Heart Failure Score Research Articles

Dose Escalation of Tamoxifen in Patients with Low Endoxifen Level: Evidence for Therapeutic Drug Monitoring—The TADE Study

Endoxifen is the major mediator of tamoxifen effect and endoxifen levels <15 nmol/L may be associated with increased risk of breast cancer recurrence. We increased tamoxifen dose in breast cancer patients with low endoxifen levels and assessed the influence of various parameters on reaching 15 nmol/L and 30 nmol/L endoxifen levels. Tamoxifen dose was increased in those with endoxifen levels below 30 nmol/L. Toxicity, including hot flash score, was measured. CYP2D6 metabolizer status was classified as ultra-rapid (UM), extensive (EM), intermediate (IM), or poor (PM) based genotype of somatic DNA. Dosage was escalated in 68 of 122 participants. On 20 mg tamoxifen, 24% had endoxifen levels below 15 nmol/L and this reduced to 6% following dose escalation. In over 50% of cases, there was no identified cause for low endoxifen. Low baseline endoxifen level, and not CYP2D6 metabolizer status, independently predicted reaching threshold targets for both the 15 nmol/L and 30 nmol/L targets (P = 0.04 and 0.003 respectively). The 15 nmol/L target was reached in all UM/EM and IM patients, 63% of PM patients, and 58% of those with baseline endoxifen of <10 nmol/L. There was no correlation between hot flash score and genotype or any tamoxifen metabolite level including endoxifen (R = 0.07). Low endoxifen on standard dose tamoxifen was the only independent predictor of failure to achieve potentially therapeutic levels. Trials examining tamoxifen dose escalation and breast cancer outcome should be guided by endoxifen levels alone, without reference to CYP2D6 genotype or presence of hot flashes. Clin Cancer Res; 22(13); 3164-71. ©2016 AACRSee related commentary by Hertz and Rae, p. 3121.

Focal fibrosis and diffuse fibrosis are predictors of reversed left ventricular remodeling in patients with non-ischemic cardiomyopathy

BackgroundPrognostic value of myocardial fibrosis in patients with non-ischemic idiopathic dilated cardiomyopathy (DCM) is not well-defined. We sought to assess the association of focal and diffuse myocardial fibrosis with left ventricular reversed remodeling (LVRR). MethodsPatients with DCM who underwent cardiac MRI with baseline and subsequent follow-up echocardiography were included in the study. Post-contrast T1 times were corrected for renal function, body size, gadolinium dose and time after Gadolinium injection. Patients were followed over a median time of 29months to evaluate changes of left ventricular end-systolic volume (LVESV). A Linear Mixed Model was used to assess the relationship between the LVESV during follow-up, corrected post-T1 value delayed hyperenhancement (DHE), and modified Seattle Heart Failure Score (SHFS). ResultsA total of 103 patients (mean age 51±15years, 61% male) were evaluated. The mean LVEF was 33±11%, LVESVi 62±39ml/m2, and T1 time 416±98. DHE was identified in 45 patients (44%). Patients with focal DHE (n=45) had higher LVESVi at baseline and during follow-up (p=0.024). Post T1 value >450 was an independent predictor of LVRR at the follow-up (Δ=24.6ml/m2 SE 14.6ml/2, p=0.0480) in patients despite the presence of DHE, even after adjusting for their SHFS. ConclusionWhile DCM patients with focal DHE demonstrated greater adverse LV remodeling than those without focal fibrosis, diffuse fibrosis independently predicts LVRR in DCM patients in patients despite the presence of focal fibrosis.

Carotid Atherosclerosis and Stroke in Atrial Fibrillation

Whether consideration of carotid intima-media thickness (cIMT) and carotid plaque would improve risk prediction of ischemic stroke in persons with atrial fibrillation (AF) is unknown. The purpose of this study was to assess the improvement in risk prediction of stroke by adding cIMT and carotid plaque to the CHA2DS2-VASc (variables age, heart failure, hypertension, diabetes mellitus, myocardial infarction, and peripheral arterial disease) score. We included participants from the Atherosclerosis Risk in Communities (ARIC) study (mean age, 63 years) who developed AF within 5 years after carotid measurement, were not on warfarin, and had no prior stroke at AF diagnosis. AF was ascertained from study ECGs and diagnosis codes, and stroke was physician adjudicated. Multivariable Cox models were used to assess association between carotid indices and ischemic stroke. Improvement in 10-year risk prediction of stroke was assessed by the C-statistic, net reclassification improvement, and relative integrated discrimination improvement. There were 81 (11.2%) stroke events that occurred among 724 participants with AF during a mean follow-up of 8.5 years. Increased cIMT and presence of carotid plaque were significantly associated with increased stroke risk. The addition of cIMT+plaque to the CHA2DS2-VASc score marginally increased the C-statistic (95% confidence interval) from 0.685 (0.623-0.747) to 0.698 (0.638-0.759). The net reclassification improvement and integrated discrimination improvement for cIMT+plaque were 0.091 (95% confidence interval, 0.012-0.170) and 0.101 (95% confidence interval, 0.002-0.226), respectively. Increased cIMT and presence of carotid plaque are associated with increased risk of ischemic stroke in individuals with AF. Furthermore, they may improve risk prediction of stroke, over and above the CHA2DS2-VASc score.

Efficacy of biventricular pacing on preventing heart failure in patients with high degree atrioventricular block (BIVPACE-AVB Trial)

To investigate the long-term effect of biventricular (BIV) and right ventricular apical (RVA) pacing on cardiac function in patients with high-degree atrioventricular block (AVB) and left ventricular ejection fraction(LVEF)over 35%. A total of 118 consecutive patients with high-degree AVB in six hospitals from East China between May 2009 and December 2012 were enrolled in this randomized, double-blind and parallel controlled study. Patients were randomly assigned to BIV and RVA pacing with or without LV lead on after one-week cardiac resynchronization therapy (CRT). Cardiac function including New York Heart Association(NYHA), 6 minute walking distance (6MWD), Minnesota living with heart failure (MLHF) score, LVEF, left ventricular end-diastolic volumes/diameters (LVEDV/LVEDD) and other echocardiography parameters, as well as N-terminal pro-B-type natriuretic peptide (NT-proBNP)were assessed at 6 months and 12 months. A total of 114 patients were successfully implanted with CRT. Cardiac function was significantly improved after one-week BIV pacing (n=57) compared with pre-CRT: rate of patients with NYHA Ⅲ (25.44%(29/114) vs. 9.65%(11/114)), MLHF score (17.1±13.6 vs. 26.9±21.6), 6MWD ((315.4±121.8)m vs. (291.8±102.9)m) and NT-proBNP (157.0(70.0, 639.0) ng/L vs. 444.7(144.0, 1 546.0)ng/L, all P<0.05). In BIV group, 6MWD extended from (314.8±142.7)m to (332.7±117.5)m at 6 months (P<0.05), LVEF increased from (60.7±7.9)% at 1 week to (56.6±10.7)% at 6 months(P<0.05), both LVEDV and LVEDD decreased at 12 months compared with at 1 week ((116.2±39.5)ml vs. (131.4±49.6)ml and (50.2±5.6)mm vs. (52.5±6.8)mm, P<0.05). In RVA group (n=57), 6MWD increased at 6 months compared that at 1week ((342.4±109.9)m vs. (310.2±105.1)m, P<0.05), NT-proBNP was higher at 12 months than that at 1 week (349.5(191.8, 884.3)ng/L vs. 127.0(70.3, 336.7)ng/L, P<0.05). Compared with RVA group, BIV group had a bigger shrink in LVEDV decrease at 12 months was more significant in BIV group ((-16.68±24.30)ml vs. (9.09±29.30)ml, P<0.05). Cardiac pacing could acutely improve the cardiac function in patients with high-degree AVB and LVEF over 35%. Improvements on cardiac function and remodeling are more significant after 12-month BIV pacing than that of RVA pacing. Clinical Trail Registry: Chinese Clinical Trial Registry, ChiCTR-TRC-10000832.

Community Screening for Nonischemic Cardiomyopathy in Asymptomatic Subjects ≥65 Years With Stage B Heart Failure

A process to identify and target a selected population at risk of heart failure (HF) could facilitate screening and prevention. We sought to develop an effective screening process from clinical characteristics, functional capacity, and electrocardiogram (ECG). Asymptomatic subjects ≥65years, with ≥1 HF risks were recruited from the community. Subjects with valvular disease, ejection fraction <40%, and atrial fibrillation were excluded. All underwent clinical evaluation including assessment of HF risk using Framingham HF score and Atherosclerosis Risk in Communities (ARIC) score, ECG, echocardiography, and 6-minute walk (6MW) test. After 14 ± 4months, new HF was assessed using Framingham criteria. A randomly selected derivation cohort was used to integrate ARIC score and 6MW in a classification and regression tree (CART) analysis, with the remaining population used for validation. Of the 419 subjects (age 70 ± 5; 48% men), 52 developed HF. ARIC was more effective than the Framingham HF score (area under the curve 0.65 vs 0.53, p= 0.01). CART selected ARIC (>9.5%) and 6MW (<501 m) as cutoffs to define low-, intermediate-, and high-risk groups. Abnormal ECG further divided the intermediate group into high and low risks. The 134 subjects identified as high risk by a combined clinical and electrocardiographic strategy showed more echocardiographic features of cardiac dysfunction including LV mass, mitral e', mitral E/e', and longitudinal strain (p <0.01). New HF was significantly more frequent than in the remaining patients (20% vs 10%, p= 0.003; hazard ratio 2.08, 95% confidence interval 1.21 to 3.57, p= 0.008). Thus, initial clinical risk and electrocardiographic assessment facilitate effective HF screening by identifying a high-risk group.

Acupuncture As an Integrative Approach for the Treatment of Hot Flashes in Women With Breast Cancer: A Prospective Multicenter Randomized Controlled Trial (AcCliMaT).

To determine the effectiveness of acupuncture for the management of hot flashes in women with breast cancer. We conducted a pragmatic, randomized controlled trial comparing acupuncture plus enhanced self-care versus enhanced self-care alone. A total of 190 women with breast cancer were randomly assigned. Random assignment was performed with stratification for hormonal therapy; the allocation ratio was 1:1. Both groups received a booklet with information about climacteric syndrome and its management to be followed for at least 12 weeks. In addition, the acupuncture group received 10 traditional acupuncture treatment sessions involving needling of predefined acupoints. The primary outcome was hot flash score at the end of treatment (week 12), calculated as the frequency multiplied by the average severity of hot flashes. The secondary outcomes were climacteric symptoms and quality of life, measured by the Greene Climacteric and Menopause Quality of Life scales. Health outcomes were measured for up to 6 months after treatment. Expectation and satisfaction of treatment effect and safety were also evaluated. We used intention-to-treat analyses. Of the participants, 105 were randomly assigned to enhanced self-care and 85 to acupuncture plus enhanced self-care. Acupuncture plus enhanced self-care was associated with a significantly lower hot flash score than enhanced self-care at the end of treatment (P < .001) and at 3- and 6-month post-treatment follow-up visits (P = .0028 and .001, respectively). Acupuncture was also associated with fewer climacteric symptoms and higher quality of life in the vasomotor, physical, and psychosocial dimensions (P < .05). Acupuncture in association with enhanced self-care is an effective integrative intervention for managing hot flashes and improving quality of life in women with breast cancer.

Incremental Value of Gait Speed in Predicting Prognosis of Older Adults With Heart Failure: Insights From the IMAGE-HF Study

ObjectivesThe aim of this study was to assess the relationship between gait speed and the risk for death and/or hospital admission in older patients with heart failure (HF). BackgroundGait speed is a reliable single marker of frailty in older people and can predict falls, disability, hospital admissions, and mortality. MethodsIn total, 331 community-living patients ≥70 years of age (mean age 78 ± 6 years, 43% women, mean ejection fraction 35 ± 11%, mean New York Heart Association functional class 2.7 ± 0.6) in stable condition and receiving optimized therapy for chronic HF were prospectively enrolled and followed for 1 year. Gait speed was measured at the usual pace over 4 m, and cutoffs were defined by tertiles: ≤0.65, 0.66 to 0.99, and ≥1.0 m/s. ResultsThere was a significant association between gait speed tertiles and 1-year mortality: 38.3%, 21.9%, and 9.1% (p < 0.001), respectively. On multivariate analysis, gait speed was associated with a lower risk for all-cause death (hazard ratio: 0.62; 95% confidence interval: 0.43 to 0.88) independently of age, ejection fraction <20%, systolic blood pressure, anemia, and absence of beta-blocker therapy. Gait speed was also associated with a lower risk for hospitalization for HF and all-cause hospitalization. When gait speed was added to the multiparametric Cardiac and Comorbid Conditions Heart Failure risk score, it improved the accuracy of risk stratification for all-cause death (net reclassification improvement 0.49; 95% confidence interval: 0.26 to 0.73, p < 0.001) and HF admissions (net reclassification improvement 0.37; 95% confidence interval: 0.15 to 0.58; p < 0.001). ConclusionsGait speed is independently associated with death, hospitalization for HF, and all-cause hospitalization and improves risk stratification in older patients with HF evaluated using the Cardiac and Comorbid Conditions Heart Failure score. Assessment of frailty using gait speed is simple and should be part of the clinical evaluation process.

Evaluation and prediction of medical complications after hip fracture surgery

Objective To analyse the risk factors of medical complications after hip fracture surgery. Methods Clinical data of 327 hip fracture patients undergoing surgical treatment in Beijing Haidian Hospital from January 2009 to December 2013 were retrospectively studied. There were 114 males and 213 females with a mean age of (75.1±15.6) years, 129 patients(39.4%) had femoral neck fractures, and 198 patients(60.6%)had intertrochanteric fractures. Fifty four patients had medical complications during hospitalization (complication group) and 273 patients did not have complications (non-complications group). The clinical features, presurgical comorbidities and operative parameters were documented and compared between two groups. The risk factors of medical complications were assessed by regression analysis. Results Univariate analysis showed that age (t=2.85, P=0.007), lying in bed before fracture(χ2=12.86, P=0.000), the history of chronic obstructive pulmonary diseases(COPD) (χ2=9.45, P=0.000), coronary heart disease(χ2=10.67, P=0.000), heart failure(χ2=15.85, P=0.000), diabetes (χ2=3.22, P=0.024), cerebrovascular disease(χ2=4.21, P=0.008), anesthesia method(χ2=8.67, P=0.018), American Society of Anesthesiologists(ASA) score ≥3 level(χ2=2.01, P=0.042) and the delay time of operation (t=4.24, P=0.037) were significantly different between two groups. Multivariate regression analysis revealed that age(β=0.030, OR=1.030), lying in bed before fracture (β=2.303, OR=10.716), the history of COPD (β=0.831, OR=1.995), coronary heart disease(β=0.858, OR=2.392), heart failure(β=1.971, OR=7.333)and ASA score ≥3 level(β=0.809, OR=2.583) were the independent risk factors of medical complications after hip fracture surgery. Conclusion Age, lying in bed before fracture, the history of COPD, coronary heart disease, heart failure and ASA score ≥3 level would increase the risk of postoperative medical complications for patients with hip fracture. Key words: Hip fractures; Postoperative complications; Medical complications; Forecasting

Comparison of the symptomatic response in Indian menopausal women with different estrogen preparations for the treatment of menopausal symptoms: a randomized controlled trial.

To compare symptomatic response in Indian women using different estrogen preparations for treatment of menopausal symptoms. A randomized, single blind, four arm, parallel assignment study was conducted in VMMC and SJH, New Delhi, India. 200 Indian menopausal women were recruited and assigned into four treatment groups viz., estradiol valerate (E2V), conjugated equine estrogen (CEE), isoflavones and Placebo group. The statistical significance of categorical variables was determined by Chi-square, Fisher's exact test. In case of quantitative variable parametric test Student's t test was used. In case of quantitative variables where data are not normally distributed, Kruskal-wallis test and Wilcoxon Mann-Whitney test were used. Symptomatic response in vasomotor/vaginal symptoms was assessed in all groups. Both E2V and CEE groups were effective in reducing severity and frequency of hot flashes. 91.9% decrease was observed in mean hot flash score in the E2V group after 24weeks of treatment, 89.2% in the CEE group, 60.42% decrease in the isoflavones group. While placebo led to 47.9% decrease in mean hot flash score. After 24weeks of therapy there was significant increase in vaginal health index in the E2V and CEE and the isoflavones group. No serious side effect was reported in any of the groups. Low doses of both CEE and E2V were equally effective for management of vasomotor/vaginal symptoms when administered over 24weeks. However, it seems more reasonable to replenish with less costly and bio-identical hormone, i.e. micronized estradiol valerate which is equally effective. The trial was registered under Clinical trial registry of India prospectively (number: CTRI/2012/04/002566).

Complementary Role of Arm Circumference to Body Mass Index in Risk Stratification in Heart Failure

ObjectivesThis study was performed to investigate the complementary role of arm circumference to body mass index (BMI) in risk stratification of patients with heart failure (HF). BackgroundHigh BMI is associated with improved survival in patients with HF. However, it does not discriminate between fat and lean muscle as a predominant factor. MethodsBMI, waist circumference (WC), and mid-upper arm circumference (MUAC) were evaluated in 570 consecutive Japanese patients with HF (mean age 67.4 ± 14.0 years). Patients were stratified into low and high groups according to BMI, WC, and MUAC and combined into low- or high-BMI and low- or high-WC groups or low- or high-BMI and low- or high-MUAC groups. The endpoint was all-cause mortality. ResultsSeventy deaths occurred over a median follow-up period of 1.5 years (interquartile range: 0.7 to 2.8 years). After adjusting for several pre-existing prognostic factors, including Seattle Heart Failure Score and exercise capacity, BMI (hazard ratio [HR]: 0.68; p = 0.016), WC (HR: 0.76; p = 0.044), and MUAC (HR: 0.52; p < 0.001) were all inversely associated with prognosis. Compared with the high-BMI/high-WC group, both the low-BMI/high-WC and low-BMI/low-WC groups showed comparably poorer prognosis. However, the low-BMI/low-MUAC group but not the low-BMI/high-MUAC group showed poorer prognosis than the high-BMI/high-MUAC group. Adding MUAC to BMI (0.70 vs. 0.63, p = 0.012) but not WC to BMI (0.64 vs. 0.63, p = 0.763) significantly increased the area under the curve on receiver-operating characteristic curve analysis. ConclusionsMUAC, but not WC, plays a complementary role to BMI in predicting prognosis in patients with HF.

Psychometric Analysis of the Heart Failure Somatic Perception Scale as a Measure of Patient Symptom Perception.

Symptoms are known to predict survival among patients with heart failure (HF), but discrepancies exist between patients' and health providers' perceptions of HF symptom burden. The purpose of this study is to quantify the internal consistency, validity, and prognostic value of patient perception of a broad range of HF symptoms using an HF-specific physical symptom measure, the 18-item HF Somatic Perception Scale v. 3. Factor analysis of the HF Somatic Perception Scale was conducted in a convenience sample of 378 patients with chronic HF. Convergent validity was examined using the Physical Limitation subscale of the Kansas City Cardiomyopathy Questionnaire. Divergent validity was examined using the Self-care of HF Index self-care management score. One-year survival based on HF Somatic Perception Scale scores was quantified using Cox regression controlling for Seattle HF Model scores to account for clinical status, therapeutics, and lab values. The sample was 63% male, 85% white, 67% functionally compromised (New York Heart Association class III-IV) with a mean (SD) age of 63 (12.8) years. Internal consistency of the HF Somatic Perception Scale was α = .90. Convergent (r = -0.54, P < .0001) and divergent (r = 0.18, P > .05) validities were supported. Controlling for Seattle HF scores, HF Somatic Perception Scale was a significant predictor of 1-year survival, with those most symptomatic having worse survival (hazard ratio, 1.012; 95% confidence interval, 1.001-1.024; P = .038). Perception of HF symptom burden as measured by the HF Somatic Perception Scale is a significant predictor of survival, contributing additional prognostic value over and above objective Seattle HF Risk Model scores. This analysis suggests that assessment of a broad range of HF symptoms, or those related to dyspnea or early and subtle symptoms, may be useful in evaluating therapeutic outcomes and predicting event-free survival.

Acupuncture for Menopausal Hot Flashes: A Randomized Trial.

Hot flashes (HFs) affect up to 75% of menopausal women and pose a considerable health and financial burden. Evidence of acupuncture efficacy as an HF treatment is conflicting. To assess the efficacy of Chinese medicine acupuncture against sham acupuncture for menopausal HFs. Stratified, blind (participants, outcome assessors, and investigators, but not treating acupuncturists), parallel, randomized, sham-controlled trial with equal allocation. (Australia New Zealand Clinical Trials Registry: ACTRN12611000393954). Community in Australia. Women older than 40 years in the late menopausal transition or postmenopause with at least 7 moderate HFs daily, meeting criteria for Chinese medicine diagnosis of kidney yin deficiency. 10 treatments over 8 weeks of either standardized Chinese medicine needle acupuncture designed to treat kidney yin deficiency or noninsertive sham acupuncture. The primary outcome was HF score at the end of treatment. Secondary outcomes included quality of life, anxiety, depression, and adverse events. Participants were assessed at 4 weeks, the end of treatment, and then 3 and 6 months after the end of treatment. Intention-to-treat analysis was conducted with linear mixed-effects models. 327 women were randomly assigned to acupuncture (n=163) or sham acupuncture (n=164). At the end of treatment, 16% of participants in the acupuncture group and 13% in the sham group were lost to follow-up. Mean HF scores at the end of treatment were 15.36 in the acupuncture group and 15.04 in the sham group (mean difference, 0.33 [95% CI, -1.87 to 2.52]; P=0.77). No serious adverse events were reported. Participants were predominantly Caucasian and did not have breast cancer or surgical menopause. Chinese medicine acupuncture was not superior to noninsertive sham acupuncture for women with moderately severe menopausal HFs. National Health and Medical Research Council.

Comparative study of gabapentin and isoflavone in menopausal vasomotor symptoms.

Objective:This study was planned to compare the effects of gabapentin and isoflavones in menopausal vasomotor symptoms.Materials and Methods:This prospective comparative study was conducted on 100 patients with complaints of hot flashes, divided into two groups of 50 each. Group I received 900 mg of gabapentin and Group II received 60 mg of isoflavones daily for 3 months. The patients were interviewed to calculate hot flash, global and depression scores and were rescored after 2, 4, 8, and 12 weeks. The primary outcome measure was a change in the hot flash score from baseline. The secondary outcome was an improvement in sleep, depression, and lipid profile. Data were analyzed using Chi-square test and Student's t-test.Results:Both groups showed significant improvement in hot flash score at the end of 12 weeks (82% Group I, 74% Group II; P = 0.076). Statistically significant difference was seen at 12 weeks in sleep quality in favor of gabapentin (P = 0.011) and in depression in favor of isoflavones (0.026). Isoflavone had significant improvement in cholesterol, high-density lipoprotein, low-density lipoprotein, and triglycerides profiles after 12 weeks (P < 0.001, 0.009, 0.024 and <0.001, respectively) as compared to gabapentin.Conclusion:Isoflavone and gabapentin are equally effective in the treatment of hot flashes; however, isoflavones have better response in patients who have associated with complaints of depression and gabapentin is better who have associated sleep disturbance.

Genetic Predictive Scores in Heart Failure: Possibilities and Expectations

Heart failure (HF) remains a major health problem worldwide. Currently used HF risk prediction scores based on clinical findings, echocardiography features, biomarkers cannot propose an individualized approach to risk stratification, whereas there is variability in predictive value of different scores amongst patients with various HF phenotypes. The editorial commentary is devoted the role of the genetic risk prediction scores in the predisposition of HF development and assay in the HF medical care response. The brand new risk scores reflecting variabilities in genetic and epigenetic features in HF development are discussed also

The effect of right ventricular pacemaker lead position on functional status in patients with preserved left ventricular ejection fraction

The study was aimed at assessing the difference between the right ventricle apex versus the right ventricular outflow tract lead position in functional capacity in the patients with the preserved left ventricular ejection fraction after 12 months of pacemaker stimulation. This was a prospective, randomized, follow-up study, which lasted for 12 months. The study sample included 132 consecutive patients who were implanted with permanent anti-bradicardiac pacemaker. Regarding the right ventricular lead position the patients were divided into two groups: the right ventricle apex group consisting of 61 patients with right ventricular apex lead position. The right ventricular outflow tract group included 71 patients with right ventricular outflow tract lead position. Functional capacity was assessed by Minnesota Living With Heart Failure score, New York Heart Association class and Six Minute Walk Test. Left ventricular ejection fraction was assessed by echocardiography. Minnesota Living With Heart Failure score and New York Heart Association class had a statistically significant improvement in both study groups. The patients from right ventricle apex group walked 20.95% (p=O.03) more in comparison to starting values. The patients from right ventricular outflow tract group walked only 13.63% (p=0.09) longer distance than the startingoneConclusion. Analysis of tests of functional status New York Heart Association class and Minnesota Living With Heart Failure questionnaire showed an even improvement in the right ventricle apex and right ventricular outflow tract groups. Analysis of 6 minute walk test showed that only the patients with the preserved left ventricular ejection fraction from the right ventricle apex group had a significant improvement after 12 months of pacemaker stimulation..

Lymphocytopenia is associated with poor NYHA functional class in chronic heart failure patients with reduced ejection fraction.

In heart failure (HF) patients, functional capacity has been demonstrated to be a marker of poor prognosis, independent of left ventricular ejection fraction (EF). Lymphocyte count is currently recognized in certain risk stratification scores for chronic HF, and severe HF is associated with lymphocytopenia. However, no data exists on the association between lymphocyte count and functional capacity in patients with stable HF. This study aimed to assess the relationship between lymphocyte count and New York Heart Association (NYHA) functional capacity in systolic HF outpatients. The Turkish Research Team-HF (TREAT-HF) is a network which undertakes multi-center observational studies in HF. Data on 392 HF reduced ejection fraction (HFREF) patients from 8 HF centers are presented here. The patients were divided into two groups and compared: Group 1 comprised stable HFREF patients with mild symptoms (NYHA Class I-II), while Group 2 consisted of patients with NYHA Class III-IV symptoms. Patient mean age was 60±14 years. Lymphocyte count was lower in patients with NYHA functional classes III and IV than in patients with NYHA functional classes I and II, (0.9 [0.6-1.5]x1000 versus 1.5 [0.7-2.2]x1000, p<0.001). In multivariate logistic regression analysis, lymphocyte count (OR: 0.602, 95% CI: 0.375-0.967, p=0.036), advanced age, male gender, presence of hypertension, EF, left atrium size, systolic pulmonary artery pressure, neutrophil and basophil counts, creatinine level, and diuretic usage were associated with poor NYHA functional class in systolic HF outpatients. The present study demonstrated that in stable HFREF outpatients, lymphocytopenia was strongly associated with poor NYHA function, independent of coronary heart disease risk factors.

Abstract 17998: Impairment of Vascular Bone Marrow Niche Predicts Death in Patients With Chronic Heart Failure

Background: The bone marrow vascular niche is essential for hematopoietic regeneration. Patients with chronic heart failure are characterized by myelosuppresion and anemia. Therefore, in order to investigate whether chronic heart failure is associated with an impairment in the vascular niche of the bone marrow, we measured in bone marrow plasma levels of the prototypical angiogenic factor PlGF (placental growth factor), as well as, its soluble inhibitor, sFlt-1 (Fms-like tyrosine kinase 1), which acts as a decoy receptor for PlGF, as a measure of the functional integrity of the vascular bone marrow niche. Methods and Results: Bone marrow plasma levels of sFlt-1 and PlGF were determined by ELISA in 187 patients (mean age: 62.2±11.3years) with chronic heart failure, who were enrolled in the Frankfurt Bone Marrow-Derived Mononuclear Cell Therapy Registry. Fifty-one patients died within the 5-year follow-up period. Patients with increased bone marrow-derived sFlt-1/PlGF ratio had a 1.35-fold increased risk for death (95%CI: 1.08 to 1.68, p=0.007). This association was robust after adjustment for age, gender, left ventricular ejection fraction (LVEF), eGFR and NT-proBNP serum levels (HR:1.3, 95%CI: 1.014 to 1.678, p=0.038) or the Seattle Heart Failure score (HR:1.38, 95%CI: 1.112 to 1.723, p=0.004). Importantly, this association remained significant even after adjustment for colony-forming unit capacity (HR:1.33, 95%CI: 1.051 to 1.675, p=0.018) and SDF-1-induced migratory capacity of bone marrow-derived cells (HR:1.35, 95%CI: 1.087 to 1.678, p=0.007). Conclusions: The present study for the first time discloses that an impairment of the angiogenic potential of the bone marrow microenvironment, defined as increased sFlt-1 to PlGF ratio in the bone marrow plasma, is independently associated with mortality in patients with chronic heart failure. These data further corroborate the importance of the bone marrow-heart axis to predict clinical outcome in patients with chronic heart failure.

Abstract 12205: Prediction of Heart Failure Symptoms Using Framingham and ARIC Scores in Patients With Non Ischemic Risk Factors at 1 Year Follow up

Background: The Framingham heart failure score (FHS) and ARIC heart failure (HF) risk calculator are risk prediction tools that might facilitate the targeting of prevention strategies in pts with HF risk factors. We sought to compare their performance of predicting new HF symptoms in pts with risk factors. Method: Subjects ≥65 yo, with ≥ 1 HF risk (hypertension, type 2 diabetes, obesity, previous chemotherapy, family history of HF or previous cardiac history) were recruited from the local community. Absolute risk of incident HF risk was calculated using ARIC and FHS risk scores at baseline. Subjects underwent standard questionnaire, electrocardiogram, comprehensive echocardiogram and 6-minute walk (6MW) test. New HF based on Framingham criteria were assessed after a follow-up of 14±4 months. Results: Among 308 subjects (age 71±5 y; 50% men), median (IQR) 4 year risk of FHS and ARIC score were 4.0 (2-6.5) % and 6.2 (3.6-11.4) %, respectively. 19 participants developed new HF signs and symptoms (Framingham criteria). Compared with those remaining asymptomatic, those with new HF had higher ARIC score (p&lt;0.001), more impaired GLS (p=0.036), larger left atrium volume (p=0.05) and left ventricular (LV) mass (p=0.049. They also had significant baseline 6MW test distance (p=0.003). There was no difference between their FHS score (p=0.325) and other conventional diastolic measures including LV ejection fraction, mitral E/A, e’ and E/e’ (p=0.108-0.804). AUC of ARIC and FHS were 0.74 (p=0.001) and 0.63 (p=0.057), respectively. The AUC of 6MW was 0.698 (p=0.005) (figure). Conclusion: The ARIC score appears to be more predictive than FHS score in prediction of new HF symptoms in non-ischemic stage A HF. 6MW test maybe used as an effective screening tool in community based process.

Cardiac biomarkers in children with congenital heart disease.

Most congenital heart diseases (CHDs) have specific hemodynamics, including volume and pressure overload, as well as cyanosis and pulmonary hypertension, associated with anatomical abnormalities. Such hemodynamic abnormalities can cause activation of neurohormones, inflammatory cytokines, fibroblasts, and vascular endothelial cells, which in turn contribute to the development of pathologic conditions such as cardiac hypertrophy, fibrosis, and cardiac cell damages and death. Measuring biomarker levels facilitates the prediction of these pathological changes, and provides information about the stress placed on the myocardial cells, the severity of the damage, the responses of neurohumoral factors, and the remodeling of the ventricle. Compared to the ample information on cardiac biomarkers in adult heart diseases, data from children with CHD are still limited. We reviewed cardiac biomarkers-specifically focusing on troponin as a biomarker of myocardial damage, amino-terminal procollagen type III peptide (PIIIP) as a biomarker of myocardial fibrosis and stromal remodeling, and B-type natriuretic peptide (BNP)/N-terminal proBNP as biomarkers of cardiac load and heart failure, by introducing relevant publications, including our own, on pediatric CHD patients as well as adults. Levels of highly sensitive troponin I are elevated in patients with atrial septal defects (ASDs) and ventricular septal defects (VSDs). PIIIP levels are also elevated in patients with ASD, VSD, pulmonary stenosis, and Tetralogy of Fallot. Measurement of BNP and N-terminal proBNP levels shows good correlation with heart failure score in children. In the treatment of children with CHD requiring delicate care, it is vital to know the specific degree of myocardial damage and severity of heart failure. Cardiac biomarkers are useful tools for ascertaining the condition of CHDs with ease and are likely to be useful in determining the appropriate care of pediatric cardiology patients.

Venlafaxine in management of hot flashes in women with breast cancer: a systematic review and meta-analysis

Toxicity due to treatment causes a negative impact on quality of life in breast cancer survivors. Hot flash symptoms, described as intense sensations of heat, sweating and flushing occur in more than 50 % of breast cancer patients taking tamoxifen. We hypothesized that venlafaxine, a selective-norepinephrine reuptake inhibitor drug, was effective for reducing patient-reported hot flash scores among women treated for breast cancer compared to other non-hormonal treatments. We searched Medline, Scopus, and Cochrane Central Register of Controlled Trials from inception till May 2015 for venlafaxine (75 mg once daily or greater) with non-hormonal comparators for the treatment of hot flashes in female breast cancer patients. The primary outcome was hot flash score (derived from patient-reported hot flash severity and frequency) in randomized controlled trials. Standardized mean differences (SMD) were calculated for each study due to variation in the outcome measures. Heterogeneity was determined using I (2) statistics, and publication bias was assessed using a contour funnel plot and Egger's tests. Pooled analyses demonstrated that venlafaxine significantly reduced hot flash scores compared to the trial comparators (overall SMD 2.06; 95% confidence interval (CI) [0.40, 3.72]). There was significant heterogeneity among these studies (I (2) = 98.7%, P < 0.001). Asymmetry in the contour funnel plot suggests the presence of publication bias and a trend towards small study effects (Egger's test, P = 0.096). Venlafaxine is efficacious in managing hot flashes among women with breast cancer. This review highlights methodological issues that arise from eligible trials and recommends a collaborative approach in survivorship studies.