Heart Failure Requiring Hospital Admission Research Articles

Prognostic impact of the E/e′ ratio in patients with chronic severe aortic regurgitation undergoing aortic valve replacement

ObjectivesThe study objective was to evaluate the clinical implication of left ventricular diastolic dysfunction in patients with chronic severe aortic regurgitation undergoing aortic valve replacement. MethodsWe reviewed the medical records of 323 patients (age, 56.3 ± 14.1 years; 111 female) who underwent aortic valve replacement for chronic severe aortic regurgitation between 2005 and 2019. Left ventricular diastolic dysfunction was assessed by the ratio of peak left ventricular inflow velocity over mitral annular velocity (E/e′). The study end point was the composite of death and heart failure requiring hospital admission. ResultsThe E/e′ ratio was significantly correlated with age, left atrial dimension, left ventricular end-diastolic volume, mitral regurgitation grade, and tricuspid regurgitation grade (all P < .001). During follow-up (1748.3 patient-years), death and heart failure occurred in 36 patients (2.06/patient-year) and 9 patients (0.53/patient-year), respectively. In multivariable analysis, E/e′ ratio (per 5 increment, hazard ratio, 1.32; 95% confidence interval, 1.02-1.71; P = .03), age (hazard ratio, 1.06; 95% confidence interval, 1.03-1.10; P < .001), and left ventricular ejection fraction (hazard ratio, 0.94; 95% confidence interval, 0.90-0.98; P = .002) were independent predictors of death and heart failure. The 5-year heart failure–free survival was 94.9% ± 1.7% in patients with E/e′ less than 15% and 84.2% ± 4.2% in patients with E/e′ 15 or greater (P < .001). ConclusionsThe E/e′ ratio was significantly associated with adverse outcomes in patients with chronic severe aortic regurgitation undergoing aortic valve replacement and may be useful as a prognostic marker in such patients.

Prevalence and Prognostic Importance of Massive Tricuspid Regurgitation in Patients Undergoing Tricuspid Annuloplasty With Concomitant Left-Sided Valve Surgery: A Study on Rheumatic Valvular Heart Disease.

BackgroundThe presence of tricuspid regurgitation (TR) is very common in patients with concomitant left-sided valve disease. Recent studies have advocated an additional grading of massive TR that is beyond severe. The present study sought to characterize the spectrum of TR in patients undergoing tricuspid annuloplasty (TA) and to evaluate the prognostic value of TR severity for post-operative outcome following TA.MethodsA total of 176 patients who underwent TA with combined left-sided valve surgery, secondary to rheumatic valvular heart disease, were prospectively evaluated. The severity of TR was quantified by effective regurgitant orifice area (EROA) using the proximal isovelocity surface area method. Patients were categorized as having non-massive TR (EROA < 0.6 cm2) or massive TR (EROA ≥ 0.6 cm2). Adverse outcome was defined as all-cause mortality or heart failure requiring hospital admission following TA.ResultsA total of 55 (31%) patients were considered to have massive TR. Patients with massive TR had a greater right ventricular dimension but a smaller left ventricular dimension compared with those with non-massive TR. After a median follow-up of 39 months, 35 adverse events occurred. Cox-regression analysis showed that both continuous EROA and dichotomized EROA (massive vs. non-massive TR) were independently associated with adverse events even after multivariable adjustment. Further, Harrell C index demonstrated that the addition of massive TR provided better discrimination ability of a prediction model to known prognosticators following TA.ConclusionsMassive TR is common and up to 31% of study population had massive TR. Massive TR was associated with adverse outcome in patients undergoing TA. Classification of the severity of TR by quantitative measures and identification of massive TR in patients with concomitant left-sided valve disease are essential when considering the optimal timing of corrective surgery.

Prognostic value and reversibility of liver stiffness in patients undergoing tricuspid annuloplasty

Abstract Background Hepatic dysfunction was previously suggested to be related to poor outcome in patients undergoing tricuspid annuloplasty (TA), the predictive value of liver stiffness (LS) for adverse events is nonetheless uncertain. Purpose The aim of this study was to evaluate the prognostic value and reversibility of LS in patients undergoing TA. Methods A total of 158 patients (age 63, male 35%) who underwent TA during left-sided valve surgery were prospectively evaluated. Transient elastography was used to assess LS. Patients were divided into three groups according to tertiles of LS. Adverse outcome was defined as heart failure requiring hospital admission or mortality. Results The median LS was 13.9 (8.1–22.3) kPa which independently correlates with tricuspid regurgitation severity (assessed by effective regurgitant orifice area), inferior vena cava diameter and tricuspid annular plane systolic excursion. During a median follow-up of 31 months, 49 adverse events occurred. Multivariable Cox regression analysis demonstrated that LS was an independent predictor of adverse events. Furthermore, a higher LS tertile was predictive for adverse events (Hazard Ratio 4.19, P&amp;lt;0.01) even after adjusting for the other prognosticators. Kaplan-Meier curve showed that patients in the third tertile LS group had the highest percentage of adverse events followed by patients in the second tertile. Significant improvement of LS at 1-year post-TA was noted only in patients who had no adverse events but not in those who experienced heart failure. Conclusions The present study demonstrates that LS is predictive of adverse outcome in patients undergoing TA. These findings suggested that assessing LS, an integrative assessment of right heart condition, may aid the management of patients undergoing TA. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): The Health and Medical Research Fund from the Food and Health Bureau, the Government of Hong Kong Special Administrative Region.

PETCO2 gradient: a novel prognostic parameter in cardiopulmonary exercise testing

Abstract Background Previous parameters such as peak VO2, VE/VCO2 slope and OUES have been described to be prognostic in heart failure (HF). The aim of this study was to identify further prognostic factors of cardiopulmonary exercise testing (CPET) in HF patients. Methods A retrospective analysis of HF patients who underwent CPET from January to November 2019 in a single centre was performed. PETCO2 gradient was defined by the difference between final PETCO2 and baseline PETCO2. HF events were defined as decompensated HF requiring hospital admission or IV diuretics, or decompensated HF resulting in death. Results A total of 64 HF patients were assessed by CPET, HF events occurred in 8 (12.5%) patients. Baseline characteristics are shown in table 1. Patients having HF events had a negative PETCO2 gradient while patients not having events showed a positive PETCO2 gradient (−1.5 [IQR −4.8, 2.3] vs 3 [IQR 1, 5] mmHg; p=0.004). A multivariate Cox proportional-hazards regression analysis revealed that PETCO2 gradient was an independent predictor of HF events (HR 0.74, 95% CI [0.61–0.89]; p=0.002). Kaplan-Meier curves showed a significantly higher incidence of HF events in patients having negative gradients, p=0.002 (figure 1). Conclusion PETCO2 gradient was demonstrated to be a prognostic parameter of CPET in HF patients in our study. Patients having negative gradients had worse outcomes by having more HF events. Time to first event, decompensated heart Funding Acknowledgement Type of funding source: None

5947Predictive role of C-reactive protein levels in patients with ST-segment elevation acute myocardial infarction for heart failure related events

Abstract Background ST-segment elevation myocardial infarction (STEMI) is associated with an intense acute inflammatory response and an increased risk of death and heart failure (HF). C-reactive protein (CRP) is the inflammatory biomarker most commonly used for risk stratification in patients with cardiovascular diseases. CRP levels are known to rise and fall during STEMI in response to myocardial injury. In this study, we analyzed whether admission CRP or delayed CRP (measured at 72 hours after admission) held a greater predictive value for adverse HF events in patients with STEMI. Methods We analyzed data from the VCUART3 clinical trial enrolling 99 patients with STEMI within 12 hours of presentation at 3 sites in the United States of America treated with anakinra or placebo. CRP levels were measured with a high-sensitivity assay at time of admission and again at 72 hours later. A dedicated committee composed of individuals not involved in the conduct of the trial adjudicated HF events including a composite endpoint of death from any reason or incidence of HF defined as new-onset HF requiring hospital admission or a new prescription for a loop diuretic (D+HF) and a composite endpoint of death and HF hospitalization (D+HHF) at 1 year. We used a time-dependent Cox-regression analysis to determine the association of CRP at admission or at 72 hours with the outcomes of interest in univariate and multivariate analysis. Data are presented as median and interquartile range. (ClinicalTrials NCT01950299) Results CRP levels from admission and 72 hours were available in 90 and 87 subjects respectively and they increased from 4.6 [2.8–8.5] mg/L to 11.6 [4.6–24.5] mg/L (P&lt;0.001). Both admission CRP (CRP0) and CRP at 72 hours (CRP72) were associated with the risk of D+HF (P=0.011 and &lt;0.001, respectively) and of D+HHF (P=0.010 and P&lt;0.001, respectively); however at multivariate analysis, only CRP72 remained significantly associated with the risk of D+HF (P=0.001) and D+HHF (P=0.004) while CRP0 was not. CRP72 significantly correlated with NTproBNP levels at 72 hours (NTproBNP72, Spearman rho R=+0.37, P=0.001). NTproBNP72 predicted D+HF (P=0.030) but not independently of CRP72 (P=0.096 for NTproBNP72 and P=0.007 for CRP72 at multivariate analysis including the 2 variables). NTproBNP72 did not predict D-HHF. Conclusions Among contemporary patients with STEMI, the levels of CRP at 72 hours after admission was superior to admission CRP levels for predicting the incidence of HF events, and independent of NTproBNP levels. Our results indicate the importance of the inflammatory response during STEMI, supporting the concept of inhibiting the inflammatory response as a therapeutic strategy. Acknowledgement/Funding Funded by NHLBI 1R34HL121402; Drug supply from Swedish Orphan Biovitrum

Prognostic Value of Tricuspid Valve Geometry and Leaflet Coaptation Status in Patients Undergoing Tricuspid Annuloplasty: A Three-Dimensional Echocardiography Study

The advent of three-dimensional echocardiography (3DE) enables detailed evaluation of the tricuspid valve (TV) apparatus; nonetheless, the clinical value of preoperative 3DE is unknown in patients undergoing tricuspid annuloplasty (TA). The aim of this study was to evaluate the prognostic value of TV geometric parameters and leaflet coaptation status evaluated by 3DE in patients undergoing TA. A total of 122 patients who underwent TA during left-sided heart valve surgery were prospectively evaluated. Detailed 3DE was performed before surgery. Adverse outcome was defined as the occurrence of heart failure requiring hospital admission or all-cause mortality following TA. A total of 33 adverse events (17 heart failures and 16 deaths) occurred during a median follow-up of 36months. Tethering volume (hazard ratio=1.32; 95% CI=1.05-1.66; P=.01) and ratio of total leaflet length to closure length (hazard ratio=1.07; 95% CI=1.03-1.12; P<.01) were associated with adverse events after adjustment for age, sex, and tricuspid regurgitation vena contracta width. Receiver-operator characteristic curve analysis revealed that tethering volume (area under curve=0.73) and ratio of total leaflet length to closure length (area under curve=0.75) were most associated with adverse events at 1-year follow-up. The presence of either a large tethering volume or a low ratio of total leaflet length to closure length was predictive of an adverse outcome 1year following TA. Our study suggests that 3DE-derived TV tethering volume and ratio of total leaflet length to closure length are important preoperative measures associated with adverse events in patients undergoing TA.

Serum malondialdehyde-modified low-density lipoprotein levels on admission predict prognosis in patients with acute coronary syndrome undergoing percutaneous coronary intervention

BackgroundMalondialdehyde-modified low-density lipoprotein (MDA-LDL) is a predictive marker of cardiovascular events in patients with stable angina pectoris. However, little is known about this marker in patients with acute coronary syndrome (ACS). We investigated the prognostic relevance of MDA-LDL to cardiovascular outcomes in patients with ACS. MethodsA total of 370 consecutive patients with ACS who underwent primary percutaneous coronary intervention (PCI) were enrolled from October 2009 to September 2014 at Mitoyo General Hospital. Serum MDA-LDL levels were measured at admission. The patients were divided into three tertile groups according to serum MDA-LDL levels. The primary outcomes were cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, revascularization, and heart failure requiring hospital admission. ResultsMDA-LDL levels in patients with acute myocardial infarction were significantly greater than those in patients with unstable angina pectoris (mean±standard deviation: 133±48U/L vs. 157±69U/L, p=0.001). During follow-up [472 (195–920) days], 82 (22%) events occurred. Kaplan–Meier analysis showed that patients in the highest MDA-LDL tertile had the worst prognosis (log-rank, p<0.001). Cox regression analysis showed that serum MDA-LDL levels were an independent predictor of cardiovascular events after PCI in patients with ACS, even after adjustment for age, sex, body mass index, conventional cardiovascular risk factors, other lipid biomarkers, statin use on admission, cardiac biomarkers, and presence or absence of multivessel disease (hazard ratio: 1.80 per 1 standard deviation U/L increase, 95% confidence interval: 1.07–3.16, p=0.027). ConclusionSerum MDA-LDL levels on admission are a significant prognostic marker in patients with ACS who undergo successful PCI.

Prognostic significance of ventricular late potentials in patients with pulmonary sarcoidosis

Early detection of cardiac involvement in sarcoidosis is difficult but essential to achieve optimal treatment. Signal-averaged electrocardiography (SAECG) can detect subtle cardiac electrical abnormalities termed late potentials (LPs) and would be useful for the early diagnosis of cardiac involvement. This study aims to investigate the prognostic significance of LP in patients with pulmonary sarcoidosis. We prospectively studied 74 patients with pulmonary sarcoidosis without overt electrocardiographic abnormalities. All participants underwent SAECG, cardiac echocardiography, and 24-hour ambulatory Holter monitoring. Serum angiotensin-converting enzyme and B-type natriuretic peptide levels were also evaluated. We followed these patients for the evaluation of incidence of cardiac events including cardiac death, arrhythmias, and heart failure requiring hospital admission. Of the studied population, 29 patients (39.2%) had detectable LP. During a mean follow-up period of 9.8 years, 8 patients with LPs had cardiovascular events, including development of complete atrioventricular block (n = 4), ventricular tachycardia (n = 2), and heart failure (n = 2). Meanwhile, only 1 of 45 patients without LP developed cardiac event (heart failure). Multivariate analyses revealed that LPs were associated with an increased risk of developing cardiac events (hazard ratio 9.66; 95% confidence interval 1.20-78.01; P = .033) whereas age, sex, serum angiotensin-converting enzyme and B-type natriuretic peptide levels, number of premature ventricular contractions on 24-hour Holter monitoring, and echocardiographic parameters were not associated with subsequent cardiac events. SAECG might possibly be useful for the early detection of cardiac sarcoidosis and, if independently validated, could eventually be considered as a screening test for further risk stratification.

Applying current normative data to prognosis in heart failure: The Fitness Registry and the Importance of Exercise National Database (FRIEND)

IntroductionPercent of predicted peak VO2 (ppVO2) is considered a standard measure for establishing disease severity, however, there are known limitations to traditional normative values. This study sought to compare ppVO2 from the newly derived “Fitness Registry and the Importance of Exercise: a National Database” (FRIEND) registry equation to conventional prediction equations in a clinical cohort of patients undergoing cardiopulmonary exercise testing (CPX). Methods and resultsWe selected 1094 patients referred for evaluation of heart failure (HF) symptoms who underwent CPX. ppVO2 was calculated using the FRIEND, Wasserman/Hansen and Jones equations. Participants were followed for a median of 4.5 years [Interquartile range 3.5–6.0] for the composite endpoint of death, advanced HF therapy, or acute decompensated HF requiring hospital admission. Mean age was 48 ± 15 years and 62% were female. The FRIEND registry equation predicted the lowest ppVO2 (measured/predicted; 71 ± 31%), compared to the Wasserman/Hansen (74 ± 29%) and Jones equations (83 ± 33%) (p < 0.001). All expressions of peak VO2 were significant as univariate predictors of outcome with no significant differences between equations on pairwise analysis of receiver operating characteristic curves. When compared at a similar threshold of ppVO2 the event rate was significantly lower in the FRIEND registry equation versus the currently used Wasserman and Jones equations. ConclusionThe use of the newly derived FRIEND registry equation predicts HF outcomes; however, it appears to predict a higher predicted VO2; the clinical implication being a lower threshold of percent predicted peak VO2 should be considered when risk stratifying patients with HF.

High levels of stromal cell-derived factor-1α predict secondary cardiac events in stable patients with a history of myocardial infarction

BackgroundWe recently showed that stromal cell-derived factor (SDF)-1α, a pro-inflammatory mediator, is produced in infarcted myocardium and is associated with left ventricular (LV) adverse remodeling and progressive dysfunction following acute myocardial infarction (AMI). The current study examined whether SDF-1α levels in the peripheral vein can provide prognostic information of outcomes in stable patients with a history of MI. MethodsPlasma levels of SDF-1α in the peripheral vein were measured by enzyme-linked immunosorbent assay in 192 stable patients with a history of MI. All patients were followed prospectively for a period of 90 months or until occurrence of one of the following cardiac events: cardiac death, non-fatal myocardial infarction, unstable angina requiring unplanned coronary revascularization, or worsening heart failure requiring hospital admission. ResultsDuring the follow-up period (77±26 months), 30 patients had cardiac events. Multivariate Cox analysis revealed that high levels of SDF-1α (≥2162pg/mL; a cut-off value determined by receiver-operating characteristic analysis) were a significant predictor of cardiac events, independent of traditional risk factors (HR: 1.98; 95% CI: 1.38–2.85; p<0.001). The addition of high levels of SDF-1α to conventional risk factors including brain natriuretic peptide improved net reclassification improvement (NRI) and integrated discrimination improvement (IDI) (NRI 0.90, p<0.0001; and IDI 0.05, p=0.002). ConclusionsHigh levels of SDF-1α predicted secondary cardiac events in stable patients with a history of MI. SDF-1α levels may be a useful risk assessment tool in patients with a history of MI.

Experience of a Newly Established Multidisciplinary Heart Failure Clinic at a VA Hospital

Experience of a Newly Established Multidisciplinary Heart Failure Clinic at a VA Hospital

0271 : Predictive factors and prognostic value of myocardial viability in cardiac magnetic resonance imaging and impact of revascularization therapy through 121 cases

The purpose of this study is to evaluate predictive factor and the impact of myocardial viability assessment by cardiac magnetic resonance imaging (CMRI) and of revascularization therapy in 121 patients with coronary artery disease (CAD). Between September 2009 and August 2014, we collected 121patients followed up for chronic ischemic heart disease or myocardial infarction (MI). We conducted a descriptive study of echocardiographic and CMRI data. Transmurality is analyzed semi-quantitatively. Alone were considered viable segments having a transmurality less than 50%. Predictive factors of myocardial viability in cardiac magnetic resonance imaging was sought in univariate then multivariate analysis: only angina recurrences was purveyor of presence of viability (p=0.02) and ventricular tachycardia (p=0.001), apical thrombus (p=0,01), apical dyskinésia (p=0.02), restrictive mitral flow (0.01), The left ventricular end-diastolic diameter>70mm (p<0.0001) and ejection fraction <25% (p<0.0001) were in favor of lack of viability. 46% of patients had a delayed contrast enhancement <50% showing presence of myocardial viability, whose 41.6% in the suites of an MI and 58.4% with chronic ischemic LV dysfunction. 38% of patients underwent surgical revascularization and angioplasty in 62%. After a mean follow-up of approximately one year, we have 28% of disappearance of angina recurrences, Heart failure requiring hospital admission is decreased in 36% and the LVEF is improved between 5 and 15% in 22%. With the increase in the prevalence of ischemic heart disease, myocardial hibernation research and prediction of functional recovery after revascularization are important to clarify. CMRI remains the gold standard for prognostic stratification.

New mechanistic and therapeutic targets for pediatric heart failure: report from a National Heart, Lung, and Blood Institute working group.

Pediatric heart failure (HF) is the inability of the heart of an infant, child, or adolescent to meet the body’s metabolic demands. It involves circulatory, neurohumoral, and molecular abnormalities that manifest as edema, respiratory distress, growth failure, and exercise intolerance. The myriad causes include inherited and acquired myocardial anomalies (cardiomyopathy [CM]), volume overload (intracardiac shunts, valvular regurgitation), and the unique hemodynamics predicated by a functional single ventricle (palliated complex congenital heart disease [CHD]). Although the societal and financial costs of adult HF are well known, the burden of pediatric HF is less familiar, but no less onerous. New-onset HF requiring hospital admission occurs in 0.87 per 100 000 children,1 yet that does not include the growing population with CHD-related HF. In 2006, there were nearly 14 000 pediatric hospitalizations for HF from all causes in the United States.2 The rate of HF-related admissions was nearly 18 per 100 000 children,2 which is comparable to severe sepsis.3 The mortality for pediatric HF hospitalizations is significant. The 7% overall hospital mortality rate exceeds the 4% mortality of adult HF admissions4 and represents a 20-fold increase over children without HF.2 With comorbidities like renal failure, sepsis, or stroke, hospital mortality in pediatric HF can exceed 20%,2 yet the risk does not end with discharge. After an initial HF hospitalization, only 21% of children in 1 study avoided readmission, death, or transplantation.5 Pediatric HF treatment is resource intensive. Although the total healthcare costs for pediatric HF are lower than for adults, per-patient costs are higher. The estimated hospital charge per pediatric HF admission in 2006 was >$135 000, with aggregate charges exceeding $1.8 billion.6 Certain subpopulations of pediatric HF incurred disproportionally higher costs. For example, single-ventricle CHD averaged >$200 000 per hospitalization,7 whereas adult …

Diabetes, aliskiren, and heart failure: let's bring ASTRONAUT down to earth

This editorial refers to ‘Effect of aliskiren on post-discharge outcomes among diabetic and non-diabetic patients hospitalized for heart failure: insights from the ASTRONAUT trial’[†][1], by A.P. Maggioni et al. , on page 3117 ASTRONAUT (Aliskiren Trial on Acute Heart Failure Outcomes) failed to show that aliskiren was superior to placebo in reducing cardiovascular events when prescribed to patients with a reduced left ventricular ejection fraction who had recently recovered from worsening heart failure requiring hospital admission.1,2 Clinicians are tempted to look at outcome in patient subgroups because they are required to evaluate the efficacy and safety of an intervention for individual patients and believe that such analyses may help them in their practice. Unfortunately, subgroup analyses are commonly misinterpreted and often misleading.3–5 In ASTRONAUT, interactions between the effects of treatment and patient characteristics were sought in 21 subgroups, including two separate analyses by age. For the primary endpoint, cardiovascular death or re-hospitalization for heart failure at 6 months, no statistically significant subgroup interactions were identified, although a trend ( P = 0.08) was noted for diabetes. The analysis was then repeated for four secondary endpoints; now potentially 105 subgroup analyses. For all-cause mortality, this identified a nominally statistically significant interaction ( P < 0.01) between treatment assigned and diabetes; patients who did not have diabetes who were assigned to aliskiren appeared to fare better. This led the investigators to speculate that the neutral outcome in ASTRONAUT might be due to a lack of effect, or even harm, amongst patients bearing a diagnosis of diabetes mellitus and that substantial benefit may have accrued in other patients. However, the simplest explanation for most subgroup effects is a chance observation due to multiple testing.3–5 Some corroborative evidence can be found suggesting that aliskiren might be harmful in … [1]: #fn-2

Assessment of lipophilic vs. hydrophilic statin therapy in Acute Myocardial Infarction (The ALPS-AMI study)

Purpose: Statins reduce the incidence of cardiovascular events in patients with acute myocardial infarction (AMI). Although previous studies have reported some potential differences in the efficacy between lipophilic and hydrophilic statins, no randomized study addressing this issue has been performed. In the present study, we aimed to compare the efficacy of therapy involving the use of lipophilic atorvastatin or hydrophilic pravastatin for secondary prevention after AMI. Methods: A prospective, randomized, open-labeled, multicenter study comprised 510 patients (412 men; mean age, 65.98±11.59 years) with AMI, who were randomly allocated to receive either atorvastatin (n = 253) or pravastatin (n = 257) to maintain their low-density lipoprotein-cholesterol (LDL-C) levels < 100 mg/dL, according to the Japan Atherosclerosis Society Guidelines for prevention of atherosclerotic cardiovascular diseases. Treatment was initiated within 4 days after AMI onset and patients were followed for 2 years after the primary coronary intervention. The composite primary endpoint consisted of death due to any cause, nonfatal myocardial infarction, nonfatal stroke, unstable angina or congestive heart failure requiring hospital admission, or any type of coronary revascularization. Results: There was no difference in Kaplan-Meier event-free curves of the 2 groups (p = 0.1435 by the log-rank test) for primary endpoints, which occurred in 52 patients (20.55%) in the pravastatin group and in 66 patients (25.68%) in the atorvastatin group. Serum total cholesterol and LDL-C levels decreased more significantly in the atorvastatin group than in the pravastatin group (p < 0.01 each at 1, 2, 6, 12, and 24 months). Per-protocol analysis and intention-to-treat analysis yielded comparable results between the 2 groups. Safety and treatment adherence were similar between the 2 groups. Moreover, no significant changes were observed in serum levels of HbA1c, brain natriuretic peptide, and creatinine in both groups during the follow-up period. Conclusion: Although the efficacy of pravastatin in the lowering LDL-C level was less potent than that of atorvastatin, its protective effects against secondary cardiovascular events were not inferior to those exerted by atorvastatin. This is the first multicenter trial to indicate that the efficacy and safety of lipophilic and hydrophilic statin therapy is comparable in Japanese patients with AMI.

Remote Ischemic Preconditioning Improves Outcome at 6 Years After Elective Percutaneous Coronary Intervention

Postprocedural myocardial infarction (type 4a) has been shown to be an adverse prognostic indicator after elective percutaneous coronary intervention (PCI). The Cardiac Remote Ischemic Preconditioning in Coronary Stenting (CRISP Stent) study demonstrated that remote ischemic preconditioning reduced procedural symptoms, ECG ST-segment deviation, and cardiac troponin I release after elective PCI and reduced the major adverse cardiac and cerebral event (MACCE) rate at 6 months. We were interested to confirm if this early benefit in MACCE rate in the remote ischemic preconditioning group was sustained long-term. Patients were telephoned by researchers blinded to the randomization details. MACCE, defined as all-cause mortality, nonfatal myocardial infarction, transient ischemic attack or stroke, and heart failure requiring hospital admission, were adjudicated by case note and national database review. One hundred ninety-two (89.3%) of the 225 patients with elective PCI randomized in the original study were available for long-term follow-up (mean time to event or last follow-up: 1579.7±603.6 days). There were a total of 59 (30.7%) MACCEs. Patients with an MACCE had a higher mean cardiac troponin I after PCI (±SD): 2.07±6.99 versus 0.91±2.07 ng/mL (P=0.05). The MACCE rate at 6 years remained lower in the remote ischemic preconditioning group (hazard ratio, 0.58; 95% confidence interval, 0.35-0.97; P=0.039; absolute risk reduction=0.13 and number needed to treat=8 to prevent the MACCE at 6 years). Remote ischemic preconditioning reduces the incidence of postprocedural cardiac troponin I after elective PCI and confers an MACCE-free survival benefit at both short- and long-term follow-up. URL: http://www.ukcrn.org.uk. Unique identifier: UKCRN 4074.

Prediction of Contrast‐Induced Nephropathy With Persistent Renal Dysfunction and Adverse Long‐term Outcomes in Patients With Acute Myocardial Infarction Using the Mehran Risk Score

Contrast-induced nephropathy (CIN) has been generally considered to be transient and associated with unfavorable clinical outcomes. The aim of this study was to investigate whether Mehran risk score could predict CIN with persistent renal dysfunction and long-term clinical outcomes in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI). We analyzed the clinical data of 1041 AMI patients. The primary end point was defined as major adverse cardiovascular and cerebrovascular event (MACCE) including death, reinfarction, target vessel revascularization, heart failure requiring hospital admission, and stroke. Patients were categorized into 4 groups according to risk scores: low (≤ 5, n = 596), moderate (6-10, n = 265), high (11-15, n = 111), and very high (≥16, n = 69). Among the 148 patients (14.2%) who developed CIN, persistent renal dysfunction was observed in 68 patients. Presence in high- or very high-risk groups was the most important independent risk factor of CIN with persistent renal dysfunction (odds ratio: 3.35, 95 confidence interval [CI]: 1.89-5.92, P < 0.001). Furthermore, patients in higher-risk groups experienced significantly more MACCE and mortality 2 years after PCI. Using multivariate analysis, significant increase in the hazard ratio (HR) for MACCE was noted in moderate- (HR: 1.40, 95% CI: 0.97-2.03, P = 0.075), high- (HR 1.96, 95% CI: 1.22-3.15, P = 0.006), and very high-risk (HR 2.40, 95% CI: 1.36-4.21, p = 0.002) groups, compared with the low-risk group. The very high-risk group had approximately 6-fold increase in mortality over the low-risk group (HR: 6.22, 95% CI: 2.77-13.95, P < 0.001). Mehran risk score predicted CIN with persistent renal dysfunction and long-term clinical outcomes in patients with AMI.

Prognostic value of myocardial perfusion SPECT images in combination with the maximal heart rate at exercise testing in Japanese patients with suspected ischemic heart disease: a sub-analysis of J-ACCESS

We assessed whether a combination of summed stress scores (SSS) using exercise myocardial perfusion SPECT (Ex-SPECT) and maximal heart rate accurately predicts cardiac events through a sub-analysis of J-ACCESS (Japanese Assessment of Cardiac Events and Survival Study by Quantitative Gated SPECT) which was conducted to evaluate the prognosis of Japanese patients with suspected ischemic heart disease. In J-ACCESS, 2,373 patients with suspected coronary artery disease not receiving beta-blocker treatment underwent Ex-SPECT. These patients were categorized into the following four groups: Group A [achieved target heart rate (THR) and SSS < 4: n = 631], B (did not achieve THR and SSS < 4: n = 612), C (achieved THR and SSS >or= 4: n = 570), and D (did not achieve THR and SSS >or= 4: n = 560). We evaluated the incidence rate of cardiac events including cardiac death, myocardial infarction, and heart failure requiring hospital admission during a 3-year period. In Group A, B, C, and D, 9 of 631 (1.4%), 15 of 612 (2.4%), 23 of 570 (4.0%) and 30 of 560 (5.4%) patients experienced cardiac events, respectively. Although the hazard ratio of the SSS >or= 4 was 2.45 (p < 0.001) and that of the attained THR was 0.69 (p = 0.10) in the multiple Cox regression analysis, Kaplan-Meier curves showed that the cardiac events rate was lower in the order of A, B, C, and D (p < 0.001). The combination of SSS using Ex-SPECT and the maximal heart rate is a useful predictor of cardiac events in patients with suspected coronary artery disease.

Rationale and design of assessment of lipophilic vs. hydrophilic statin therapy in acute myocardial infarction (the ALPS-AMI) study

Statins reduce the incidence of cardiovascular events in patients with acute myocardial infarction (AMI). Although all statins are equally effective in secondary prevention, there might be certain differences in the effects of lipophilic and hydrophilic statins. Therefore, our aim is to compare the effectiveness of lipophilic atorvastatin and hydrophilic pravastatin in secondary prevention after AMI. This study is a prospective, randomized, open-label, multicenter study of 500 patients with AMI. Patients that have undergone successful percutaneous coronary intervention will be randomly allocated to receive either atorvastatin or pravastatin with the treatment goal of lowering their low-density lipoprotein-cholesterol level below 100 mg/dl for 2 years. The primary endpoint will be death due to any cause, nonfatal MI, nonfatal stroke, unstable angina, or congestive heart failure requiring hospital admission, or any type of coronary revascularization. This is the first multicenter trial to compare the effects and safety of lipophilic and hydrophilic statin therapy in Japanese patients with AMI. It addresses an important issue and could influence the use of statin treatment in the secondary prevention of coronary artery disease.

Factors associated with development of late significant tricuspid regurgitation after successful left-sided valve surgery

Background: Persistent significant tricuspid regurgitation (TR) after successful left-sided valve surgery is frequently reported. Objectives: To evaluate the incidence, risk factors and clinical impact of development of late significant TR...