Early discharge and home treatment of patients with low-risk pulmonary embolism with the oral factor Xa inhibitor rivaroxaban: an international multicentre single-arm clinical trial

AIMS

To investigate the efficacy and safety of early transition from hospital to ambulatory treatment in low-risk acute PE, using the oral factor Xa inhibitor rivaroxaban.

METHODS AND RESULTS

We conducted a prospective multicentre single-arm investigator initiated and academically sponsored management trial in patients with acute low-risk PE (EudraCT Identifier 2013-001657-28). Eligibility criteria included absence of (i) haemodynamic instability, (ii) right ventricular dysfunction or intracardiac thrombi, and (iii) serious comorbidities. Up to two nights of hospital stay were permitted. Rivaroxaban was given at the approved dose for PE for ≥3 months. The primary outcome was symptomatic recurrent venous thromboembolism (VTE) or PE-related death within 3 months of enrolment. An interim analysis was planned after the first 525 patients, with prespecified early termination of the study if the null hypothesis could be rejected at the level of α = 0.004 (<6 primary outcome events). From May 2014 through June 2018, consecutive patients were enrolled in seven countries. Of the 525 patients included in the interim analysis, three (0.6%; one-sided upper 99.6% confidence interval 2.1%) suffered symptomatic non-fatal VTE recurrence, a number sufficiently low to fulfil the condition for early termination of the trial. Major bleeding occurred in 6 (1.2%) of the 519 patients comprising the safety population. There were two cancer-related deaths (0.4%).

CONCLUSION

Early discharge and home treatment with rivaroxaban is effective and safe in carefully selected patients with acute low-risk PE. The results of the present trial support the selection of appropriate patients for ambulatory treatment of PE.

Survival and quality of life after early discharge in low-risk pulmonary embolism

Introduction

Early discharge of patients with acute low-risk pulmonary embolism requires validation by prospective trials with clinical and quality-of-life outcomes.

Methods

The multinational Home Treatment of Patients with Low-Risk Pulmonary Embolism with the Oral Factor Xa Inhibitor Rivaroxaban (HoT-PE) single-arm management trial investigated early discharge followed by ambulatory treatment with rivaroxaban. The study was stopped for efficacy after the positive results of the predefined interim analysis at 50% of the planned population. The present analysis includes the entire trial population (576 patients). In addition to 3-month recurrence (primary outcome) and 1-year overall mortality, we analysed self-reported disease-specific (Pulmonary Embolism Quality of Life (PEmb-QoL) questionnaire) and generic (five-level five-dimension EuroQoL (EQ-5D-5L) scale) quality of life as well as treatment satisfaction (Anti-Clot Treatment Scale (ACTS)) after pulmonary embolism.

Results

The primary efficacy outcome occurred in three (0.5%, one-sided upper 95% CI 1.3%) patients. The 1-year mortality was 2.4%. The mean±sd PEmb-QoL decreased from 28.9±20.6% at 3 weeks to 19.9±15.4% at 3 months, a mean change (improvement) of −9.1% (p<0.0001). Improvement was consistent across all PEmb-QoL dimensions. The EQ-5D-5L was 0.89±0.12 at 3 weeks after enrolment and improved to 0.91±0.12 at 3 months (p<0.0001). Female sex and cardiopulmonary disease were associated with poorer disease-specific and generic quality of life; older age was associated with faster worsening of generic quality of life. The ACTS burden score improved from 40.5±6.6 points at 3 weeks to 42.5±5.9 points at 3 months (p<0.0001).

Conclusions

Our results further support early discharge and ambulatory oral anticoagulation for selected patients with low-risk pulmonary embolism. Targeted strategies may be necessary to further improve quality of life in specific patient subgroups.

Relevance of supraventricular runs detected after cerebral ischemia

OBJECTIVE

Prolonged ECG monitoring after stroke frequently reveals short paroxysmal atrial fibrillation (pAF) and supraventricular (SV) runs. The minimal duration of atrial fibrillation (AF) required to induce cardioembolism, the relevance of SV runs, and whether short pAF results from cerebral damage itself are currently being debated. We aimed to study the relevance of SV runs and short pAF detected by prolonged Holter ECG after cerebral ischemia during long-term follow-up.

METHODS

Analysis is from the prospective Find-AF trial (ISRCTN46104198). We included patients with acute cerebral ischemia. Those without AF on admission received 7-day Holter ECG monitoring. We differentiated patients with AF on admission (AF-adm), with pAF (>30 seconds), with SV runs (>5 beats but <30 seconds in a 24-hour ECG interval), and without SV runs (controls). During follow-up, those with baseline pAF received another 7-day Holter ECG to examine AF persistence.

RESULTS

A total of 254 of 281 initially included patients were analyzed (mean age 70.0 years, 45.3% female). Forty-three (16.9%) had AF-adm. A total of 211 received 7-day Holter ECG monitoring: 27 (12.8%) had pAF, 67 (31.8%) had SV runs, and 117 (55.5%) were controls. During a mean 3.7 years of follow-up, the SV runs group had more recurrent strokes (p = 0.04) and showed numerically more novel AF (12% vs 5%, p = 0.09) than the controls. Seventy-five percent of the patients with manifest pAF detected after cerebral ischemia still had AF during follow-up (50% paroxysmal, 50% persisting/permanent).

CONCLUSIONS

Patients with cerebral ischemia and SV runs had more recurrent strokes and numerically more novel AF during follow-up and could benefit from further prolonged ECG monitoring. pAF detected after stroke is not a temporal phenomenon.

Determinants of submaximal exercise capacity in patients at risk for heart failure with preserved ejection fraction-results from the DIAST-CHF study

Objectives and Background

The aim of this study was to identify determinants of submaximal exercise capacity as measured by 6 min walking distance in patients at risk for heart failure with preserved ejection fraction (HFpEF).

Methods

A cross‐sectional analysis from the prospective cohort programme Prevalence and Clinical Course of Diastolic Dysfunction and Heart Failure (DIAST‐CHF) that included a total of 1937 patients (age, 50–85 years) with >1 risk factor (hypertension, atherosclerotic disease, diabetes mellitus, and obstructive sleep apnoea) was carried out. Besides comprehensive clinical phenotyping, standardized 6 min walk test and state‐of‐the‐art echocardiography were performed, and blood samples for biomarker assessment were obtained. Patients with an ejection fraction <50% or without evaluable exercise test were excluded from this analysis.

Results

One thousand three hundred eighty‐seven patients fulfilled all criteria for this analysis. In the univariate analysis, 6 min walk distance was inversely related to E/e′ values (P < 0.001). In the multivariate analysis, 6 min walk distance decreased significantly with age, female sex, increasing body mass index, diabetes, chronic obstructive lung disease, and peripheral artery disease. However, the association of 6 min walk distance with resting parameters of diastolic function was significantly attenuated with multivariate regression. In contrast, mid‐regional pro‐adrenomedullin, mid‐regional pro‐atrial natriuretic peptide, and N‐terminal pro‐B‐type natriuretic peptide were independently associated with submaximal exercise capacity when added to the base model (all P < 0.001).

Conclusions

Classical risk factors for heart failure and neuroendocrine activation are independently associated with sub‐maximal exercise capacity, while diastolic function parameters obtained at rest were not. This observation substantiates the role of co‐morbidities as relevant contributors to the clinical picture of HFpEF and the limitation of resting indices of diastolic function for diagnosing HFpEF.

Finding atrial fibrillation in stroke patients: Randomized evaluation of enhanced and prolonged Holter monitoring--Find-AF(RANDOMISED) --rationale and design

BACKGROUND

Detecting paroxysmal atrial fibrillation (AF) in patients with ischemic strokes presenting in sinus rhythm is challenging because episodes are often short, occur randomly, and are frequently asymptomatic. If AF is detected, recurrent thromboembolism can be prevented efficiently by oral anticoagulation. Numerous uncontrolled studies using various electrocardiogram (ECG) devices have established that prolonged ECG monitoring increases the yield of AF detection, but most established procedures are time-consuming and costly. The few randomized trials are mostly limited to cryptogenic strokes. The optimal method, duration, and patient selection remain unclear. Repeated prolonged continuous Holter ECG monitoring to detect paroxysmal AF within an unspecific stroke population may prove to be a widely applicable, effective secondary prevention strategy.

STUDY DESIGN

Find-AFRANDOMISED is a randomized and controlled prospective multicenter trial. Four hundred patients 60 years or older with manifest (symptoms ≥24 hours or acute computed tomography/magnetic resonance imaging lesion) and acute (symptoms ≤7 days) ischemic strokes will be included at 4 certified stroke centers in Germany. Those with previously diagnosed AF/flutter, indications/contraindications for oral anticoagulation, or obvious causative blood vessel pathologies will be excluded. Patients will be randomized 1:1 to either enhanced and prolonged Holter ECG monitoring (10 days at baseline and after 3 and 6 months) or standard of care (≥24-hour continuous ECG monitoring, according to current stroke guidelines). All patients will be followed up for at least 12 months.

OUTCOMES

The primary end point is newly detected AF (≥30 seconds) after 6 months, confirmed by an independent adjudication committee. We plan to complete recruitment in autumn 2014. First results can be expected by spring 2016.

Abstract T P174: Stroke Severity in Patients With Different Durations of Atrial Fibrillation

Background: Persistent atrial fibrillation (AF) is a common risk factor for stroke. Strokes caused by AF are usually more severe as compared to stroke in patients without AF. Recent evidence suggests that stroke risk in paroxysmal AF is similar to persistent AF, but which minimal duration of AF already increases stroke risk, is unknown. We aimed to compare stroke severity in stroke patients with different durations of AF.

Methods: 272 stroke patients were prospectively included. 43 had AF on admission (persistent AF). During 7-day-Holter-ECG, an additional 29 patients were diagnosed with AF of at least 30 seconds (paroxysmal AF). 200 patients had no AF > 30 seconds. Of these, 72 had supraventricular runs of at least 10 beats during 24h-Holter ECG. Stroke severity was characterised by NIH stroke scale (NIHSS) and modified Rankin scale (mRS). All values are given as median (25%/75%) and compared by Mann-Whitney-U-Test.

Results: NIHSS and mRS values were similar in patients with persistent and paroxysmal AF (see table: p=0.239 (NIHSS), p=0.623 (mRS), respectively. In patients with no AF, NIHSS: 2 (1-4) and mRS: 2 (1-3) were significantly lower as compared to patients with paroxysmal AF (NIHSS: p <0.001; mRS: p=0.034).

NIHSS and mRS did not differ in patients with short episodes of paroxysmal AF (6 minutes or shorter) as compared to patients with medium duration of episodes (6 minutes to 6 hours) or long episodes > 6 hours.

In patients with no AF, the presence of supraventricular runs of at least 10 beats was not associated with higher NIHSS or mRS as compared to patients without supraventricular runs (p=0.239 and p=0.621, respectively).

Conclusion: Our results suggests that patients with paroxysmal AF of at least 30 seconds during 7-day-Holter have strokes similar to patients with persistent AF. Whether these patients benefit similarly to persistent AF patients from anticoagulation for secondary stroke prevention, should be investigated in further prospective randomised trials.

Excessive supraventricular ectopic activity is indicative of paroxysmal atrial fibrillation in patients with cerebral ischemia

BACKGROUND

Detecting paroxysmal atrial fibrillation (PAF) in patients with cerebral ischemia is challenging. Frequent premature atrial complexes (PAC/h) and the longest supraventricular run on 24-h-Holter (SV-run(24 h)), summarised as excessive supraventricular ectopic activity (ESVEA), may help selecting patients for extended ECG-monitoring, especially in combination with echocardiographic marker LAVI/a' (left atrial volume index/late diastolic tissue Doppler velocity).

METHODS

Retrospective analysis from the prospective monocentric observational trial Find-AF (ISRCTN-46104198). Patients with acute stroke or TIA were enrolled at the University Hospital Göttingen, Germany. Those with sinus rhythm at presentation received 7-day Holter-monitoring. ESVEA was quantified in one 24-hour interval free from PAF. Echocardiographic parameters were assessed prospectively.

RESULTS

PAF was detected in 23/208 patients (11.1%). The median was 4 [IQR 1; 22] for PAC/h and 5 [IQR 0; 9] for SV-run(24 h). PAF was more prevalent in patients with ESVEA: 19.6% vs. 2.8% for PAC/h >4 vs. ≤ 4 (p<0.001); 17.0% vs. 4.9% for SV-run(24 h >5) vs. ≤ 5 beats (p = 0.003). Patients with PAF showed more supraventricular ectopic activity: 29 PAC/h [IQR 9; 143] vs. 4 PAC/h [1]; [14] and longest SV-run(24 h = 10) [5]; [21] vs. 0 [0; 8] beats (both p<0.001). Both markers discriminated between the PAF- and the Non-PAF-group (area under receiver-operator-characteristics-curve 0.763 [95% CI 0.667; 0.858] and 0.716 [0.600; 0.832]). In multivariate analyses log(PAC/h) and log(SV-run(24 h)) were independently indicative of PAF. In Patients with PAC/h ≤ 4 and normal LAVI/a' PAF was excluded, whereas those with PAC/h >4 and abnormal LAVI/a' showed high PAF-rates.

CONCLUSIONS

ESVEA discriminated PAF from non-PAF beyond clinical factors including LAVI/a' in patients with cerebral ischemia. Normal LAVI/a'+PAC/h ≤ 4 ruled out PAF, while prevalence was high in those with abnormal LAVI/a'+PAC/h >4.

High-sensitivity troponin assay improves prediction of cardiovascular risk in patients with cerebral ischaemia

BACKGROUND AND PURPOSE

Clinical scores are recommended for predicting cardiovascular risk in patients with cerebral ischaemia to inform secondary prevention. Blood biomarkers may improve prediction beyond clinical scores.

METHODS

Within the observational Find-AF trial (ISRCTN46104198), 197 patients >18 years of age with cerebral ischaemia and without atrial fibrillation had blood sampled at baseline. The predictive value of five biomarkers for a combined vascular endpoint (acute coronary syndrome, stroke, cardiovascular death) and all-cause mortality was determined, alone and in addition to the Essen Stroke Risk Score (ESRS), Stroke Prognostic Instrument 2 (SPI-2) and National Institutes of Health Stroke Scale (NIH-SS).

RESULTS

There were 23 vascular events (11.7%) and 13 deaths (6.6%) to 1 year follow-up. In multivariate analyses of all markers, only high-sensitivity troponin T (hsTropT) remained independently predictive for vascular events (p=0.045) and all-cause mortality (p=0.004). hsTropT was higher in patients with a vascular event (median 12.7 ng/ml vs 5.1 ng/ml), and patients with hsTropT above the median of 6.15 ng/ml had vascular events more frequently (HR 3.86, p=0.008). For prediction of vascular events as well as all-cause mortality, hsTropT significantly improved multivariate Cox regression models with ESRS, SPI-2 or NIH-SS. The c-statistic increased non-significantly from 0.695 (ESRS) or 0.710 (hsTropT) to 0.747 (ESRS+hsTropT) and from 0.699 (SPI-2) to 0.763 (SPI-2+hsTropT). No patient with a low-risk ESRS and an hsTropT below the median had a vascular event or died.

CONCLUSIONS

hsTropT predicts vascular events and all-cause mortality in patients with acute cerebral ischaemia and improves prediction beyond established clinical scores.

Effect of spironolactone on diastolic function and exercise capacity in patients with heart failure with preserved ejection fraction: the Aldo-DHF randomized controlled trial

IMPORTANCE

Diastolic heart failure (ie, heart failure with preserved ejection fraction) is a common condition without established therapy, and aldosterone stimulation may contribute to its progression.

OBJECTIVE

To assess the efficacy and safety of long-term aldosterone receptor blockade in heart failure with preserved ejection fraction. The primary objective was to determine whether spironolactone is superior to placebo in improving diastolic function and maximal exercise capacity in patients with heart failure with preserved ejection fraction.

DESIGN AND SETTING

The Aldo-DHF trial, a multicenter, prospective, randomized, double-blind, placebo-controlled trial conducted between March 2007 and April 2012 at 10 sites in Germany and Austria that included 422 ambulatory patients (mean age, 67 [SD, 8] years; 52% female) with chronic New York Heart Association class II or III heart failure, preserved left ventricular ejection fraction of 50% or greater, and evidence of diastolic dysfunction.

INTERVENTION

Patients were randomly assigned to receive 25 mg of spironolactone once daily (n=213) or matching placebo (n=209) with 12 months of follow-up.

MAIN OUTCOME MEASURES

The equally ranked co-primary end points were changes in diastolic function (E/e') on echocardiography and maximal exercise capacity (peak VO2) on cardiopulmonary exercise testing, both measured at 12 months.

RESULTS

Diastolic function (E/e') decreased from 12.7 (SD, 3.6) to 12.1 (SD, 3.7) with spironolactone and increased from 12.8 (SD, 4.4) to 13.6 (SD, 4.3) with placebo (adjusted mean difference, -1.5; 95% CI, -2.0 to -0.9; P < .001). Peak VO2 did not significantly change with spironolactone vs placebo (from 16.3 [SD, 3.6] mL/min/kg to 16.8 [SD, 4.6] mL/min/kg and from 16.4 [SD, 3.5] mL/min/kg to 16.9 [SD, 4.4] mL/min/kg, respectively; adjusted mean difference, +0.1 mL/min/kg; 95% CI, -0.6 to +0.8 mL/min/kg; P = .81). Spironolactone induced reverse remodeling (left ventricular mass index declined; difference, -6 g/m2; 95% CI, -10 to-1 g/m2; P = .009) and improved neuroendocrine activation (N-terminal pro-brain-type natriuretic peptide geometric mean ratio, 0.86; 95% CI, 0.75-0.99; P = .03) but did not improve heart failure symptoms or quality of life and slightly reduced 6-minute walking distance (-15 m; 95% CI, -27 to -2 m; P = .03). Spironolactone also modestly increased serum potassium levels (+0.2 mmol/L; 95% CI, +0.1 to +0.3; P < .001) and decreased estimated glomerular filtration rate (-5 mL/min/1.73 m2; 95% CI, -8 to -3 mL/min/1.73 m2; P < .001) without affecting hospitalizations.

CONCLUSIONS AND RELEVANCE

In this randomized controlled trial, long-term aldosterone receptor blockade improved left ventricular diastolic function but did not affect maximal exercise capacity, patient symptoms, or quality of life in patients with heart failure with preserved ejection fraction. Whether the improved left ventricular function observed in the Aldo-DHF trial is of clinical significance requires further investigation in larger populations.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: ISRCTN94726526; Eudra-CT No: 2006-002605-31.

Abstract WP141: The Role Of Paroxysmal Atrial Fibrillation In Patients With Retinal Artery Occlusion (rao)

Background: Patients with retinal artery occlusion (RAO) have a 2.0 fold increase in risk for subsequent stroke and share similar risk factors with stroke patients. The pathophysiologic role of atrial fibrillation (AF), especially in its paroxysmal presentation, is poorly understood. We hypothesized that AF is similarly prevalent in RAO as in ischemic stroke (IS).

Materials and methods: In the Find-AF-eye trial, 50 patients with RAO were subsequently recruited into a prospective cohort study. 49 patients with venous retinal thrombosis (VRT) and 280 patients with ischemic stroke (IS) served as controls. Comprehensive evaluation included carotid artery Duplex examination, 7-day Holter ECG, transthoracal and transesophageal echocardiography and assessment of lipid and glucose status. AF was defined as an atrial arrhythmia for at least 30 seconds.

Results: 6 RAO patients (12.0 %), 5 VRT patients (10.2 %) and 48 IS (17.1 %) patients had a history of AF or had AF in the admission ECG. During 7-day Holter, 34 additional patients were diagnosed to have paroxysmal AF during 7-day Holter (2 RAO, 4 VRT, 28 IS patients). The overall prevalence of any AF was not significantly different between RAO (16.0 %) and VRT (18.3 %), p=0.79, but tended to be higher in IS (27.1 %), p=0.109 vs. RAO and p=0.195 vs. VRT.

Conclusion: Our data do not support a relevant pathophysiologic role of AF in patients with RAO.

Impact of obstructive sleep apnoea on diastolic function

We investigated whether obstructive sleep apnoea (OSA) independently affects diastolic function in a primary care cohort of patients with cardiovascular risk factors. 378 study participants with risk factors for diastolic dysfunction were prospectively included and a polygraphy was performed in all patients. Diastolic dysfunction was assessed by comprehensive echocardiography including tissue Doppler. Sleep apnoea was classified according to apnoea/hypopnoea index (AHI) as none (AHI <5 events·h(-1)), mild (AHI ≤5 to <15 events·h(-1)) or moderate-to-severe (AHI ≥15 events·h(-1)). Patients with central sleep apnoea (n=14) and patients with previously diagnosed sleep apnoea (n=12) were excluded. In the remaining 352 subjects, 21.6% had an AHI ≥15 events·h(-1). The prevalence of diastolic dysfunction increased with the severity of sleep apnoea from 44.8% (none) to 56.8% (mild) to 69.7% (moderate-to-severe sleep apnoea) (p=0.002). The degree of diastolic dysfunction also increased with sleep apnoea severity (p=0.004). In univariate regression analysis, age, desaturation index, AHI, cardiac frequency, angiotensin receptor 1 antagonist therapy, body mass index (BMI) and left ventricular mass were associated with diastolic dysfunction. In multivariate regression analysis, only age, BMI, AHI and cardiac frequency were independently associated with diastolic dysfunction. Moderate-to-severe OSA is independently associated with diastolic dysfunction in patients with classical risk factors for diastolic dysfunction.

Abstract 3420: High-sensitivity Troponin T Improves Cardiovascular Risk Prediction In Patients With Cerebral Ischemia

Background Patients with a cerebral ischemic event are at high risk of recurrent ischemia and other cardiovascular events. Clinical scores are recommended to predict cardiovascular risk in patients with cerebral ischemia to inform secondary preventive measures. Biomarkers may improve risk prediction beyond clinical scores and therefore secondary prevention.

Methods Within the observational Find-AF trial (ISRCTN 46104198), 197 patients aged >18 years with cerebral ischemia and without atrial fibrillation had blood sampled at baseline and completed 1-year follow-up. Predictive value of 5 novel cardiovascular biomarkers for a combined vascular endpoint (acute coronary syndrome, stroke, cardiovascular death) and all-cause mortality was determined, alone and in addition to Essen Stroke Risk Score (ESRS), Stroke Prognostic Instrument 2 (SPI-2), National Institutes of Health Stroke Scale (NIH-SS) and Modified Rankin Scale (MRS).

Results There were 23 vascular events (11.7%) and 13 deaths (6.6%) during 1 year. In multivariate analyses of all 5 markers, only high-sensitivity Troponin T (hs-TropT) remained significantly predictive of vascular events (p=0.045) and all-cause mortality (p=0.004). Hs-TropT was higher in patients with a vascular event (median 12.7 [6.8; 49.6] ng/mL vs. 5.1 [1.5; 11.7] ng/mL) and patients with hs-TropT above the median of 6.15 ng/mL were more likely to have a vascular event (Hazard Ratio 4.0, p=0.006 on log-rank test). For prediction of vascular events as well as all-cause mortality, hs-TropT significantly contributed to multivariate Cox-regression models with ESRS, SPI-2, or each combined with NIH-SS or MRS as covariates. C-statistic increased numerically from 0.689 (ESRS) to 0.743 (ESRS+hs-TropT) and 0.696 (SPI-2) to 0.758 (SPI-2+hs-TropT) (p=n.s.). Areas under the receiver-operator characteristics curves for vascular events were 0.694 (SPI-2), 0.712 (ESRS), 0.743 (ESRS+hs-TropT), 0.755 (hs-TropT) and 0.760 (SPI-2+hs-TropT). No patient with a low-risk ESRS ≤2 and a hs-TropT below the median had a vascular event during 1 year follow-up.

Conclusion Hs-TropT is predictive of major vascular events and all-cause mortality in patients with cerebral ischemia and improves prediction by established clinical scores.

Abstract 3398: Excessive Supraventricular Ectopic Activity On 24h-Holter Predicts Paroxysmal Atrial Fibrillation In Patients With Cerebral Ischemia Presenting In Sinus Rhythm

Background Detection of paroxysmal atrial fibrillation (PAF) in patients with cerebral ischemia is challenging. Echocardiography (LAVI/á, an index of left atrial remodeling) can select a subgroup of patients for extended ECG-monitoring. Excessive supraventricular ectopic activity (ESVEA), measured as atrial premature beats (APB) and longest supraventricular run on 24h-Holter-ECG (SV-run 24h ) may further improve prediction of PAF.

Methods Retrospective analysis from a prospective monocentric observational trial (Find-AF) in patients >18y with cerebral ischemia (ISRCTN 46104198). PAF was diagnosed by 7d-Holter monitoring. Transthoracic echocardiography parameters were prospectively assessed. ESVEA was quantified in one 24h interval, which had to be free from PAF. For the present analysis, 44 patients with atrial fibrillation at baseline and 20 patients with limited evaluability for ESVEA (9 with pacemaker rhythms, 4 with low-quality recordings and 7 with PAF who had no 24h interval free from PAF) were excluded.

Results PAF was detected in 21 out of 215 patients (9.8%) of the analysis population. PAF was more prevalent in those with ESVEA above the median: 17.3 vs. 2.7% for APB > vs. <= 4/h (p<0.001 chi-square test); 15.9 vs. 3.7% for SV-run 24h > vs. <= 5 beats (p=0.003). ESVEA differed between PAF and Non-PAF: APB median 17/h [IQR 9; 143] vs. 4/h [1; 15] and SV-run 24h 10 [7; 18] vs. 0 [0; 8] beats (both p<0.001, Mann-Whitney-U test). Both parameters discriminated moderately between PAF and Non-PAF (area under the receiver-operator-characteristics curve 0.751 and 0.730, respectively). In multivariate analysis with age, sex, body-mass index, systolic blood pressure, hypertension, heart failure and LAVI/á as covariates, log(APB/h) (p=0.027) and log(SV-run 24h ) (p=0.022) were independently predictive for the presence of PAF. 0% of patients with normal LAVI/á and APB <=4/h, 5.6% of those with either abnormal LAVI/á or APB >4/h, and 27.1% of those with both abnormal LAVI/á and APB >4/h had PAF (p<0.001 chi-square). Results were similar when PAF-cases were included that had been diagnosed clinically until 1-year follow-up.

Conclusions In patients with cerebral ischemia, ESVEA discriminates PAF from Non-PAF beyond clinical factors and LAVI/á. PAF is ruled out in patients with normal LAVI/á and APB <=4/h, while prevalence is high in those with abnormal LAVI/á and APB >4/h.

Exercise training improves exercise capacity and diastolic function in patients with heart failure with preserved ejection fraction: results of the Ex-DHF (Exercise training in Diastolic Heart Failure) pilot study

OBJECTIVES

We sought to determine whether structured exercise training (ET) improves maximal exercise capacity, left ventricular diastolic function, and quality of life (QoL) in patients with heart failure with preserved ejection fraction (HFpEF).

BACKGROUND

Nearly one-half of patients with heart failure experience HFpEF, but effective therapeutic strategies are sparse.

METHODS

A total of 64 patients (age 65 ± 7 years, 56% female) with HFpEF were prospectively randomized (2:1) to supervised endurance/resistance training in addition to usual care (ET, n = 44) or to usual care alone (UC) (n = 20). The primary endpoint was the change in peak Vo(2) after 3 months. Secondary endpoints included effects on cardiac structure, diastolic function, and QoL.

RESULTS

Peak Vo(2) increased (16.1 ± 4.9 ml/min/kg to 18.7 ± 5.4 ml/min/kg; p < 0.001) with ET and remained unchanged (16.7 ± 4.7 ml/min/kg to 16.0 ± 6.0 ml/min/kg; p = NS) with UC. The mean benefit of ET was 3.3 ml/min/kg (95% confidence interval [CI]: 1.8 to 4.8, p < 0.001). E/e' (mean difference of changes: -3.2, 95% CI: -4.3 to -2.1, p < 0.001) and left atrial volume index (milliliters per square meter) decreased with ET and remained unchanged with UC (-4.0, 95% CI: -5.9 to -2.2, p < 0.001). The physical functioning score (36-Item Short-Form Health Survey) improved with ET and remained unchanged with UC (15, 95% CI: 7 to 24, p < 0.001). The ET-induced decrease of E/e' was associated with 38% gain in peak Vo(2) and 50% of the improvement in physical functioning score.

CONCLUSIONS

Exercise training improves exercise capacity and physical dimensions of QoL in HFpEF. This benefit is associated with atrial reverse remodeling and improved left ventricular diastolic function. (Exercise Training in Diastolic Heart Failure-Pilot Study: A Prospective, Randomised, Controlled Study to Determine the Effects of Physical Training on Exercise Capacity and Quality of Life [Ex-DHF-P]; ISRCTN42524037).

Transthoracic echocardiography to rule out paroxysmal atrial fibrillation as a cause of stroke or transient ischemic attack

BACKGROUND AND PURPOSE

We assessed whether echocardiography can predict paroxysmal atrial fibrillation (PAF) in patients with cerebral ischemia presenting in sinus rhythm.

METHODS

Within the prospective Find-AF cohort, 193 consecutive patients with cerebral ischemia and sinus rhythm on presentation had evaluation of echocardiographic parameters of left atrial size and function. PAF was diagnosed by 7-day Holter monitoring.

RESULTS

In 26 patients with PAF, late diastolic Doppler (A) and tissue Doppler (a') velocities were lower whereas left atrial diameter, left atrial volume index (LAVI), LAVI/A, and LAVI/a' were larger (P<0.05 for all) than they were in 167 patients without PAF. In multivariate models A, a', LAVI/A, and LAVI/a' predicted the presence of PAF. Area under the receiver operating characteristic curve to diagnose PAF was highest for LAVI/a' (0.813 [0.738; 0.889]). A previously suggested cut-off of LAVI/a'<2.3 had 92% sensitivity, 55.8% specificity, and 98% negative predictive value for PAF.

CONCLUSIONS

LAVI/a'<2.3 can effectively rule out PAF in patients with cerebral ischemia.

Impaired physical quality of life in patients with diastolic dysfunction associates more strongly with neurohumoral activation than with echocardiographic parameters: quality of life in diastolic dysfunction

BACKGROUND

Quality of life (QoL) is impaired in diastolic heart failure. Little is known about QoL in diastolic dysfunction (DD) without heart failure.

METHODS

In the DIAST-CHF observational study, outpatients with risk factors for or a history of heart failure were included. In a cross-sectional analysis, we classified patients with preserved systolic function as having normal diastolic function (N, n = 264) or DD without (DD-, n = 957) or with (DD+, n = 321) elevated filling pressures according to echocardiography. Quality of life was evaluated by the Short Form 36 (SF-36) questionnaire.

RESULTS

Short Form 36 physical function (SF-36-PF) was worse in DD+ (mean ± SD 67.2 ± 25.6) than in DD- (76.2 ± 22.7, P < .05) than in N (mean ± SD 81.1 ± 23.5, P < .01). Other physical dimensions and the physical component score were also lower in DD, whereas the mental component score did not differ. The SF-36-PF correlated weakly with echocardiographic indicators of diastolic function. In multivariate linear regression controlling for age, sex, body mass index, depressiveness as assessed by Patient Health Questionnaire 9, N-terminal probrain-type natriuretic peptide, and midregional proadrenomedullin (MR-proADM), individual echocardiographic parameters or grade of DD was not independently associated with SF-36-PF, whereas the presence of DD+ was. Both N-terminal probrain-type natriuretic peptide and MR-proADM were independently associated with SF-36-PF, with MR-proADM showing the stronger association.

CONCLUSIONS

Physical dimensions of QoL are reduced in DD. Impaired SF-36-PF is only weakly associated with DD per se but rather seems to be contingent on the presence of elevated filling pressures. Biomarkers are more strongly and independently associated with SF-36-PF and may be more adequate surrogate markers of QoL in DD than echocardiographic measurements.

Heart failure therapy in diabetic patients-comparison with the recent ESC/EASD guideline

Background

To assess heart failure therapies in diabetic patients with preserved as compared to impaired systolic ventricular function.

Methods

3304 patients with heart failure from 9 different studies were included (mean age 63 ± 14 years); out of these, 711 subjects had preserved left ventricular ejection fraction (≥ 50%) and 994 patients in the whole cohort suffered from diabetes.

Results

The majority (>90%) of heart failure patients with reduced ejection fraction (SHF) and diabetes were treated with an ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) or with beta-blockers. By contrast, patients with diabetes and preserved ejection fraction (HFNEF) were less likely to receive these substance classes (p < 0.001) and had a worse blood pressure control (p < 0.001). In comparison to patients without diabetes, the probability to receive these therapies was increased in diabetic HFNEF patients (p < 0.001), but not in diabetic SHF patients. Aldosterone receptor blockers were given more often to diabetic patients with reduced ejection fraction (p < 0.001), and the presence and severity of diabetes decreased the probability to receive this substance class, irrespective of renal function.

Conclusions

Diabetic patients with HFNEF received less heart failure medication and showed a poorer control of blood pressure as compared to diabetic patients with SHF. SHF patients with diabetes were less likely to receive aldosterone receptor blocker therapy, irrespective of renal function.

The novel biomarker growth differentiation factor 15 in heart failure with normal ejection fraction

AIMS

Heart failure with normal ejection fraction (HFnEF) is an important clinical entity that remains incompletely understood. The novel biomarker growth differentiation factor 15 (GDF-15) is elevated in systolic heart failure (HFrEF) and is predictive of an adverse outcome. We investigated the clinical relevance of GDF-15 plasma levels in HFnEF.

METHODS AND RESULTS

A subgroup of patients from the ongoing DIAST-CHF observational trial, with a history of chronic heart failure (CHF) or positive Framingham criteria at presentation, was selected. Patients were classified as having either HFrEF (n=86) or HFnEF (n=142) and compared with healthy elderly controls (n=188) from the same cohort. Growth differentiation factor 15 levels in HFnEF were significantly higher than in controls and similar to those in HFrEF. In multivariate analysis, factors significantly associated with GDF-15 levels were age, sex, estimated glomerular filtration rate (eGFR), presence of HFrEF and HFnEF. Growth differentiation factor 15 correlated with multiple echocardiographic markers of diastolic function and was associated with 6 min walk test performance and SF-36 physical score on multivariate analysis in all patients. When using a classification for HFnEF that did not employ N-terminal pro brain natriuretic peptide (NT-proBNP) as a diagnostic criterion, the diagnostic properties of GDF-15 for detecting HFnEF tended to be superior to those of NT-proBNP, and a combination significantly improved diagnostic accuracy.

CONCLUSION

Growth differentiation factor 15 is elevated in HFnEF to a similar degree as in HFrEF. It is independently associated with impairment in exercise capacity and in physical components of quality of life. Diagnostic precision of GDF-15 is at least as good as that of NT-proBNP and combining both markers improves diagnostic accuracy.

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.

Dysfunction of soluble guanylyl cyclase in aorta and kidney of Goto-Kakizaki rats: influence of age and diabetic state

Type 2 diabetes mellitus is frequently associated with arterial hypertension. The mechanisms involved in this association are not known in detail, but endothelial dysfunction and a blunted vascular response to endogenous vasodilators are thought to play a role. In the present study we investigated the in vitro activity of vascular and renal soluble guanylyl cyclase in type 2 diabetic Goto-Kakizaki rats aged 5, 15, and 30 weeks, in comparison with age-matched Wistar controls. Blood pressure was monitored by radiotelemetry, and serum glucose and insulin concentrations were measured by standard assays. Goto-Kakizaki rats of all age groups had serum glucose concentrations significantly higher than those of corresponding Wistar controls. Serum insulin was unchanged until 15 weeks of age and was elevated in the 30-week-old diabetic rats. Blood pressure in Goto-Kakizaki rats was significantly higher than that in Wistar controls, and heart rate was significantly lower. Mesenteric arteries of diabetic rats showed a blunted relaxation in response to acetylcholine and sodium nitroprusside. In aortic tissue from Wistar rats an age-dependent increase was found in nitric oxide-stimulated cGMP formation, which was absent in the diabetic animals. Moreover, the maximum activity of soluble guanylyl cyclase was significantly lower in Goto-Kakizaki rats in all age groups studied. In renal tissue no differences were found between diabetic and control rats, except at 30 weeks of age when Goto-Kakizaki rats showed a significant reduction in basal and stimulated guanylyl cyclase activity. In conclusion, the present study shows a persistent reduction in vascular nitric oxide-sensitive guanylyl cyclase in Goto-Kakizaki rats, which occurred shortly after weaning and may contribute to the elevation in blood pressure in this strain of genetically diabetic rats.

Influence of circadian time, ageing, and hypertension on the urinary excretion of nitric oxide metabolites in rats

Urinary excretion of NO metabolites (NOx) was measured in male spontaneously hypertensive rats (SHR) and their normotensive Wistar-Kyoto controls (WKY) in two age groups: young (11 weeks) and old (58 weeks). Urine was collected every 6 h throughout 24 h with and without injection interperitoneally of N(G)-nitro-L-arginine-methyl-ester (L-NAME), 30 mg/kg, at 7:00 or 19:00 h. In addition, blood pressure changes by L-NAME were evaluated using radiotelemetry. In both strains of rats, injection of L-NAME abolished almost completely the urinary excretion of NOx, indicating that urinary NOx indeed reflect the endogenous rate of NO synthesis. Time-dependent variation in urinary NOx excretion was observed in WKY rats of both ages (analysis of variance, P<0.05), with higher excretion in the dark period. In SHR rats, time-dependent variation in NOx excretion was lost, and the overall amount of NOx excreted within 24 h was significantly lower in young SHR than in age-matched WKY rats. Moreover, blood pressure increases by L-NAME were significantly smaller in SHR than in WKY rats. In old rats of both strains, NOx excretion was reduced, and the difference between the strains disappeared. Our findings demonstrate that ageing is accompanied by a loss in NOx excretion, and suggest that hypertension in SHR leads to a reduction in NO synthesis already at young age.