Heart

Gurvitch, R; Webb, J G

doi: 10.1136/hrt.2010.197061pmid: 20610454

Thiene, Gaetano; Basso, Cristina

doi: 10.1136/hrt.2009.188953pmid: 20610455

Liew, Reginald

doi: 10.1136/hrt.2010.194407pmid: 20610456

Many patients who survive an acute myocardial infarction (AMI) remain at risk of sudden cardiac death despite optimal medical treatment. AMI survivors are currently risk assessed and selected for implantable cardioverter defibrillator (ICD) insertion mainly on the basis of their left ventricular ejection fraction. Several other cardiovascular tests are available that can detect the myocardial substrate abnormalities and help refine risk. These investigations include ECG-based tests (signal averaged ECG and T-wave alternans), Holter-based recordings (heart rate variability and heart rate turbulence) and imaging techniques (cardiac magnetic resonance). Recent evidence also points towards a potential role for other indices on the 12-lead ECG and genetic profiling in risk prediction. This study reviews the current evidence for the use of these tests in AMI survivors and addresses their pros and cons in guiding the selection of ICD recipients.

Fox, K A A; Eagle, K A; Gore, J M; Steg, Ph G; Anderson, F A; ,

doi: 10.1136/hrt.2009.190827pmid: 20511625

The aim of GRACE was to provide a large multinational registry of the full spectrum of patients with acute coronary syndromes (ACS) in order to define patient characteristics and outcomes and derive predictive risk scores. The study was designed and administered by an independent steering committee; data analyses were performed under the guidance of the steering committee at the Center for Outcomes Research of the University of Massachusetts. Regular feedback regarding local, regional and international guideline and performance measures was provided to individual hospitals and clusters of hospitals. Regional and international benchmark data were available to all sites. Main GRACE involved 123 hospitals in 14 countries in North and South America, Europe, Australia and New Zealand. GRACE2 (Expanded GRACE) comprised 154 hospitals in Europe, North and South America, Asia, Australasia and China. Continuous recruitment and follow-up took place between 1999 and 2009. The first 10 -20 patients per site (depending on hospital size) were enrolled each month, resulting in the recruitment of 102 341 patients, who were categorized as having ST-segment elevation myocardial infarction, non-ST-elevation myocardial infarction or unstable angina. Standardized case report forms (datafax or electronic) were completed by trained study coordinators, and included fields relating to demographic factors, comorbid conditions, treatments and in-hospital and post-discharge (6-month) events. Blood sampling, genetic analyses and longer-term follow-up were undertaken in GRACE substudies. Prospective individual patient follow-up was carried out. All sites were audited locally; 10% of individual patient records were audited in a 2-year cycle. Less than 1% of 20 key baseline fields, and less than 1% of discharge diagnosis and discharge status data, were missing. Six-month follow-up was 85% complete. Publications and risk scores are available at http://www.outcome.org/grace. Proposals for specific analyses were considered, in competition, by an independent publications committee.

Gotzmann, Michael; Hehen, Tobias; Germing, Alfried; Lindstaedt, Michael; Yazar, Aydan; Laczkovics, Axel; Mumme, Achim; Mügge, Andreas; Bojara, Waldemar

doi: 10.1136/hrt.2009.180661pmid: 19884109

ObjectiveThis prospective study aimed to determine to what extent clinical symptoms and neurohumoral activation are improved in patients with severe aortic valve stenosis after transcatheter aortic valve implantation (TAVI) with the CoreValve prosthesis.MethodsFrom June 2008 to June 2009 consecutive patients with symptomatic severe aortic valve stenosis (area<1 cm2), age≥75 years with a logistic EuroSCORE ≥15% or age>60 years plus additional specified risk factors were evaluated for TAVI. Examinations of study patients were performed before and 30 days after TAVI and comprised assessment of quality of life (Minnesota living with heart failure questionnaire, [MLHFQ]) 6-minute walk test, measurement of B-type natriuretic peptide and echocardiography. Aortic valve prosthesis was inserted retrograde using a femoral arterial or a subclavian artery approach.ResultsIn 44 consecutive patients (mean age 79.1±7 years, 50% women, mean left ventricular ejection fraction 55.8±8.5%) TAVI was successfully performed. Follow-up 30 days after TAVI showed a significantly improved quality of life (baseline 44±19.1 vs 28±17.5 MLHFQ Score, p<0.001) and an enhanced distance in the 6-minute walk test (baseline 204±103 vs 266±123 m, p<0.001). B-type natriuretic peptide levels were reduced (baseline 725±837 vs 423±320 pg/ml, p=0.005).ConclusionsOur preliminary results show a significant clinical benefit and a reduction of neurohormonal activation in patients with severe and symptomatic aortic valve stenosis early after TAVI.

van Bommel, R J; Gorcsan, J; Chung, E S; Abraham, W T; Gjestvang, F T; Leclercq, C; Monaghan, M J; Nihoyannopoulos, P; Peraldo, C; Yu, C-M; Demas, M; Gerritse, B; Bax, J J

doi: 10.1136/hrt.2010.192542

Palka, Ilona; Nessler, Jadwiga; Nessler, Bohdan; Piwowarska, Wiesława; Tracz, Wieslawa; Undas, Anetta

doi: 10.1136/hrt.2010.192740pmid: 20610458

BackgroundThromboembolic complications occur more frequently in patients with chronic heart failure (CHF) than in the general population. Formation of a compact fibrin clot resistant to lysis has been shown in arterial and venous thrombosis.ObjectiveTo investigate fibrin clot properties in patients with CHF.MethodPlasma clot permeability, compaction, turbidity and fibrinolysis were assessed in 36 consecutive patients with stable CHF (30M, 6F; aged 64±10 years, left ventricular ejection fraction (LVEF) 34.9±6.7%) and 36 controls matched for age, sex, cardiovascular risk factors and medication. Exclusion criteria were LVEF >40%, anticoagulant therapy, previous thromboembolic events, atrial fibrillation.ResultsClots obtained from plasma of patients with CHF had 23% lower clot permeability (p<0.0001), 13% less clot compaction (p<0.001), 15% faster fibrin polymerisation (p<0.0001) and tended to have prolonged fibrinolysis time (p=0.1) compared with controls. C-reactive protein and fibrinogen were associated inversely with clot permeability (R2=0.84, p<0.0001 and R2=0.79, p<0.0001, respectively) and positively with fibrinolysis time (R2=0.88, p<0.0001 and R2=0.80, p<0.0001, respectively) in patients with CHF. Plasma thrombin–antithrombin complex concentrations were inversely correlated with clot permeability (R2=0.88, p<0.0001) and positively with fibrinolysis time (R2=0.91, p<0.0001). Left atrium diameter, but not LVEF, correlated with fibrinolysis time (R2=0.61, p=0.027).ConclusionsPatients with CHF with sinus rhythm are characterised by faster formation of compact plasma fibrin clots, which might predispose to thromboembolic complications.

Hill, Sharleen F; Sheppard, Mary N

doi: 10.1136/hrt.2009.185157pmid: 20511306

BackgroundThe concept of non-atherosclerotic coronary artery pathology in sudden cardiac death (SCD) has not been given the attention it deserves.ObjectiveTo determine the incidence of non-atherosclerotic coronary artery pathology in SCD and raise awareness among cardiologists and pathologists alike.DesignRetrospective non-case-controlled analysis.SettingCardiac pathology centre at the National Heart and Lung Institute and Royal Brompton Hospital.SubjectsBetween 1994 and 2008, the hearts of 1647 people undergoing SCD were referred for pathological assessment to ascertain the precise aetiology of SCD.ResultsFifty (3.0%) of the 1647 cases of SCD were associated with non-atherosclerotic coronary pathology (31 male subjects (62%) and 19 female subjects (38%, age range (8 weeks–71 years)). Twenty four of the 50 cases had anomalous coronary arteries (48%); eight cases had coronary artery dissection (16%); six cases had coronary artery vasculitis (12%); six cases had coronary artery spasm (12%); three cases had idiopathic arterial calcification of infancy (6%); two cases had fibromuscular dysplasia (4%) and one case had a benign tumour occluding the left coronary ostium (2%). Only 20 of the 50 patients (40%) were documented to have experienced cardiac symptoms such as syncope, chest pain on exertion or breathlessness before their SCD. Twelve of the patients (24%) died during or immediately after physical exertion.ConclusionNon-atherosclerotic coronary disease is associated with sudden death in all age groups, particularly younger, male patients. Cardiologists need to be aware of these entities and investigate any patient who has cardiac symptoms especially with exertion.

Kim, Joon Bum; Ju, Min Ho; Yun, Sung Cheol; Jung, Sung Ho; Chung, Cheol Hyun; Choo, Suk Jung; Lee, Taek Yeon; Song, Hyun; Lee, Jae Won

doi: 10.1136/hrt.2010.192435pmid: 20610459

BackgroundAlthough the Maze procedure is regarded as the most effective way to restore sinus rhythm in patients with chronic atrial fibrillation (AF), it remains unclear whether this procedure offers long-term clinical benefits in patients undergoing mechanical valve replacement.Methods and resultsBetween 1999 and 2007, 402 patients with AF-associated mitral valve (MV) disease underwent MV replacement with a mechanical prosthesis. Of these patients, 159 underwent valve replacement plus the Maze procedure, whereas 243 received valve replacement alone. The composite end points of cardiac death and cardiac-related morbidities were compared in these two groups using the inverse-probability-of-treatment-weighted method. At a median follow-up time of 63.1 months (range 0.2–123.9 months), patients who had undergone the Maze procedure were at significantly lower risk of thromboembolic events (hazard ratio (HR)=0.26, 95% confidence interval (CI) 0.07 to 0.95; p=0.041) and were at comparable risk of death (HR=0.96, 95% CI 0.44 to 2.07; p=0.907) and cardiac death (HR=1.26, 95% CI 0.53 to 3.01; p=0.598) compared with patients who underwent MV replacement alone. The composite risk of death or major events was lower in the Maze procedure group (HR=0.64, 95% CI 0.38 to 1.08; p=0.093).ConclusionsCompared with MV replacement alone, the addition of the Maze procedure was associated with a reduction in thromboembolic complications and better long-term event-free survival in patients with AF undergoing mechanical MV replacement. Prospective randomised data are necessary to confirm the findings of this study.

Andréll, P; Yu, W; Gersbach, P; Gillberg, L; Pehrsson, K; Hardy, I; Ståhle, A; Andersen, C; Mannheimer, C

doi: 10.1136/hrt.2009.177188pmid: 20483898

ObjectiveTo assess the long-term effect of spinal cord stimulation (SCS) on angina symptoms and quality of life in patients with refractory angina pectoris defined as severe angina due to coronary artery disease resistant to conventional pharmacological therapy and/or revascularisation.MethodsDuring 2003–2005, all patients with refractory angina referred for SCS treatment at 10 European centres were consecutively included in the European registry for refractory angina (European Angina Registry Link, EARL), a prospective, 3-year follow-up study. In the present study, the SCS-treated patients were followed-up regarding angina symptoms and quality of life assessed was with a generic (Short Form 36, SF-36) and a disease-specific (Seattle Angina Questionnaire, SAQ) quality of life questionnaire.ResultsIn total, 235 patients were included in the study. After screening, 121 patients were implanted and followed up 12.1 months after implantation. The implanted patients reported fewer angina attacks (p<0.0001), reduced short-acting nitrate consumption (p<0.0001) and improved Canadian Cardiovascular Society class (p<0.0001). Furthermore, quality of life was significantly improved in all dimensions of the SF-36 and the SAQ. Seven (5.8%) of the implanted patients died within 1 year of follow up.ConclusionsSCS treatment is associated with symptom relief and improved quality of life in patients with refractory angina pectoris suffering from severe coronary artery disease.