Prognostic impact of echocardiographic derived precapillary wedge pressure and pulmonary vascular resistances in patients with heart failure

Background

A reliable echocardiographic algorithm for the estimation of precapillary wedge pressure (PCWP) and pulmonary vascular resistances (PVR) has been recently validated by our group in a large cohort of patients undergoing right heart catheterization (RHC) (1). Those metrics may add relevant clinical and prognostic information in patients with heart failure (HF).

Objective

To assess the clinical/prognostic significance of echocardiographic derived PCWP and PVR in a large cohort of chronic HF patients on modern treatments.

Methods

Outpatients with chronic HF with either reduced (≤40%) or mildly reduced LVEF (41–49%) underwent a thorough clinical multiparametric assessment and were followed-up for a composite endpoint of cardiac death, appropriate ICD shock, or first HF hospitalization.

Results

Out of 1,483 patients prospectively enrolled (70±12 years, 73% males, 42% ischemic etiology, LVEF 35±8%), PCWP (16.4±5.8 mmHg) was elevated (>15 mmHg) in 53% of cases, while PVR (1.7±0.7) was elevated (>3 WU) in 6% of cases. Of the latter group, most (92%) had also elevated PCWP. Patients with increased PCWP were older, had a higher heart rate and lower cardiac output, showed a higher degree of left and right chamber remodeling, had a higher neurohormonal activation, worse renal function, worse functional capacity and ventilatory efficiency on effort (all p<0.001). Those patients with high PCWP and PVR showed higher heart rate and pulmonary pressures, lower cardiac output, and right ventricular function, higher neurohormonal activation, lower functional capacity and ventilatory efficiency on effort compared to patients with high PCWP but normal PVR (all p<0.01). The optimal prognostic cut-point was identified for both PCWP (16.2 mmHg) and PVR (2 WU) by log-rank maximal likelihood ratio. Over a median follow-up of 22 (8–37) months, both measures significantly stratified patients for the risk of the primary endpoint at Kaplan-Meier analysis (log-rank 92.9, p<0.001 for PCWP; log-rank 17.3, p<0.001 for PVR). At multivariable Cox regression analysis (adjusted for age, sex, ischemic HF etiology, renal function, LVEF, and NT-proBNP), PCWP (hazard ratio, HR 1.77 [95% CI 1.30–2.40], p<0.001) but not PVR (HR 1.15 [95% CI 0.88–1.51], p=0.31) remained an independent predictor of the primary outcome.

Conclusion

The estimation of PCWP and PVR by echocardiography add relevant clinical and prognostic information and may help in the decision making in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

Valve disease in cardiac amyloidosis: an echocardiographic score

Background

Cardiac amyloidosis (CA) may affect all cardiac structures, including the valves.

Methods

From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR-) or light-chain (AL-) CA, and age- and sex-matched controls. We chose 31 echocardiographic items related to the mitral, aortic and tricuspid valves, giving a value of 1 to each abnormal item.

Results

Patients with ATTR-CA displayed more often a shortened/hidden and restricted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL-CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (13.6–17.4) in ATTR-CA, 11.0 (9.3–14.9) in AL-CA, 12.8 (11.1–14.4) in ATTR-CA controls, and 11.0 (9.1–13.0) in AL-CA controls (p=0.004 for ATTR- vs. AL-CA, 0.009 for ATTR-CA vs. their controls, and 0.461 for AL-CA vs. controls). Area under the curve values to diagnose ATTR-CA were 0.782 in patients with ATTR-CA or matched controls, and 0.773 in patients with LV hypertrophy.

Conclusions

Patients with ATTR-CA have a prominent impairment of mitral valve structure and function, and higher score values. The valve score is quite effective in identifying patients with ATTR-CA among patients with CA or unexplained hypertrophy.

Funding Acknowledgement

Type of funding sources: None.

Clinical and prognostic significance of left ventricular outflow tract velocity time integral (LVOT-VTI) in patients with chronic heart failure

Background

The echocardiographic evaluation of cardiac output relies on the product of the flow across the left ventricular outflow tract (LVOT), estimated through its velocity time integral (LVOT-VTI), and its cross-sectional area, estimated through the formula πr2. Considering the geometrical assumption behind such formula, LVOT-VTI has been proposed as a more reproducible surrogate of cardiac systolic function and showed prognostic value in the critical care setting. However, the role of such measure in patients with chronic heart failure (HF) remains unexplored.

Objective

To assess the clinical and prognostic significance of LVOT-VTI in a contemporary cohort of patients with chronic HF.

Methods

Outpatients with chronic HF with a LV ejection fraction <50% were prospectively enrolled to undergo a clinical, echocardiographic, and biohumoral assessment, and were followed-up for the endpoint of all-cause death.

Results

Finally, 971 patients were enrolled (71±12 years, 72% men, 50% ischemic etiology, LVEF 35±9%). Most patients showed a NYHA class I-II (74%) and were treated with ACE-inhibitors/ARBs or ARNI (81%), beta-blockers (95%), and mineralocorticoid receptor antagonists (71%). Patients were distinguished in three subgroups according to LVOT-VTI tertiles <19 (n=324), 19–24 (n=324), or ≥24 (n=323). Compared with the other two subgroups, patients with LVOT-VTI <19 showed worse NYHA class, lower LVEF and tricuspid annular plane systolic excursion (TAPSE), and higher E/e', left atrial volume index (LAVi), estimated systolic pulmonary arterial pressure (sPAP), and NT-proBNP concentration (all p<0.001). No differences were observed as for patients' age, HF etiology, and therapies (all p>0.05). Over a median follow-up of 22 (9–34) months, 103 (11%) patients met the primary endpoint. LVOT-VTI significantly stratified the risk of death, observing 65 (20%), 21 (7%), and 17 (5%) events across the subgroups with values <19, 19–24, or ≥24 (log-rank 33, p<0.001). At multivariable regression analysis, LVOT-VTI <19 (HR 2.06 [95% 1.21–3.49], p=0.008), but not LVEF <30% (p=0.614) was an independent predictor of all-cause death in a model adjusted for age, sex, ischemic etiology, renal function, hemoglobin, E/e', LAVi, TAPSE, sPAP, and NT-proBNP.

Conclusion

LVOT-VTI is associated with disease severity and is a strong predictor of all-cause death in patients with chronic HF.

Funding Acknowledgement

Type of funding sources: None.

Haemodynamic forces as predictors of cardiac remodelling and outcome in heart failure with reduced ejection fraction treated with sacubitril/valsartan

Background

Angiotensin receptor-neprilysin inhibitor (ARNI) is a cornerstone of treatment in heart failure (HF) with reduced ejection fraction (HFrEF), but its effectiveness shows interindividual differences.

Objectives

To evaluate the predictive value of echo-derived hemodynamic forces (HDF), together with other echocardiographic, biohumoral and cardiopulmonary parameters on a) response to ARNI after 6 months; b) adverse cardiovascular events at follow-up.

Methods

Eighty-nine consecutive HFrEF patients from two HF centers performed clinical evaluation, laboratory analyses, rest echocardiography and cardiopulmonary exercise testing. Response to ARNI at 6 months was considered in patients without HF admissions, death, or urgent heart transplant and with a ≥50% reduction in NT-proBNP levels and/or ≥10% increase in left ventricle ejection fraction. After 6 months, patients were followed up for a composite endpoint of cardiovascular death, HF-related hospitalization and new-onset atrial fibrillation.

Results

Response to ARNI was documented in 45/89 (51%) of patients. At baseline, responders and non-responders were paired in clinical assessment, conventional echocardiography, functional status and therapy. At multivariate logistic regression analysis, HDF-derived whole cardiac cycle left ventricle strength (wLVS) was the only independent predictor of ARNI response at 6 months (odds ratio 1.36, 95% confidence interval 1.10–1.67; p=0.004). A wLVS ≥3.7% showed a good accuracy in predicting ARNI response (AUC = 0.736, 0.607–0.840; p<0.0001). During a median of 33 (IQR 23–41) months, wLVS increase from baseline to 6-month (ΔwLVS) showed a high discrimination ability at time-dependent ROC analysis (optimal cut-off: ≤0.5%; AUC=0.811, 0.69–0.90; p<0.0001), stratified prognosis at Kaplan-Meier analysis (log-rank p<0.0001), and remained an independent prognostic predictor of the composite endpoint (hazard ratio 0.76, 0.61–0.95; p<0.01) even after adjusting for clinical, functional and conventional echocardiographic parameters.

Conclusions

HDF analysis may help predict ARNI response and optimize follow-up and medical/device strategies in patients with HfrEF.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Fondazione Toscana Gabriele Monasterio, Pisa, Italy

Transmural voltage gradient dispersion and heterogeneity in brugada syndrome phenotype - a novel workflow for advanced mapping using endocardial unipolar electrograms J-point elevation

Funding Acknowledgements

Type of funding sources: None.

Background

Differential action potential duration shortening across the right ventricular (RV) myocardial wall is primarily responsible for the Brugada Syndrome (BrS) phenotype [1]. To date, data on electrical substrate characterization in humans with BrS phenotype is limited and risk evaluation is still controversial.

Purpose

We hypothesized that Uni-JEl mapping could be used as a marker of transmural voltage gradient dispersion resulting. Our aim was to evaluate Uni-JEl mapping in defining arrhythmogenic substrates in patients with BrS phenotype.

Methods

12 patients were included in our analysis. 2 normal patients provided control data and 10 asymptomatic subjects with spontaneous type-1 BrS underwent 3D RV mapping (CARTO3 System, Biosense Webster). Among BrS patients we had 3 patients with arrhythmic events (aborted sudden death or appropriate ICD therapies) during follow-up (median 56, interquartile range: 46-74 months) and 7 patients without arrhythmic events. In the former group we had 1 patient with inducibility of VT/VF during EPS (EPS+) and 2 patients non-inducibles during EPS (EPS-), in the latter group we had 3 patients with EPS+ and 4 patients with EPS-. Electrophysiological data and signals were exported and OpenEP [2] was used to convert Carto proprietary data formats into Matlab format (Fig.1). Uni-JEl was calculated for each point map as the unipolar value at J point on surface electrocardiogram. Uni-JEl values were then interpolated in Paraview to create Uni-JEl maps, interpolating data points on the mesh cell (Fig.1). Finally, a region of interest (ROI) was selected and the calculation of mean Uni-JEI (MUni-JEI, as a measure of voltage gradient dispersion), interquartile range and range (intrqUni-JEI and ∆Uni-JEI, as markers of heterogeneity of dispersion) was performed. Results are shown as mean ± standard deviation for the group of BrS patients and the actual values for the two controls.

Results

BrS patients showed Muni-JEl, intrqUni-JEl and ∆Uni-JEI higher than controls (2.03 mV ± 0.31 mV vs 0,82 mV and 1,1 mV, 1.90 mV ± 0.82 mV vs 1,04 mV and 1,18 mV 6.26 mV ± 1.98 mV vs 3,54 mV and 4,01 mV, respectively). BrS patients with arrhythmic events during the follow-up showed higher intrqUni-JEl and the ∆Uni-JEI respect to BrS with EPS+ and without arrhythmic events during follow-up (2.31 mV ± 0.44 mV vs 0.78 mV ± 0.11 mV and 6.69 mV ± 2.27 mV vs 3.98 mV ± 0.31 mV). Figure 2 shows some examples of calculated Uni-JEl maps for each group under study.

Conclusions

In this work we introduced a novel workflow for the electrical substrate characterization of subjects with BrS phenotype. The results from our preliminary analysis indicate that a higher transmural voltage gradient dispersion and heterogeneity can be found in type-1 BrS with respect to normal subjects. Voltage gradient dispersion heterogeneity could be used to better recognize high risk BrS patients regardless of VT/VF inducibility during EPS.

C42 MULTI–CHAMBER SPECKLE TRACKING IMAGING AND DIAGNOSTIC VALUE OF LEFT ATRIAL STRAIN IN CARDIAC AMYLOIDOSIS

Background

Amyloid deposits in all cardiac chambers, impairing their function. We investigated for the first time if a speckle–tracking echocardiography (STE) analysis extended to all 4 chambers might hold additive diagnostic value for CA and its subtypes (amyloid transthyretin [ATTR–] and light–chain [AL]–CA).

Methods

We evaluated 423 consecutive patients undergoing a diagnostic workup for CA in 2 referral centres from 2015 to 2020.

Results

CA was diagnosed in 261 patients (62%; ATTR–CA, n = 144, 34%; AL–CA, n = 117, 28%). Patients with CA had an impaired function of all cardiac chambers, particularly those with ATTR–CA. Peak left atrial longitudinal strain (LA–PALS) was the only STE parameter that predicted CA and ATTR–CA independent of laboratory and standard echocardiographic variables (Model 1). It also predicted ATTR–CA among patients with unexplained hypertrophy regardless of a diagnostic score (IWT score). Patients with either LA–PALS or LA–peak atrial contraction strain (PACS) in the first quartile (LA–PALS <6.65% or LA–PACS <3.62%) had an almost 4–fold higher likelihood of CA and ATTR–CA regardless of Model 1. Among patients with unexplained hypertrophy, those with LA–PALS or LA–PACS in the first quartile had an almost 9–fold higher likelihood of ATTR–CA irrespective of Model 1, and a 2–fold higher likelihood of ATTR–CA beyond the IWT score.

Conclusions

STE measures of all 4 chambers are abnormal in patients with CA, particularly in those with ATTR–CA. LA strain holds independent diagnostic significance. Among patients screened for CA, those with LA–PALS <6.65% and/or LA–PACS <3.62% have a high likelihood of CA and ATTR–CA.

C63 PHENOTYPE – GENOTYPE RELATIONSHIP IN ARRHYTHMOGENIC CARDIOMYOPATHY

Background

Arrhythmogenic cardiomyopathy (ACM) is a primary disease of the myocardium with arrhythmic manifestations and fibro–fatty replacement either of the right (RV) or the left ventricle (LV) at the cardiac magnetic resonance (CMR). Over the last decade, different mutations in cardiac genes associated with heterogeneous phenotypes have been identified.

Aim

To investigate the genotype–phenotype relationships in ACM patients. Firstly, the phenotypic expression was defined in definite mutation carriers. Secondly, the prognostic significance of mutations was assessed across different phenotypes.

Methods

The study population included 281 patients with suspected ACM, based on family history, clinical and electrocardiographic evaluation, echocardiographic and CMR findings (Fig.1), studied at our Institution since 2012. All patients underwent genetic evaluation using Sanger sequencing and NGS of mutations in desmosomal (desmoplakin [DSP], plakophilin–2[PKP2], plakoglobin[JUP], desmoglein–2 [DSG2], desmocollin–2 [DSC2]) or non desmosomal genes. The composite endpoint included cardiac death, sustained and non–sustained ventricular tachycardia (VT), ventricular fibrillation (VF), appropriate defibrillator shock/antitachycardia pacing (ATP).

Results

The genetic test was positive in 113 patients (40%), 82 (73%) for desmosomal genes (41 DSP, 15 DSG2, 15 PKP2, 5 JUP, 6 DSC2), and 31 (27%) for non–desmosomal genes (4 titin, 2 TMEM 43, 2 lamin A/C, 23 others). Gene–positive compared to gene–negative (n = 168, 60%) patients showed a higher prevalence of LV ejection fraction (EF)<50% (14%vs.6%, p<0.011), LV and RV LGE (62%vs.46%, p < 0.001, 20%vs.12%, p<0.02), RV dilatation (27%vs.17%, p<0.041) (Table 1). DSG2 mutations were associated mainly to biventricular (7/15,46%) or RV involvement (4/15,26%), while DSP mutations to LV involvement (24/41,58%). During a median 36–month follow–up (IQ.range 12–56), 55 patients (19%) experienced the composite endpoint (35 non–sustained VT; 11 sustained VT – 3 ATP, 1 defibrillator–shock–; 9 VF, all treated by defibrillator–shock). At Kaplan–Meier analysis, DSP mutations were associated with the worst prognosis (Fig. 3). Conclusion Diverse genotypes were differently associated with LV dysfunction/LGE, RV dilatation/LGE. DSP mutations were associated with higher arrhythmic risk. Genetic screening may result in a better risk stratification, useful for clinical decision–making.

P294 AN ECHOCARDIOGRAPHIC SCORE OF VALVE DISEASE IN PATIENTS WITH CARDIAC AMYLOIDOSIS

Background

Cardiac amyloidosis (CA) affects all cardiac structures, including the valves. We summarized the echocardiographic features of valve disease in a score.

Methods

From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR–) or light–chain (AL–) CA, and selected age– and sex–matched controls. The Amyloid VAlve (AVA) score included 31 items related to the mitral, aortic and tricuspid valves (which can be properly assessed in standard echocardiograms), with a value of 1 for each abnormal item.

Results

Patients with ATTR–CA displayed more often a shortened/hidden and retracted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL–CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (interquartile interval 13.6–17.4) in ATTR–CA, 11.0 (9.3–14.9) in AL–CA, 12.8 (11.1–14.4) in ATTR–CA controls, and 11.0 (9.1–13.0) in AL–CA controls (p = 0.004 for ATTR– vs. AL–CA, 0.009 for ATTR–CA vs. their controls, and 0.461 for AL–CA vs. controls). We compared the AVA and two validated diagnostic scores (IWT and AMYLI). AUC values for the diagnosis of ATTR–CA were 0.782, 0.846 and 0.902, respectively, in patients with ATTR–CA or matched controls, and 0.773, 0.706 and 0.679 in patients with LV hypertrophy (n = 67, 84%) (all non–significant p values).

Conclusions

Patients with ATTR–CA have a prominent impairment of mitral valve structure and function, and higher score values. The AVA score is quite effective in identifying patients with ATTR–CA among patients with CA or with unexplained hypertrophy.

Deformation imaging by strain in chronic heart failure over sacubitril/valsartan: a multicenter echocardiographic registry (DISCOVER) ARNI

Background

Sacubitril/valsartan changed the treatment of heart failure with reduced ejection fraction (HFrEF), due to the positive effects morbidity and mortality partly mediated by left ventricular reverse remodeling (LVRR). The aim of this multicenter study was to identify echocardiographic predictors of LVRR after sacubitril/valsartan administration.

Methods

Patients with HFrEF requiring therapy with sacubitril/valsartan from 13 Italian centers were included. Echocardiographic indexes including speckle tracking echocardiography (STE) were used to predict LVRR (defined as LV end-systolic volume reduction and ejection fraction [LVEF] improvement >10% at follow-up) at 6 months follow-up as the primary endpoint. Changes in symptoms (NYHA class) and neurohormonal activations (N-terminal-pro-brain natriuretic peptide [NTproBNP]) were also evaluated as secondary endpoints. Patients with poor acoustic windows and missing data were excluded.

Results

The final population consisted of 341 patients (mean age: 65±10 years; 18% female, median LVEF 30% [interquartile range:25; 34]. At 6 months follow-up, cardiac dimensions and function, including left heart STE parameters, improved (Table 1). Moreover, 82 (24%) patients showed early complete response (LVRR and LVEF ≥35%), 55 (16%) early incomplete response (LVRR and LVEF <35%), 204 (60%) no response (no LVRR and LVEF <35%) after 6 months of sacubitril/valsartan. Among patients with ischemic etiology, 68% (108) did not develop LV RR. Age, sex, general characteristics, baseline NYHA class and NT-pro BNP did not significantly differ between the groups.Conversely, baseline LV dimensions and LVEF showed significant differences between the groups (p<0.0001). Also, STE parameters were considerably better in group 1 compared to group 2 and 3 both at baseline and follow-up. Non-ischemic etiology, a lower left atrial volume index and a higher global longitudinal strain were all independent predictors of LVRR at multivariable logistic analysis (all p<0.01). With ROC and spline curves, LV GLS >−9.3% showed a good accuracy in predicting LV RR (Figure 1). LA strain was the best predictor of positive changes in NYHA class and NT-proBNP (all p<0.05).

Conclusions

STE parameters at baseline could be useful to predict LVRR and early clinical response to sacubitril-valsartan, and thus could be used as a guide for treatment in patients with HFrEF.

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Reverse remodelling criteria to predict cardiovascular death in heart failure with reduced or mid-range ejection fraction

Aims

Reverse remodelling (RR) is the recovery from left ventricle (LV) dilatation and dysfunction. There are no established definitions of RR. We sought to identify RR criteria that better predicted cardiovascular death.

Methods and results

Forty-two studies used 25 criteria to define RR, most commonly (n=12) as LV end-systolic volume (LVESV) reduction ≥15%. We evaluated 927 patients with LV ejection fraction (LVEF) <50% undergoing 2 echocardiograms within 12±2 months. Over a median 2.8-year follow-up after the second echocardiogram (1.3–4.9), 123 cardiovascular deaths occurred (13%). Model 1 included age, LVEF, N-terminal pro-B-type natriuretic peptide (NT-proBNP), ischaemic aetiology, cardiac resynchronization therapy (CRT), estimated glomerular filtration rate (eGFR), New York Heart Association (NYHA), and LVESV index (LVESVi), and Model 2 the validated 3C-HF score. Two RR criteria proved particularly effective in risk reclassification over Model 1 and Model 2: LVEF increase ≥1 category (severe [LVEF ≤30%], moderate [LVEF 31–40%], mild LV dysfunction [LVEF 41–55%] and normal LV function [LVEF ≥56%]), and LVEF increase >10 U. The same 2 criteria yielded independent prognostic significance and improved reclassification also in patients with LVEF <40% or LVEF ≤35%. LVEF increase ≥1 category and LVEF increase >10 U displayed a stronger prognostic value than LVESV reduction ≥15%, both in the whole population and the subsets with LVEF <40% or ≤35%.

Funding Acknowledgement

Type of funding sources: None.

Heterogeneity of right ventricular refractory period: a novel prognostic predictor in type-1 Brugada

Funding Acknowledgements

Type of funding sources: None.

Risk stratification in Brugada syndrome (BrS) is needed especially for the choice of an Implantable Cardiac Defibrillator (ICD). To date the predictive value of either clinical or conventional electrophysiological indexes in type 1 electrocardiographic pattern BrS is rather low.

We aimed to evaluate the eventual prognostic significance of refractoriness heterogeneity of right ventricular outflow tract, an emergent relevant pathophysiological substrate, at electrophysiological study (EPS) in patients with BrS.

From 5 centers 348 patients were retrospectively selected (age 44 ± 15 years, males 68%). Eighty-five (24%) patients had an ICD. EPS was proposed in patients with spontaneous type-1 ECG pattern regardless of symptoms, or in patients with drug-induced type-1 ECG pattern with symptoms (n = 174). The difference in the refractory period between the right ventricular outflow tract and the apex (ΔRPRVOT-apex) at EPS was evaluated as a prognostic factor. The optimal ΔRPRVOT-apex cutpoint for prognosis prediction was calculated through a P-spline hazard ratio analysis. Thus, ΔRPRVOT-apex  was compared through different statistical analyses to other other clinical or conventional electrophysiological prognostic indexes previosly described in literature. 

During a 36-month median follow-up (range 6-228) 3 SCD and 10 appropriate ICD shocks (aborted SCD, aSCD) occurred. Fifty patients (29%) had a positive EPS (induction of sustained ventricular tachycardia, VT, or ventricular fibrillation, VF, during the procedure). At multivariable logistic analysis, only ΔRPRVOT-apex  and late potentials remained independent predictors of a positive EPS. At Cox Proportional Hazard analysis, family history of SCD, history of syncope, VT/VF inducibility and a ΔRPRVOT-apex >60 ms were all univariate predictors of SCD/aSCD. At bivariate analysis, a ΔRPRVOT-apex >60 ms remained an independent predictor of SCD/aSCD even when adjusted the other univariate predictors. At C-Statistic analysis, the strongest predictive model was the one using ΔRPRVOT-apex >60 ms as covariate with a C-statistics (95% CI) of 0.72 (0.51-0.93). At Kaplan-Meyer curves, ΔRPRVOT-apex >60 ms was confirmed a strong predictor of SCD/aSCD and another very interesting observation was possible: patients with positive EPS, but a ΔRPRVOT-apex < 60 ms, had a similar risk to SCD/aSCD compared to patients with a negative EPS, while those with a positive EPS and a ΔRPRVOT-apex > 60 ms were found to be at a higher risk of events.

Refractory period heterogeneity of the right ventricle defined as ΔRPRVOT-apex > 60 ms at EPS is a strong and independent predictor of SCD/aSCD in patients with BrS, beyond VT/VF inducibility at EPS and common clinical predictors. Abstract Figure.

Central and obstructive apneas prevalence in heart failure with reduced, mid-range and preserved ejection fraction

Background

Central apneas (CA) and obstructive apneas (OA) are highly prevalent in heart failure (HF) both with reduced and preserved systolic function. However, a comprehensive evaluation of apnea prevalence across HF according to ejection fraction (i.e HF with patients with reduced, mid-range and preserved ejection fraction- HFrEf, HFmrEF and HFpEF, respectively) throughout the 24 hours has never been done before.

Materials and methods

700 HF patients were prospectively enrolled and then divided according to left ventricular EF (408 HFrEF, 117 HFmrEF, 175 HFpEF). All patients underwent a thorough evaluation including: 2D echocardiography; 24-h Holter-ECG monitoring; cardiopulmonary exercise testing; neuro-hormonal assessment and 24-h cardiorespiratory monitoring.

Results

In the whole population, prevalence of normal breathing (NB), CA and OA at daytime was 40%, 51%, and 9%, respectively, while at nighttime 15%, 55%, and 30%, respectively.

When stratified according to left ventricular EF, CA prevalence decreased from HFrEF to HFmrEF and HFpEF: (daytime CA: 57% vs. 43% vs. 42%, respectively, p=0.001; nighttime CA: 66% vs. 48% vs. 34%, respectively, p<0.0001), while OA prevalence increased (daytime OA: 5% vs. 8% vs. 18%, respectively, p<0.0001; nighttime OA: 20 vs. 29 vs. 53%, respectively, p<0.0001).

When assessing moderte-severe apneas, defined with an apnea/hypopnea index >15 events/hour, prevalence of CA was again higher in HFrEF than HFmrEF and HFpEF both at daytime (daytime moderate-severe CA: 28% vs. 19% and 23%, respectively, p<0.05) and at nighttime (nighttime moderate-severe CA: 50% vs. 39% and 28%, respectively, p<0.05). Conversely, moderate-severe OA decreased from HFrEF to HFmrEF to HFpEF both at daytime (daytime moderate-severe OA: 1% vs. 3% and 8%, respectively, p<0.05) and nighttime (noghttime moderate-severe OA: 10% vs. 11% and 30%, respectively, p<0.05).

Conclusions

Daytime and nighttime apneas, both central and obstructive in nature, are highly prevalent in HF regardless of EF. Across the whole spectrum of HF, CA prevalence increases and OA decreases as left ventricular systolic dysfunction progresses, both during daytime and nighttime.

Funding Acknowledgement

Type of funding source: None

Central apneas and Ticagrelor related dyspnea in patients with acute coronary syndrome

Background

Patients treated with ticagrelor often develop dyspnea of unknown origin. We aim to explore the contribution of central apneas to ticagrelor-related dyspnea in patients with acute coronary syndrome (ACS).

Methods

We consecutively enrolled patients with ACS, preserved left ventricular ejection fraction and no history of obstructive sleep apnea, treated either with ticagrelor 90 mg bid (n=30) or prasugrel 10 mg od (n=24). One week after ACS onset, all patients underwent, beyond thorough cardiovascular and respiratory assessment, 24-hour cardiorespiratory monitoring and assessment of chemosensitivity to hypercapnia.

Results

Patients treated with ticagrelor reported more frequently dyspnea than patients treated with prasugrel (43% versus 4%, p=0.001), despite no difference in demographic, clinical, echocardiographic and pulmonary data. Patients with dyspnea induced by ticagrelor showed higher apnea-hypopnea and central apnea index both at daytime and at nighttime compared to patients treated with ticagrelor but without dyspnea and patients treated with prasugrel (daytime AHI: 26 [7–34] vs 6 [4–14] and 6 [0–11] events/hour; nighttime AHI: 65 [17–72] vs 22 [8–37] and vs 11 [4–23] events/hour; daytime CAI: 5 [1–15] vs 1 [0–6] and 0 [0–1) events/hour; nighttime CAI 34 [2–55] vs 3 [0–9] and 0 [0–1], all p<0.05). Likewise, they also presented with higher hypercapnic ventilatory response (2.4 [1.9–2.7] vs 1.3 [1.1–1.9] and 0.9 [0.5–2.1] L/min/mmHg, all p<0.05).

Conclusions

Central apneas should be considered a likely mechanism of dyspnea in ACS patients treated with ticagrelor. A drug-related sensitization of the chemoreflex may be the cause of ventilatory instability in this setting.

Funding Acknowledgement

Type of funding source: None

Sacubitril/valsartan improves ventilation stability in patients with chronic heart failure

Background

Sacubitril/valsartan (SV) ameliorates symptoms and prognosis in patients with heart failure and reduced ejection fraction (HFrEF), but the reasons for such effects are unclear. The impact of SV on ventilation has never been investigated. In HFrEF, apneas are highly prevalent both at daytime and nighttime and are associated with increased mortality.

Purpose

We hypothesize that treatment with SV could favourably stabilize ventilation by reducing the severity of central apneas in patients with HFrEF.

Methods

51 patients with HFrEF (mean age 67±9 years, mean left ventricular ejection fraction, LVEF 27±7%) and apneas defined by an apnea-hypopnea index, AHI≥5 (median 16, interquartile range 8–28) events/hour, eligible to treatment with SV and previously on optimal medical therapy for HFrEF, were enrolled. An extensive evaluation including cardiac ultrasound and a 24-hour cardiorespiratory monitoring was performed.

Results

After six months of treatment with SV, left ventricle systolic and diastolic function, mitral regurgitation (MR), left atrial volume (LAVI) and systolic pulmonary artery pressure (sPAP) were improved. Severity of apneas was reduced by 50%, 65% and 36% throughout the 24-hour, at daytime and nighttime, respectively.

Conclusion

Besides its known efficacy on cardiac remodeling, SV positively decreases the apneic burden in patients with HFrEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics unrestricted grant

Reverse remodelling, changes in diastolic function and their prognostic value compared to natriuretic peptides

Background

Reverse remodelling (RR) is the recovery from left ventricular (LV) dilation and dysfunction in response to treatment for heart failure (HF). RR is usually associated with improved prognosis. The impact of RR on indices of diastolic function, and the relative prognostic value of RR, changes in diastolic function and natriuretic peptide levels are currently unknown.

Methods

We analysed data from patients with stable systolic HF (LV ejection fraction [LVEF] <50%) undergoing 2 transthoracic echocardiograms (TTE) within 12±2 months. RR was defined as a ≥15% reduction in LV end-systolic volume index (LVESVi). The follow-up started after the second TTE.

Results

927 patients were evaluated (68±12 years; median LVEF 35% [interquartile interval 30–43%]; 27% women; 52% ischaemic aetiology). Patients experiencing RR (n=286, 31%) displayed more prominent positive changes in several parameters reflecting diastolic dysfunction, namely E/e' ratio, left atrial volume index (LAVi), and systolic pulmonary artery pressure (sPAP), as well as N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP; Figure). In the whole population, percent changes (Δ%) LVESVi displayed weak but significant correlations with Δ% E/e' (r=0.237, p<0.001), LAVi (r=0.316, p<0.001), and sPAP (r=0.158, p<0.001), and also with Δ% NT-proBNP (r=0.279, p<0.001). There were 123 cardiovascular deaths and 4 heart transplantations over 2.8 years (1.3–4.9). Δ% LVESVi, RR, Δ% sPAP and Δ% NT-proBNP were univariate predictors of this endpoint. In 2 multivariable models including Δ% sPAP and Δ% NT-proBNP and either RR or Δ% LVESVi, only Δ% NT-proBNP emerged as independent predictor of outcome (hazard ratio 1.01, 95% confidence interval 1.01–1.02; p<0.001).

Conclusions

A recovery of LV geometry is accompanied by positive modifications in several indices related to diastolic function, as well as a decrease in NT-proBNP levels. Percent changes in NT-proBNP over 12 months are stronger predictors of outcome than variations in LV geometry or sPAP.

Funding Acknowledgement

Type of funding source: None

Two common echocardiographic variables to diagnose cardiac amyloidosis: the AMYLoidosis Index (AMYLI) score

Background

Early diagnosis of cardiac amyloidosis (CA) is warranted to initiate specific treatment and improve outcome. The amyloid light chain (AL) and inferior wall thickness (IWT) scores have been proposed to assess patients referred by hematologists or with unexplained left ventricular (LV) hypertrophy, respectively. These scores are composed of 4 or 5 variables, respectively, including strain data, and no decisional cut-offs were introduced.

Methods

Based on 2 variables common to the AL and IWT scores, we defined a simple score named AMYLoidosis Index (AMYLI) as the product of relative wall thickness (RWT) and E/e' ratio, and assessed its diagnostic performance. Optimal rule-out cut-offs were searched as those with negative likelihood ratio (LR−) <0.1.

Results

In the derivation cohort (n=251), CA was ultimately diagnosed in 111 patients (44%). The 2.22 score value was selected as rule-out cut-off (LR- 0.0). In the hematology subset, AL CA was finally diagnosed in 32 patients (48%), with 2.36 as rule-out cut-off (LR− 0.0). In the hypertrophy subset, ATTR CA was diagnosed in 79 patients (43%), with 2.22 as best rule-out cut-off (LR− 0.0). In the validation cohort (n=691), where more patients were diagnosed with CA (94% and 68% in the hematology and in the hypertrophy subsets, respectively), the 2.22 rule-out cut-off had a LR− = ∞ (as no patient scoring <2.22 had CA). In the hematology and hypertrophy subsets, the 2.36 and 2.22 cut-offs were effective for ruling-out CA, with both LR− = ∞ (as no patient scoring <2.36 or 2.22, respectively, had CA).

Conclusions

The AMYLI score (RWT* E/e') is simpler than those proposed and similarly accurate. A 2.22 cut-off value excludes CA diagnosis in patients undergoing a diagnostic screening for CA, while a <2.36 and a <2.22 value may be better considered in the subsets with either blood dyscrasia or unexplained hypertrophy, respectively.

Funding Acknowledgement

Type of funding source: None

P215 Effects of ARNI therapy on left atrial and ventricular longitudinal deformation and functional capacity in HFrEF patients

Background

valsartan and sacubitril combination (angiotensin receptor-neprilysin inhibitor, ARNI) was superior, in randomized trials, to lone ACE inhibitors in terms of reduction of cardiovascular mortality rate and hospitalization for acute heart (HF) in patients with HF with reduced ejection fraction (HFrEF). Purpose: the main goal of our study was to assess the effects of ARNI on left atrial (LA) and left (LV) and right ventricular (RV) function, evaluated by standard and speckle tracking echocardiography (STE), and on patients’ functional capacity by cardiopulmonary exercise testing (CPET), in patients with HFrEF. Methods: we prospectively enrolled 16 patients with a LV EF ≤35% and >18 years old, in two different centers with high expertise in HF management. Exclusion criteria included: symptomatic hypotension, stage IV renal failure (eGFR < 30 ml/min/1.73 m2), ACE-inhibitor (ACEi) intolerance or previous angioedema, poor acoustic window, refuse to participate to the study. At enrollment (T0), all patients were in therapy with ACEi or sartans (ARBs) and underwent physical examination, ECG, blood test (including NT-proBNP), standard echo, STE and CPET. We shifted therapy from ACEi/ARBs according to HF guidelines and we repeated all tests after 6 months. Results: population had an average age of 63 ± 9 years, 94% was males. Etiology was ischemic in one third of the subjects. At 6 months follow up, NT-proBNP was significantly lower (512.2 ± 518.5 vs 431.2 ± 330.1 ng/l, p 0,001) together with reduced LV filling pressure evaluated by E/A ratio and E/e’ ratio (11.2 ± 8.6 vs 8.8 ± 4.8, p 0.01). LV EF improved from 31.7 ± 3.4% to 36.2 ± 7.2% (p 0.01) and LV dimensions decreased. LV global longitudinal strain (GLS) did not change significantly while free wall RV GLS increased from – 20.4 ± 6.3% to – 24.6 ± 9%, p 0.001, as peak atrial longitudinal strain (PALS) did (16.1 ± 2.6% vs 27.6 ± 4.1%, p 0.001). Between CPET indexes, only VE/VCO2 slope improved but only with borderline statistical significance (32.7 ± 5.3 vs 29.7 ± 6.8, p 0.05, Fig. 1). Conclusions: this preliminary study evaluated for the first time the effects of ARNI on echocardiographic and CPET parameters at the same time. Our results could explain the favorable clinical benefits of ARNI therapy in HFrEF: improved biventricular function, lower LV filling pressure and a more efficient ventilatory response during effort.

Abstract P215 Figure. Fig.1

P2729NT-proBNP and high-sensitivity cardiac troponin T to diagnose cardiac amyloidosis

Background

Cardiac amyloidosis (CA) is characterized by the accumulation of misfolded proteins into amyloid fibrils, leading to cardiomyocyte toxicity, extracellular volume expansion and ventricular pseudohypertrophy. As a consequence of such processes, natriuretic peptides and cardiac troponins are chronically elevated in CA and hold significant prognostic value. The diagnostic yield of these biomarkers for CA has never been explored so far.

Methods

Plasma levels of N-terminal fraction of pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) were measured in 230 patients referred to a tertiary centre with the clinical suspicion of cardiac amyloidosis. The final diagnosis was established according to current protocols, which include clinical, electrocardiographic, biohumoral, instrumental (echocardiography, cardiac magnetic resonance, diphosphonate scintigraphy), and biopsy examinations.

Results

Patients were aged 79 (interquartile interval 73–83) years and were predominantly males (n=147, 64%). Mean left ventricular (LV) ejection fraction was 55% (48–62%), and mean LV mass indexed was 150 (120–178) g/m2. CA was confirmed in 86 patients (37%), who had either light chain (AL) amyloidosis (n=25, 29%) or transthyretin (ATTR) amyloidosis (n=61, 71%). Alternative diagnoses were hypertensive cardiopathy (n=69, 48%), valvular disease (n=27, 19%), hypertrophic cardiomyopathy (n=18, 13%), or left ventricular hypertrophy with unknown or multifactorial mechanisms. Patients with CA showed higher NT-proBNP (5507 ng/L [2348–10326] vs. 1332 [392–3752], p<0.001) and hs-cTnT (65 ng/L [48–114] vs. 35 [21–52], p<0.001) than those without CA. The area under the curve (AUC) values for NT-proBNP and hs-cTnT were 0.712 and 0.775 respectively (p=0.062 for the difference). The combination of the two biomarkers improved discrimination over NT-proBNP alone (p=0.011), but not over hs-cTnT (p=0.470) (Figure). A NT-proBNP level <600 ng/L or a hs-cTnT level <17 ng/L were optimal for ruling out amyloidosis, with a negative predictive value of 95% in both cases.

Patients with AL amyloidosis had higher NT-proBNP and hs-cTnT than those with ATTR (10809 ng/L [6292–17483] vs. 3084 [1841–7624], p=0.014; 130 ng/L [64–211] vs. 61 [48–95], p=0.006). The difference was even more prominent when biomarker levels were normalized for LV mass (NT-proBNP/LV mass, 33.9 ng/L/g [20.4–53.8] vs. 10.0 [5.8–23.5], p=0.002; hs-cTnT/LV mass, 0.48 ng/L/g [0.25–0.71] vs. 0.19 [0.14–0.26], p=0.001). NT-proBNP and hs-cTnT could effectively discriminate patients with AL amyloidosis among subjects with clinical suspicion of CA (AUC values of 0.787 and 0.805 respectively) (Figure).

Figure 1

Conclusions

Plasma NT-proBNP and hs-cTnT have diagnostic value in patients with suspected CA. In the subgroup with CA, both biomarkers are higher in patients with AL amyloidosis even when normalizing for LV mass, possibly because of a greater cardiotoxic effect of light-chain fibrils.

P3525Buspirone effect on chemoreflex and central apneas in heart failure

Background

Increased chemosensitivity to carbon dioxide (CO2) is an important trigger of central apneas in heart failure (HF), contributing to HF progression and mortality. We hypothesized that buspirone, a 5HT1A receptor agonist that inhibits serotonergic chemoreceptor neuron firing in animals, can decrease CO2 chemosensitivity, thus preventing CA in patients with HF.

Methods

Sixteen patients with systolic HF (age 71.3±5.8 years, left ventricular ejection fraction 29.8±7.8%) and moderate-severe central apneas (nighttime apnea/hypopnea index AHI≥15 events/hour) underwent a double-blind, placebo-controlled, cross over, randomized study of oral buspirone administration (45 mg/day for 1 week).

Results

Buspirone reduced CO2 chemosensitivity compared to placebo (1.2 IR [1.1–1.5] vs. 2.0 [1.6–2.2] L/min/mmHg, p=0.008). Furthermore, buspirone improved: the AHI at nighttime (16.5 [8.5–24.7] vs. 27.5 [23.0–37.3] events/hour, p=0.002), and daytime (8.0 [2.3–11.5] vs. 11.5 [6.3–18.8] events/hour, p=0.006); the central apnea index at nighttime (4.0 [1.0–19.0] vs. 12.5 [8.3–27.3] events/hour, p=0.01) and daytime (1.0 [0.0–3.0] vs. 4.0 [1.3–6.0] events/hour, p=0.009); and the oxygen desaturation index at nighttime (4.7 [1.0–11.0] vs. 20.0 [8.7–26.5] events/hour, p=0.004) and daytime (0.2 [0.1–0.7] vs. 1.2 [0.3–4.8] events/hour, p=0.005). Buspirone showed a good safety profile and had no effect on neurohormones, arrhythmias, exercise capacity and mood/daytime sleepiness.

Conclusion

Buspirone reduces CO2 chemosensitivity and inhibits central apneas both during the day and the night in patients with systolic HF.

Psychopathology and traffic violations in subjects who have lost their driving license

BACKGROUND

The persistence of risky behaviors while driving and traffic accidents despite campaigns to increase awareness suggest that there may be underlying causes that maintain proneness to traffic violations. The aim of the current study was to assess: a) the prevalence of psychopathology in a sample of people who have lost their driving license due to former traffic violations and b) the discriminatory capacity of each psychopathological disorder to differentiate among people with high and low proneness to perform risky behaviors while driving.

METHODS

383 participants in a course to recover their driving license after its loss due to previous traffic violations were included. The International Neuropsychiatric Interview (M.I.N.I.) according to DSM-IV was used to assess psychopathology.

RESULTS

Between 67% and 76.2% of the participants had been affected by a lifetime psychopathological disorder until the moment of assessment. The most prevalent diagnoses were substance abuse including alcohol (52.5-62.7%), ADHD (19.7-28.5%), depression (7.9-14.4%) and anxiety (3.6-12.4%). Substance abuse and ADHD also showed the strongest set of associations with specific risk behaviors, but ADHD emerged as the most discriminant disorder to distinguish between those people at high and low risk of while driving.

CONCLUSIONS

The results of the current study suggest that addressing psychopathology explicitly to prevent risky behaviors and recidivism while driving would provide benefits in this area.

Prevalence of home artificial nutrition in Italy in 2005: A survey by the Italian Society for Parenteral and Enteral Nutrition (SINPE)

AIM

To determine the prevalence (cases per million inhabitants) of home artificial nutrition (HAN), enteral (HEN) and parenteral (HPN), in Italy, grouped according to administrative regions, patient age and primary disease, and to analyze the impact both of the presence of an HAN regional regulation and of demographic characteristics.

METHODS

In April 2005, the Regional Coordinators of the Italian Society for Parenteral and Enteral Nutrition (SINPE) recorded all the ongoing cases of HAN using a structured questionnaire and were asked to estimate the representativeness of the collected sample with respect to the total expected HAN.

RESULTS

A total of 6955 cases of HAN (93.5% adults, 6.5% pediatric patients < or = 18 years) were recorded in 16 of the 20 Italian regions (80% of the Italian population; sample representativeness 78%). HAN prevalence 152.6 (83.9% HEN, 16.1% HPN); the HAN range among the regions was: prevalence 28.1-519.8; oncological disease 13.8-75.7%, neurological disease 15.5-79.9%, intestinal failure 1.3-14.0%. An HAN regulation was present in 11 regions. A positive association (P=0.012) was found between the number of years since the regulation was issued and the HAN prevalence, and also between the % neurological patients and the population density (P=0.130) and the % inhabitants > or = 75 years (P=0.040).

CONCLUSIONS

The need for HAN regards a great number of patients throughout the country; there are substantial differences between the regions with respect to both the prevalence and the use of HAN in various disease categories. A specific regulation may favor the development of HAN.

[Natriuretic peptides in heart failure]

The recent discovery of cardiac endocrine function, together with the development of accurate and feasible assay methods for cardiac natriuretic hormone evaluation, i.e. for B-type natriuretic peptide (BNP) and inactive peptide NT-proBNP have confirmed their pathophysiological and clinical significance for cardiovascular disease assessment. Concerning heart failure, their value is for diagnostic screening in selected/unselected populations, for differential diagnosis of dyspnea and for prognostic stratification, and as a guide for follow-up and treatment of patients. Recent Italian recommendations pointed out that BNP/NT-proBNP has a role in ruling-out the diagnosis of heart failure in patients with dubious signs/symptoms: plasma BNP/NT-proBNP concentrations help in the clinical evaluation of chronic heart failure patients when risk stratification is needed, whereas the routine BNP/NT-proBNP assay is still not recommended to guide therapeutic decision-making.

Percutaneous management of benign renal cysts

Percutaneous emptying of benign renal cysts represents the adopted treatment for this kind of pathology. The introduction of pure ethilic alcohol (95 degrees) is usually associated with emptying because it determines the necrosis of the secreting epithelious with recurrences and little significant complications. This treatment is the less bloody solution that can be executed in surgery and for this reason it is proposed in the time as an alternative to surgery treatment of removal.

[Anesthesia with isoflurane in surgery of the anterior segment of the eye]

The effects of isoflurane on intraocular pressure (IOP) were studied in 46 patients undergoing cataract surgery. The IOP was measured 30 minutes after premedication, 10 minutes after induction of anesthesia and 10 minutes after administration of isoflurane. Since a significant decrease of IOP was found to occur after the administration of volatile agent, and in account of absence of complications or side effects, the Authors conclude that isoflurane can be considered a suitable anesthetic agent in ophthalmic surgery.

The decline of renal function slowed by very low phosphorus intake in chronic renal patients following a low nitrogen diet

The rate of progression of renal failure has been evaluated in two homogenous groups of chronic renal patients with early insufficiency. In both groups the diet supplied the same amount of calories (approximately 35 Kcal/kg/day) and the protein intake was equally restricted (approximately, 0.6 g/kg/day); however, in Group 1 the phosphorus intake was lower (6.5 mg/kg/day) than in Group 2 (12 mg/kg/day). In both groups the rate of decline of creatinine clearance decreased when patients changed from a free mixed diet to the specially controlled diets, but in Group 1 (lower phosphorus intake) this change was much more marked than in Group 2. Elevated mean levels of serum phosphate and of urinary output of phosphate per unit of creatinine clearance, and elevated mean levels of serum iPTH were found in the patients of Group 2, whereas Group 1 patients had normal mean levels of serum phosphate and of iPTH, and the phosphaturia per unit of creatinine clearance was almost normal. The role of such abnormalities in urinary and serum phosphate, and of secondary hyperparathyroidism, on the progression of renal failure is discussed.

Restricted phosphorus and nitrogen intake to slow the progression of chronic renal failure: a controlled trial

Twenty chronically azotemic patients (experimental group) with a mean creatinine clearance of 22.5 +/- 9.4 ml/min followed a diet supplying daily, per kilogram of body weight, 7.0 mg of phosphorus and 0.5 g of protein, mostly of high biological value, for 11.3 months. A group of 19 similar patients (control group) followed a diet supplying daily, per kilogram of body weight, 12 mg of phosphorus and 0.8 g of protein for a similar period of time. In the experimental group, the serum inorganic phosphorus, urea, and iPTH (both N-terminal and C-terminal fragments) decreased significantly. The creatinine clearance decreased by -0.59 +/- 0.7 ml/min per month prior to the commencement of the experimental diet and increased by a mean of 0.1 +/- 0.4 ml/min per month during the period of study. In the control group, the serum inorganic phosphorus increased, the serum urea and iPTH remained practically constant, and the mean creatinine clearance continued to decrease at a rate not significantly different from that prior to the onset of the study (-0.50 +/- 0.66 and -0.44 +/- 0.10 ml/min per month, respectively). The mechanisms by which the low-phosphorus, low-nitrogen diet slows the progression of renal failure are discussed, and the practical importance of prescribing the dietetic restriction early in the course of renal disease is stressed.

Three years experience with a very low nitrogen diet supplemented with essential amino acids and keto-analogues in the treatment of chronic uraemia

A low nitrogen, low phosphorus diet, supplemented with essential amino acids and keto-analogues, was administered to 48 chronic uraemics for a maximum of 36 months. In 10 cases renal function deteriorated and dialysis was started; eight patients changed to the dialytic therapy having difficulties in complying to the diet and three died for reasons not directly related to renal failure. The remaining twenty-seven patients are still on dietetic treatment and their renal function has not changed significantly. Their serum inorganic phosphorus and their circulating iPTH decreased significantly. Their subjective and objective conditions are satisfactory and no manifestation of protein malnutrition or other unwanted effects are detectable.