Prevalence of Infective Endocarditis in Enterococcus faecalis Bacteremia

BACKGROUND

Enterococcus faecalis is the third most frequent cause of infective endocarditis (IE). Despite this, no systematic prospective echocardiography studies have examined the prevalence of IE in patients with E. faecalis bacteremia.

OBJECTIVES

This study sought to determine the prevalence of IE in patients with E. faecalis bacteremia. The secondary objective was to identify predictors of IE.

METHODS

From January 1, 2014, to December 31, 2016, a prospective multicenter study was conducted with echocardiography in consecutive patients with E. faecalis bacteremia. Predictors of IE were assessed using multivariate logistic regression with backward elimination.

RESULTS

A total of 344 patients with E. faecalis bacteremia were included, all examined using echocardiography, including transesophageal echocardiography in 74% of the cases. The patients had a mean age of 74.2 years, and 73.5% were men. Definite endocarditis was diagnosed in 90 patients, resulting in a prevalence of 26.1 ± 4.6% (95% confidence interval [CI]). Risk factors for IE were prosthetic heart valve (odds ratio [OR]: 3.93; 95% CI: 1.76 to 8.77; p = 0.001), community acquisition (OR: 3.35; 95% CI: 1.74 to 6.46; p < 0.001), ≥3 positive blood culture bottles (OR: 3.69; 95% CI: 1.88 to 7.23; p < 0.001), unknown portal of entry (OR: 2.36; 95% CI: 1.26 to 4.40; p = 0.007), monomicrobial bacteremia (OR: 2.73; 95% CI: 1.23 to 6.05; p = 0.013), and immunosuppression (OR: 2.82; 95% CI: 1.20 to 6.58; p = 0.017).

CONCLUSIONS

This study revealed a high prevalence of 26% definite IE in patients with E. faecalis bacteremia, suggesting that echocardiography should be considered in all patients with E. faecalis bacteremia.

Influence of renal impairment on aldosterone status, calcium metabolism, and vasopressin activity in outpatients with systolic heart failure

Aims

Renal dysfunction (RD) is associated with increased morbidity and mortality in heart failure (HF). At present, no specific treatment for patients with RD, to prevent progression of HF, has been developed. How different hormone axes—and thereby potential treatment options—are affected by RD in HF warrants further investigations.

Methods and results

Patients with left ventricular ejection fraction (LVEF) <0.45% were enrolled prospectively from an outpatient HF clinic. Glomerular filtration rate was estimated by the Chronic Kidney Disease Epidemiology Collaboration equation (eGFR), and patients were grouped by eGFR: eGFR group I, ≥90 mL/min/1.73 m²; eGFR group II, 60–89 mL/min/1.73 m²; and eGFR group III, ≤59 mL/min/1.73 m². Multivariate linear regression models were developed to evaluate the associations between eGFR groups and hormones. A total of 149 patients participated in the study. Median age was 69 [interquartile range (IQR): 64–73] and 26% were female; LVEF was 33% (IQR: 27–39), 78% were in functional class II–III, median eGFR was 74 (54–89) mL/min/1.73 m², and median N‐terminal pro‐brain natriuretic peptide was 1303 pg/mL (IQR: 441–2740). RD was associated with increased aldosterone, parathyroid hormone (PTH), and copeptin concentrations (P < 0.05 for all) after adjustment for traditional confounders and medical treatment.

Conclusions

RD is associated with increased concentrations of aldosterone, PTH, and copeptin in systolic HF outpatients. Our results underscore the importance of treatment with mineralocorticoid receptor antagonist in systolic HF in particular in patients with RD and suggest that vasopressin and parathyroid receptor antagonism are potential treatment options in HF patients with known RD.

Iron deficiency: Prevalence and relation to cardiovascular biomarkers in heart failure outpatients

BACKGROUND

Both iron deficiency (ID) and cardiovascular biomarkers are associated with a poor outcome in heart failure (HF). The relationship between different cardiovascular biomarkers and ID is unknown, and the true prevalence of ID in an outpatient HF clinic is probably overlooked.

OBJECTIVES

To identify the prevalence of ID in a HF clinic and evaluate whether ID is associated with increased plasma concentrations of different cardiovascular biomarkers that carry a poor prognosis.

METHODS

We prospectively included 149 patients with systolic HF referred to an outpatients HF clinic. ID was defined as ferritin<100 μg/L or ferritin 100-300 μg/L and Tranferin-saturation<0.20. Five different cardiovascular biomarkers were analyzed on frozen plasma.

RESULTS

The patients had a median age of 70 (Interquartile range: 64-75) years, 25% were females, 29% were in functional class III-IV and LVEF was 32 (27-39) %. The prevalence of ID was 45% (95%-confidence interval (CI): 37-53%). In multivariate analyses, ID was not associated with plasma concentrations of troponin I, NT-proBNP, MR-proANP, chromogranin A or copeptin (P>0.05 for all) but with plasma concentrations of hs-CRP (odds ratio: 2.03, 95%-CI: 1.02-4.02, P=0.043).

CONCLUSION

ID is frequent in an outpatient HF clinic. ID is not associated with cardiovascular biomarkers after adjustment for traditional confounders. Inflammation, but not neurohormonal activation is associated with ID in systolic HF. Further studies are needed to understand iron metabolism in elderly HF patients.

Influence of renal impairment on myocardial function in outpatients with systolic heart failure: an echocardiographic and cardiac biomarker study

BACKGROUND

Renal dysfunction (RD) is associated with poor outcome in systolic heart failure (HF). Left ventricular ejection fraction (LVEF) is not depressed to a greater extent in patients with RD compared to patients with normal renal function, but it is relatively unknown whether other measures of myocardial function are impaired by RD. The objective of the present study is to evaluate whether RD in systolic HF is associated with excessive impairment of myocardial function, evaluated by strain analysis and cardiac biomarkers.

METHODS

Patients with LVEF <0.45% were enrolled from an outpatient HF clinic. The patients underwent advanced echocardiography. Glomerular filtration rate was estimated by the CKD-EPI equation (eGFR) and patients grouped by eGFR: eGFR group-I, ≥ 90 ml/min/1.73 m(2); eGFR group-II, 60-89 ml/min/1.73 m(2); and eGFR group-III, ≤ 59 ml/min/1.73 m(2). Multivariate regression models were developed to evaluate the associations between eGFR groups, echocardiographic measures and cardiac biomarkers.

RESULTS

A total of 149 patients participated in the study. Median age was 69 years, 26% were female; LVEF was 33%. Patients with a low eGFR were older (P < 0.001), but there were no differences in frequency of atrial fibrillation, hypertension, diabetes and ischemic heart disease between eGFR groups (P > 0.05 for all). RD was associated with impaired global longitudinal strain (P = 0.018), increased E/e' (P = 0.032), larger left atria (P = 0.038) and increased levels of proANP (P < 0.001), NT-proBNP (P < 0.001) and troponin I (P = 0.019) after adjustment for traditional confounders.

CONCLUSIONS

Echocardiographic measures and biomarkers reflecting different aspects of myocardial function are impaired in systolic HF patients with RD and the increased mortality risk in these patients may partly be explained by a depressed cardiac function.

Incidence and Predictors of End-Stage Renal Disease in Outpatients With Systolic Heart Failure

Background—

Renal dysfunction is an important prognostic factor in heart failure (HF), but whether this dysfunction progresses to end-stage renal disease (ESRD) is unknown. Therefore, we examined incidence and predictors of ESRD in outpatients with HF.

Methods and Results—

Patients with systolic HF were identified in The Danish Heart Failure database and new-onset ESRD from the Danish Registry on Dialysis. Renal function was estimated by The Chronic Kidney Disease Epidemiology Collaboration equation and patients grouped by estimated glomerular filtration rate (eGFR)—group I: ≥60 mL/min per 1.73 m 2 , group II: 30 to 59 mL/min per 1.73 m 2 , group III: 15 to 29 mL/min per 1.73 m 2 , group IV: <15 mL/min per 1.73 m 2 . Cox hazard models for time to ESRD, to death, and the composite end point of ESRD or death were constructed and predictors of ESRD identified. A total of 8204 patients were included in the analyses. Median age was 70 years (Q, 61–77), 28% were women, median left ventricular ejection fraction was 30% (Q, 24–40), and median eGFR was 68 (Q, 51–85) mL/min per 1.73 m 2 . Forty-one patients developed ESRD (1.3/1000 patient-years). Baseline eGFR group II ( P <0.001), eGFR group III ( P <0.001), eGFR group IV ( P <0.001), uncontrolled hypertension ( P =0.049), need of diuretics, and age <60 years ( P =0.016) were associated with time to ESRD.

Conclusions—

ESRD is rare in outpatients with systolic HF and is mainly observed in patients with an eGFR <30 mL/min per 1.73 m 2 . A low eGFR, age <60 years, need of diuretics, and uncontrolled hypertension identify patients with an increased risk for ESRD.

Prognostic significance of cardiovascular biomarkers and renal dysfunction in outpatients with systolic heart failure: a long term follow-up study

OBJECTIVE

To assess whether the prognostic significance of cardiovascular (CV) biomarkers, is affected by renal dysfunction (RD) in systolic heart failure (HF).

BACKGROUND

It is unknown, whether the prognostic significance of CV biomarkers, such as N-terminal-pro-brain-natriuretic-peptide (NT-proBNP), high-sensitive troponin T (hsTNT), pro-atrial natriuretic peptide (proANP), copeptin and pro-adrenomedullin (proADM), is affected by renal function in HF.

METHODS

Clinical data and laboratory tests from 424 patients with systolic HF were collected prospectively. The patients were followed for 4.5 years (interquartile range: 2-7.7 years). CV biomarkers were analyzed on frozen plasma, and renal function was estimated by the Modification of Diet in Renal Disease (MDRD) formula. Cox proportional hazard models for mortality risk were constructed and tests for interaction between each CV biomarker and RD were performed.

RESULTS

Median age was 73 years (51-83), 29% were female, LVEF was 30% (13-45), 74% were NYHA classes I-II and estimated glomerular filtration rate (eGFR) was 68 ml/min/1.73 m(2) (18-157). A total of 252 patients died. All five biomarkers--log(NT-proBNP) (HR: 2.13, 95% CI: 1.57-2.87:, P<0.001), hsTNT (HR: 3.07, 95% CI: 1.90-4.96 P<0.001), proANP (HR: 1.02, 95% CI: 1.01-1.03, P<0.001), copeptin (HR: 1.02, 95% CI: 1.01-1.03, P=0.008) and proADM (HR: 2.37, 95% CI: 1.66-3.38, P<0.001)--were associated with mortality risk, but not affected by RD (P>0.05 for all interactions).

CONCLUSION

Established and new CV biomarkers are closely associated with renal function in HF. However, their prognostic significance is not affected by RD, and all CV biomarkers can be used for risk stratification independently of renal function.

Regulation of synaptic ribbons in rat pineal gland explants by norepinephrine and sympathetic neurons in a co-culture model

The hypothesis that synaptic ribbons in the mammalian pinealocyte are influenced by adrenergic mechanisms was tested in the present study using a co-culture model of pineal glands and superior cervical ganglia from neonatal rats. Pineal gland explants survived and showed a high degree of differentiation when cultured for up to 30 days regardless of the presence or absence of superior cervical ganglia. Pineal glands also had neurotrophic properties promoting the survival and neurite extension from superior cervical ganglia. Synaptic ribbons were a common ultrastructural feature in all pineal cultures. There was a significant decline in synaptic ribbon numbers when co-cultured with superior cervical ganglia for both 7 and 30 days. A similar significant decrease in synaptic ribbon frequency was observed after treatment of pineal explants with norepinephrine (10(-5 )M) for both 7 and 30 days. These findings are consistent with the hypothesis that neural mechanisms play an important role in regulating synaptic ribbon numbers, at least during early development. The study also illustrates the utility of pineal gland-superior cervical ganglia co-cultures as a model for future investigations of neuron-target interactions in the pineal.

Neurotrophic effects of the pineal gland: role of non-neuronal cells in co-cultures of the pineal gland and superior cervical ganglia

The pineal gland (PG) is a source of several trophic factors. In this study, PG and superior cervical ganglia (SCG) from Sprague-Dawley neonates (1-day-old) were co-cultured to test the hypothesis that endogenous release of PG NGF (or an NGF-like cytokine) is sufficient to promote survival of SCG neurons. Neuronal density of SCG neurons was significantly enhanced when co-cultured with PG for 7 days compared to SCG cultured alone. SCG survival and neurite formation in PG co-cultures was less than in SCG treated with exogenous NGF (100 ng/ml). The neurotrophic effect of PG co-cultures was abolished when 1% anti-NGF was added to the medium. Co-cultures of SCG neurons with established 7-day PG cultures induced extensive SCG neurite formation within 24 hr compared to SCG co-cultured with 1-day PG cultures. This suggests that PG neurotrophic effects are due to PG non-neuronal cells (nnc) that proliferate to confluency by 7 days in culture. S-antigen-positive pinealocytes did not proliferate in culture. There was decreased SCG survival when neurons were seeded onto PG cultures that had been previously killed by drying, which suggests that the neurotrophic effects of nnc are not substrate-dependent. Immunocytochemical characterization of PG nnc revealed a heterogenous mixture of astrocytes, macrophage/microglia, and fibroblasts. These findings support the hypothesis that NGF is actively secreted by PG and that nnc are the principal source of this neurotophin.