. [PMID: 16949478 DOI: 10.1016/j.jacc.2006.07.010] [Citation(s) in RCA: 863] [Impact Index Per Article: 47.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death—Executive Summary. Circulation 2006. [DOI: 10.1161/circulationaha.106.178104] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Myerburg RJ, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Priori SG, Moss AJ, Priori SG, Antman EM, Blanc JJ, Budaj A, Camm AJ, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death—Executive Summary. J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.07.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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20
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Zipes DP, Camm AJ, Borggrefe M, Buxton AE, Chaitman B, Fromer M, Gregoratos G, Klein G, Moss AJ, Myerburg RJ, Priori SG, Quinones MA, Roden DM, Silka MJ, Tracy C, Smith SC, Jacobs AK, Adams CD, Antman EM, Anderson JL, Hunt SA, Halperin JL, Nishimura R, Ornato JP, Page RL, Riegel B, Blanc JJ, Budaj A, Dean V, Deckers JW, Despres C, Dickstein K, Lekakis J, McGregor K, Metra M, Morais J, Osterspey A, Tamargo JL, Zamorano JL. ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (writing committee to develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation 2006; 114:e385-484. [PMID: 16935995 DOI: 10.1161/circulationaha.106.178233] [Citation(s) in RCA: 807] [Impact Index Per Article: 44.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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21
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Matsumura Y, Takata J, Kitaoka H, Hamada T, Okawa M, Kubo T, Doi Y. Low-dose dobutamine stress echocardiography predicts the improvement of left ventricular systolic function and long-term prognosis in patients with idiopathic dilated cardiomyopathy. J Med Ultrason (2001) 2006; 33:17-22. [DOI: 10.1007/s10396-005-0061-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Accepted: 07/25/2005] [Indexed: 10/24/2022]
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22
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van Jaarsveld CHM, Ranchor AV, Kempen GIJM, Coyne JC, van Veldhuisen DJ, Sanderman R. Epidemiology of heart failure in a community-based study of subjects aged > or = 57 years: incidence and long-term survival. Eur J Heart Fail 2005; 8:23-30. [PMID: 16209932 DOI: 10.1016/j.ejheart.2005.04.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2004] [Accepted: 04/27/2005] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Survival data from hospital-based or clinical trial studies of patients with chronic heart failure (CHF) do not represent survival in community-based settings. AIMS To determine the incidence of CHF and the associated long-term survival in a community-based sample aged > or = 57 years and to assess the mortality risk associated with sex and age. METHODS This study was part of the Groningen Longitudinal Aging Study. RESULTS Annual incidence of CHF per 1000 ranged from 2.5 in middle aged adults (57-60 years) up to 22.4 in older females (> or = 80 years) and 28.2 in older males (> or = 80 years). The 1, 2, 5 and 7-year survival rates were 74%, 65%, 45%, 32% for patients with CHF, compared to 97%, 94%, 80% and 70% in a matched reference group without CHF. Higher age (> or = 76 years) was a risk factor for mortality (OR = 2.1) and male sex was a risk factor in those aged < or = 75 years (OR = 1.9) but not for older patients. CONCLUSION Long-term survival rates for patients with CHF in the community were worse than the known survival rates from clinical trials. There is a need for studies describing the care of patients with CHF in the community, including the type of care, the provider, the quality of care and the outcome.
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Affiliation(s)
- Cornelia H M van Jaarsveld
- Northern Centre for Healthcare Research, Department of Public Health and Health Psychology, University Medical Centre Groningen, PO Box 196, 9700 AD Groningen, The Netherlands.
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Senni M, De Maria R, Gregori D, Gonzini L, Gorini M, Cacciatore G, Gavazzi A, Pulignano G, Porcu M, Maggioni AP. Temporal trends in survival and hospitalizations in outpatients with chronic systolic heart failure in 1995 and 1999. J Card Fail 2005; 11:270-8. [PMID: 15880335 DOI: 10.1016/j.cardfail.2004.11.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract Background Community and hospital studies have suggested that survival of patients with heart failure (HF) has increased; however, the causes of the improvement and the hospital readmission rates remain undetermined. Methods and Results We compared survival and hospital admission rates in 2 cohorts enrolled in a national registry of outpatients with HF secondary to left ventricular (LV) systolic dysfunction referred to cardiology centers in 1995 (n = 712) and 1999 (n = 603). One year after enrollment, 163 of 1315 patients (12%) were dead. Survival rates were 85% in the 1995 versus 91% in the 1999 cohort. Older age, New York Heart Association (NYHA) class III-IV, anemia, hyponatremia, hypotension, and a lower LV ejection fraction (LVEF) were associated to an increased risk of all-cause mortality by multivariate analysis. Furthermore a significant independent cohort effect was observed: the adjusted risk of death was 1.30 (95% CI 1.16-1.45) for the 1995 versus 1999 cohort (survival difference adjusted P = .0067). The proportion of patients admitted to hospital declined significantly in 1999 versus 1995, for all causes (20% versus 27%, P = .006), for cardiac causes (16% versus 22%, P = .002), and for worsening congestive heart failure (8% versus 15%, P = .0005). Survival free from HF admission was 69% in 1995 versus 84% in 1999 (adjusted P = .0001); NYHA class III-IV, hypotension, diuretics and a lower LVEF were associated to an increased risk of this combined end point by multivariate analysis, as well as the enrollment year (relative risk 1.38, 95% CI 1.22-1.56, P = .0039). Conclusion In a national cardiologic registry of outpatients with systolic HF, survival improved and hospital admissions decreased over a 4-year period. These results underscore the importance of networking and the careful implementation of practice guidelines to elevate standards of care.
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Affiliation(s)
- Michele Senni
- Cardiovascular Medicine, Department of Cardiovascvular and Internal Medicine, Riuniti Hospital, Bergamo, Italy
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24
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Klein GJ, Krahn AD, Skanes AC, Yee R, Gula LJ. Primary Prophylaxis of Sudden Death in Hypertrophic Cardiomyopathy, Arrhythmogenic Right Ventricular Cardiomyopathy, and Dilated Cardiomyopathy. J Cardiovasc Electrophysiol 2005; 16 Suppl 1:S28-34. [PMID: 16138882 DOI: 10.1111/j.1540-8167.2005.50116.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
We present an evidence-based overview of primary prevention of sudden cardiac death. Several recent studies have provided important data regarding pharmacologic and device-based therapy for patients with conditions that confer high risk for sudden death. A rational approach to these therapies, with emphasis on implanted cardiovertor defibrillators, is discussed.
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Affiliation(s)
- George J Klein
- Division of Cardiology, University of Western Ontario, London, Ontario, Canada.
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25
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Edmunds LH. Reading tarot cards. Surg Clin North Am 2004; 84:323-31, xii-xiii. [PMID: 15053196 DOI: 10.1016/s0039-6109(03)00223-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In some patients acute myocardial infarction and/or infarct expansion induces progressive left ventricular dilatation that eventually leads to heart failure and death. The five year mortality after onset of heart failure is 50%. Chronically stretched viable myocardium adjacent to or remote from an expanding infarction initiates a myopathic process that leads to progressive myocyte apoptosis and adverse postinfarction remodeling. Revascularization of stunned or hibernating myocardium restores contractility and benefits patients in heart failure; however, revascularization does not restore contractility to myopathic, remodeling myocardium. Contemporary operations for heart failure temporarily reduce ventricular wall stress, but fail to reverse stretch induced myocyte apoptosis, which may not be reversible. Logically, prevention of this myopathic process after acute infarction seems required to extend survival. It follows that surgeons should operate before adverse postinfarction left ventricular remodeling occurs, using new operations, rather than afterwards.
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Affiliation(s)
- L Henry Edmunds
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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26
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Levy D, Kenchaiah S, Larson MG, Benjamin EJ, Kupka MJ, Ho KKL, Murabito JM, Vasan RS. Long-term trends in the incidence of and survival with heart failure. N Engl J Med 2002; 347:1397-402. [PMID: 12409541 DOI: 10.1056/nejmoa020265] [Citation(s) in RCA: 1479] [Impact Index Per Article: 67.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Heart failure is a major public health problem. Long-term trends in the incidence of heart failure and survival after its onset in the community have not been characterized. METHODS We used statistical models to assess temporal trends in the incidence of heart failure and Cox proportional-hazards regression to evaluate survival after the onset of heart failure among subjects in the Framingham Heart Study. Cases of heart failure were classified according to the date of onset: 1950 through 1969 (223 cases), 1970 through 1979 (222), 1980 through 1989 (307), and 1990 through 1999 (323). We also calculated 30-day, 1-year, and 5-year age-adjusted mortality rates for each period. RESULTS Heart failure occurred in 1075 subjects (51 percent of whom were women). As compared with the rate for the period from 1950 through 1969, the incidence of heart failure remained virtually unchanged among men in the three subsequent periods but declined by 31 to 40 percent among women (rate ratio for the period from 1990 through 1999, 0.69; 95 percent confidence interval, 0.51 to 0.93). The 30-day, 1-year, and 5-year age-adjusted mortality rates among men declined from 12 percent, 30 percent, and 70 percent, respectively, in the period from 1950 through 1969 to 11 percent, 28 percent, and 59 percent, respectively, in the period from 1990 through 1999. The corresponding rates among women were 18 percent, 28 percent, and 57 percent for the period from 1950 through 1969 and 10 percent, 24 percent, and 45 percent for the period from 1990 through 1999. Overall, there was an improvement in the survival rate after the onset of heart failure of 12 percent per decade (P=0.01 for men and P=0.02 for women). CONCLUSIONS Over the past 50 years, the incidence of heart failure has declined among women but not among men, whereas survival after the onset of heart failure has improved in both sexes. Factors contributing to these trends need further clarification.
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Affiliation(s)
- Daniel Levy
- National Heart, Lung, and Blood Institute's Framingham Heart Study, Framingham, Mass, USA
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Abstract
Reovirus-induced murine myocarditis provides an excellent model for the human disease. Cardiac tissue damage varies between reovirus strains, and is caused by a direct viral cytopathogenic effect. One determinant of virus-induced cardiac tissue damage is the cardiac interferon-beta (IFN-beta) response to viral infection. Nonmyocarditic reoviruses induce more IFN-beta and/or are more sensitive to the antiviral effects of IFN-beta in cardiac cells than myocarditis reoviruses. The roles of interferon regulatory factors (IRFs) in the cardiac response to viral infection are reviewed, and results suggest possible cardiac-specific variations in IRF-3 and IRF-1 function. In addition, data are presented indicating that the role of IRF-2 in regulation of IFN-beta expression is cell type-specific and differs between skeletal and cardiac muscle cells. Together, results suggest that the heart may provide a unique environment for IRF function, critical for protection against virus-induced cardiac damage.
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Affiliation(s)
- Barbara Sherry
- Department of Microbiology, Pathology and Parasitology, College of Veterinary Medicine, North Carolina State University, Raleigh 27606, USA.
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Cappato R, Negroni S, Bentivegna S, Bianchetti F, Pecora D, Morandi F, Furlanello F. Role of implantable cardioverter defibrillators in dilated cardiomyopathy. J Cardiovasc Electrophysiol 2002; 13:S106-9. [PMID: 11843459 DOI: 10.1111/j.1540-8167.2002.tb01962.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Idiopathic dilated cardiomyopathy (DCM) accounts for about 10,000 deaths per year in western countries. Of these deaths, 8% to 51% occur suddenly, with more than half of the events due to a ventricular arrhythmia. Improvement in diagnostic techniques and therapeutic strategies, together with changes in secular trends, have likely contributed to the reported trend toward improved survival in recent years. Identification of DCM patients at higher risk of sudden death is difficult. Poor left ventricular function is the strongest predictor of all-cause death, whereas a history of sustained unstable ventricular arrhythmia or cardiac arrest identifies patients at high risk of sudden death. Recent data suggest that a history of syncope, regardless of inducibility at programmed electrical stimulation, may be a risk factor of sudden death. Despite the absence of controlled studies, use of implantable cardioverter defibrillator therapy for primary prevention can be considered in patients with unexplained syncope as well as subgroups of DCM patients awaiting transplantation. In patients who survive a cardiac arrest or an unstable ventricular tachycardia, use of implantable cardioverter defibrillator therapy is associated with improved survival during follow-up and should be considered as a first-line therapy.
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Affiliation(s)
- Riccardo Cappato
- Arrhythmia and Electrophysiology Center, Policlinico San Donato, Milan, Italy.
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Abstract
The goals of heart failure therapy have shifted from purely hemodynamic manipulation to a combination of hemodynamic and neurohumoral modulation. Vasodilators with neurohumoral modulatory properties [such as ACE inhibitors (ACEi) and third generation beta-blockers] have become the cornerstone of chronic heart failure therapy. These newer agents have proven to improve morbidity and mortality in adults with chronic heart failure. Pure vasodilators still have a place in the treatment of acute decompensated heart failure and in patients who are intolerant to ACEi or beta-blocker therapy. In decompensated heart failure management, improvement of cardiac output is of paramount importance and restoration of normal hemodynamics takes priority over modulation of cardiac maladaptation. Under these circumstances agents that improve contractility and modify cardiac preload and afterload are used. In the intensive care unit setting inodilators offer the advantage of an added positive inotropic effect. NO donors play an important role when close titration of blood pressure is also needed. It is the purpose of this manuscript to address principles and current practice regarding the use of vasodilators in pediatric heart failure. ACE inhibitors and third generation beta-blockers due to their importance in today's therapeutic approach to heart failure are the focus of more detailed articles in this issue of Progress in Pediatric Cardiology.
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Nield LE, McCrindle BW, Bohn DJ, West LJ, Coles JG, Freedom RM, Benson LN. Outcomes for children with cardiomyopathy awaiting transplantation. Cardiol Young 2000; 10:358-66. [PMID: 10950333 DOI: 10.1017/s1047951100009665] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To determine factors associated with outcomes after listing for transplantation in children with cardiomyopathies. BACKGROUND Childhood cardiomyopathies form a heterogeneous group of diseases, and in many, the prognosis is poor, irrespective of the etiology. When profound heart failure develops, cardiac transplantation can be the only viable option for survival. METHODS We included all children with cardiomyopathy listed for transplantation between 12/89 and 4/98 in this historical cohort study. RESULTS We listed 31 patients, 15 male and 16 female, 27 with dilated and 4 with restrictive cardiomyopathy, for transplantation. The median age at listing was 5.7 years, with a range from fetal life to 17.8 years. Transplantation was achieved in 23 (74%), with a median interval from listing of 54 days, and a range from zero to 11.4 years. Of the patients, 14 were transplanted within 30 days of listing. Five patients (16%) died before transplantation. Within the Canadian algorithm, one of these was in the third state, and four in the fourth state. One patient was removed from the list after 12 days, having recovered from myocarditis, and two remain waiting transplantation after intervals of 121 and 476 days, respectively. Patients who died were more likely to be female (5/5 vs. 11/26; p=0.04) and to have been in the third or fourth states at listing (5/5 vs. 15/26; p=0.04). The use of mechanical ventricular assistance, in 10 patients, was not a predictor of an adverse outcome. While not statistically significant, survival to transplantation was associated with treatment using inhibitors of angiotensin converting enzyme, less mitral regurgitation, a higher mean ejection fraction and cardiac index, and lower right ventricular systolic pressure. CONCLUSIONS Children with cardiomyopathy awaiting transplantation have a mortality of 16% related to their clinical state at the time of listing.
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MESH Headings
- Adolescent
- Angiotensin-Converting Enzyme Inhibitors/therapeutic use
- Cardiomyopathy, Dilated/complications
- Cardiomyopathy, Dilated/mortality
- Cardiomyopathy, Dilated/physiopathology
- Cardiomyopathy, Dilated/therapy
- Cardiomyopathy, Restrictive/complications
- Cardiomyopathy, Restrictive/mortality
- Cardiomyopathy, Restrictive/physiopathology
- Cardiomyopathy, Restrictive/therapy
- Child, Preschool
- Cohort Studies
- Female
- Heart Transplantation
- Humans
- Infant
- Infant, Newborn
- Male
- Mitral Valve Insufficiency/etiology
- Ontario/epidemiology
- Prognosis
- Stroke Volume
- Survival Analysis
- Systole
- Ventricular Pressure
- Waiting Lists
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Affiliation(s)
- L E Nield
- Department of Paediatrics, The Hospital for Sick Children, The University of Toronto School of Medicine, Ontario, Canada
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Agarwal AK, Venugopalan P, Meharali AK, de Debono D. Idiopathic dilated cardiomyopathy in an Omani population of the Arabian Peninsula: prevalence, clinical profile and natural history. Int J Cardiol 2000; 75:147-58; discussion 158-9. [PMID: 11077126 DOI: 10.1016/s0167-5273(00)00315-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
We have analysed prospectively the prevalence and clinical profile of idiopathic dilated cardiomyopathy (IDC) in a circumscribed native population of the Sultanate of Oman over 3 years (1992-1994). Identified patients were followed up for a period ranging from 1 to 8 years (median 4 years) and the variables related to outcome determined. IDC was diagnosed in 97 patients, giving a prevalence of 43.2/100,000 population during the study period. 84.5% of patients were aged over 35 years and males outnumbered females (M/F=1.4:1). Factors related to poor outcome were an initial left ventricular ejection fraction </=30% (P=0.01), severe symptoms, i.e. NYHA functional class III or IV at presentation (P=0.04), and significant ventricular tachycardia during follow up (P=0.02). However, multivariate regression analysis yielded only low LVEF as the predictor of poor outcome (P=0.01). When analysed from age of onset of symptoms, survival figures were 94% at 1 year (95% CI 88 to 99%), 76% at 5 years (95% CI 67 to 86%) and 68% at 8 years (95% CI 54 to 82%). Mean survival was 6.5 years (95% CI 6 to 7 years). Patients were still at risk of fatal ventricular arrhythmia even when haemodynamically stable and had left ventricular ejection fraction >30%.
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Affiliation(s)
- A K Agarwal
- Department of Cardiology, Sultan Qaboos University, Muscat, Oman.
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33
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Abstract
PURPOSE To explore the use of neuroendocrine monitoring for more timely diagnosis of dilated cardiomyopathy (DCM) in Duchenne's muscular dystrophy (DMD) and to determine the effects of angiotensin-converting enzyme inhibitors (ACEI) and beta-blockers on neuroendocrine levels, left ventricular diastolic diameter (LVDd), ejection fraction, and mortality rate on DMD. METHODS Eighty-five patients with DMD underwent yearly cardiac monitoring including neuroendocrine screening. Eleven patients had symptoms of DCM develop once plasma neuroendocrine levels increased. At this point the patients received ACEI for 9 to 62 months (35.8 +/- 18.4 months) and beta-blockers for 7 to 60 months (31.6 +/- 20.1 months). RESULTS The combination of ACEI and beta-blockers relieved symptoms and signs of heart failure in all 11 patients and significantly reduced atrial natriuretic protein (ANP) levels from 197.5 +/- 152.1 pg/mL to 25.5 +/- 16.2 pg/mL ( P <.002) at 15.5 +/- 8.2 months, brain natriuretic protein from 523.8 +/- 434.8 pg/mL to 59.3 +/- 24. 2 pg/mL ( P <.05) at 12.2 +/- 3.1 months (data complete for 5 patients), norepinephrine levels from 1114 +/- 689 pg/mL to 360 +/- 257 pg/mL at 20.5 +/- 9.6 months for 11 patients (P =.001), and LVDd from 65.9 +/- 9.2 mm to 63.3 +/- 6.3 mm (P =.15) at 15.0 +/- 7.4 months for 10 patients, including 3 for whom the LVDd increased by 2 to 6 mm. The combination increased left ventricular ejection fraction (LVEF) from 25.1% +/- 9.2% to 36.5% +/- 5.8% (P <.001) at 17.1 +/- 11.0 months for 10 patients. For 9 of the patients ANP levels remained lower throughout the 36.8 +/- 20.1 month course of the follow-up. Two patients had sudden severe re-elevations of ANP levels just before death from congestive heart failure after 44 and 23 months of therapy, respectively. CONCLUSION Neuroendocrine level monitoring can assist in the diagnosis of DCM in patients with DMD. Combination therapy with ACEI and beta-blockers can significantly decrease neuroendocrine activation and LVDd and reverse symptoms and signs of congestive heart failure for patients with DMD.
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Affiliation(s)
- Y Ishikawa
- Department of Pediatrics, National Yakumo Hospital, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newwark, NJ, USA
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Venugopalan P, Agarwal AK, Akinbami FO, El Nour IB, Subramanyan R. Improved prognosis of heart failure due to idiopathic dilated cardiomyopathy in children. Int J Cardiol 1998; 65:125-8. [PMID: 9706806 DOI: 10.1016/s0167-5273(98)00084-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
We analyzed the outcome of 18 children with idiopathic dilated cardiomyopathy (IDC). There was a striking female preponderance (M:F = 1:3.5) and 15 (83%) presented below the age of 2 years. Follow up for a mean duration of 3.5 years revealed complete recovery in seven (43%) and an additional three (19%) became asymptomatic. Three (19%) died and another three (19%) continued to be symptomatic but in controlled heart failure. Two were lost to follow up. Among those who improved, the majority (75%) did so in 1.5 years. Three of five patients who received periodic dobutamine infusion showed improvement in quality of life. The survivals of 94% at 1 year and 87% at 3 years are significantly better than those previously reported. This is the first such study of IDC in children from the Arab peninsula.
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Affiliation(s)
- P Venugopalan
- Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman
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35
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Affiliation(s)
- B Sherry
- College of Veterinary Medicine, North Carolina State University, Raleigh 27606, USA
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36
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Di Lenarda A, De Maria R, Gavazzi A, Gregori D, Parolini M, Sinagra G, Salvatore L, Longaro F, Bernobich E, Camerini F. Long-term survival effect of metoprolol in dilated cardiomyopathy. The SPIC (Italian Multicentre Cardiomyopathy Study) Group. HEART (BRITISH CARDIAC SOCIETY) 1998; 79:337-44. [PMID: 9616339 PMCID: PMC1728660 DOI: 10.1136/hrt.79.4.337] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the additive effect of metoprolol treatment on long-term incidence of fatal and non-fatal cardiac events in idiopathic dilated cardiomyopathy. DESIGN 586 patients with idiopathic dilated cardiomyopathy were prospectively enrolled in a multicentre registry and followed up for a mean (SD) of 52 (32) months. Metoprolol, carefully titrated to the maximum tolerated dose, was added to conventional heart failure treatment in 175 patients. RESULTS Survival and transplant-free survival at seven years were significantly higher in the 175 metoprolol treated patients than in the remaining 411 on standard treatment (81% v 60%, p < 0.001, and 69% v 49%, p < 0.001, respectively). By multivariate analysis, metoprolol independently predicted survival and transplant-free survival (relative risk reduction values for all cause mortality and combined mortality or transplantation 51% (95% confidence interval 21% to 69%), p = 0.002, and 34% (5% to 53%), p = 0.01, respectively). New York Heart Association class, left ventricular end diastolic diameter, and pulmonary wedge pressure were also predictive. Seven year survival (80% v 62%, p = 0.004) and transplant-free survival (68% v 51%, p = 0.005) were significantly higher in 127 metoprolol treated cases than in 127 controls selected from the entire control cohort and appropriately matched. Metoprolol was associated with a 30% reduction in all cause mortality (7% to 48%, p = 0.015) and a 26% reduction in mortality or transplantation (7% to 41%, p = 0.009). CONCLUSIONS The addition of metoprolol to standard heart failure treatment, including angiotensin converting enzyme inhibitors, was effective in the long-term, reducing both all cause mortality and transplantation in patients with idiopathic dilated cardiomyopathy.
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Affiliation(s)
- A Di Lenarda
- Department of Cardiology, Ospedale Maggiore and University, Trieste, Italy
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Arola A, Tuominen J, Ruuskanen O, Jokinen E. Idiopathic dilated cardiomyopathy in children: prognostic indicators and outcome. Pediatrics 1998; 101:369-76. [PMID: 9480999 DOI: 10.1542/peds.101.3.369] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To determine the outcome of Finnish children and adolescents with idiopathic dilated cardiomyopathy (IDCM) and factors that might be useful as prognostic indicators. METHODOLOGY The clinical profile and course of 62 Finnish children and adolescents (median age, 13 months; range, 1 day to 20 years) with IDCM in 1980 to 1991 were evaluated to detect factors that might predict outcome. Factors studied included age, gender, family history, previous viral illness, and symptoms and signs at presentation. Furthermore, data on serial electrocardiographic, echocardiographic, and chest x-ray examinations, histologic findings, and treatments were analyzed. RESULTS During a mean (+/-SD) follow-up of 3.9 +/- 4.5 years (range, 1 day to 25 years), 10 patients (16%) recovered, 17 (27%) had residual disease, 4 (6.4%) underwent heart transplantation, and 31 (50%) died. Infants (<1 year of age) and adolescent (>/=15 years of age) male patients with progressing symptoms of left ventricular failure after initiation of medical therapy tended to have the poorest outcome. However, in multivariate analysis, only histologic evidence of endocardial fibroelastosis, clinical signs of right ventricular failure at presentation, and the need for anticoagulative therapy during follow-up, the last an expression of a severely impaired left ventricular systolic function, appeared to be significant predictors of long-term outcome. CONCLUSIONS Our study confirms that the outcome of children with IDCM still remains poor. However, a group of patients, mainly infants, make a full recovery. Adolescent male patients as well as infants suffering from endocardial fibroelastosis with persisting symptoms of congestive heart failure after initiation of medical therapy tend to have the poorest outcome. These patients need a careful follow-up at short time intervals and, in the case of lacking response to medical treatment with resulting growth failure and/or poor quality of life, should be offered urgent heart transplantation.
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Affiliation(s)
- A Arola
- Department of Pediatrics, University of Turku, Turku, Finland
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Brachmann J, Hilbel T, Grünig E, Benz A, Haass M, Kübler W. Ventricular arrhythmias in dilated cardiomyopathy. Pacing Clin Electrophysiol 1997; 20:2714-8. [PMID: 9358519 DOI: 10.1111/j.1540-8159.1997.tb06121.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although prognosis of dilated cardiomyopathy (DCM) has improved due to advances in diagnosis and therapy, still too many sudden cardiac deaths occur in DCM. Spontaneous ventricular ectopy is a very common finding in patients with DCM, but the prognostic significance of Holter monitoring remains controversial. Other noninvasive methods, e.g., late potentials and QT dispersion, have not yet contributed to the evaluation of prognosis for arrhythmogenic events in DCM. Programmed ventricular stimulation has been repeatedly used to stratify long-term prognosis, yet satisfactory data are still missing as many deaths occur in patients without inducible arrhythmias. Several prognostic studies are still in progress, and preliminary data for the use of ICDs already appear to be promising. In patients with poor left ventricular function and ICDs in situ, prognosis is determined by progression of heart failure. Heart transplantation may be the ultimate therapeutic instrument for end-stage heart failure patients. For patients with advanced DCM and increased risk for malignant arrhythmias who are unsuitable for orthotopic heart transplantation, the combined therapy with an ICD and dynamic cardiomyoplasty may be an alternative treatment.
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MESH Headings
- Arrhythmias, Cardiac/diagnosis
- Arrhythmias, Cardiac/etiology
- Arrhythmias, Cardiac/prevention & control
- Arrhythmias, Cardiac/therapy
- Cardiac Pacing, Artificial
- Cardiomyopathy, Dilated/complications
- Cardiomyopathy, Dilated/therapy
- Death, Sudden, Cardiac/etiology
- Electrocardiography, Ambulatory
- Heart Ventricles
- Humans
- Prognosis
- Risk Factors
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Affiliation(s)
- J Brachmann
- Department of Cardiology, University Hospital, Heidelberg, Germany.
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Massie BM, Shah NB. Evolving trends in the epidemiologic factors of heart failure: rationale for preventive strategies and comprehensive disease management. Am Heart J 1997; 133:703-12. [PMID: 9200399 DOI: 10.1016/s0002-8703(97)70173-x] [Citation(s) in RCA: 399] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- B M Massie
- Department of Medicine and the Cardiovascular Research Institute of the University of California, San Francisco, Department of Veterans Affairs Medical Center, 94121, USA
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Abstract
Statistics regarding long-term survival for patients with heart failure are discouraging today. Converting enzyme inhibitors have produced a modest effect on mortality. beta-Blockers may be the next addition to standard therapy for heart failure because they generate consistent improvements in hemodynamic factors, symptom scores, and submaximal exercise tolerance in randomized, controlled clinical trials. They augment ejection fraction, reduce heart volume, and consistently lower neurohormonal activation as reflected by plasma norepinephrine levels. Trials with carvedilol and bisoprolol suggest an effect on mortality similar to that with converting enzyme inhibitor trials. Future studies, especially the beta-blocker Evaluation Survival Trial (BEST), with mortality as the main end point should elucidate the degree of effect on mortality further.
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Affiliation(s)
- T W Hash
- Section of Cardiology, Medical College of Georgia, Augusta 30912-3150, USA
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Grzybowski J, Bilińska ZT, Ruzyłło W, Kupść W, Michalak E, Szcześniewska D, Poplawska W, Rydlewska-Sadowska W. Determinants of prognosis in nonischemic dilated cardiomyopathy. J Card Fail 1996; 2:77-85. [PMID: 8798109 DOI: 10.1016/s1071-9164(96)80026-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dilated cardiomyopathy, a heart muscle disease of unknown cause, is characterized by high mortality and is a major cause of cardiac transplantation. It has become, therefore, increasingly important to identify patients at higher risk. The aim of this study was to assess which of the data obtained at the time of diagnosis are the best predictors of survival. METHODS AND RESULTS One hundred forty-four patients with dilated cardiomyopathy (118 men; mean age, 39 years) were assessed clinically, noninvasively, and hemodynamically. The effect of variables derived from the evaluation on outcome (death or heart transplantation) was examined. During a mean follow-up time of 4.1 years, 68 patients (47%) died and 9 (6%) underwent heart transplantation. The 1-, 2-, and 5-year transplant-free survival rate was 79, 69, and 44%, respectively. Cox multivariate regression analysis identified three variables as independent predictors of outcome: (1) pulmonary artery systolic pressure, P = .0001; (2) left ventricular ejection fraction, P = .0013; and (3) left ventricular end-diastolic dimension, P = .007. The prognostic index was constructed from regression coefficients and parameters significant in the Cox model. The minimal prognostic index in the study group was 1.4 and the maximal was 6.0 with a corresponding 1-year survival of 98 and 18%, respectively. The validity of the prognostic index was tested in the consecutive group of 81 patients, who were followed for a mean 2.3 years. The prognostic index of the poor outcome group differed significantly from that in survivors (3.7 vs 2.9, respectively, P < .01). The sensitivity and specificity of model predictions were 68 and 52%, respectively. CONCLUSIONS The severity of pulmonary hypertension and left ventricular dysfunction provides an independent insight into the prognosis of patients with dilated cardiomyopathy. The prognostic index is useful when assessing prognosis and may be helpful in the timing of heart transplantation.
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Affiliation(s)
- J Grzybowski
- Department of General Cardiology, National Institute of Cardiology, Warsaw, Poland
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