Endogenous Cushings syndrome is associated with impaired myocardial work efficiency

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): German Ministry of Research and Education within the Comprehensive Heart Failure Center, Würzburg

OnBehalf

STAAB Cohort Study and CV-CORT-EX Study

Background

Endogenous Cushing’s syndrome (CS) is associated with increased cardiovascular morbidity and mortality. Long-term remission (LTR) after successful treatment is considered to positively affect the cardiovascular system including the heart. Left ventricular (LV) myocardial work (MyW) based on pressure-strain loops is a novel tool to non-invasively assess LV performance and is considered less load-dependent than LV ejection fraction (LVEF) and global longitudinal strain (GLS). We analyzed LV function in patients with overt CS and CS in LTR in comparison to healthy individuals derived from a local population-based cohort.

Methods/Results: In a cross-sectional analysis, we compared n = 31 comprehensively characterized patients with overt CS (mean age 48 ± 12 years, 71% women) and 49 patients with CS in LTR (53 ± 12 years, 77% women) with a control group who underwent transthoracic echocardiography. As control group, we analyzed a population-based sample of apparently healthy individuals (in sinus rhythm, free from CV risk factors, and no significant valve disease) from a population-based cohort: n = 439, 49 ± 11 years, 56% women. MyW assessment was performed off-line using EchoPAC (GE, version 202).

Systolic and diastolic blood pressure, HbA1c, and body mass index were significantly higher in patients with either overt CS or CS in LTR when compared to healthy participants (without significant differences between both patient groups). LVEF was equal between all three groups, but GLS was significantly lower in healthy participants and tended to be lower in LTR when compared to patients with CS. Global work index was equal between all three groups, but global wasted work was significantly higher in CS patients when compared to healthy participants, resulting in lower global work efficiency (Table).

Conclusion

In contrast to LVEF as established parameter of cardiac function, myocardial work analysis revealed functional alterations in patients with current and previous cortisol excess when compared to healthy individuals derived from a population-based sample. CS patients´ hearts appear to perform larger amounts of wasted work even during long-term remission. Abstract Figure.

Mild autonomous cortisol secretion portends similar cardiac compromise as overt endogenous Cushings syndrome

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): German Ministry of Research and Education within the Comprehensive Heart Failure Centre Würzburg

OnBehalf

CV-CortEx

Background

Endogenous Cushing’s syndrome (CS) results in increased cardiovascular morbidity and mortality. This risk seems to be lower in patients with incidentally discovered mild autonomous cortisol secretion (MACS) but without the clinical features of CS. We aimed to describe and compare the cardiac morphology and function in patients with overt CS and MACS to a representative sample of a local prospective population-based cohort (STAAB).

Methods/Results: We comprehensively characterized 40 patients with overt CS (mean age 47 ± 13 years, 75% women) and 18 patients with MACS (62 ± 11 years, 56% women; both p ≤ 0.001 when compared to CS) including detailed transthoracic echocardiography. Logistic regression adjusted for age and sex showed no significant differences between both groups regarding body mass index (BMI), systolic and diastolic blood pressure (BP), lipids, HbA1c, and echocardiographic parameters of cardiac morphology and function (table). The comparison with STAAB participants (n = 4965, 55 ± 12 years, 52% women; logistic regression adjusted for age and sex) revealed significantly higher BMI, triglycerides, HbA1c, and diastolic but not systolic BP (table). Compared to STAAB participants, patients exhibited a smaller left ventricle (LV) with thicker septal and posterior walls, and a less favorable diastolic function. LV ejection fraction (LVEF) was higher, although longitudinal contraction, measured by tricuspid annular plane systolic excursion (TAPSE), and LV global longitudinal strain (GLS) were lower in both ventricles compared to STAAB participants (table).

Conclusion

Patients with both MACS or CS exhibited a compromised metabolic profile and diastolic function pattern when compared to a population-based cohort. Higher LVEF despite lower GLS suggests a compensatory increase in LV radial contraction in states of hypercortisolism. Cardiac impairment was similar in patients with CS or MACS suggesting an adverse effect of hypercortisolism even at clinically inconspicuous levels. Abstract Figure.

P4380Echocardiographically determined myocardial work An emerging bioassay for clinical studies Results from the STAAB cohort study

Introduction

A novel echocardiographic method to non-invasively determine myocardial work based on speckle-tracking derived longitudinal strain and blood pressure has recently been validated and offers new opportunities to study the mechanistic associations. Heart failure patients with prolonged electrical conduction (ie, left bundle branch block) exhibit reduced myocardial global work efficiency (GWE) due to an increase in global wasted work (GWW), which could be improved by biventricular pacing. We here investigated the association of ETI and myocardial work in a non-diseased population.

Methods

The Characteristics and Course of Heart Failure STAges A/B and Determinants of Progression (STAAB) cohort study carefully characterized a representative sample of the population of a medium-sized town in Germany, aged 30–79 years and free from heart failure. Off-line analysis of the standardized, quality-controlled transthoracic echocardiograms regarding myocardial work yields the following parameters: global constructive work (GCW): work performed during shortening in systole and adding negative work during lengthening in isovolumic relaxation; global wasted work (GWW): negative work performed during lengthening in systole adding work performed during shortening in isovolumic relaxation; and global work efficiency (GWE): GCW/(GCW+GWW).

Results

We performed myocardial work analysis in 935 individuals from the sample of the first planned STAAB interim analysis who were in sinus rhythm, had preserved left ventricular ejection fraction and were free from significant valvular disease (51% female, 53±12 years). In linear regression including age, sex, heart rate, and ETI, we found increasing heart rate (64±10 bpm), QRS width (95±12 ms), QT interval (414±28 ms), and PQ interval (164±28 ms) associated with lower GWE (−0.11, −0.02, −0.03, and −0.001, respectively; all p<0.05) and higher GWW (+2.64, +0.29, +0.79, +0.16 mmHg%, respectively; all p<0.05).

Conclusion

In subjects free of overt cardiac disease, GWE strongly associated with ETI. Prolonged atrio-ventricular and intra-ventricular coupling and repolarization was associated with an increase in wasted work, while constructive work was not affected. These findings not only suggest a positive effect on myocardial energetics by reducing the heart rate, but also advocate the concept of myocardial work as a bioassay that is responsive to subtle changes. Myocardial work holds promise to be further studied in diseased patient groups.

Acknowledgement/Funding

German Ministry of Research and Education within the Comprehensive Heart Failure Centre Würzburg (BMBF 01EO1004 and 01EO1504)

P1532Asymptomatic structural heart disease in individuals without apparent cardiovascular risk factors An unnoticed potential precursor stage of heart failure. Results from the STAAB cohort study

Background and aim

Prevention of heart failure (HF) relies on early identification and elimination of cardiovascular risk factors. ACC/AHA guidelines define consecutive asymptomatic precursor stages of HF, i.e. stage A (with risk factors for HF), and stage B (asymptomatic cardiac dysfunction). We aimed to identify frequency and characteristics of individuals at risk for HF, i.e. stage A and B, in the general population.

Methods

The prospective Characteristics and Course of Heart Failure Stages A-B and Determinants of Progression (STAAB) cohort study phenotyped a representative sample of 5000 residents (aged 30–79 y) of a medium sized German town, reporting no previous HF diagnosis. Echocardiography was highly quality-controlled. We applied these definitions: HF stage A: ≥1 risk factor for HF (hypertension, arteriosclerotic disease, diabetes mellitus, obesity, metabolic syndrome), but no structural heart disease (SHD); HF stage B: asymptomatic but SHD [reduced left ventricular (LV) ejection fraction, LV hypertrophy, LV dilation, stenosis or grade 2/3 regurgitation of aortic/mitral valve, grade 2/3 diastolic dysfunction], or prior myocardial infarction; Normal (N): no risk factor and no SHD. We focused on subjects in stage B without apparent cardiovascular risk factors qualifying for A (B-not-A) compared to those with risk factors (BA) and N. The first half of the sample (n=2473) served as derivation set (D), the second half (n=2434) as validation set (V).

Results

We found 42% (D)/45% (V) of subjects in stage A, and 18% (D)/17% (V) in stage B. Among stage B subjects, 31% (D)/29% (V) were B-not-A. Compared to BA, B-not-A subjects were younger [47 vs. 63 y (D)/50 vs 63 years (V); both p<0.001] and more often female [78% vs 56% (D)/79% vs 62% (V); both p<0.001], had higher LV ejection fraction [59% vs 56% (D)/53% vs 48% (V); both p<0.05], lower E/e' [6.7 vs 9.9 (D)/6.9 vs. 9.3 (V); both p<0.001], higher LV volume [64 vs 59 mL/m2 (D)/54 vs 48 mL/m2 (V); both p≤0.01], lower hemoglobin [13.3 vs 13.9 g/dL (D, p=0.02)/13.4 vs 13.8 g/dL (V, p=0.08); both adjusted for sex], and lower QTc interval [423 vs 433 ms (D)/427 vs 438 ms (V); both p≤0.001). Compared to N, subjects in B-not-A were more often female [78% vs 56% (D)/79% vs 61% (V); both p<0.001], had larger QTc interval [423 vs 418 ms (D)/427 vs 420 ms (V); both p<0.05], and more often anemia [11% vs 5% (D, p=0.02)/9% vs 5% (V, p=0.12)].

Conclusions

We confirmed, by extensive internal validation, the presence of a hitherto undescribed group of individuals with relevant myocardial alterations, but lacking respective risk factors. Since algorithms in primary prevention do not include echocardiography, this subgroup might be missed. Further investigations should 1) externally validate our finding, 2) study the prognostic course of subjects in group B-not-A, and 3) elaborate the material differences between B-not-A and N to identify potential further novel risk factors for HF.

Acknowledgement/Funding

German Ministry of Research and Education within the Comprehensive Heart Failure Centre Würzburg (BMBF 01EO1004 and 01EO1504)

4305The interrelation of left ventricular geometry with myocardial work

Introduction

A novel echocardiographic method to non-invasively determine myocardial work based on speckle-tracking derived longitudinal strain and blood pressure has recently been validated and offers new opportunities to study mechanistic associations. Left ventricular (LV) dilation and LV hypertrophy are acknowledged precursors of myocardial dysfunction and ultimately heart failure, but the mechanisms are still not well understood. We aimed to assess the association of LV geometry and myocardial work in a non-diseased population.

Methods

The Characteristics and Course of Heart Failure STAges A/B and Determinants of Progression (STAAB) cohort study carefully characterized a representative sample of the population of a medium-sized town in Germany, aged 30–79 years. By off-line analysis of the standardized, quality-controlled transthoracic echocardiograms the following parameters describing myocardial work can be derived. Global constructive work (GCW): work performed during shortening in systole and adding negative work during lengthening in isovolumic relaxation; global wasted work (GWW): negative work performed during lengthening in systole adding work performed during shortening in isovolumic relaxation; global work efficiency (GWE): GCW/(GCW+GWW). Further, LV volumes and mass were measured and indexed to body surface area.

Results

Myocardial work analysis was performed in 1568 individuals, who were in sinus rhythm, had preserved LV ejection fraction (EF), and were free from significant valvular disease (50.3% female, aged 53±12 years). In linear regression, we included age, sex, LVEF, low-density lipoprotein (LDL), glycosylated hemoglobin (HbA1c), heart rate, body mass index, hypertension as well as LV mass index (LVMi) and LV end-diastolic volume index (LVEDVi) as parameters of LV geometry. We found increasing LVEDVi (52±10 mL/m2), associated with higher GWW (+0.35, p<0.001) and lower GWE (–0.01, p<0.05), while increasing LVMi (73±17 g/m2) was associated with both, higher GWW (+0.23, p<0.01) and GCW (+1.6, p<0.05) resulting in a lower GWE (–0.09, p<0.01).

Conclusion

The new echocardiography-based method to non-invasively assess myocardial work offers new insights into the relationship of LV geometry and myocardial work in a non-diseased population. While larger LV volumes were associated with more wasted work, higher LV mass was associated with an increase in both constructive and wasted work. Both alterations of LV geometry adversely affected myocardial work efficiency. This new echocardiographic method is change-sensitive and thus holds promise to further explore the relationship of LV geometry with myocardial work in different disease entities.

Acknowledgement/Funding

Funding of the STAAB cohort study in the frame of the Comprehensive Heart Failure Center, BMBF 01EO1004 and 01EO1504

The β-blocker uptitration in elderly with heart failure regarding biomarker levels: CIBIS-ELD substudy

AIM

We investigated if the baseline value of mid-regional pro-atrial natriuretic peptide (NP), N-terminal pro-B-type NP and copeptin may be helpful in optimizing β-blocker uptitration in elderly patients with heart failure.

PATIENTS & METHODS

According to the biomarkers' levels, 457 patients were divided into three subgroups and compared with each other at baseline and 3 months after.

RESULTS

All mid-regional pro-atrial NP and N-terminal pro-B-type NP subgroups had significant amelioration of left ventricle ejection fraction and New York Heart Association (NYHA) class after 3 months of β-blocker uptitration (p < 0.001). More prominent improvement of left ventricle ejection fraction and New York Heart Association class was observed in subgroups with lower versus higher NPs levels.

CONCLUSION

NPs levels, unlike copeptin levels, might be useful tool for objective selection of elderly heart failure patients who could have the greatest benefit of forced uptitration.

[Assessment of subjective physical well-being in heart failure : Validation of the FEW16 questionnaire]

INTRODUCTION

Improvement in the quality of life (QoL) is a major goal of therapy for heart failure (HF) patients. Physical well-being as an important component of QoL has not yet been sufficiently covered by disease-specific assessment instruments. The aim of the study was to validate the questionnaire for assessing subjective physical well-being (FEW16) in HF patients with preserved ejection fraction (HFpEF) from the exercise training in diastolic heart failure (Ex-DHF‑P) trial.

METHOD

A total of 64 HFpEF patients (65 years, 56 % female) were randomized to usual routine treatment with (n = 44) or without training (n = 20). At baseline and 3 months, patients were clinically evaluated and assessed using appropriate questionnaires on the QoL (SF36), physical well-being (FEW16) and depression (PHQ-D).

RESULTS

The FEW16 showed good values for Cronbachs' alpha coefficients (0.85-0.93). The cross-validity with SF36 and PHQ-D was highly significant but more so for psychological aspects. At baseline, the FEW16 score correlated with age, the subscale resilience with age and the 6 min walking distance test. At follow-up, the total and resilience scores had improved in the training group. In contrast to the SF36, the FEW16 did not detect differences between the groups in Ex-DHF‑P.

DISCUSSION

The FEW16 questionnaire showed good internal consistency and correlation with SF36, its total score and resilience had improved after training; however, it did not reflect different changes between the study groups. The FEW16 is therefore more suited to assess general/mental well-being than the subjective physical well-being.

Tolerability and Feasibility of Beta-Blocker Titration in HFpEF Versus HFrEF: Insights From the CIBIS-ELD Trial

OBJECTIVES

This study evaluated the tolerability and feasibility of titration of 2 distinctly acting beta-blockers (BB) in elderly heart failure patients with preserved (HFpEF) and reduced (HFrEF) left ventricular ejection fraction.

BACKGROUND

Broad evidence supports the use of BB in HFrEF, whereas the evidence for beta blockade in HFpEF is uncertain.

METHODS

In the CIBIS-ELD (Cardiac Insufficiency Bisoprolol Study in Elderly) trial, patients >65 years of age with HFrEF (n = 626) or HFpEF (n = 250) were randomized to bisoprolol or carvedilol. Both BB were up-titrated to the target or maximum tolerated dose. Follow-up was performed after 12 weeks. HFrEF and HFpEF patients were compared regarding tolerability and clinical effects (heart rate, blood pressure, systolic and diastolic functions, New York Heart Association functional class, 6-minute-walk distance, quality of life, and N-terminal pro-B-type natriuretic peptide).

RESULTS

For both of the BBs, tolerability and daily dose at 12 weeks were similar. HFpEF patients demonstrated higher rates of dose escalation delays and treatment-related side effects. Similar HR reductions were observed in both groups (HFpEF: 6.6 beats/min; HFrEF: 6.9 beats/min, p = NS), whereas greater improvement in NYHA functional class was observed in HFrEF (HFpEF: 23% vs. HFrEF: 34%, p < 0.001). Mean E/e' and left atrial volume index did not change in either group, although E/A increased in HFpEF.

CONCLUSIONS

BB tolerability was comparable between HFrEF and HFpEF. Relevant reductions of HR and blood pressure occurred in both groups. However, only HFrEF patients experienced considerable improvements in clinical parameters and left ventricular function. Interestingly, beta-blockade had no effect on established and prognostic markers of diastolic function in either group. Long-term studies using modern diagnostic criteria for HFpEF are urgently needed to establish whether BB therapy exerts significant clinical benefit in HFpEF. (Comparison of Bisoprolol and Carvedilol in Elderly Heart Failure [HF]

PATIENTS

A Randomised, Double-Blind Multicentre Study [CIBIS-ELD]; ISRCTN34827306).

Auditory brainstem implants in neurofibromatosis Type 2: is open speech perception feasible?

OBJECT

Patients with bilateral auditory nerve destruction may perceive some auditory input with auditory brainstem implants (ABIs). Despite technological developments and trials in new stimulation sites, hearing is very variable and of limited quality. The goal of this study was to identify advantageous and critical factors that influence the quality of auditory function, especially speech perception.

METHODS

The authors conducted a prospective study on ABI operations performed with the aid of multimodality neuromonitoring between 2005 and 2009 in 18 patients with neurofibromatosis Type 2. Outcome was evaluated by testing word recognition (monotrochee-polysyllabic word test at auditory-only mode [MTPa]) and open speech perception (Hochmair-Schulz-Moser [HSM] sentence test), both in pure auditory mode. The primary outcome was the HSM score at 24 months. The predictive meaning of general clinical data, tumor volume, number of active electrodes, duration of deafness, and early hearing data was examined.

RESULTS

In 16 successful ABI activations the average score for MTPa was 89% (SD 13%), and for HSM it was 41% (SD 32%) at 24 months. There were 2 nonresponders, 1 after radiosurgery and the other in an anatomical variant. Direct facial nerve reconstruction during the same surgery was followed by successful nerve recovery in 2 patients, with a simultaneous very good HSM result. Patients' age, tumor extension, and tumor volume were not negative predictors. There was an inverse relationship between HSM scores and deafness duration; 50% or higher HSM scores were found only in patients with ipsilateral deafness duration up to 24 months. The higher the deafness sum of both sides, the less likely that any HSM score will be achieved (p = 0.034). In patients with total deafness duration of less than 240 months, higher numbers of active electrodes were significantly associated with better outcomes. The strongest cross-correlation was identified between early MTPa score at 3 months and 24-month HSM outcome.

CONCLUSIONS

This study documents that open-set speech recognition in pure auditory mode is feasible in patients with ABIs. Large tumor volumes do not prevent good outcome. Positive preconditions are short ipsilateral and short bilateral deafness periods and high number of auditory electrodes. Early ability in pure auditory word recognition tests indicates long-term capability of open speech perception.

Regional differences among female patients with heart failure from the Cardiac Insufficiency BIsoprolol Study in ELDerly (CIBIS-ELD)

BACKGROUND

The aim of our study was to examine regional differences in the demographics, etiology, risk factors, comorbidities and treatment of female patients with heart failure (HF) in the Cardiac Insufficiency BIsoprolol Study in ELDerly (CIBIS-ELD) clinical trial.

METHODS AND RESULTS

One hundred and fifty-nine female patients from Germany and 169 from Southeastern (SE) Europe (Serbia, Slovenia and Montenegro) were included in this subanalysis of the CIBIS-ELD trial. Women comprised 54% of the study population in Germany and 29% in SE Europe. German patients were significantly older. The leading cause of HF was arterial hypertension in German patients, 71.7% of whom had a preserved ejection fraction. The leading etiology in SE Europe was the coronary artery disease; 67.6% of these patients had a reduced left ventricular ejection fraction (34.64 ± 7.75%). No significant differences were found in the prevalence of traditional cardiovascular risk factors between the two regions (hypertension, diabetes, hypercholesterolemia, smoking and family history of myocardial infarction). Depression, chronic obstructive pulmonary disease and malignancies were the comorbidities that were noted more frequently in the German patients, while the patients from SE Europe had a lower glomerular filtration rate. Compared with the German HF patients, the females in SE Europe received significantly more angiotensin converting enzyme inhibitors, loop diuretics and less frequently angiotensin receptor blockers and mineralocorticoid receptor antagonists.

CONCLUSIONS

Significant regional differences were noted in the etiology, comorbidities and treatment of female patients with HF despite similar risk factors. Such differences should be considered in the design and implementation of future clinical trials, especially as women remain underrepresented in large trial populations.

A genome-wide association study identifies 6p21 as novel risk locus for dilated cardiomyopathy

AIMS

Dilated cardiomyopathy (DCM) is one of the leading causes for cardiac transplantations and accounts for up to one-third of all heart failure cases. Since extrinsic and monogenic causes explain only a fraction of all cases, common genetic variants are suspected to contribute to the pathogenesis of DCM, its age of onset, and clinical progression. By a large-scale case-control genome-wide association study we aimed here to identify novel genetic risk loci for DCM.

METHODS AND RESULTS

Applying a three-staged study design, we analysed more than 4100 DCM cases and 7600 controls. We identified and successfully replicated multiple single nucleotide polymorphism on chromosome 6p21. In the combined analysis, the most significant association signal was obtained for rs9262636 (P = 4.90 × 10(-9)) located in HCG22, which could again be replicated in an independent cohort. Taking advantage of expression quantitative trait loci (eQTL) as molecular phenotypes, we identified rs9262636 as an eQTL for several closely located genes encoding class I and class II major histocompatibility complex heavy chain receptors.

CONCLUSION

The present study reveals a novel genetic susceptibility locus that clearly underlines the role of genetically driven, inflammatory processes in the pathogenesis of idiopathic DCM.

Sinus rhythm versus atrial fibrillation in elderly patients with chronic heart failure--insight from the Cardiac Insufficiency Bisoprolol Study in Elderly

BACKGROUND

It has been suggested that patients with chronic HF and atrial fibrillation (AF) may respond differently to beta-blockers than those in sinus rhythm (SR).

METHODS

In this predefined analysis of the CIBIS-ELD trial, a total of 876 chronic HF patients (164 patients with AF) were randomized to bisoprolol or carvedilol. During the 12-week-treatment phase, beta-blockers were doubled fortnightly up to the target dose or maximally tolerated dose, which was maintained for 4 weeks.

RESULTS

Patients with AF had lower left ventricular ejection fraction (LVEF), exercise capacity, self-rated health, quality of life (QoL) scores for both SF36 physical and psychosocial component, and higher NYHA class than those in SR. Beta-blocker titration was associated with clinical improvement in both AF and SR patients: LVEF, 6-minute walk distance, physical and psychosocial components of QoL scores, self-rated health and NYHA class (p<0.05, for all). The extent of improvement did not differ between patients with AF and in SR and did not differ between bisoprolol and carvedilol. Heart rate (HR) at baseline was higher in the AF group, and remained higher until the end of the trial. Patients with higher baseline HR had larger reductions in HR, regardless of rhythm. AF patients more frequently reached target beta-blocker dose compared to those in SR (p<0.005).

CONCLUSIONS

Elderly patients with chronic HF and AF derive comparable clinical benefits from beta-blocker titration as those in SR. Patients with AF tolerate higher beta-blocker doses than those in SR, which appears to be related to higher baseline HR.

Impact of the β1-adrenoceptor Arg389Gly polymorphism on heart-rate responses to bisoprolol and carvedilol in heart-failure patients

This pharmacogenetic substudy of the prospective, double-blind, randomized CIBIS-ELD trial determined the impact of the β1-adrenoceptor Arg189Gly polymorphism on heart-rate responses to bisoprolol or carvedilol in elderly patients with heart failure (421 with sinus rhythm, 107 with atrial fibrillation). Patients were randomized 1:1 to bisoprolol or carvedilol with a fortnightly dose-doubling scheme and guideline target doses. Patients with sinus rhythm responded essentially identically to bisoprolol and carvedilol, independent of genotype. Atrial fibrillation patients homozygous for Arg389 had a much smaller response to carvedilol than carriers of at least one Gly389 allele (mean difference 12 bpm, P < 0.00001). Carvedilol up to 2 × 12.5 mg did not reduce heart rate in Arg389Arg homozygotes at all. Interestingly, the immediate response to carvedilol did not differ between genotypes. The Arg389Gly polymorphism has a major impact on the heart-rate response to carvedilol (but not bisoprolol) in patients with heart failure plus atrial fibrillation.

Gender-specific predictors of early mortality after coronary artery bypass graft surgery

BACKGROUND

Female gender is a risk factor for early mortality after coronary artery bypass graft surgery (CABG). Yet, the causes for this excess mortality in women have not been fully explained.

OBJECTIVES

To analyse gender differences in early mortality (30 days post surgery) after CABG and to identify variables explaining the association between female gender and excess mortality, taking into account preoperative clinical and psychosocial, surgical and postoperative risk factors.

METHODS

A total of 1,559 consecutive patients admitted to the German Heart Institute Berlin (2005-2008) for CABG were included in this prospective study. A comprehensive set of prespecified preoperative, surgical and postoperative risk factors were examined for their ability to explain the gender difference in early mortality.

RESULTS

Early mortality after CABG was higher in women than in men (6.9 vs. 2.4 %, HR 2.91, 95 % CI 1.70-4.96, P < 0.001). Women were older than men (+4.7 years, P < 0.001), had lower self-assessed preoperative physical functioning (-16 points on a scale from 0 to 100, P < 0.001), and had higher rates of postoperative low cardiac output syndromes (6.6 vs. 3.3 %, P = 0.01), respiratory insufficiency (9.4 vs. 5.3 %, P = 0.006) and resuscitation (5.2 vs. 1.8 %, P = 0.001). The combination of these factors explained 71 % of the gender difference in early mortality; age and physical functioning alone accounted for 61 %. Adjusting for these variables, HR for female gender was 1.36 (95 % CI 0.77-2.41, P = 0.29).

CONCLUSIONS

Age, physical function and postoperative complications are key mediators of the overmortality of women after aortocoronary bypass surgery. Self-assessed physical functioning should be more seriously considered in preoperative risk assessment particularly in women.

Telemedicine in heart failure: pre-specified and exploratory subgroup analyses from the TIM-HF trial

BACKGROUND

Meta-analyses have suggested that remote telemedical management (RTM) positively affects clinical outcomes in chronic HF patients. The results of two recent randomised RTM trials do not corroborate these results. We aim to report prospectively defined and exploratory subgroup analyses for the TIM-HF trial and to identify a patient profile that could potentially benefit from RTM for further investigation in randomised clinical trials.

METHODS

In TIM-HF, 710 stable chronic HF patients, in NYHA class II or III with a history of HF decompensation within 2 years previously or a LVEF ≤ 25% were randomly assigned (1:1) to RTM or usual care. The primary outcome was total death and secondary outcomes included days lost due to death or HF hospitalisation and a composite of cardiovascular death and HF hospitalisation. Twelve subgroups were prospectively defined and patient profiling was investigated for the subgroup with a prior history of HF decompensation, an LVEF ≥ 25% and a PHQ-9 score<10.

RESULTS

The subgroup treatment effects were significant for total mortality for the PHQ-9 subgroup only (p for interaction<0.027). For the outcome 'number of days lost due to hospitalisation for HF or death', the subgroup treatment effects were significant (p for interaction<0.05) for patients with a prior HF decompensation or an ICD implant or a PHQ score of <10 and for the patient-profiling subgroup.

CONCLUSIONS

Telemedicine management may not be appropriate for all HF patients. Future research needs to investigate which HF population may benefit from this intervention.

Telemedical Interventional Monitoring in Heart Failure (TIM-HF), a randomized, controlled intervention trial investigating the impact of telemedicine on mortality in ambulatory patients with heart failure: study design

AIMS

Remote patient management (telemonitoring) may help to detect early signs of cardiac decompensation, allowing optimization of and adherence to treatments in chronic heart failure (CHF). Two meta-analyses have suggested that telemedicine in CHF can reduce mortality by 30-35%. The aim of the TIM-HF study was to investigate the impact of telemedical management on mortality in ambulatory CHF patients. Methods CHF patients [New York Heart Association (NYHA) II/III, left ventricular ejection fraction (LVEF)≤35%] with a history of cardiac decompensation with hospitalization in the past or therapy with intravenous diuretics in the prior 24 months (no decompensation required if LVEF≤25%) were randomized 1:1 to an intervention group of daily remote device monitoring (electrocardiogram, blood pressure, body weight) coupled with medical telephone support or to usual care led by the patients' local physician. In the intervention group, 24/7 physician-led medical support was provided by two central telemedical centres. A clinical event committee blinded to treatment allocation assessed cause of death and reason for hospitalization. The primary endpoint was total mortality. The first secondary endpoint was a composite of cardiovascular mortality or hospitalization due to heart failure. Other secondary endpoints included cardiovascular mortality, all-cause and cause-specific hospitalizations (all time to first event) as well as days lost due to heart failure hospitalization or cardiovascular death (in % of follow-up time), and changes in quality of life and NYHA class. Overall, 710 CHF patients were recruited. The mean follow-up was 21.5±7.2 months, with a minimum of 12 months. Perspective The study will provide important prospective outcome data on the impact of telemedical management in patients with CHF.

Impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study

BACKGROUND

This study was designed to determine whether physician-led remote telemedical management (RTM) compared with usual care would result in reduced mortality in ambulatory patients with chronic heart failure (HF).

METHODS AND RESULTS

We enrolled 710 stable chronic HF patients in New York Heart Association functional class II or III with a left ventricular ejection fraction ≤35% and a history of HF decompensation within the previous 2 years or with a left ventricular ejection fraction ≤25%. Patients were randomly assigned (1:1) to RTM or usual care. Remote telemedical management used portable devices for ECG, blood pressure, and body weight measurements connected to a personal digital assistant that sent automated encrypted transmission via cell phones to the telemedical centers. The primary end point was death from any cause. The first secondary end point was a composite of cardiovascular death and hospitalization for HF. Baseline characteristics were similar between the RTM (n=354) and control (n=356) groups. Of the patients assigned to RTM, 287 (81%) were at least 70% compliant with daily data transfers and no break for >30 days (except during hospitalizations). The median follow-up was 26 months (minimum 12), and was 99.9% complete. Compared with usual care, RTM had no significant effect on all-cause mortality (hazard ratio, 0.97; 95% confidence interval, 0.67 to 1.41; P=0.87) or on cardiovascular death or HF hospitalization (hazard ratio, 0.89; 95% confidence interval, 0.67 to 1.19; P=0.44).

CONCLUSIONS

In ambulatory patients with chronic HF, RTM compared with usual care was not associated with a reduction in all-cause mortality.

CLINICAL TRIAL REGISTRATION

URL: http://www.ClinicalTrials.gov. Unique identifier: NCT00543881.

Titration to target dose of bisoprolol vs. carvedilol in elderly patients with heart failure: the CIBIS-ELD trial

Aims

Various beta-blockers with distinct pharmacological profiles are approved in heart failure, yet they remain underused and underdosed. Although potentially of major public health importance, whether one agent is superior in terms of tolerability and optimal dosing has not been investigated. The aim of this study was therefore to compare the tolerability and clinical effects of two proven beta-blockers in elderly patients with heart failure.

Methods and results

We performed a double-blind superiority trial of bisoprolol vs. carvedilol in 883 elderly heart failure patients with reduced or preserved left ventricular ejection fraction in 41 European centres. The primary endpoint was tolerability, defined as reaching and maintaining guideline-recommended target doses after 12 weeks treatment. Adverse events and clinical parameters of patient status were secondary endpoints. None of the beta-blockers was superior with regards to tolerability: 24% [95% confidence interval (CI) 20–28] of patients in the bisoprolol arm and 25% (95% CI 21–29) of patients in the carvedilol arm achieved the primary endpoint (P= 0.64). The use of bisoprolol resulted in greater reduction of heart rate (adjusted mean difference 2.1 b.p.m., 95% CI 0.5–3.6, P= 0.008) and more, dose-limiting, bradycardic adverse events (16 vs. 11%; P= 0.02). The use of carvedilol led to a reduction of forced expiratory volume (adjusted mean difference 50 mL, 95% CI 4–95, P= 0.03) and more, non-dose-limiting, pulmonary adverse events (10 vs. 4%; P < 0.001).

Conclusion

Overall tolerability to target doses was comparable. The pattern of intolerance, however, was different: bradycardia occurred more often in the bisoprolol group, whereas pulmonary adverse events occurred more often in the carvedilol group.

This study is registered with controlled-trials.com, number ISRCTN34827306.

Association of glucose metabolism with diastolic function along the diabetic continuum

AIMS/HYPOTHESIS

Hyperglycaemia and insulin resistance have been linked to diastolic dysfunction experimentally. We investigated the association between glucose metabolism and diastolic function along the whole spectrum of glucose metabolism states.

METHODS

In the observational Diagnostic Trial on Prevalence and Clinical Course of Diastolic Dysfunction and Diastolic Heart Failure (DIAST-CHF) study, patients with risk factors for heart failure were included. We analysed data including comprehensive echocardiography from a subgroup of patients classified by OGTT and history as normal (n = 343), prediabetic (n = 229) and non-insulin treated (n = 335) or insulin-treated (n = 178) type 2 diabetic.

RESULTS

While ejection fraction did not differ, markers of diastolic function significantly worsened across groups. Prediabetes represented an intermediate between normal glucose metabolism and diabetes with regard to echocardiography changes. Prevalence and severity of diastolic dysfunction increased significantly (p < 0.001) along the diabetic continuum. Glucose metabolism status was significantly associated with prevalence of diastolic dysfunction on multivariate logistic regression analysis. In the whole cohort, HbA(1c) correlated with early diastolic mitral inflow velocity (E):early diastolic tissue Doppler velocity at mitral annulus (e') ratio (E:e') (r = 0.20, p < 0.001). HbA(1c) was significantly associated with E:e' on multivariate analysis. Similarly, glucose metabolism status was significantly associated with E:e' on multivariate analysis. The distance walked in 6 min decreased along the diabetic spectrum and was significantly correlated with E:e' and grade of diastolic dysfunction.

CONCLUSIONS/INTERPRETATION

Glucose metabolism is associated with diastolic dysfunction across the whole spectrum. Our data extend previous observations into the prediabetic and normal range, and may be relevant to preventive approaches, as no effective treatment has been identified for diastolic heart failure once established.

Primary care-based multifaceted, interdisciplinary medical educational intervention for patients with systolic heart failure: lessons learned from a cluster randomised controlled trial

Background

Chronic (systolic) heart failure (CHF) is a common and disabling condition. Adherence to evidence-based guidelines in primary care has been shown to improve health outcomes. The aim was to explore the impact of a multidisciplinary educational intervention for general practitioners (GPs) (Train the trainer = TTT) on patient and performance outcomes.

Methods

This paper presents the key findings from the trial and discusses the lessons learned during the implementation of the TTT trial. Primary care practices were randomly assigned to the TTT intervention or to the control group. 37 GPs (18 TTT, 19 control) were randomised and 168 patients diagnosed with ascertained CHF (91 TTT, 77 control) were enrolled. GPs in the intervention group attended four meetings addressing clinical practice guidelines and pharmacotherapy feedback. The primary outcome was patient self-reported quality of life at seven months, using the SF-36 Physical Functioning scale. Secondary outcomes included other SF-36 scales, the Kansas City Cardiomyopathy Questionnaire (KCCQ), total mortality, heart failure hospital admissions, prescribing, depressive disorders (PHQ-9), behavioural change (European Heart Failure Self-Care Behaviour Scale), patient-perceived quality of care (EUROPEP) and improvement of heart failure using NT-proBNP-levels. Because recruitment targets were not achieved an exploratory analysis was conducted.

Results

There was high baseline achievement in both groups for many outcomes. At seven months, there were no significant mean difference between groups for the primary outcome measure (-3.3, 95%CI -9.7 to 3.1, p = 0.30). The only difference in secondary outcomes related to the prescribing of aldosterone antagonists by GPs in the intervention group, with significant between group differences at follow-up (42 vs. 24%, adjusted OR = 4.0, 95%CI 1.2–13; p = 0.02).

Conclusion

The intervention did not change the primary outcome or most secondary outcomes. Recruitment targets were not achieved and the under-recruitment of practices and patients alongside a selection bias of participating GPs, prohibit definite conclusions, but the CI indicates a non-effectiveness of the intervention in this sample. We describe the lessons learned from conducting the trial for the future planning and conduct of confirmatory trials in primary care.

Trial registration

ISRCTN08601529.

[Changes in treatment of squamous cell carcinoma over time. A process analysis]

BACKGROUND

The incidence of squamous cell carcinoma is rapidly increasing and requires process-optimized treatment dependent on the course of the patient's individual disease. Patient-based data on squamous cell carcinoma were used to analyze the treatment modalities before DRGs were introduced, after their introduction and after discussion about process-optimization in context of clinical pathways.

PATIENTS AND METHODS

From the recorded data in the department of dermatology, all squamous cell carcinoma cases were identified and evaluated. In addition to patient characteristics, parameters describing the process, for example, length of stay in hospital, pre- and post-interventional days, were collected.

RESULTS

Between 1998-2002, 2004-2006 and January to June 2007, 658 patients were treated for squamous cell carcinoma. In contrast to the times before DRGs, the treatment process has been significantly optimized, reducing the pre- and post-operative days and thus the duration of stay. Analysis of clinical pathways as part of the continuous improvement process was hardly able to detect further improvement. However, the weekly distribution of the admitted patients has been improved.

CONCLUSIONS

Patients with squamous cell carcinoma requiring surgical excision benefit from an optimized process, just as do impatient facilities. However, optimized treatment modalities carry hardly any potential of improvement by the invention of clinical pathways.

Does the quality of dental images depend on patient's age and sex ?- Explanations from the forensic sciences

The objective of this analysis was to investigate the dependency of image quality of dental panoramic radiographs on patient's age and sex, and to demonstrate that forensic science can explain these relationships. The image qualities of 100 dental panoramic radiographs obtained from 50 patients with two devices were assessed by ten independent observers of different specialisations. Image quality decreased with increasing age of the patients (P=0.003). One of the devices turned out to be superior to the other; however, this difference between the devices was present only in older patients but not in young ones (P=0.03). Image quality was higher in women than in men (P=0.01). The observed influences of age and sex are explained by results of forensic investigations concerning age-related changes of the dental pulp and sex differences of the skull geometry. Thus forensic science can elucidate effects relevant for everyday clinical practice. Studies on dental image quality must consider age and sex of the patients.

[Physical activity and prevention of Alzheimer's dementia: current evidence and feasibility of an interventional trial]

There is accumulating evidence from animal and epidemiologic studies that physical exercise is neuroprotective in healthy animals and humans and can prevent cognitive decline in chronic neurodegenerative processes like Alzheimer's dementia. However, data from well-designed interventional, randomized non-pharmacologic trials is lacking in contrast to other areas of medicine like prevention of hypertension, diabetes or the antipsychotic-associated metabolic syndrome. The demonstration of a potential positive effect of physical exercise on preventing dementia using a controlled study design would represent a significant progress in the prevention of dementia and public health, especially as long as other treatments for dementia prevention are lacking.

Critical evaluation of methods for determination of body fat content in children: back to basic parameters?

Considering the increasing prevalence of obesity among children and of obesity related disorders in the pediatric population, the reliable evaluation of body fat content in children is of critical importance in research and clinical medicine. In this study, we assessed the congruency of different estimates for body fat content in prepubertal children. We determined anthropometric parameters, such as BMI and skinfold thickness, and bioelectrical impedance in 676 prepubertal Caucasian children. We calculated body fat percentage (BF%) from these parameters applying 5 distinct algorithms and established raw centiles for these models. Expectedly, girls had significantly higher BF% regardless of the method applied. There were, however, significant variances in the calculated amount of BF% between the algorithms, with BIA based equations giving highest BF%, while skinfold based equations tended to provide lower BF% values. Direct comparison of the algorithms revealed a high degree of inconsistency and poor agreement in the assessment of body fat with variations of >10% BF%. Great differences in basic parameters, such as DeltaBMI (3.2 kg/m (2)) or Deltaskinfolds (1.75-fold), would be needed to reliably predict correct ranking of 10% difference in body fat with 95% probability. In summary, BF% strongly varies depending on both the method as well as the algorithm used. This questions the applicability of such field methods for the assessment of BF% for comparative analyses and the superiority of information over basic parameters such as BMI.