Role of TBX20 Truncating Variants in Dilated Cardiomyopathy and Left Ventricular Noncompaction

BACKGROUND

Less than 40% of patients with dilated cardiomyopathy (DCM) have a pathogenic/likely pathogenic genetic variant identified. TBX20 has been linked to congenital heart defects; although an association with left ventricular noncompaction (LVNC) and DCM has been proposed, it is still considered a gene with limited evidence for these phenotypes. This study sought to investigate the association between the TBX20 truncating variant (TBX20tv) and DCM/LVNC.

METHODS

TBX20 was sequenced by next-generation sequencing in 7463 unrelated probands with a diagnosis of DCM or LVNC, 22 773 probands of an internal comparison group (hypertrophic cardiomyopathy, channelopathies, or aortic diseases), and 124 098 external controls (individuals from the gnomAD database). Enrichment of TBX20tv in DCM/LVNC was calculated, cosegregation was determined in selected families, and clinical characteristics and outcomes were analyzed in carriers.

RESULTS

TBX20tv was enriched in DCM/LVNC (24/7463; 0.32%) compared with internal (1/22 773; 0.004%) and external comparison groups (4/124 098; 0.003%), with odds ratios of 73.23 (95% CI, 9.90-541.45; P<0.0001) and 99.76 (95% CI, 34.60-287.62; P<0.0001), respectively. TBX20tv was cosegregated with DCM/LVNC phenotype in 21 families for a combined logarythm of the odds score of 4.53 (strong linkage). Among 57 individuals with TBX20tv (49.1% men; mean age, 35.9±20.8 years), 41 (71.9%) exhibited DCM/LVNC, of whom 14 (34.1%) had also congenital heart defects. After a median follow-up of 6.9 (95% CI, 25-75:3.6-14.5) years, 9.7% of patients with DCM/LVNC had end-stage heart failure events and 4.8% experienced malignant ventricular arrhythmias.

CONCLUSIONS

TBX20tv is associated with DCM/LVNC; congenital heart defect is also present in around one-third of cases. TBX20tv-associated DCM/LVNC is characterized by a nonaggressive phenotype, with a low incidence of major cardiovascular events. TBX20 should be considered a definitive gene for DCM and LVNC and routinely included in genetic testing panels for these phenotypes.

Design and baseline characteristics of SALT-HF trial: hypertonic saline therapy in ambulatory heart failure

AIMS

Hypertonic saline solution (HSS) plus intravenous (IV) loop diuretic appears to enhance the diuretic response in patients hospitalized for heart failure (HF). The efficacy and safety of this therapy in the ambulatory setting have not been evaluated. We aimed to describe the design and baseline characteristics of the SALT-HF trial participants.

METHODS AND RESULTS

'Efficacy of Saline Hypertonic Therapy in Ambulatory Patients with HF' (SALT-HF) trial was a multicenter, double-blinded, and randomized study involving ambulatory patients who experienced worsening heart failure (WHF) without criteria for hospitalization. Enrolled patients had to present at least two signs of volume overload, use ≥ 80 mg of oral furosemide daily, and have elevated natriuretic peptides. Patients were randomized 1:1 to treatment with a 1-h infusion of IV furosemide plus HSS (2.6-3.4% NaCl depending on plasmatic sodium levels) versus a 1-h infusion of IV furosemide at the same dose (125-250 mg, depending on basal loop diuretic dose). Clinical, laboratory, and imaging parameters were collected at baseline and after 7 days, and a telephone visit was planned after 30 days. The primary endpoint was 3-h diuresis after treatment started. Secondary endpoints included (a) 7-day changes in congestion data, (b) 7-day changes in kidney function and electrolytes, (c) 30-day clinical events (need of IV diuretic, HF hospitalization, cardiovascular mortality, all-cause mortality or HF-hospitalization).

RESULTS

A total of 167 participants [median age, 81 years; interquartile range (IQR), 73-87, 30.5% females] were randomized across 13 sites between December 2020 and March 2023. Half of the participants (n = 82) had an ejection fraction >50%. Most patients showed a high burden of comorbidities, with a median Charlson index of 3 (IQR: 2-4). Common co-morbidities included diabetes mellitus (41%, n = 69), atrial fibrillation (80%, n = 134), and chronic kidney disease (64%, n = 107). Patients exhibited a poor functional NYHA class (69% presenting NYHA III) and several signs of congestion. The mean composite congestion score was 4.3 (standard deviation: 1.7). Ninety per cent of the patients (n = 151) presented oedema and jugular engorgement, and 71% (n = 118) showed lung B lines assessed by ultrasound. Median inferior vena cava diameter was 23 mm, (IQR: 21-25), and plasmatic levels of N-terminal-pro-B-type natriuretic peptide (NTproBNP) and antigen carbohydrate 125 (CA125) were increased (median NT-proBNP 4969 pg/mL, IQR: 2508-9328; median CA125 46 U/L, IQR: 20-114).

CONCLUSIONS

SALT-HF trial randomized 167 ambulatory patients with WHF and will determine whether an infusion of hypertonic saline therapy plus furosemide increases diuresis and improves decongestion compared to equivalent furosemide administration alone.

Optimization of Patient Pathway in Heart Failure with Reduced Ejection Fraction and Worsening Heart Failure. Role of Vericiguat

Heart failure (HF) is a progressive condition with periods of apparent stability and repeated worsening HF events. Over time, unless optimization of HF treatment, worsening HF events become more frequent and patients enter into a cycle of recurrent events with high morbidity and mortality. In patients with HF there is an activation of deleterious neurohormonal pathways, such as the renin angiotensin aldosterone system and the sympathetic system, and an inhibition of protective pathways, including natriuretic peptides and guanylate cyclase. Therefore, HF burden can be reduced only through a holistic approach that targets all neurohormonal systems. In this context, vericiguat may play a key role, as it is the only HF drug that activates the nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate system. On the other hand, it has been described relevant disparities in the management of HF population. Consequently, it is necessary to homogenize the management of these patients, through an integrated patient-care pathway that should be adapted at the local level. In this context, the development of new technologies (ie, video call, specific platforms, remote control devices, etc.) may be very helpful. In this manuscript, a multidisciplinary group of experts analyzed the current evidence and shared their own experience to provide some recommendations about the therapeutic optimization of patients with recent worsening HF, with a particular focus on vericiguat, and also about how the integrated patient-care pathway should be performed.

Natural History of MYH7-Related Dilated Cardiomyopathy

BACKGROUND

Variants in myosin heavy chain 7 (MYH7) are responsible for disease in 1% to 5% of patients with dilated cardiomyopathy (DCM); however, the clinical characteristics and natural history of MYH7-related DCM are poorly described.

OBJECTIVES

We sought to determine the phenotype and prognosis of MYH7-related DCM. We also evaluated the influence of variant location on phenotypic expression.

METHODS

We studied clinical data from 147 individuals with DCM-causing MYH7 variants (47.6% female; 35.6 ± 19.2 years) recruited from 29 international centers.

RESULTS

At initial evaluation, 106 (72.1%) patients had DCM (left ventricular ejection fraction: 34.5% ± 11.7%). Median follow-up was 4.5 years (IQR: 1.7-8.0 years), and 23.7% of carriers who were initially phenotype-negative developed DCM. Phenotypic expression by 40 and 60 years was 46% and 88%, respectively, with 18 patients (16%) first diagnosed at <18 years of age. Thirty-six percent of patients with DCM met imaging criteria for LV noncompaction. During follow-up, 28% showed left ventricular reverse remodeling. Incidence of adverse cardiac events among patients with DCM at 5 years was 11.6%, with 5 (4.6%) deaths caused by end-stage heart failure (ESHF) and 5 patients (4.6%) requiring heart transplantation. The major ventricular arrhythmia rate was low (1.0% and 2.1% at 5 years in patients with DCM and in those with LVEF of ≤35%, respectively). ESHF and major ventricular arrhythmia were significantly lower compared with LMNA-related DCM and similar to DCM caused by TTN truncating variants.

CONCLUSIONS

MYH7-related DCM is characterized by early age of onset, high phenotypic expression, low left ventricular reverse remodeling, and frequent progression to ESHF. Heart failure complications predominate over ventricular arrhythmias, which are rare.

Gender differences in drug titration among heart failure patients with reduced ejection fraction in the ETIFIC trial

INTRODUCTION AND OBJECTIVES

Optimal medical therapy decreases mortality and heart failure (HF) hospitalizations in HF patients with reduced left ventricular ejection fraction. Women have been underrepresented in clinical trials and not specifically evaluated. This study aimed to compare the safety and effectiveness of drug titration in women vs men.

METHODS

This post hoc gender study of the ETIFIC multicenter randomized trial included hospitalized patients with new-onset HF with reduced ejection fraction and New York Heart Association II-III and no contraindications to beta-blockers. A structured 4-month titration process was implemented in HF clinics. The primary endpoint was the mean relative dose (% of target dose) of beta-blockers achieved by women vs men. Secondary endpoints included the mean relative doses of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists, adverse events, and other clinical outcomes at 6 months.

RESULTS

A total of 320 patients were included, 83 (25.93%) women and 237 (74.06%) men (76 vs 213 analyzed). The mean±standard deviation of the relative doses achieved by women vs men were as follows: beta-blockers 62.08%±30.72% vs 64.4%±32.77%, with a difference of-2.32% (95%CI,-10.58-5.94), P = .580; and mineralocorticoid receptor antagonists 79.85%±27.72% vs 67.29%±31.43%, P =.003. No other differences in drug dosage were found. Multivariate analysis showed nonsignificant differences. CV mortality was 1 (1.20%) vs 3 (1.26%), P=1, and HF hospitalizations 0 (0.00%) vs 10 (4.22%), P=.125.

CONCLUSIONS

In a post hoc analysis from the HF-titration ETIFIC trial, we found nonsignificant gender differences in drug dosage, cardiovascular mortality, and HF hospitalizations. Trial registry number: NCT02546856.

Combination of late gadolinium enhancement and genotype improves prediction of prognosis in non-ischemic dilated cardiomyopathy

Aims

Genotype and left ventricular scar on cardiac magnetic resonance (CMR) are increasingly recognized as risk markers for adverse outcomes in non‐ischaemic dilated cardiomyopathy (DCM). We investigated the combined influence of genotype and late gadolinium enhancement (LGE) in assessing prognosis in a large cohort of patients with DCM.

Methods and results

Outcomes of 600 patients with DCM (53.3 ± 14.1 years, 66% male) who underwent clinical CMR and genetic testing were retrospectively analysed. The primary endpoints were end‐stage heart failure (ESHF) and malignant ventricular arrhythmias (MVA). During a median follow‐up of 2.7 years (interquartile range 1.3–4.9), 24 (4.00%) and 48 (8.00%) patients had ESHF and MVA, respectively. In total, 242 (40.3%) patients had pathogenic/likely pathogenic variants (positive genotype) and 151 (25.2%) had LGE. In survival analysis, positive LGE was associated with MVA and ESHF (both, p < 0.001) while positive genotype was associated with ESHF (p = 0.034) but not with MVA (p = 0.102). Classification of patients according to genotype (G+/G−) and LGE presence (L+/L−) revealed progressively increasing events across L−/G−, L−/G+, L+/G− and L+/G+ groups and resulted in optimized MVA and ESHF prediction (p < 0.001 and p = 0.001, respectively). Hazard ratios for MVA and ESHF in patients with either L+ or G+ compared with those with L−/G− were 4.71 (95% confidence interval: 2.11–10.50, p < 0.001) and 7.92 (95% confidence interval: 1.86–33.78, p < 0.001), respectively.

Conclusion

Classification of patients with DCM according to genotype and LGE improves MVA and ESHF prediction. Scar assessment with CMR and genotyping should be considered to select patients for primary prevention implantable cardioverter‐defibrillator placement.

Association of Genetic Variants With Outcomes in Patients With Nonischemic Dilated Cardiomyopathy

BACKGROUND

The clinical relevance of genetic variants in nonischemic dilated cardiomyopathy (DCM) is unsettled.

OBJECTIVES

The study sought to assess the prognostic impact of disease-causing genetic variants in DCM.

METHODS

Baseline and longitudinal clinical data from 1,005 genotyped DCM probands were retrospectively collected at 20 centers. A total of 372 (37%) patients had pathogenic or likely pathogenic variants (genotype positive) and 633 (63%) were genotype negative. The primary endpoint was a composite of major adverse cardiovascular events. Secondary endpoints were end-stage heart failure (ESHF), malignant ventricular arrhythmia (MVA), and left ventricular reverse remodeling (LVRR).

RESULTS

After a median follow-up of 4.04 years (interquartile range: 1.70-7.50 years), the primary endpoint had occurred in 118 (31.7%) patients in the genotype-positive group and in 125 (19.8%) patients in the genotype-negative group (hazard ratio [HR]: 1.51; 95% confidence interval [CI]: 1.17-1.94; P = 0.001). ESHF occurred in 60 (16.1%) genotype-positive patients and in 55 (8.7%) genotype-negative patients (HR: 1.67; 95% CI: 1.16-2.41; P = 0.006). MVA occurred in 73 (19.6%) genotype-positive patients and in 77 (12.2%) genotype-negative patients (HR: 1.50; 95% CI: 1.09-2.07; P = 0.013). LVRR occurred in 39.6% in the genotype-positive group and in 46.2% in the genotype-negative group (P = 0.047). Among individuals with baseline left ventricular ejection fraction ≤35%, genotype-positive patients exhibited more major adverse cardiovascular events, ESHF, and MVA than their genotype-negative peers (all P < 0.02). LVRR and clinical outcomes varied depending on the underlying affected gene.

CONCLUSIONS

In this study, DCM patients with pathogenic or likely pathogenic variants had worse prognosis than genotype-negative individuals. Clinical course differed depending on the underlying affected gene.

Prevalence of hypertrophic cardiomyopathy in a large sample of the Spanish working population

BACKGROUND AND OBJECTIVES

To date, in Spain, there are no studies that have evaluated the prevalence of hypertrophic cardiomyopathy in the general population. The aim of this study was to assess the prevalence of hypertrophic cardiomyopathy in a large sample of the working population of Spain.

MATERIALS AND METHODS

The study included 13,179 workers (73% men; mean age, 40 years) from 5 regions of Spain who, between May 2008 and November 2010, had a medical examination with an electrocardiogram. The workers with suggestive abnormalities in the electrocardiogram or a predisposing medical history (exertional syncope or sudden death of a family member younger than 50 years) were referred for an echocardiographic evaluation. We defined hypertrophic cardiomyopathy as a parietal thickness ≥13mm in any segment of the left ventricle. We estimated the prevalence of hypertrophic cardiomyopathy in the entire sample and in the workers without hypertension.

RESULTS

A total of 1008 workers were selected for the echocardiogram, although only 496 (49.2% of those selected) of these attended the appointment. After the echocardiogram, we detected 16 cases of hypertrophic cardiomyopathy, estimating a prevalence of 0.24% for the entire sample. In the subgroup of workers with no hypertension, we observed 10 cases of hypertrophic cardiomyopathy, which corresponds to an estimated prevalence of 0.19%.

CONCLUSIONS

In our sample of the working population in Spain, the estimated prevalence of hypertrophic cardiomyopathy was 0.24%. In the subgroup of patients with no hypertension, the estimated prevalence was 0.19%.

Prevalence of hypertrophic cardiomyopathy in a large sample of the Spanish working population

BACKGROUND AND OBJECTIVES

To date, in Spain, there are no studies that have evaluated the prevalence of hypertrophic cardiomyopathy in the general population. The aim of this study was to assess the prevalence of hypertrophic cardiomyopathy in a large sample of the working population of Spain.

MATERIALS AND METHODS

The study included 13,179 workers (73% men; mean age: 40 years) from 5 regions of Spain who, between May 2008 and November 2010, had a medical examination with an electrocardiogram. The workers with suggestive abnormalities in the electrocardiogram or a predisposing medical history (exertional syncope or sudden death of a family member younger than 50 years) were referred for an echocardiographic evaluation. We defined hypertrophic cardiomyopathy as a parietal thickness ≥13mm in any segment of the left ventricle. We estimated the prevalence of hypertrophic cardiomyopathy in the entire sample and in the workers without hypertension.

RESULTS

A total of 1008 workers were selected for the echocardiogram, although only 496 (49.2% of those selected) of these attended the appointment. After the echocardiogram, we detected 16 cases of hypertrophic cardiomyopathy, estimating a prevalence of 0.24% for the entire sample. In the subgroup of workers with no hypertension, we observed 10 cases of hypertrophic cardiomyopathy, which corresponds to an estimated prevalence of 0.19%.

CONCLUSIONS

In our sample of the working population in Spain, the estimated prevalence of hypertrophic cardiomyopathy was 0.24%. In the subgroup of patients with no hypertension, the estimated prevalence was 0.19%.

Risk predictors in a Spanish cohort with cardiac laminopathies. The REDLAMINA registry

INTRODUCTION AND OBJECTIVES

According to sudden cardiac death guidelines, an implantable cardioverter-defibrillator (ICD) should be considered in patients with LMNA-related dilated cardiomyopathy (DCM) and ≥ 2 risk factors: male sex, left ventricular ejection fraction (LVEF) <45%, nonsustained ventricular tachycardia (NSVT), and nonmissense genetic variants. In this study we aimed to describe the clinical characteristics of carriers of LMNA genetic variants among individuals from a Spanish cardiac-laminopathies cohort (REDLAMINA registry) and to assess previously reported risk criteria.

METHODS

The relationship between risk factors and cardiovascular events was evaluated in a cohort of 140 carriers (age ≥ 16 years) of pathogenic LMNA variants (54 probands, 86 relatives). We considered: a) major arrhythmic events (MAE) if there was appropriate ICD discharge or sudden cardiac death; b) heart failure death if there was heart transplant or death due to heart failure.

RESULTS

We identified 11 novel and 21 previously reported LMNA-related DCM variants. LVEF <45% (P=.001) and NSVT (P <.001) were related to MAE, but not sex or type of genetic variant. The only factor independently related to heart failure death was LVEF <45% (P <.001).

CONCLUSIONS

In the REDLAMINA registry cohort, the only predictors independently associated with MAE were NSVT and LVEF <45%. Therefore, female carriers of missense variants with either NSVT or LVEF <45% should not be considered a low-risk group. It is important to individualize risk stratification in carriers of LMNA missense variants, because not all have the same prognosis.

Noninferiority of heart failure nurse titration versus heart failure cardiologist titration. ETIFIC multicenter randomized trial

INTRODUCTION AND OBJECTIVES

Beta-blockers, angiotensin-converting enzyme inhibitors (ACE inhibitors), angiotensin-II-receptor-blockers (ARB), and mineralocorticoid-receptor antagonists decrease mortality and heart failure (HF) hospitalizations in HF patients with reduced left ventricular ejection fraction. The effect is dose-dependent. Careful titration is recommended. However, suboptimal doses are common in clinical practice. This study aimed to compare the safety and efficacy of dose titration of the aforementioned drugs by HF nurses vs HF cardiologists.

METHODS

ETIFIC was a multicenter (n=20) noninferiority randomized controlled open label trial. A total of 320 hospitalized patients with new-onset HF, reduced ejection fraction and New York Heart Association II-III, without beta-blocker contraindications were randomized 1:1 in blocks of 4 patients each stratified by hospital: 164 to HF nurse titration vs 156 to HF cardiologist titration (144 vs 145 analyzed). The primary endpoint was the beta-blocker mean relative dose (% of target dose) achieved at 4 months. Secondary endpoints included ACE inhibitors, ARB, and mineralocorticoid-receptor antagonists mean relative doses, associated variables, adverse events, and clinical outcomes at 6 months.

RESULTS

The mean±standard deviation relative doses achieved by HF nurses vs HF cardiologists were as follows: beta-blockers 71.09%±31.49% vs 56.29%±31.32%, with a difference of 14.8% (95%CI, 7.5-22.1), P <.001; ACE inhibitors 72.61%±29.80% vs 56.13%±30.37%, P <.001; ARB 44.48%±33.47% vs 43.51%±33.69%, P=.93; and mineralocorticoid-receptor antagonists 71%±32.12% vs 70.47%±29.78%, P=.86; mean±standard deviation visits were 6.41±2.82 vs 2.81±1.58, P <.001, while the number (%) of adverse events were 34 (23.6) vs 30 (20.7), P=.55; and at 6 months HF hospitalizations were 1 (0.69) vs 9 (5.51), P=.01.

CONCLUSIONS

ETIFIC is the first multicenter randomized trial to demonstrate the noninferiority of HF specialist-nurse titration vs HF cardiologist titration. Moreover, HF nurses achieved higher beta-blocker/ACE inhibitors doses, with more outpatient visits and fewer HF hospitalizations. Trial registry number: NCT02546856.

Current functioning of cardio-oncology units in Spain

PURPOSE

The aim of the current survey was to describe the functioning of cardio-oncology (C-O) units in Spain.

METHODS

All members of the Spanish Society of Cardiology pertaining to scientific communities related to C-O received questionnaires on the existence of specific programs at their institutions. A second, more extensive questionnaire was sent to the centers which reported C-O organization.

RESULTS

We identified 56 centers with C-O programs of which 32 (62.5%) replied to the extended questionnaire. 28% of all centers reported having a multidisciplinary unit involving specialists in several areas. More than 80% of the centers developed surveillance protocols locally adapted which included advanced echocardiographic techniques (68%) or troponin (82%).

CONCLUSIONS

The number of institutions with C-O programs is still limited but higher than reported in a survey in 2017. Development of multidisciplinary units of C-O should be promoted to improve the cardiovascular health of cancer patients.

Expression of epicardial adipose tissue thermogenic genes in patients with reduced and preserved ejection fraction heart failure

Epicardial adipose tissue has been proposed to participate in the pathogenesis of heart failure. The aim of our study was to assess the expression of thermogenic genes (Uncoupling protein 1 (UCP1), peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α), and PR-domain-missing 16 (PRDM16) in epicardial adipose tissue in patients with heart failure, stablishing the difference according to left ventricular ejection fraction (reduced or preserved). Among the 75 patients in our study, 42.7% (n=32) had reduced left ventricular ejection fraction. UCP1, PGC1α and PRDM16 mRNA in EAT were significantly lower in patients with reduced left ventricular ejection fraction. Multiple regression analysis showed that age, male gender, body max index, presence of obesity, type-2-diabetes mellitus, hypertension and coronary artery disease and left ventricular ejection fraction were associated with the expression levels of UCP1, PGC1α and PRDM16 mRNA. Thermogenic genes expressions in epicardial adipose tissue (UCP1: OR 0.617, 95%CI 0.103-0.989, p=0.042; PGC1α: OR 0.416, 95%CI 0.171-0.912, p=0.031; PRDM16: OR 0.643, 95%CI 0.116-0.997, p=0.044) were showed as protective factors against the presence of heart failure with reduced left ventricular ejection fraction, and age (OR 1.643, 95%CI 1.001-3.143, p=0.026), presence of coronary artery disease (OR 6.743, 95%CI 1.932-15.301, p<0.001) and type-2-diabetes mellitus (OR 4.031, 95%CI 1.099-7.231, p<0.001) were associated as risk factors. The adequate expression of thermogenic genes has been shown as possible protective factors against heart failure with reduced ejection fraction, suggesting that a loss of functional epicardial adipose tissue brown-like features would participate in a deleterious manner on heart metabolism. Thermogenic genes could represent a future novel therapeutic target in heart failure.

Reduced levels of anti-MDA LDL antibodies in patients with carbohydrate metabolism disorders

BACKGROUND

Diabetic patients undergoing percutaneous coronary intervention (PCI) have a worse prognosis than non-diabetic patients. The anti-oxidized LDL antibodies (anti-LDLox ab) have recently been suggested to be protective against the development of diabetes. The aim of this study was to compare the levels of IgG and IgM anti-oxidized LDL antibodies with reference to the new diagnostic criteria for carbohydrate metabolism disorders after an oral glucose tolerance test (OGTT) in hospitalized patients scheduled to undergo percutaneous coronary intervention.

METHODS

We undertook a cross-sectional study of 110 patients undergoing PCI. The patients were classified as being normal (oral glucose test tolerance normal, OGTT-N), or having impaired glucose tolerance (IGT) or type 2 diabetes mellitus (T2DM) according to their glucose levels at baseline and after an OGTT.

RESULTS

An inverse slope was found in the levels of IgG anti-oxidized LDL antibodies between the OGTT-N patients (optical density (OD) = 0.109) and the patients with IGT (OD = 0.099) or T2DM (OD = 0.084) (p = 0.019). An inverse correlation was also detected between the levels of IgG anti-oxidized LDL antibodies and baseline glycemia (r = -0.23, p = 0.018).

CONCLUSIONS

Patients with coronary disease and carbohydrate metabolism disorders have much lower levels of IgG anti-oxidized LDL antibodies than normoglycemic patients.

[Benefits of cardiac resynchronization therapy in patients with atrial fibrillation who have not undergone atrioventricular node ablation]

The aim of this study was to compare the effects of cardiac resynchronization therapy on left ventricular function and reverse remodeling in patients in sinus rhythm with the effects in patients with atrial fibrillation who have not undergone atrioventricular node ablation. Echocardiographic and clinical parameters were evaluated at baseline and after 6 months of cardiac resynchronization therapy in 55 patients: 15 had atrial fibrillation and 40 were in sinus rhythm. Device programming was similar in the 2 groups, as were the reductions in QRS interval and echocardiographic measures of asynchrony observed after implantation. However, although significant improvements in end-systolic volume and ejection fraction were seen in both groups, reverse remodeling was greater in patients in sinus rhythm (reduction in end-systolic volume 30.9%+/-24.6% vs 12.5%+/-18.6%; P=.024), as was the relative increase in ejection fraction (15.4%+/-12.6% vs 5.0%+/-7.2%; P=.010). Cardiac resynchronization therapy in patients with atrial fibrillation who had not undergone atrioventricular node ablation resulted in significant improvements in ejection fraction and reverse remodeling, but these were less than those observed in patients in sinus rhythm.

[Mild hyperhomocysteinemia, low folate levels and prognosis of acute coronary syndrome without ST elevation]

BACKGROUND AND OBJECTIVE

The influence of homocysteine metabolism on the prognosis of acute coronary syndrome without ST elevation is controversial.

PATIENTS AND METHOD

Prospective study of 109 patients admitted because of acute coronary syndrome without ST elevation. Basal plasmatic levels of homocysteine and folates were obtained. Clinical features and survival data on follow-up were registered.

RESULTS

Both two years-free-of-events and total survival were lower in patients with low folate levels (36.5% vs 72.5%, p = 0.02; 48% vs 94%, p < .001). Patients with high homocysteine levels had lower two years-free-of-events survival (57.4% vs 89.1%, p < .01); but no difference in the total survival was observed (86.3% vs 97.3%, p = 0.11). The multivariate analysis showed that low folate levels was an independent predictor of mortality (odds ratio [OR] = 8.33; 95% confidence interval [CI], 1.88-33.33; p < 0.01), and moderate high homocysteine was an independent predictor of events on follow-up (OR = 4.34; 95% CI, 1.47-12.50; p < 0.01).

CONCLUSIONS

Patients with high homocysteine or low folate levels have a poor prognosis compared with those with normal levels. On the other hand, low folate levels and moderate hyiperhomocysteinemia are independent predictors of bad prognosis in the follow-up.

[How many patients admitted for heart failure are eligible for cardiac resynchronization therapy? Analysis of the Andalusian Heart Failure Registry (RAIC) study]

INTRODUCTION AND OBJECTIVES

The objective was to determine what percentage of patients admitted for heart failure met criteria for cardiac resynchronization therapy.

METHODS

The study involved registry data on heart failure admissions at 16 public hospitals in Andalusia, Spain between May and July 2004. Criteria for cardiac resynchronization therapy from American College of Cardiology and American Heart Association guidelines were applied: a left ventricular ejection fraction < or = 0.35, New York Heart Association functional class III or IV, and a QRS interval > 120 ms. Outcome was evaluated at 3 months. Multivariate (i.e., logistic regression) analysis was used to identify independent variables associated with meeting resynchronization therapy criteria.

RESULTS

The study included 674 patients (43.3% women, mean age 71[11] years). Of these, 5.6% met resynchronization therapy criteria at admission. There was no significant difference in the cardiovascular event rate at 3 months between patients who met resynchronization therapy criteria and those who did not (34.2% vs 23.4%, respectively). Admitting hospital (odds ratio [OR]=0.30, 95% confidence interval [CI], 0.11-0.79), ischemic etiology (OR=2.71, 95% CI, 1.26-5.81), the presence of left bundle branch block (OR=14.97, 95% CI, 5.95-37.64), and mitral regurgitation (OR=4.18, 95% CI, 1.93-9.04) were all independently associated with meeting resynchronization therapy criteria at both admission and short-term follow-up.

CONCLUSIONS

The percentage of patients who met cardiac resynchronization therapy criteria was small, but their short-term prognosis was poor. A number of clinical variables associated with meeting resynchronization therapy criteria were identified.

Influence of 677 C-->T polymorphism of methylenetetrahydrofolate reductase on medium-term prognosis after acute coronary syndromes

Various common genotypes of the polymorphism 677 C-->T of the methylenetetrahydrofolate reductase enzyme result in lower activity of the enzyme and in a subsequent increase in homocysteine levels. Many studies have analyzed the connection between this polymorphism and the beginning of coronary artery disease. However, conclusions have been controversial, and evidence of a connection between this polymorphism and the prognosis of coronary artery disease has been poorly evaluated. This prospective study evaluated the prognostic relevance of genotype TT in a cohort of 155 patients admitted to our hospital for treatment of an acute coronary syndrome accompanied by evidence of coronary atherosclerosis on coronary angiography. We found that patients with the genotype TT had higher homocysteine levels than did patients with the CT and CC genotypes (15.72 +/- 6.92 micromol/L vs 12.11 +/- 5.40 micromol/L and 12.01 +/- 4.25 micromol/L, P=0.01). After a mean follow-up of 13.4 +/- 7.4 months, we observed similar rates of major adverse cardiovascular events (CC, 29%; CT, 22%; and TT, 25%) and cardiovascular death (CC, 11%; CT, 7%; and TT, 8%). No difference in cardiovascular-death-free survival (log-rank analysis, 0.81; P=0.66) or event-free survival (log-rank analysis, 0.76; P=0.68) was found. The presence of genotype TT was not an independent predictor of prognosis after multivariate analysis by means of the Cox regression survival model. In conclusion, the presence of the TT genotype of the 677 C-->T polymorphism of the methylenetetrahydrofolate reductase enzyme was not related to prognosis in patients admitted to the hospital after an acute coronary syndrome.

Evolución de las hospitalizaciones por insuficiencia cardíaca en Andalucía en la última década

BACKGROUND AND OBJECTIVES

The cost of hospitalization represents the greatest proportion of total expenditure due to heart failure. Our objective was to analyze the trends of morbidity of chronic heart failure in Andalusia between 1990-2000.

MATERIAL AND METHODS

The data on hospitalizations in Andalusia (title 428 of the ninth revision of the International Disease Classification) were obtained from the National Survey of Hospital Morbidity of the National Institute of Statistics. The rates, standardized by age and gender, of admission due to heart failure were calculated by the direct standardization method.

RESULTS

The absolute number of hospitalizations due to hear failure in people over 45 years was 4,345 in 1990 and 10,153 in 2000 (a relative increase of 230%) and it represents 14.2% hospitalizations in Spain. The increase was focused on those over 65 years and the standardized rates were slightly greater in women than in men.

CONCLUSIONS

Hospitalization discharge rates increased mostly in the population older than 65 and women showed hospitalization rates slightly greater than men.

Tratamiento médico de la insuficiencia cardiaca por disfunción sistólica

Heart failure due to systolic dysfunction is a clinical syndrome that is characterized by the appearance of the signs or symptoms of heart failure in the presence of structural heart disease that has led to decreased left ventricular contractility. Current clinical practice guidelines emphasize the importance of diagnosing and treating left ventricular dysfunction in patients without symptoms of heart disease. It is essential that currently available scientific findings are taken into account when treating all patients seen with this condition, from dietary advice to use of the most sophisticated devices. We do not know the precise treatment responses of patient belonging to subgroups that were underrepresented in large clinical trials. The present article, written after the recent publication of European and American clinical practice guidelines, provides a summary of recommended medical treatment for patients with heart failure due to systolic dysfunction.

[Therapeutic attitude after coronariography in elderly patients with ischemic heart disease]

INTRODUCTION

The incidence of ischemic heart disease in the elderly is high. These patients are increasing referred for coronariography.

OBJECTIVES

Identify factors associated with coronary revascularization in elderly patients.

MATERIAL AND METHODS

Retrospective study of 473 patients > or = 75 years who underwent coronariography in relationship with ischemic heart disease. Their clinical-epidemiological characteristics and treatment adopted were analyzed. A multivariate analysis model was used to identify factors associated with revascularization.

RESULTS

Mean age was 77.6 +/- 2.8 years; 70.4% were men. A total of 36% smoked, 53% were hypertensive, 33% diabetics and 30% dislipidemic. Thirty one % had multivessel disease and 11% involvement of left coronary trunk. There was evidence of anterior descending artery in 68%. Medical treatment was done in 48.4%, percutaneous revascularization in 41.5% and surgical in 10.1%. Patients with lesions of the anterior descending artery were revascularized in greater proportion: 67.7% vs 32.3%; p. 0.001. A logistic regression model was used to identify revascularization predictors, obtaining a direct relationship with the involvement of the anterior descending artery (OR: 4.87; 95% CI: 2.98-7.94; (p < 0.001) and inverse on with the previous revascularization (OR: 0.47; 95% CI: 0.26-0.85; p < 0.02), left ventricular dysfunction (OR: 0.58; 95% CI: 0.39-0.88; p = 0.01) and presence of multivessel disease (OR: 0.51; 95% CI: 0.31-0.84; p < 0.01).

CONCLUSIONS

The elderly subjects with ischemic heart disease who underwent coronariography received revascularizing treatment in somewhat more than 50% of the cases. A direct relationship was found between involvement of the anterior descending artery and performance of revascularizing treatment and an inverse on between previous revascularization, left ventricular dysfunction and presence of multivessel disease.

Influencia del tratamiento temprano con estatinas en la función endotelial tras el infarto de miocardio en pacientes con valores normales de colesterol. Estudio VAATOPE (VAlue of ATOrvastatin in Postinfarction Endothelium)

BACKGROUND AND OBJECTIVE

Recent studies have suggested that statins reduce the rate of subsequent coronary events when these drugs are indicated early alter an acute coronary event. One potential mechanism by which these drugs might reduce the likelihood of such events is by enhancing endothelial function. The aim of this study was to determine whether early cholesterol reduction with atorvastatin improved endothelial function after acute myocardial infarction in patients with normal cholesterol levels.

PATIENTS AND METHOD

Patients with a first acute myocardial infarction and normal levels of cholesterol were assigned to treatment with 10 mg atorvastatin (n = 15) or placebo (n = 15) for 8 weeks. Patients who had previously received treatment with statins were excluded. Brachial ultrasound was used to measure endothelium-dependent flow-mediated dilation and response to endothelium-independent nitroglycerin. Total and LDL cholesterol levels and the distribution of risk factors were similar on admission and before randomization in both groups. All patients were assessed between 5 and 7 days postinfarction and after 8 weeks.

RESULTS

Total and LDL cholesterol levels were significantly decreased after atorvastatin treatment. Total cholesterol decreased by 11% (p < 0.01) and LDL cholesterol by 18% (p < 0.01). Without atorvastatin flow-mediated dilation was unchanged (mean [SEM] 9.3 [1.7%] to 10.6 [1.7%]) but it increased with atorvastatin (8.9 [1.4%] to 16.5 [1.7%], p < 0.05). The response to nitroglycerin was similar in both groups during the period of study.

CONCLUSIONS

The early administration of atorvastatin appears to enhance endothelial function in patients with acute myocardial infarction and normal levels of cholesterol.

[Effect of exercise on systolic left ventricular outflow velocity in healthy adults]

The occurrence of exercise-induced dynamic obstruction of the left ventricular outflow tract in patients without cardiomyopathy has recently been reported. However, it is not known if this phenomenon is a normal response to exercise in healthy adults. We studied 23 healthy adults using exercise Doppler echocardiography. We measured the left ventricular outflow velocity at rest and after maximum tolerated exercise. After a mean exercise duration of 12 min 45 s (2 min 32 s), the heart rate was 97.61 (6.71)% of the theoretical maximum. Left ventricular outflow velocity increased from 1.07 (0.18) m/s (range: 0.77-1.44 m/s) to 1.58 (0.35) m/s (range: 1.09-2.4 m/s). In healthy adults, exercise increased the left ventricular outflow velocity by 50%, though in no subject was it greater than 2.5 m/s. This observation appears to rule out the possibility that a high intraventricular pressure gradient is a normal response to exercise in healthy adults.

[Update in arrhythmogenic right ventricular cardiomyopathy: genetic, clinical presentation and risk stratification]

Arrhythmogenic right ventricular cardiomyopathy (ARVC), or dysplasia, is a genetic heart muscle disease whose diagnosis is often a challenge for the clinician. It is one of the commonest causes of sudden cardiac death in the young. The classic description of the disease describes the end stage of a process where the myocardium, mainly of the right ventricle, has been substituted by fibrofatty tissue. Thus the early stages of the disease with subtle symptomatology are often missed. Unfortunately the risk of a fatal outcome is no less severe. The genetic basis is under investigations. Disease causing mutations in important cell adhesion genes (plakoglobin, desmoplakin) provide the basis for improved diagnosis and understanding of the pathogenesis. Animal models support the pathogenic theory that alterations on the integrity of the adhesion junction is followed by a cellular death and progressive fibrofatty replacement, the substrate for ventricular arrhythmias. Due the growing complexity and numerous phenotypic variations reported, sometimes in the same family, international registries have been created. The present review aims to summarise the current concepts on ARVC emphasising the genetic studies, the diagnosis, new diagnostic techniques and prognosis.