Rhythmos (E-Journal - First Department of Cardiology / Evagelismos General Hospital of Athens)
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Iron Deficiency in Patients With Congestive Heart Failure
Get PDFA large percentage of patients with chronic heart failure (HF) have anemia, defined as hemoglobin (Hb) of <12 g/dl, hovering around 30% in non-hospitalized HF patients and about 50% of hospitalized patients.1,2 The presence of anemia is an independent risk factor, associated with increased rates of mortality, HF hospitalization and morbidity. The cause of anemia in HF is multifactorial with 63.8% of patients having at least two factors that cause anemia. Chronic kidney insufficiency, iron deficiency, vitamin B12 deficiency, hemodilution, chronic diseases, and cachexia are the most common causes.3 Iron deficiency with or without anemia is common in patients with HF, relates to disease severity, and is a strong and independent predictor of outcome.4 Iron deficiency is defined as a ferritin level < 100μg/L or ferritin level 100-299 μg/L with a transferrin saturation < 20%.4 Anemic patients were more often iron deficient than non anemic patients. There are two types of iron deficiency, the absolute and the functional iron deficiency (Fig. 2)... (excerpt
Statin-Induced Musculoskeletal Problems: Disconcerting Reports and Data
Get PDFStatins are molecules of fungal origin, which inhibit the hydroxymethylglutaryl-CoA (HMG-CoA) reductase enzyme, a key step in the sterol biosysnthesis, rendering them powerful cholesterol lowering medications contributing to significant prevention of cardiovascular disease.1 Statins are characterized by differences in bioavailability, lipo/hydrophilicity, cytochrome P-450 mediated metabolism and cellular transport mechanisms, differences that are reflected in their relative capacity in LDL-cholesterol lowering and possibly in parenchymal or muscular toxicities.2 Statin intolerance comprises, among others, musculoskeletal problems, such as statin-induced muscle and tendon disorders which are the most common cause of statin discontinuation.3-10Musculoskeletal ProblemsStatin therapy has long been associated with musculoskeletal (MS) problems in approximately 10% - 25% of patients treated in real-world clinical practice, but such problems have rarely been reported in controlled clinical trials,3,4 and their incidence has thus far been underestimated.5 Studies have concentrated on creatine kinase (CK) elevations to identify myopathy. However, many patients can have normal serum CK levels despite myalgia and persistent weakness and muscle biopsy - proven myopathy. Discontinuation of statin and rechalllenge may be required to prove that it is statin-related. Several risk factors may predispose patients to statin-related MS problems, including advanced age, family history of myopathy, statin dose, and interacting medications (e.g., azole antifungals, cimetidine, fibrates, macrolide antibiotics, protease inhibitors and cyclosporine) (Table 1).5,6,8 ... (excerpt
Transvenous Temporary Cardiac Pacing
Get PDFTransvenous temporary cardiac pacing is a rather old but still contemporary life-saving technique, with a unique value in the treatment of critically ill patients suffering from rhythm disturbances and associated hemodynamic compromise. Physicians involved in the management of such patients should always keep in mind the indications and contraindications of transvenous temporary cardiac pacing, and should be at least familiar with the insertion technique and the post-insertion care
Cardiology News /Recent Literature Review / First Quarter 2014
Get PDFAthens Cardiology Update 2014: Athens (Crown Plaza Hotel), 10-12/4/2014HRS Meeting: San Francisco, 7-10/5/2014EuroPCR: Paris, 20-23/5/2014CardioStim: Nice, 18-21/6/2014ESC Congress: Barcelona, 30/8-3/9/14TCT: Washington, 12-17/9/14HCS Annual Meeting: Athens, 23-25/10/2014AHA: Chicago, 15-19/11/14Cutting Inappropriate ICD Shocks: Long Arrhythmia-Detection Time Strategy Confirmed Programming implantable cardioverter defibrillators (ICDs) to delay the time they take to treat ventricular arrhythmias cuts mortality by 23% and inappropriate shocks by more than one-half in a meta-analysis encompassing ~4900 patients. The included studies were prospective and multicenter and covered both primary and secondary prevention and patients with either ischemic or nonischemic cardiomyopathy. The risk of syncope did not rise significantly with longer detection times, despite traditional concerns that lots of patients would not tolerate prolonged arrhythmia exposure before their ICD is allowed to deliver therapy, either shocks or antitachycardia pacing (ATP). Instead, the extra time frequently gave devices a better chance to exclude non–life-threatening arrhythmias like atrial fibrillation and to let otherwise self-terminating ventricular arrhythmias play out on their own. Current nominal settings used by some ICD manufacturers are likely to be too aggressive, with arrhythmia detection times that in some cases may be as short as 1-3 s. These results highlight the importance of setting longer default ICD detection times. The analysis included 4896 patients from the MADIT-RIT, ADVANCE 3, and PROVIDE randomized trials and the RELEVANT nonrandomized study. Overall, 264 patients received appropriate shocks and 253 experienced inappropriate shocks at follow-up (12 - 17 months). The relative risk (RR) of death from any cause was 0.77 (p=0.02) in the prolonged-detection-time groups compared with controls; the risks of inappropriate shocks and appropriate and inappropriate ATP also fell significantly. Why there were fewer deaths with longer detection times is unclear but it may derive from less exposure to potential hazards of shocks and ATP; inappropriate shocks may up mortality, and ATP poses a small risk of inducing ventricular fibrillation; or it may be due to some other factor, e.g. avoidance of treatment for multiple ICD therapies (e.g., prescription of antiarrhythmic drugs) (Scott PA et al, Heart Rhythm 2014; DOI:10.1016/j.hrthm.2014.02.009. Epub 2014 Feb 12)... (excerpt
Renal Denervation for Resistant Hypertension: Blinded or Unblinding Recent Trial?
Get PDFRenal artery sympathetic denervation, performed via a percutaneous catheter ablation procedure applying radiofrequency energy, has been developed to address renal sympathetic overactivity as a pivotal mechanism in the pathophysiology of hypertension.1 In 2009, the first-in-man experience with this procedure was published.2 Several studies followed, including the Symplicity HTN-1 trial (n=45), the randomized Symplicity HTN-2 trial (n=106) and the expanded open-label Symplicity-2 study (n=153).3-6 However, all the initial evidence suffered from important limitations related to small cohort size, short follow-up and by and large incomplete data.1 According with a review and meta-analysis of 12 studies, most of them being observational studies without a control group, renal denervation in a total population of 561 patients with resistant hypertension, resulted in a significant reduction in mean blood pressure at 6 months.7 In the controlled studies (2 randomized controlled trials, n=133; and 1 observational study with a control group, n=50), there was a reduction in mean systolic and diastolic blood pressure at 6 months of –28.9 mm Hg and –11.0 mm Hg, respectively, compared with the control groups (p < 0.0001). In the uncontrolled studies (n=396), there was a reduction in mean systolic and diastolic blood pressure at 6 months of –25.0 mm Hg and –10.0 mm Hg, respectively, compared with the pre-procedural values (p < 0.00001). One renal artery dissection and 4 femoral pseudoaneurysms were reported as procedural complications.7... (excerpt
Cardiology News / Recent Literature Review / Second Quarter 2014
Get PDFESC Congress: Barcelona, 30/8-3/9/14TCT: Washington, 12-17/9/14HCS Annual Meeting: Athens, 23-25/10/2014AHA: Chicago, 15-19/11/1420th Annual Boston AF Symposium: Orlando, 8-10/1/15HCS Working Groups Seminar: Ioannina, 2/2015ACC: San Diego, 14-16/3/15HRS: Boston, 13-16/5/15EuroPCR: Paris, 19-22/5/15Europace: Milan, 21-24/6/15ESC: London, 29/8-2/9/15Short QT Syndrome is Highly Lethal A total of 62 out of 73 short QT syndrome (SQTS) patients (84% male; mean age, 26 ± 15 years; corrected QT interval, 329 ± 22 ms) were followed for 60 ± 41 months. Cardiac arrest (CA) was the most frequent presenting symptom (40% of probands). There was an age dependency in the susceptibility to arrhythmias, with a peak in the occurrence of CA in the first year of life (4%) and a second peak (1.3%) between 20 and 40 years of age; the probability of a first occurrence of CA by 40 years of age was 41%. Despite the male predominance, female patients had a similar risk profile. Familial disease was present in 44% of kindreds, but the yield of genetic screening was low (14%). A history of CA was the only predictor of recurrences at follow-up (p< 0.0000001). Arrhythmias occurred mainly at rest. The authors concluded that SQTS is highly lethal with CA often as the first manifestation of the disease with a peak incidence in the first year of life; survivors of CA have a high CA recurrence rate; implantation of a defibrillator is strongly recommended (Mazzanti A et al, J Am Coll Cardiol 2014;63:1300-1308).Inferior Vena Cava (IVC) Filters in Patients With Acute Symptomatic Venous Thromboembolism (VTE) and a Significant Bleeding Risk Lower Pulmonary Embolism Mortality but Increase Risk of Recurrence In a prospective cohort study of patients with acute VTE identified from the RIETE (Computerized Registry of Patients With Venous Thromboembolism), the investigators assessed the association between IVC filter insertion due to significant bleeding risk and the 30-day outcomes [all-cause mortality, pulmonary embolism (PE)-related mortality, and VTE rates]. Of 40,142 patients who had acute symptomatic VTE, 371 received an IVC filter. A total of 344 patients treated with a filter were matched with 344 patients treated without a filter. There was a non-significant trend toward lower risk of all-cause death for filter insertion (6.6% vs 10.2%; p = 0.12). The risk adjusted PE-related mortality rate was lower for filter insertion than no insertion (1.7% vs 4.9%; p = 0.03). Risk-adjusted recurrent VTE rates were higher for filter insertion than for no insertion (6.1% vs 0.6%; p < 0.001). The authors concluded that in patients presenting with VTE and a significant bleeding risk, IVC filter insertion compared with anticoagulant therapy was associated with a lower risk of PE-related death and a higher risk of recurrent VTE (Muriel et al, J Am Coll Cardiol 2014;63:1675–1683). ... (excerpt
Cardiology News /Recent Literature Review / Last Quarter 2012
Get PDFHCS Working Group Seminars will take place in Thessaloniki, 14-16/2/2013 ACC Meeting is slated for San Francisco, 9-11/3/13 HRS Meeting will take place in Denver, 8-11/5/13 EuroPCR to be held in Paris, 21-24/5/13 EuroPace will be held in Athens, 23-26/6/13 ESC Congress will be held in Amsterdam, 31/8-4/9/13 TCT Meeting: San Francisco, 28/10-1/11/13 AHA 2013: Dallas, 16-20/11/13 Metoprolol is not Effective in Long QT Syndromes Types 1 and 2 Compared to Propranolol and NadololThe effect of beta blockers was assessed in 382 LQT1/ LQT2 patients (56% female, 27% symptomatic, mean heart rate 76 bpm, mean QTc 472 ms) started on propranolol (n=134), metoprolol (n=147), and nadolol (n=101) at a median age of 14 years. The QTc shortening with propranolol was significantly greater than with other beta-blockers in all patients and in the subset with QTc >480 ms. None of the asymptomatic patients had arrhythmia events. Among symptomatic patients (n=101), 15 had syncope. The QTc shortening was significantly less pronounced among patients with syncope. There was a greater risk of syncope for symptomatic patients initiated on metoprolol compared to users of the other 2 beta-blockers combined, after adjustment for genotype (odds ratio: 3.95, p=0.025). Kaplan-Meier analysis showed a significantly lower event-free survival for symptomatic patients receiving metoprolol compared to propranolol/nadolol. The authors concluded that propranolol and nadolol are significantly more effective than metoprolol in preventing arrhythmic events in symptomatic patients. Also, propranolol was superior to both nadolol and metoprolol in terms of shortening the QTc, particularly in high-risk patients with markedly prolonged QTc. Patients with syncope had significantly less QTc shortening than the event-free patients (Chockalingam P et al, J Am Coll Cardiol 2012;60:2092–2099).Still Limitations in Subcutaneous ICDA total of 118 patients (75% males, mean age 50 years) received the entirely subcutaneous implantable cardioverter defibrillator (S-ICD) system. After 18 months of follow-up, 8 patients experienced 45 successful appropriate shocks (98% first shock conversion efficacy). No sudden deaths occurred. Inappropriate shocks occurred in 15 patients (13%), mainly due to T-wave oversensing, mostly solved by a software upgrade and changing the sensing vector of the S-ICD. Complications were noted in 16 patients (14%), more frequently in the first 15 implantations per center. The authors concluded that S-ICD is effective in terminating ventricular arrhythmias, but it has still limitations due to its subcutaneous position. Inappropriate therapy is an important issue in the S-ICD. However, both inappropriate shocks and device-related complications seemed to be related to a learning curve of both the device and the physician (Nordkamp et al, J Am Coll Cardiol 2012;60:1933–1939)... (excerpt
Echocardiographic Findings in Carcinoid Syndrome
Get PDFA 57-year-old Caucasian female was referred to our Cardiology department due to hypertension, flushing, and diarrhea. She had a medical history of hypertension and paroxysmal atrial fibrillation. On physical examination, the patient had a heart rate of 70 bpm and a respiratory rate of 12 breaths/min. Her temperature was 37°C and her blood pressure was 120/80 mmHg. Cardiac examination revealed a left parasternal holosystolic murmur, and a palpable right ventricular heave. Lung auscultation was unremarkable. From the initial biochemical exam she had no specific abnormalities. The ECG showed sinus rhythm, negative T-waves in leads III, V1-5. The transthoracic echocardiography study revealed a left ventricle with normal size and normal systolic function and dilatation of the left atrium, whereas the right cardiac chambers were dilated with thickened, immobile leaflets of the tricuspid and pulmonic valve, leading to malcoaptation and severe tricuspid and pulmonic regurgitation. (Figures 1-5) The clinical and echocardiographic findings raised the suspicion of carcinoid heart disease. Abdominal CT demonstrated hepatic metastases and the patient was treated with chemotherapy and with the somatostatin analog octreotide... (excerpt
Pregnancy and Cardiovascular Disease
Get PDFThe cardiovascular system undergoes significant changes during pregnancy to adapt to and accommodate the increased metabolic demands of the fetus and the mother. These adaptations produce an important hemodynamic burden on patients with underlying heart disease, and confer an increase in morbidity and mortality. Furthermore, pregnancy may cause specific cardiovascular disorders, which can impose a risk to the pregnant woman and to her fetus. It is estimated that in the western world 0.2-4% of all pregnancies are complicated by cardiovascular diseases (CVD). This risk is in the ascending order as the age of first pregnancy is increasing and as the number of cardiovascular risk factors is rising (e.g. smoking, hypercholesterolemia, diabetes, hypertension, obesity). During pregnancy, the most frequent cardiovascular events relate to hypertension (6–8%). On the other hand, in the western world, the most frequent CVD present during pregnancy is congenital heart disease-CHD (circa 75%), while rheumatic heart disease predominates in the other countries (circa 70%) and CHD is seen in ~15%. In pregnant women with heart disease, maternal death is estimated around 1% but it varies depending on the underlying CVD; neonatal complications occur in 20–28% and neonatal mortality ranges between 1% and 4%. In general, CVDs are the most common cause of maternal death during pregnancy in the Western industrialized world.4 Thus, women of child-bearing age with CVD or cardiovascular risk factors should be counseled and managed early by an interdisciplinary team of gynecologists, cardiologists, and, when necessary, cardiothoracic surgeons... (excerpt
Cardiology News /Recent Literature Review / Third Quarter 2013
Get PDFHCS Meeting: Athens, 10-12/10/2013 TCT Meeting: San Francisco, 28/10-1/11/13 AHA 2013: Dallas, 16-20/11/13 ACC 2014: Washington, DC, 29-31/3/2014 Athens Cardiology Update 2014: Athens (Crown Plaza Hotel), 10-12/4/2014 HRS Meeting: San Francisco, 7-10/5/2014 EuroPCR: Paris, 20-23/5/2014 CardioStim 2014: Nice, 18-21/6/2014 Percutaneous Left Atrial Appendage Closure May be a Therapeutic Alternative in Patients with Atrial Fibrillation (AF) and Absolute Contraindications to Anticoagulation TherapyLeft atrial appendage closure (LAAC) with the AMPLATZER Cardiac Plug (ACP) was successfully performed in 51 of 52 (98%) patients (aged 74+8 years) with AF and absolute contraindications to anticoagulation therapy. Most patients received dual-antiplatelet therapy after the procedure for 1-3 months and single antiplatelet therapy thereafter. Main complications were device embolization (1.9%) and pericardial effusion (1.9%), with no cases of periprocedural stroke. At follow-up (20+5 months), death rate was 5.8%, stroke 1.9%, systemic embolism 0%, pericardial effusion 1.9%, and major bleeding 1.9%. The presence of mild peridevice leak was observed in 16.2% of patients at the 6-month follow-up as evaluated by transesophageal echo. There were no cases of device thrombosis. The authors concluded that in patients with nonvalvular AF at high risk of cardioembolic events and absolute contraindications to anticoagulation, LAAC using the ACP device followed by dual-/single-antiplatelet therapy was associated with a low rate of embolic and bleeding events and no device thrombosis at short and midterm follow-up (Urena M et al, J Am Coll Cardiol 2013;62:96–102). Preliminary Favorable Experience With Percutaneous Left Atrial Appendage Suture Ligation Using the LARIAT Device in Patients With Atrial FibrillationPercutaneous ligation of the left atrial appendage (LAA) with the LARIAT device (a snare with a pre-tied suture guided epicardially over the LAA) was success-fully performed in 85 of 89 (96%) patients with complete closure achieved in 81 patients, while 4 had a <2-3-mm residual LAA leak. There were 3 complications (during pericardial access, n=2; & transseptal catheterization, n=1). Adverse events included severe pericarditis post-operatively (n=2), late pericardial effusion (n=1), sudden death (n=2), & late strokes (n=2). At 1 (81 of 85) & 3 months (77 of 81) post-ligation, 95% of the patients had complete LAA closure by transesophageal echo (TEE). Of the 65 patients undergoing 1-year TEE, there was 98% complete LAA closure, including patients with previous leaks. The authors concluded that LAA closure with the LARIAT device can be performed effectively with acceptably low complication rate (Bartus et al, J Am Coll Cardiol 2013;62:108–118)... (excerpt