Comparative prognostic importance of measures of left atrial structure and function in non-ischaemic dilated cardiomyopathy

AIMS

To compare the association between measures of left atrial (LA) structure and function, derived from cardiovascular magnetic resonance (CMR), with cardiovascular (CV) death or non-fatal heart failure (HF) events in patients with non-ischaemic dilated cardiomyopathy (DCM).

METHODS AND RESULTS

CMR studies of 580 prospectively recruited patients with DCM in sinus rhythm (median age 54 [interquartile range 44-64] years, 61% men, median LVEF 42% [30-51%]) were analysed for measures of LA structure (left atrial maximum volume index [LAVImax], left atrial minimum volume index [LAVImin]) and function (left atrial emptying fraction [LAEF], left atrial reservoir strain [LARS], left atrial conduit strain [LACS] and left atrial booster strain [LABS]). Over median follow-up of 7.4 years, 103 patients (18%) met the primary endpoint. Apart from LACS, each measure of LA structure and function was associated with the primary endpoint after adjusting for other important prognostic variables. The addition of each LA metric to a baseline model containing the same important prognostic covariates improved model discrimination, with LAVImin providing the greatest improvement (C-statistic improvement: 0.702 to 0.738; χ2 test comparing likelihood ratio p < 0.0001; categorical net reclassification index: 0.210 (95% CI 0.023-0.392)). Patients in the highest tercile of LAVImin had similar event rates to those with persistent atrial fibrillation. Measures of LA strain did not enhance model discrimination above LA volumetric measures.

CONCLUSION

Measure of left atrial structure and function offer important prognostic information in patients with DCM and enhance prediction of adverse outcomes. LA strain was not incremental to volumetric analysis for risk prediction.

Genetic Architecture of Acute Myocarditis and the Overlap With Inherited Cardiomyopathy

BACKGROUND

Acute myocarditis is an inflammatory condition that may herald the onset of dilated cardiomyopathy (DCM) or arrhythmogenic cardiomyopathy (ACM). We investigated the frequency and clinical consequences of DCM and ACM genetic variants in a population-based cohort of patients with acute myocarditis.

METHODS

This was a population-based cohort of 336 consecutive patients with acute myocarditis enrolled in London and Maastricht. All participants underwent targeted DNA sequencing for well-characterized cardiomyopathy-associated genes with comparison to healthy controls (n=1053) sequenced on the same platform. Case ascertainment in England was assessed against national hospital admission data. The primary outcome was all-cause mortality.

RESULTS

Variants that would be considered pathogenic if found in a patient with DCM or ACM were identified in 8% of myocarditis cases compared with <1% of healthy controls (P=0.0097). In the London cohort (n=230; median age, 33 years; 84% men), patients were representative of national myocarditis admissions (median age, 32 years; 71% men; 66% case ascertainment), and there was enrichment of rare truncating variants (tv) in ACM-associated genes (3.1% of cases versus 0.4% of controls; odds ratio, 8.2; P=0.001). This was driven predominantly by DSP-tv in patients with normal LV ejection fraction and ventricular arrhythmia. In Maastricht (n=106; median age, 54 years; 61% men), there was enrichment of rare truncating variants in DCM-associated genes, particularly TTN-tv, found in 7% (all with left ventricular ejection fraction <50%) compared with 1% in controls (odds ratio, 3.6; P=0.0116). Across both cohorts over a median of 5.0 years (interquartile range, 3.9-7.8 years), all-cause mortality was 5.4%. Two-thirds of deaths were cardiovascular, attributable to worsening heart failure (92%) or sudden cardiac death (8%). The 5-year mortality risk was 3.3% in genotype-negative patients versus 11.1% for genotype-positive patients (Padjusted=0.08).

CONCLUSIONS

We identified DCM- or ACM-associated genetic variants in 8% of patients with acute myocarditis. This was dominated by the identification of DSP-tv in those with normal left ventricular ejection fraction and TTN-tv in those with reduced left ventricular ejection fraction. Despite differences between cohorts, these variants have clinical implications for treatment, risk stratification, and family screening. Genetic counseling and testing should be considered in patients with acute myocarditis to help reassure the majority while improving the management of those with an underlying genetic variant.

Mediastinal Lymphadenopathy, Class-Switched Auto-Antibodies and Myocardial Immune-Complexes During Heart Failure in Rodents and Humans

Mediastinal lymphadenopathy and auto-antibodies are clinical phenomena during ischemic heart failure pointing to an autoimmune response against the heart. T and B cells have been convincingly demonstrated to be activated after myocardial infarction, a prerequisite for the generation of mature auto-antibodies. Yet, little is known about the immunoglobulin isotype repertoire thus pathological potential of anti-heart auto-antibodies during heart failure. We obtained human myocardial tissue from ischemic heart failure patients and induced experimental MI in rats. We found that anti-heart autoimmunity persists during heart failure. Rat mediastinal lymph nodes are enlarged and contain active secondary follicles with mature isotype-switched IgG2a B cells. Mature IgG2a auto-antibodies specific for cardiac antigens are present in rat heart failure serum, and IgG and complement C3 deposits are evident in heart failure tissue of both rats and human patients. Previously established myocardial inflammation, and the herein provided proof of B cell maturation in lymph nodes and myocardial deposition of mature auto-antibodies, provide all the hallmark signs of an established autoimmune response in chronic heart failure.

Bacteriological study of Neisseria strains isolated in Romania 1971-1992

1496 Neisseria strains isolated from patients and carriers from 24 counties in Romania and Bucharest in 1971-1992 were studied. Serogroup A identified in 84.5% in 1987 shows a remarkable decrease in pre- and post-epidemic periods when serogroups B and C reach rates varying from 0 to 66.6% in 1975 for B and 38.8% in 1974 for C. Non-groupable strains were more frequently isolated in inter-epidemic periods, especially in carriers. Sensitivity to antibiotics of the meningococcal strains revealed a law rate of resistant strains, the most active antibiotics in decreasing order being: penicillin, chloramphenicol, tetracycline, ampicillin, rifampicin and erythromycin. Serogroup A was the most resistant to sulfamides as compared to the other serogroups, its resistance rate rising from 18.1% strains resistant to sulfathiazole in 1980-1985 to 60.7% in 1987 and to 83.3% in 1988.

Epidemiology of meningococcal meningitis in Romania 1971-1991

The paper describes the endemic epidemic picture of meningococcal meningitis in Romania over 1971-1991 period. After the epidemic of 1970 with 1051 cases and a morbidity of 5.2 %000, the incidence of the disease suddenly decreased; thus in 1972-1984 the number of cases ranged from 191 to 534 per year, corresponding to a morbidity rate of 0.9 - 2.3 %000. Starting with the autumn of 1985 the incidence of meningococcal meningitis increased rapidly, reaching a maximum value in 1987 (2623 cases) and a morbidity rate of 11.4 %000. A spectacular decrease to 250-270 cases per year in 1990-1991 and a morbidity rate of 1.1 - 1.2 %000 were reported. Mortality followed closely the morbidity curve with a maximum in 1987 (0.4 %000). By contrast, lethality was higher in endemic periods with a maximum of 7.9% (1972), 8.9% (1975) and 6.3% (1990-1991), in the remaining years the lowest index being 1.4% (1980). The meningococcal meningitis epidemic of 1987 was due to group A Neisseria meningitidis identified in 84.5% of isolates from patients, the same serogroup decreasing in endemic periods to 0 (1991) or 5.5% (1974).

[The attitude of pulmonary tuberculosis patients towards treatment, a factor in the efficacy of chemotherapy]

The paper reports on the efficiency at the first treatment of pulmonary tuberculosis chemotherapy in a homogeneous group of 124 bacillary men, belonging to the territory of the Tb out-patient clinic no. 2, all admitted in the Galaţi Hospital of pulmonary diseases, between 1985 and 1986. This group was divided into 4 subgroups, as a function of the degree of participation to chemotherapy (intermittent treatment 2/7 intensive, for a short period-6 months), i.e.: a) cooperative-conformist in 66 patients; b) cooperative-over-particular in 20 patients without therapeutic failure; c) non-cooperative by interest 21 (16.93%) with 11 failures (52.3%); d) completely noncooperative (nonsocial) 17-13.71% with 13 failures (76.48%). In the 124 patients, 26 failures were recorded (20.97%) but in 19.35% the therapeutic failure was determined by non-compliance; of them, 20 patients left the hospital without the physician's advice. For improving compliance, the individual health education, cooperation with psychologist or psychiatrist, the final compulsory isolation of the nonsocial patients are recommended.