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Gierula J, Straw S, Cole CA, Lowry JE, Paton MF, McGinlay M, Witte KK, Grant PJ, Wheatcroft SB, Drozd M, Slater TA, Cubbon RM, Kearney MT. Diabetes mellitus does not alter mortality or hospitalisation risk in patients with newly diagnosed heart failure with preserved ejection fraction: Time to rethink pathophysiological models of disease progression. Diab Vasc Dis Res 2024; 21:14791641231224241. [PMID: 38623877 PMCID: PMC11022676 DOI: 10.1177/14791641231224241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/17/2024] Open
Abstract
INTRODUCTION Type 2 diabetes is a common and adverse prognostic co-morbidity for patients with heart failure with reduced ejection fraction (HFrEF). The effect of diabetes on long-term outcomes for heart failure with preserved ejection fraction (HFpEF) is less established. METHODS Prospective cohort study of patients referred to a regional HF clinic with newly diagnosed with HFrEF and HFpEF according to the 2016 European Society of Cardiology guidelines. The association between diabetes, all-cause mortality and hospitalisation was quantified using Kaplan-Meier or Cox regression analysis. RESULTS Between 1st May 2012 and 1st May 2013, of 960 unselected consecutive patients referred with suspected HF, 464 and 314 patients met the criteria for HFpEF and HFrEF respectively. Within HFpEF and HFrEF groups, patients with diabetes were more frequently male and in both groups patients with diabetes were more likely to be treated with β-adrenoceptor antagonists and angiotensin converting enzyme inhibitors. After adjustment for age, sex, medical therapy and co-morbidities, diabetes was associated with increased mortality in individuals with HFrEF (HR 1.46 95% CI: 1.05-2.02; p = .023), but not in those with HFpEF (HR 1.26 95% CI 0.92-1.72; p = .146). CONCLUSION In unselected patients with newly diagnosed HF, diabetes is not an adverse prognostic marker in patients with HFpEF, but is in HFrEF.
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Affiliation(s)
- John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Charlotte A Cole
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Melanie McGinlay
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Medical Clinic 1, University Hospital Aachen, Aachen, Germany
| | - Peter J Grant
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Stephen B Wheatcroft
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Michael Drozd
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Thomas A Slater
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Straw S, Cole CA, McGinlay M, Drozd M, Slater TA, Lowry JE, Paton MF, Levelt E, Cubbon RM, Kearney MT, Witte KK, Gierula J. Guideline-directed medical therapy is similarly effective in heart failure with mildly reduced ejection fraction. Clin Res Cardiol 2023; 112:111-122. [PMID: 35781605 PMCID: PMC9849301 DOI: 10.1007/s00392-022-02053-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 06/10/2022] [Indexed: 01/22/2023]
Abstract
AIMS Current guidelines recommend that disease-modifying pharmacological therapies may be considered for patients who have heart failure with mildly reduced ejection fraction (HFmrEF). We aimed to describe the characteristics, outcomes, provision of pharmacological therapies and dose-related associations with mortality risk in HFmrEF. METHODS AND RESULTS We explored data from two prospective observational studies, which permitted the examination of the effects of pharmacological therapies across a broad spectrum of left ventricular ejection fraction (LVEF). The combined dataset consisted of 2388 unique patients, with a mean age of 73.7 ± 13.2 years of whom 1525 (63.9%) were male. LVEF ranged from 5 to 71% (mean 37.2 ± 12.8%) and 1504 (63.0%) were categorised as having reduced ejection fraction (HFrEF), 421 (17.6%) as HFmrEF and 463 (19.4%) as preserved ejection fraction (HFpEF). Patients with HFmrEF more closely resembled HFrEF than HFpEF. Adjusted all-cause mortality risk was lower in HFmrEF (hazard ratio [HR] 0.86 (95% confidence interval [CI] 0.74-0.99); p = 0.040) and in HFpEF (HR 0.61 (95% CI 0.52-0.71); p < 0.001) compared to HFrEF. Adjusted all-cause mortality risk was lower in patients with HFrEF and HFmrEF who received the highest doses of beta-blockers or renin-angiotensin inhibitors. These associations were not evident in HFpEF. Once adjusted for relevant confounders, each mg equivalent of bisoprolol (HR 0.95 [95% CI 0.91-1.00]; p = 0.047) and ramipril (HR 0.95 [95%CI 0.90-1.00]; p = 0.044) was associated with incremental reductions in mortality risk in patients with HFmrEF. CONCLUSIONS Pharmacological therapies were associated with lower mortality risk in HFmrEF, supporting guideline recommendations which extend the indications of these agents to all patients with LVEF < 50%. HFmrEF more closely resembles HFrEF in terms of clinical characteristics and outcomes. Pharmacological therapies are associated with lower mortality risk in HFmrEF and HFrEF, but not in HFpEF.
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Affiliation(s)
- Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | | | - Michael Drozd
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Thomas A Slater
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Eylem Levelt
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK. .,Department of Internal Medicine I, University Clinic, RWTH Aachen University, Aachen, DE, Germany.
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Abdul Samad NH, Lowry JE, Cole CA, Straw S, Gierula J, Witte KK, Paton MF. Left ventricular dysfunction, heart failure, and mortality risk factors in de novo pacemaker recipients and those requiring pacemaker generator replacement. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Pacing the right ventricle (RV) can lead to adverse remodelling of the left ventricle (LV), LV dysfunction, increased risk of heart failure hospitalisation (HFH) and mortality. Despite RV pacing avoidance programming becoming commonplace, pacemaker patients remain at risk of pacing-induced cardiomyopathy. New pacing strategies and cardiac resynchronisation therapy are available therapeutic options, but it is unclear which patients should be targeted, and when.
Purpose
This study examined the effects of RV pacing on LV function, the risk of heart failure requiring hospitalisation and all-cause mortality in patients during the first 12 months of pacemaker therapy, compared to those at pacemaker generator replacement (PGR).
Methods
Data were obtained from a cohort of patients who underwent de novo pacemaker implantation between 2014 and 2017, and patients requiring PGR between 2008 and 2011 at a single tertiary UK hospital, with follow-up from 12 months. Clinical, echocardiographic, and pacemaker variables, medication, and past medical history data were collected. Predictors of a combined endpoint of all-cause mortality or HFH were assessed using cox-regression analysis, with predictors of impaired LV function analysed using multivariable regression analysis.
Results
514 newly implanted (NI) patients (mean age, 75 years; 66% male) were recruited, and 491 patients (mean age, 76 years; 56% male) requiring PGR. After a mean follow up of 887 days, 79 NI patients (16%) were deceased (n=27) or had been hospitalised for HF (n=52), whereas after a mean follow up of 668 days, 56 patients after PGR (12%) were deceased (n=34) or had been hospitalised (n=22) for HF. After 12 months of pacemaker therapy, 182 (35%) NI patients had a LV ejection fraction (LVEF) <50%, which had a higher incidence at PGR of 197 (40%). Age was the only significant predictor of mortality or HFH for both NI and PGR (hazard ratio (HR), 1.068; 95% confidence interval (CI), 1.039 to 1.098; p<0.001 vs 1.035; 95% CI, 1.007 to 1.064; p=0.014), respectively). Univariate analysis revealed baseline LVEF (2.439; 95 percent CI, 1.279 to 4.659; p=0.007), RV pacing burden, medication and blood chemistry were significant predictors of the combined outcome at PGR but not at NI (Table 2). Multivariable analysis of predictors of LV impairment (<50% LVEF) showed history of MI (odds ratio (OR), 0.47; 95% CI, 0.29 to 0.78; p=0.003), RV pacing burden (1.01; 95% CI, 1.01 to 1.02; p<0.001) and creatinine (1.06; 95% CI, 1.02 to 1.10; p=0.004) were independently associated in both cohorts.
Conclusions
Our data suggest that there remains a similar subgroup of people from initial implantation to PGR at risk of LV impairment that might benefit from medication optimisation or novel pacing strategies. Further research is required to better identifying these people to direct more complex therapies to those with the most to gain.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The research is supported by a National Institute for Health Research (NIHR) clinician scientist fellowship (NIHRCS-2012-032). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. This research was supported by the NIHR Leeds Clinical Research Facility.
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Affiliation(s)
- N H Abdul Samad
- Leeds Institute of Cardiovascular and Metabolic Medicine , Leeds , United Kingdom
| | - J E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine , Leeds , United Kingdom
| | - C A Cole
- Leeds Institute of Cardiovascular and Metabolic Medicine , Leeds , United Kingdom
| | - S Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine , Leeds , United Kingdom
| | - J Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine , Leeds , United Kingdom
| | - K K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine , Leeds , United Kingdom
| | - M F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine , Leeds , United Kingdom
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Gierula J, Cole CA, Drozd M, Lowry JE, Straw S, Slater TA, Paton MF, Byrom RJ, Garland E, Halliday G, Winsor S, Lyall GK, Birch K, McGinlay M, Sunley E, Grant PJ, Wessels DH, Ketiar EM, Witte KK, Cubbon RM, Kearney MT. Atrial fibrillation and risk of progressive heart failure in patients with preserved ejection fraction heart failure. ESC Heart Fail 2022; 9:3254-3263. [PMID: 35790085 PMCID: PMC9715884 DOI: 10.1002/ehf2.14004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS Understanding of the pathophysiology of progressive heart failure (HF) in patients with heart failure with preserved ejection fraction (HFpEF) is incomplete. We sought to identify factors differentially associated with risk of progressive HF death and hospitalization in patients with HFpEF compared with patients with HF and reduced ejection fraction (HFrEF). METHODS AND RESULTS Prospective cohort study of patients newly referred to secondary care with suspicion of HF, based on symptoms and signs of HF and elevated natriuretic peptides (NP), followed up for a minimum of 6 years. HFpEF and HFrEF were diagnosed according to the 2016 European Society of Cardiology guidelines. Of 960 patients referred, 467 had HFpEF (49%), 311 had HFrEF (32%), and 182 (19%) had neither. Atrial fibrillation (AF) was found in 37% of patients with HFpEF and 34% with HFrEF. During 6 years follow-up, 19% of HFrEF and 14% of HFpEF patients were hospitalized or died due to progressive HF, hazard ratio (HR) 0.67 (95% CI: 0.47-0.96; P = 0.028). AF was the only marker that was differentially associated with progressive HF death or hospitalization in patients with HFpEF HR 2.58 (95% CI: 1.59-4.21; P < 0.001) versus HFrEF HR 1.11 (95% CI: 0.65-1.89; P = 0.7). CONCLUSIONS De novo patients diagnosed with HFrEF have greater risk of death or hospitalization due to progressive HF than patients with HFpEF. AF is associated with increased risk of progressive HF death or hospitalization in HFpEF but not HFrEF, raising the intriguing possibility that this may be a novel therapeutic target in this growing population.
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Affiliation(s)
- John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Charlotte A Cole
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Michael Drozd
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Thomas A Slater
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | | | | | | | - Gemma K Lyall
- Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | - Karen Birch
- Faculty of Biological Sciences, University of Leeds, Leeds, UK
| | | | - Emma Sunley
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Peter J Grant
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | | | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,University Clinic, RWTH, Aachen, DE, USA
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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Paton MF, Gierula J, Lowry JE, Cairns DA, Bose Rosling K, Cole CA, McGinlay M, Straw S, Byrom R, Cubbon RM, Kearney MT, Witte KK. Personalised reprogramming to prevent progressive pacemaker-related left ventricular dysfunction: A phase II randomised, controlled clinical trial. PLoS One 2021; 16:e0259450. [PMID: 34898655 PMCID: PMC8668131 DOI: 10.1371/journal.pone.0259450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 10/15/2021] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Pacemakers are widely utilised to treat bradycardia, but right ventricular (RV) pacing is associated with heightened risk of left ventricular (LV) systolic dysfunction and heart failure. We aimed to compare personalised pacemaker reprogramming to avoid RV pacing with usual care on echocardiographic and patient-orientated outcomes. METHODS A prospective phase II randomised, double-blind, parallel-group trial in 100 patients with a pacemaker implanted for indications other than third degree heart block for ≥2 years. Personalised pacemaker reprogramming was guided by a published protocol. Primary outcome was change in LV ejection fraction on echocardiography after 6 months. Secondary outcomes included LV remodeling, quality of life, and battery longevity. RESULTS Clinical and pacemaker variables were similar between groups. The mean age (SD) of participants was 76 (+/-9) years and 71% were male. Nine patients withdrew due to concurrent illness, leaving 91 patients in the intention-to-treat analysis. At 6 months, personalised programming compared to usual care, reduced RV pacing (-6.5±1.8% versus -0.21±1.7%; p<0.01), improved LV function (LV ejection fraction +3.09% [95% confidence interval (CI) 0.48 to 5.70%; p = 0.02]) and LV dimensions (LV end systolic volume indexed to body surface area -2.99mL/m2 [95% CI -5.69 to -0.29; p = 0.03]). Intervention also preserved battery longevity by approximately 5 months (+0.38 years [95% CI 0.14 to 0.62; p<0.01)) with no evidence of an effect on quality of life (+0.19, [95% CI -0.25 to 0.62; p = 0.402]). CONCLUSIONS Personalised programming in patients with pacemakers for bradycardia can improve LV function and size, extend battery longevity, and is safe and acceptable to patients. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03627585.
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Affiliation(s)
- Maria F. Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Judith E. Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - David A. Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom
| | - Kieran Bose Rosling
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | | | | | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Rowena Byrom
- Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - Richard M. Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Mark T. Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
| | - Klaus K. Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Leeds, United Kingdom
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Straw S, McGinlay M, Gierula J, Lowry JE, Paton MF, Cole C, Drozd M, Koshy AO, Mullens W, Cubbon RM, Kearney MT, Witte KK. Impact of QRS duration on left ventricular remodelling and survival in patients with heart failure. J Cardiovasc Med (Hagerstown) 2021; 22:848-856. [PMID: 34261079 DOI: 10.2459/jcm.0000000000001231] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIMS In patients with chronic heart failure, QRS duration is a consistent predictor of poor outcomes. It has been suggested that for indicated patients, cardiac resynchronization therapy (CRT) could come sooner in the treatment algorithm, perhaps in parallel with the attainment of optimal guideline-directed medical therapy (GDMT). We aimed to investigate differences in left ventricular (LV) remodelling in those with narrow QRS (NQRS) compared with wide QRS (WQRS) in the absence of CRT, whether an early CRT strategy resulted in unnecessary implants and the effect of early CRT on outcomes. METHODS Our cohort consisted of 214 consecutive patients with LV ejection fraction (LVEF) of 35% or less who underwent repeat echocardiography 1 year after enrolment. Of these, 116 patients had NQRS, and 98 had WQRS of whom 40 received CRT within 1 year and 58 did not. RESULTS In the absence of CRT, patients with WQRS had less LV reverse remodelling compared with those with NQRS, with differences in ΔLVEF (+2 vs. +9%, P < 0.001) ΔLV end-diastolic diameter (-1 vs. -2 mm, P = 0.095), ΔLV end-systolic diameter (-2 vs. -4.5 mm, P = 0.038), LV end-systolic volume (-12.6 vs. -25.0 ml, P = 0.054) and LV end-diastolic volume (-7.3 vs. -12.2 ml, P = 0.071). LVEF was more likely to improve by at least 10% if patients had NQRS or received CRT (P = 0.08). Thirteen (24%) patients with WQRS achieved an LVEF greater than 35% in the absence of CRT; however, none achieved greater than 50%. CONCLUSION A strictly linear approach to heart failure therapy might lead to delays to optimal treatment in those patients with the most to gain from CRT and the least to gain from GDMT.
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Affiliation(s)
- Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Melanie McGinlay
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Charlotte Cole
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Michael Drozd
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Aaron O Koshy
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, University Hasselt, Genk, Belgium
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds
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7
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Gierula J, Lowry JE, Paton MF, Cole CA, Byrom R, Koshy AA, Chumun H, Kearney LC, Straw S, Bowen TS, Cubbon RM, Keenan AM, Stocken DD, Kearney MT, Witte KK. Response by Gierula et al to Letter Regarding Article, "Personalized Rate-Response Programming Improves Exercise Tolerance After 6 Months in People With Cardiac Implantable Electronic Devices and Heart Failure: A Phase II Study". Circulation 2020; 142:e319-e320. [PMID: 33166218 DOI: 10.1161/circulationaha.120.050610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Charlotte A Cole
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Rowenna Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Aaron A Koshy
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Hemant Chumun
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Lorraine C Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - T Scott Bowen
- Leeds Faculty of Biological Sciences (T.S.B.), University of Leeds, Leeds, United Kingdom
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Anne-Maree Keenan
- Leeds School of Healthcare (A.- M.K.), University of Leeds, Leeds, United Kingdom
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research (D.D.S.), University of Leeds, Leeds, United Kingdom
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.A.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, Leeds, United Kingdom
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8
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Straw S, McGinlay M, Relton SD, Koshy AO, Gierula J, Paton MF, Drozd M, Lowry JE, Cole C, Cubbon RM, Witte KK, Kearney MT. Effect of disease-modifying agents and their association with mortality in multi-morbid patients with heart failure with reduced ejection fraction. ESC Heart Fail 2020; 7:3859-3870. [PMID: 32924331 PMCID: PMC7754757 DOI: 10.1002/ehf2.12978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/30/2020] [Accepted: 08/10/2020] [Indexed: 12/26/2022] Open
Abstract
Aims An increasing proportion of patients with heart failure with reduced ejection fraction (HFrEF) have co‐morbidities. The effect of these co‐morbidities on modes of death and the effect of disease‐modifying agents in multi‐morbid patients is unknown. Methods and results We performed a prospective cohort study of ambulatory patients with HFrEF to assess predictors of outcomes. We identified four key co‐morbidities—ischaemic aetiology of heart failure, diabetes mellitus, chronic obstructive pulmonary disease (COPD), and chronic kidney disease (CKD)—that were highly prevalent and associated with an increased risk of all‐cause mortality. We used these data to explore modes of death and the utilization of disease‐modifying agents in patients with and without these co‐morbidities. The cohort included 1789 consecutively recruited patients who had an average age of 69.6 ± 12.5 years, and 1307 (73%) were male. Ischaemic aetiology of heart failure was the most common co‐morbidity, occurring in 1061 (59%) patients; 503 (28%) patients had diabetes mellitus, 283 (16%) had COPD, and 140 (8%) had CKD stage IV/V. During mean follow‐up of 3.8 ± 1.6 years, 737 (41.5%) patients died, classified as progressive heart failure (n = 227, 32%), sudden (n = 112, 16%), and non‐cardiovascular deaths (n = 314, 44%). Multi‐morbid patients were older (P < 0.001), more likely to be male (P < 0.001), and had higher New York Heart Association class (P < 0.001), despite having higher left ventricular (LV) ejection fraction (P = 0.001) and lower LV end‐diastolic diameter (P = 0.001). Multi‐morbid patients were prescribed lower doses of disease‐modifying agents, especially patients with COPD who received lower doses of beta‐adrenoceptor antagonists (2.7 ± 3.0 vs. 4.1 ± 3.4 mg, P < 0.001) and were less likely to be implanted with internal cardioverter defibrillators (7% vs. 13%, P < 0.001). In multivariate analysis, COPD and diabetes mellitus conferred a >2.5‐fold and 1.5‐fold increased risk of sudden death, whilst higher doses of beta‐adrenoceptor antagonists were protective (hazard ratio per milligram 0.92, 95% confidence interval 0.86–0.98, P = 0.009). Each milligram of bisoprolol‐equivalent beta‐adrenoceptor antagonist was associated with 9% (P = 0.001) and 11% (P = 0.023) reduction of sudden deaths in patients with <2 and ≥2 co‐morbidities, respectively. Conclusions Higher doses of beta‐adrenoceptor antagonist are associated with greater protection from sudden death, most evident in multi‐morbid patients. Patients with COPD who appear to be at the highest risk of sudden death are prescribed the lowest doses and less likely to be implanted with implantable cardioverter defibrillators, which might represent a missed opportunity to optimize safe and proven therapies for these patients.
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Affiliation(s)
- Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Samuel D Relton
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Aaron O Koshy
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | - Michael Drozd
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | | | | | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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9
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Baldwin MM, Birch KM, Taylor BJ, Geirula J, Paton MF, Lowry JE, Kearney MT, Witte KK, Ferguson C. Feasibility And Effectiveness Of High-intensity Interval Training With Blood Flow Restriction In Heart Failure. Med Sci Sports Exerc 2020. [DOI: 10.1249/01.mss.0000685204.16599.de] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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10
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Gierula J, Lowry JE, Paton MF, Cole CA, Byrom R, Koshy AO, Chumun H, Kearney LC, Straw S, Bowen TS, Cubbon RM, Keenan AM, Stocken DD, Kearney MT, Witte KK. Personalized Rate-Response Programming Improves Exercise Tolerance After 6 Months in People With Cardiac Implantable Electronic Devices and Heart Failure. Circulation 2020; 141:1693-1703. [DOI: 10.1161/circulationaha.119.045066] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Heart failure with reduced ejection fraction (HFrEF) is characterized by blunting of the positive relationship between heart rate and left ventricular (LV) contractility known as the force-frequency relationship (FFR). We have previously described that tailoring the rate-response programming of cardiac implantable electronic devices in patients with HFrEF on the basis of individual noninvasive FFR data acutely improves exercise capacity. We aimed to examine whether using FFR data to tailor heart rate response in patients with HFrEF with cardiac implantable electronic devices favorably influences exercise capacity and LV function 6 months later.
Methods:
We conducted a single-center, double-blind, randomized, parallel-group trial in patients with stable symptomatic HFrEF taking optimal guideline-directed medical therapy and with a cardiac implantable electronic device (cardiac resynchronization therapy or implantable cardioverter-defibrillator). Participants were randomized on a 1:1 basis between tailored rate-response programming on the basis of individual FFR data and conventional age-guided rate-response programming. The primary outcome measure was change in walk time on a treadmill walk test. Secondary outcomes included changes in LV systolic function, peak oxygen consumption, and quality of life.
Results:
We randomized 83 patients with a mean±SD age 74.6±8.7 years and LV ejection fraction 35.2±10.5. Mean change in exercise time at 6 months was 75.4 (95% CI, 23.4 to 127.5) seconds for FFR-guided rate-adaptive pacing and 3.1 (95% CI, −44.1 to 50.3) seconds for conventional settings (analysis of covariance;
P
=0.044 between groups) despite lower peak mean±SD heart rates (98.6±19.4 versus 112.0±20.3 beats per minute). FFR-guided heart rate settings had no adverse effect on LV structure or function, whereas conventional settings were associated with a reduction in LV ejection fraction.
Conclusions:
In this phase II study, FFR-guided rate-response programming determined using a reproducible, noninvasive method appears to improve exercise time and limit changes to LV function in people with HFrEF and cardiac implantable electronic devices. Work is ongoing to confirm our findings in a multicenter setting and on longer-term clinical outcomes.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02964650.
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Affiliation(s)
- John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Judith E. Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Maria F. Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Charlotte A. Cole
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Rowenna Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Aaron O. Koshy
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Hemant Chumun
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Lorraine C. Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - T. Scott Bowen
- Faculty of Biological Sciences, School of Medicine (T.S.B.), University of Leeds, United Kingdom
| | - Richard M. Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | | | - Deborah D. Stocken
- Leeds Institute of Clinical Trials Research (D.D.S), University of Leeds, United Kingdom
| | - Mark T. Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
| | - Klaus K. Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine (J.G., J.E.L., M.F.P., C.A.C., R.B., A.O.K., H.C., L.C.K., S.S., R.M.C., M.T.K., K.K.W.), University of Leeds, United Kingdom
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11
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Mercer BN, Koshy A, Drozd M, Walker AMN, Patel PA, Kearney L, Gierula J, Paton MF, Lowry JE, Kearney MT, Cubbon RM, Witte KK. Ischemic Heart Disease Modifies the Association of Atrial Fibrillation With Mortality in Heart Failure With Reduced Ejection Fraction. J Am Heart Assoc 2019; 7:e009770. [PMID: 30371286 PMCID: PMC6474978 DOI: 10.1161/jaha.118.009770] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background The CASTLE‐AF (Catheter Ablation versus Standard Conventional Therapy in Patients With Left Ventricular Dysfunction and Atrial Fibrillation) trial recently reported that catheter ablation of atrial fibrillation (AF) improves survival in heart failure (HF) with reduced ejection fraction (HFrEF). However, established AF was not associated with mortality in trials of contemporary HFrEF pharmacotherapies. We investigated whether HFrEF pathogenesis may influence the conclusions of studies evaluating the prognostic impact of AF. Methods and Results Using a prospective cohort study of 791 patients with HFrEF, with AF determined using 24‐hour ambulatory ECG monitoring, univariable and multivariable Cox regression analyses were used to define the association between AF and mode‐specific mortality (mean follow‐up of 5.4 years). One‐year HF‐related hospitalization was assessed with binary logistic regression analysis. One‐year cardiac remodeling was assessed in a subgroup (n=378) using echocardiography. AF was present in 28.2% of patients, with 9.4% of these being paroxysmal. While AF was associated with increased risk of all‐cause mortality (hazard ratio, 1.27; 95% confidence interval 1.03–1.57), with diverging survival curves after 1 year of follow‐up, this association was lost in age‐sex–adjusted analyses. However, AF was associated with increased risk of age‐sex–adjusted all‐cause mortality in people with ischemic pathogenesis, with a statistically significant interaction between pathogenesis and AF. This was predominantly attributed to progressive HF deaths. After 1 year, HF hospitalization and cardiac remodeling were not associated with AF, even in people with ischemic pathogenesis. Conclusions AF is associated with increased risk of death in HFrEF of ischemic pathogenesis, predominantly due to progressive HF deaths during long‐term follow‐up. HFrEF pathogenesis should be considered in trial design and interpretation.
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Affiliation(s)
- Ben N Mercer
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Aaron Koshy
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Michael Drozd
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Andrew M N Walker
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Peysh A Patel
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Lorraine Kearney
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - John Gierula
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Maria F Paton
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Judith E Lowry
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Mark T Kearney
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Richard M Cubbon
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
| | - Klaus K Witte
- 1 Leeds Institute of Cardiovascular and Metabolic Medicine LIGHT Laboratories The University of Leeds United Kingdom
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12
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Paton MF, Gierula J, Jamil HA, Lowry JE, Byrom R, Gillott RG, Chumun H, Cubbon RM, Cairns DA, Stocken DD, Kearney MT, Witte KK. Optimising pacemaker therapy and medical therapy in pacemaker patients for heart failure: protocol for the OPT-PACE randomised controlled trial. BMJ Open 2019; 9:e028613. [PMID: 31320354 PMCID: PMC6661620 DOI: 10.1136/bmjopen-2018-028613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Permanent artificial pacemaker implantation is a safe and effective treatment for bradycardia and is associated with extended longevity and improved quality of life. However, the most common long-term complication of standard pacemaker therapy is pacemaker-associated heart failure. Pacemaker follow-up is potentially an opportunity to screen for heart failure to assess and optimise patient devices and medical therapy. METHODS AND ANALYSIS The study is a multicentre, phase-3 randomised trial. The 1200 participants will be people who have a permanent pacemaker for bradycardia for at least 12 months, randomly assigned to undergo a transthoracic echocardiogram with their pacemaker check, thereby tailoring their management directed by left ventricular function or the pacemaker check alone, continuing with routine follow-up. The primary outcome measure is time to all-cause mortality or heart failure hospitalisation. Secondary outcomes include external validation of our risk stratification model to predict onset of heart failure and quality of life assessment. ETHICS AND DISSEMINATION The trial design and protocol have received national ethical approval (12/YH/0487). The results of this randomised trial will be published in international peer-reviewed journals, communicated to healthcare professionals and patient involvement groups and highlighted using social media campaigns. TRIAL REGISTRATION NUMBER NCT01819662.
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Affiliation(s)
- Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Haqeel A Jamil
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Rowena Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Richard G Gillott
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Hemant Chumun
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - David A Cairns
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
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13
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Gierula J, Cubbon RM, Paton MF, Byrom R, Lowry JE, Winsor SF, McGinlay M, Sunley E, Pickles E, Kearney LC, Koshy A, Slater TA, Chumun HK, Jamil HA, Bailey KM, Barth JH, Kearney MT, Witte KK. Prospective evaluation and long-term follow-up of patients referred to secondary care based upon natriuretic peptide levels in primary care. Eur Heart J Qual Care Clin Outcomes 2019; 5:218-224. [PMID: 30452611 DOI: 10.1093/ehjqcco/qcy053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 11/07/2018] [Accepted: 11/19/2018] [Indexed: 11/13/2022]
Abstract
AIMS The UK National Institute for Health and Care Excellence (UK-NICE) and European Society of Cardiology (ESC) guidelines advise natriuretic peptide (NP) assessment in patients presenting to primary care with symptoms possibly due to chronic heart failure (HF), to determine need for specialist involvement. This prospective service evaluation aimed to describe the diagnostic and prognostic utility of these guidelines. METHODS AND RESULTS We prospectively collected clinical, echocardiography and outcomes data (minimum 5 years) from all patients referred to the Leeds HF Service for 12 months of following the initiation of the NP-guideline-directed pathway. Between 1 May 2012 and 1 August 2013, 1020 people with symptoms possibly due to HF attended either with a raised NT-pro-BNP or a previous myocardial infarction (MI) with an overall rate of left ventricular systolic dysfunction (LVSD) of 33%. Of these, 991 satisfied the ESC criteria (NT-pro-BNP ≥125 pg/mL) in whom the rate of LVSD was 32%, and 821 the UK-NICE criteria in whom the rate of LVSD was 49% in those with a previous MI, 25% in those with NT-pro-BNP concentration 400-2000 pg/mL, and 54% in those with NT-pro-BNP concentration of >2000 pg/mL. An NT-pro-BNP concentration 125-400 pg/mL had a 12% risk of LVSD. Specificity was poor in women >70 years, who made up the largest proportion of attendees. Elevated NT-pro-BNP levels were associated with lower survival even in the absence of LVSD. CONCLUSION In people referred through the ESC and UK-NICE guidelines, elevated NT-pro-BNP is a marker of increased mortality risk, but there is wide variation in specificity for LVSD. Age- and sex-adjusted criteria might improve performance.
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Affiliation(s)
- John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Rowenna Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Sarah F Winsor
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Melanie McGinlay
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Emma Sunley
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Emma Pickles
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Lorraine C Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Aaron Koshy
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Thomas A Slater
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Hemant K Chumun
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Haqeel A Jamil
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Kristian M Bailey
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Julian H Barth
- Cardiorespiratory Clinical Service Unit, Leeds Teaching Hospitals NHS Trust, Great George Street, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, Multidisciplinary Cardiovascular Research Centre, University of Leeds, Clarendon Way, Leeds, UK
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14
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Jamil HA, Mohammed SA, Gierula J, Paton MF, Lowry JE, Cubbon RM, Kearney MT, Witte KK. Prognostic Significance of Incidental Nonsustained Ventricular Tachycardia Detected on Pacemaker Interrogation. Am J Cardiol 2019; 123:409-413. [PMID: 30473328 DOI: 10.1016/j.amjcard.2018.10.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 11/25/2022]
Abstract
Symptomatic sustained ventricular tachycardia is a life threatening arrhythmia requiring prompt treatment. However, the risk associated with asymptomatic nonsustained ventricular tachycardia (NSVT) detected on routine permanent pacemaker (PPM) interrogation in patients with known cardiac conduction disease is unknown. Our aim is to determine if asymptomatic NSVT detected on PPM interrogation is associated with increased mortality. As part of a prospective observational cohort study, 582 patients with long-term pacemakers were recruited at a tertiary cardiac centre, and followed for 4 ± 1.96 years (mean ± standard deviation). At each subsequent pacemaker check, any symptoms and ventricular high-rate episodes were recorded. We excluded 17 patients due to incomplete data. In the remaining 565 patients (57% male, age 74.5 ± 19.2 years, left ventricular ejection fraction 50.0 ± 11.3%), NSVT was found in 125 (22.1%) patients with a higher prevalence in males (65% vs 54%; p = 0.033). Those with NSVT were more likely to have had coronary artery disease (p = 0) or previous myocardial infarction (p = 0.015). After correction for baseline variables, NSVT had no impact on survival (n = 52 [42%] vs n = 162 [37%]; log-rank p = 0.331, hazard ratio: 0.927, 95% confidence interval: 0.678 to 1.268, p = 0.697). In conclusion, asymptomatic NSVT identified on PPM interrogation does not appear to be associated with increased mortality, thus whether treatment to suppress this arrhythmia is of benefit remains unproven.
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Abstract
INTRODUCTION Mitral regurgitation is a common finding in patients with chronic heart failure and is associated with a progressive worsening of symptoms, reduced survival and increased cost of care. However, the use of mitral valve surgery for these patients remains controversial and has not been shown to improve survival. Consequently, research has been increasingly directed towards the nonsurgical management of this important co-morbidity of heart failure. AREAS COVERED The present review will describe the relevance of mitral regurgitation in people with chronic heart failure, the current options for percutaneous treatment and the evidence base for each of these. EXPERT COMMENTARY Although at present there are few solid data to guide heart teams in deciding what degree of mitral regurgitation to treat, in which patients, and with what, this situation is likely to change over the next two years with the release of the first large randomised trials of percutaneous interventions.
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Affiliation(s)
- Judith E Lowry
- a Leeds Institute of Cardiovascular and Metabolic Medicine , University of Leeds , Leeds , UK
| | - Stephan Fichtlscherer
- b Department of Internal Medicine, Division of Cardiology , University Hospital Frankfurt , Frankfurt am Main , Germany
| | - Klaus K Witte
- a Leeds Institute of Cardiovascular and Metabolic Medicine , University of Leeds , Leeds , UK
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16
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Gierula J, Paton MF, Lowry JE, Jamil HA, Byrom R, Drozd M, Garnham JO, Cubbon RM, Cairns DA, Kearney MT, Witte KK. Rate-Response Programming Tailored to the Force-Frequency Relationship Improves Exercise Tolerance in Chronic Heart Failure. JACC: Heart Failure 2018; 6:105-113. [DOI: 10.1016/j.jchf.2017.09.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/31/2017] [Accepted: 09/10/2017] [Indexed: 01/09/2023]
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17
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Drozd M, Gierula J, Lowry JE, Paton MF, Joy E, Jamil HA, Cubbon RM, Kearney MT, Cairns DA, Witte KK. Cardiac resynchronization therapy outcomes in patients with chronic heart failure. J Cardiovasc Med (Hagerstown) 2017; 18:962-967. [DOI: 10.2459/jcm.0000000000000584] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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Witte KK, Byrom R, Gierula J, Paton MF, Jamil HA, Lowry JE, Gillott RG, Barnes SA, Chumun H, Kearney LC, Greenwood JP, Plein S, Law GR, Pavitt S, Barth JH, Cubbon RM, Kearney MT. Effects of Vitamin D on Cardiac Function in Patients With Chronic HF: The VINDICATE Study. J Am Coll Cardiol 2016; 67:2593-603. [PMID: 27058906 PMCID: PMC4893154 DOI: 10.1016/j.jacc.2016.03.508] [Citation(s) in RCA: 147] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 03/21/2016] [Indexed: 12/31/2022]
Abstract
Background Patients with chronic heart failure (HF) secondary to left ventricular systolic dysfunction (LVSD) are frequently deficient in vitamin D. Low vitamin D levels are associated with a worse prognosis. Objectives The VINDICATE (VitamIN D treatIng patients with Chronic heArT failurE) study was undertaken to establish safety and efficacy of high-dose 25 (OH) vitamin D3 (cholecalciferol) supplementation in patients with chronic HF due to LVSD. Methods We enrolled 229 patients (179 men) with chronic HF due to LVSD and vitamin D deficiency (cholecalciferol <50 nmol/l [<20 ng/ml]). Participants were allocated to 1 year of vitamin D3 supplementation (4,000 IU [100 μg] daily) or matching non−calcium-based placebo. The primary endpoint was change in 6-minute walk distance between baseline and 12 months. Secondary endpoints included change in LV ejection fraction at 1 year, and safety measures of renal function and serum calcium concentration assessed every 3 months. Results One year of high-dose vitamin D3 supplementation did not improve 6-min walk distance at 1 year, but was associated with a significant improvement in cardiac function (LV ejection fraction +6.07% [95% confidence interval (CI): 3.20 to 8.95; p < 0.0001]); and a reversal of LV remodeling (LV end diastolic diameter -2.49 mm [95% CI: -4.09 to -0.90; p = 0.002] and LV end systolic diameter -2.09 mm [95% CI: -4.11 to -0.06 p = 0.043]). Conclusions One year of 100 μg daily vitamin D3 supplementation does not improve 6-min walk distance but has beneficial effects on LV structure and function in patients on contemporary optimal medical therapy. Further studies are necessary to determine whether these translate to improvements in outcomes. (VitamIN D Treating patIents With Chronic heArT failurE [VINDICATE]; NCT01619891)
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Affiliation(s)
- Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom.
| | - Rowena Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Haqeel A Jamil
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Richard G Gillott
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, United Kingdom
| | - Sally A Barnes
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, United Kingdom
| | - Hemant Chumun
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Lorraine C Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Sven Plein
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Graham R Law
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Sue Pavitt
- School of Dentistry, University of Leeds, Leeds, United Kingdom
| | - Julian H Barth
- Leeds Teaching Hospitals NHS Trust, Department of Clinical Biochemistry, Leeds, United Kingdom
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, United Kingdom
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Jamil HA, Gierula J, Paton MF, Byrom R, Lowry JE, Cubbon RM, Cairns DA, Kearney MT, Witte KK. Chronotropic Incompetence Does Not Limit Exercise Capacity in Chronic Heart Failure. J Am Coll Cardiol 2016; 67:1885-96. [DOI: 10.1016/j.jacc.2016.02.042] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 02/08/2016] [Accepted: 02/09/2016] [Indexed: 11/27/2022]
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Abstract
Urinary bladder wall thickness was evaluated by ultrasonography in 16 normal dogs. Sterile saline solution was administered via urinary catheters to control the degree of bladder distention. Bladder wall thickness was measured on static ultrasound images in 4 locations and at 3 degrees of bladder distention (minimal, mild, and moderate). Four randomized distention sequences with 3 distentions per sequence were performed on each dog and the data were analyzed using Williams' balanced Latin square. Mean bladder wall thickness was 2.3 mm in minimally distended bladders (0.5 ml/kg saline), 1.6 mm in mildly distended bladders (2 ml/kg saline) and 1.4 mm in moderately distended bladders (4 ml/kg saline). Mean bladder wall thickness increased significantly with increasing body weight and with decreasing bladder distention. The caudoventral measurement location produced a statistically significant smaller measurement, with a difference of 0.3 mm. Sex did not affect bladder wall thickness. Distention sequence and repetition of distentions did not affect bladder wall thickness.
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Affiliation(s)
- A L Geisse
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois, Urbana 61801, USA
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Alexander AN, Constable PD, Meier WA, French RA, Morin DE, Lowry JE, Hoffman WE. Clinical and immunohistochemical characterization of thymic lymphosarcoma in a heifer. J Vet Intern Med 1996; 10:275-8. [PMID: 8819055 DOI: 10.1111/j.1939-1676.1996.tb02062.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A 2-year-old Holstein heifer with a swollen brisket, jugular vein distention, muffled heart sounds, tachycardia, and free gas bloat was examined. Thymic lymphosarcoma was suspected based on a negative agar gel immunodiffusion test for bovine leukemia virus, presence of atypical lymphocytes in pleural fluid, and detection of a mass in the thoracic inlet. Right-sided cardiac catheterization was performed, and markedly increased jugular venous pressures (41 mm Hg) with a pressure gradient of 29 mm Hg immediately cranial to the heart indicated constriction of the cranial vena cava. Immunohistochemical staining of formalin fixed, paraffin-embedded tissue sections of the tumor using a rabbit antihuman T cell, CD3 polyclonal antibody confirmed that the neoplastic lymphocytes were of thymic origin.
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Affiliation(s)
- A N Alexander
- Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois at Urbana-Champaign 61801, USA
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Carpenter LG, Schwarz PD, Lowry JE, Park RD, Steyn PF. Comparison of radiologic imaging techniques for diagnosis of fragmented medial coronoid process of the cubital joint in dogs. J Am Vet Med Assoc 1993; 203:78-83. [PMID: 8407465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Thirty cubital joints from 16 dogs suspected of having a fragmented medial coronoid process were examined. Four breeds accounted for 87.5% of the cases: German Shepherd Dog (25%), Labrador Retriever (25%), Rottweiler (18.75%), and Golden Retriever (18.75%). Seventy-five percent of the dogs were male. Mean age of affected dogs was 13.6 months. Plain-film radiography, xeroradiography, linear tomography, arthrography, and computed tomography were performed on each cubital joint prior to surgical exploration of the joint. Three reviewers evaluated each diagnostic study and independently determined whether a fragment from the medial coronoid process could be seen. The consensus opinion was compared with the finding at surgery. Abnormalities of the medial coronoid process were detected in 25 of 30 joints at surgery. Fragmented coronoid process was found in 17 of 30 joints, and wear lesions were observed in 8 of 30 joints. Computed tomography had the highest accuracy (86.7%), sensitivity (88.2%), and negative-predictive value (84.6%) of the 5 imaging modalities evaluated (P < 0.05). Specificity and positive-predictive value of all imaging techniques were high. There was no significant difference between the diagnostic ability of plain-film radiography, xeroradiography, or linear tomography of the cubital joint. The combination of plain-film radiography and linear tomography provided an improvement in accuracy, approaching that of computed tomography.
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Affiliation(s)
- L G Carpenter
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins 80523
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Lowry JE, Carpenter LG, Park RD, Steyn PF, Schwarz PD. Radiographic anatomy and technique for arthrography of the cubital joint in clinically normal dogs. J Am Vet Med Assoc 1993; 203:72-7. [PMID: 8407464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
A technique for arthrography of the cubital joint in clinically normal large-breed dogs was developed with the objective of improving visualization of the articular margin of the medial coronoid process. A lateral approach to the cubital joint for injection of contrast medium was selected. Arthrography of 24 cubital joints was performed by using 14 dogs. Twelve combinations of iodinated contrast medium, consisting of various concentrations (3) and volumes (4), were used. Two sets of arthrograms for each of the 12 combinations of contrast medium were obtained. Five radiographic views were used for each set. All arthrograms were examined by 3 evaluators, and each articular surface received a numerical rating for how well it could be seen in each view. Results of the evaluation indicated that low volumes of contrast medium were preferable to high volumes, with 2 ml providing the best visualization. Concentration of iodine seemed less important than did volume. The numerical ratings also indicated that the articular margin of the coronoid process was clearly observed a maximum of only 24% of the time on a slightly supinated mediolateral projection. The articular margins of the head of the radius, trochlea humeri, and trochlear notch were well visualized > 90% of the time. Arthrography of the cubital joint was technically easy to perform, and complications were not encountered, but arthrographic anatomy of the cubital joint is complex. Potential uses for arthrography of the cubital joint include diagnosis of osteochondrosis, intraarticular fragments, and joint capsule ruptures.
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Affiliation(s)
- J E Lowry
- Department of Radiological Health Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins 80523
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Abstract
Venom from Africanized honey bees (derived mainly from Apis mellifera scutellata) was compared with venom from domestic, European bees by study of lethality, immunological cross-reactivity, venom yield, isoelectric focusing (IEF) patterns, and melittin titers. The LD50s of European and Africanized bee venom by iv injection in mice were similar. In venom neutralization experiments, Africanized bee venom was mixed with antibodies from a beekeeper exposed only to European bees and used to challenge mice. Survival times of mice given these mixtures were significantly prolonged, indicating that human serum antibodies to European bee venom neutralized the lethal effects of Africanized bee venom. Reservoirs from Africanized bees contained less venom than European bees (94 and 147 micrograms venom/bee, respectively) and Africanized bee venom had a lower melittin content. The IEF patterns of venom from individual European bees varied considerably, as did IEF patterns of individual Africanized bees. Pools of venom from 1,000 bees of each population of A. mellifera showed noticeable but less obvious electrophoretic differences. The findings suggest that multiple stinging, and not increased venom potency or delivery, is the cause of serious reactions from Africanized bee attacks.
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Clark TB, Henegar RB, Rosen L, Hackett KJ, Whitcomb RF, Lowry JE, Saillard C, Bove JM, Tully JG, Williamson DL. New spiroplasmas from insects and flowers: isolation, ecology, and host association. Isr J Med Sci 1987; 23:687-90. [PMID: 2889699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Eight spiroplasma strains from insects and one from spring flowers failed to react with antisera specific for any of the 11 described spiroplasma groups, with sera directed against spiroplasma Group I subgroups, or with sera directed against two unnumbered groups previously reported to occur in tabanid flies. Strains, all from Maryland, were isolated from the hemolymph of the spotted cucumber beetle Diabrotica undecimpunctata and the lampyrid beetle Ellychnia corrusca, and the guts of the cantharid beetles Cantharis bilineatus and C. carolinus. Other strains were obtained from a tabanid fly, Tabanus gladiator and from the firefly Photuris pennsylvanica in Maryland and from the mosquito Culex tritaeniorhynchus in Taiwan. An isolate from pooled Cicadulina bipunctella leafhoppers in Syria apparently represented a unique group. A single isolate from spring flowers in Oklahoma also appeared to be unrelated to existing groups or subgroups. One-way deformation tests using sera prepared against known beetle and tabanid spiroplasmas showed each of the above strains to be unique. Although these results strongly indicate that the nine strains studied are representatives of unique new spiroplasma groups, the formal designation of new groups awaits fulfillment of recently proposed criteria.
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Affiliation(s)
- T B Clark
- Agricultural Research Service, U.S. Department of Agriculture, Beltsville, MD 20705
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