Number Of Cardiac Events Research Articles

Cardiotoxicity risk factors with immune checkpoint inhibitors

BackgroundCheckpoint-inhibitor immunotherapies have had a profound effect in the treatment of cancer by inhibiting down-regulation of T-cell response to malignancy. The cardiotoxic potential of these agents was first described in murine models and, more recently, in numerous clinical case reports of pericarditis, myocarditis, pericardial effusion, cardiomyopathy, and new arrhythmias. The objective of our study was to determine the frequency of and associated risk factors for cardiotoxic events in patients treated with immune checkpoint inhibitors.MethodsMedical records of patients who underwent immunotherapy with durvalumab, ipilimumab, nivolumab, and pembrolizumab at Wake Forest Baptist Health were reviewed. We collected retrospective data regarding sex, cancer type, age, and cardiovascular disease risk factors and medications. We aimed to identify new diagnoses of heart failure, atrial fibrillation, ventricular fibrillation/tachycardia, myocarditis, and pericarditis after therapy onset. To assess the relationship between CVD risk factors and the number of cardiac events, a multivariate model was applied using generalized linear regression. Incidence rate ratios were calculated for every covariate along with the adjusted P-value. We applied a multivariate model using logistic regression to assess the relationship between CVD risk factors and mortality. Odds ratios were calculated for every covariate along with the adjusted P-value. Adjusted P-values were calculated using multivariable regression adjusting for other covariates.ResultsReview of 538 medical records revealed the following events: 3 ventricular fibrillation/tachycardia, 12 pericarditis, 11 atrial fibrillation with rapid ventricular rate, 0 myocarditis, 8 heart failure. Significant risk factors included female gender, African American race, and tobacco use with IRR 3.34 (95% CI 1.421, 7.849; P = 0.006), IRR 3.39 (95% CI 1.141, 10.055; P = 0.028), and IRR 4.21 (95% CI 1.289, 13.763; P = 0.017) respectively.ConclusionsOur study revealed 34 significant events, most frequent being pericarditis (2.2%) and atrial fibrillation (2.0%) with strongest risk factors being female gender, African American race, and tobacco use. Patients who meet this demographic, particularly those with planned pembrolizumab treatment, may benefit from early referral to a cardio-oncologist. Further investigation is warranted on the relationship between CTLA-4 and PD-L1 expression and cardiac adverse events with ICIs, particularly for these subpopulations.

Clinical features and antiarrhythmic therapy in patients with catecholaminergic polymorphic ventricular tachycardia

Aims. To evaluate the long-term efficacy of antiarrhythmic therapy in patients with catecholaminergic polymorphic ventricular tachycardia (CPVT).Methods. CPVT was diagnosed in 11 patients between the ages of 3-12 years with a minimum follow-up of 10 years. The data analyzed was obtained from existing medical records that included symptoms, family screenings, treadmill tests, electrocardiography, echocardiography, implanted cardioverter-defibrillator data (ICD), and medical treatments.Results. Cardiac events were registered in 75% of patients on beta-blocker therapy. Supraventricular arrhythmias such as atrial and atrioventicular nodal tachycardia, atrial fibrillation and atrial flutter were detected using various ECG diagnostic methods in all patients, which is significantly higher than reported in similar studies. A combination of anti-arrhythmic therapy and beta-blocker treatment reduced the number of cardiac events by 50% as compared to only beta-blocker treatment.Conclusion. Multiple supraventricular arrhythmias have a high prevalence in patients with CPVT and can trigger ventricular arrhythmia. Combined antiarrhythmic therapy is effective because it prevents cardiac events in patients with CPVT. Combined antiarrhythmic therapy improves the prognosis of patients with CPVT and may help to avoid or postpone ICD implantation.

Blood pressure difference between regular hemodialysis and hemodialysis with hemoperfusion at Haji Adam Malik Hospital, Medan-Indonesia

Background: The differences of Hemodialysis and Hemoperfusion’s combination can increase of Uremic Toxin clearance, average creatinine clearance, and Angiotensin elimination optimally. The hemodialysis and hemoperfusion’s combination also can decrease blood pressure and reduce the use of Anti Hypertension drugs so that the number of cardiac events in CKD patients may decrease. The use of ABPM is chosen because this is the best method of automatic blood pressure which has the most accurate blood pressure measuring periodically.Objective: This study aims to determine the difference of regular Hemodialysis and Hemodialysis with Hemoperfusion on blood pressure measured by using ABPM in Medan, North of Sumatra.Methods: This study was a pre-experimental study which conducted since December 2013-March 2014 to the 20 regular hemodialysis patients. The measurement included anamnesis, height, weight, systolic and diastolic blood pressure among patients with regular hemodialysis and hemodialysis with hemoperfusion. Results: The study found that about 3 of 20 subjects were out of the study. There was no significant difference found in systolic and diastolic blood pressure between regular hemodialysis and hemoperfusion group (P = 0.807 and 0.906, respectively) based on the T-paired test and Wilcoxon test. Conclusion: There was no significant difference between blood pressure measured using ABPM on the combination of hemodialysis and hemoperfusion compared with regular hemodialysis

Pharmacological interventions for preventing anthracycline-induced clinical and subclinical cardiotoxicity: A network meta-analysis of metastatic breast cancer.

Doxorubicin- and epirubicin-induced cardiotoxicities are life threatening for those suffering from breast cancer. Comparing the effects of different strategies on the prevention of these agent-induced cardiotoxicities remains unexplored.Data sources: A comprehensive review of clinical trials was performed on the prevention of epirubicin- and/or doxorubicin-induced cardiotoxicity in HER2-positive metastatic breast cancer patients. The reduction in ejection fraction was directed at evaluating cardiac toxicity.Data summary: Fourteen articles evaluated cardiotoxicity as a condition among 2945 individuals, evaluating doxorubicin, epirubicin, Liposomal Doxorubicin (LD), Pegylated Liposomal Doxorubicin (PLD), dexrazoxane plus doxorubicin or epirubicin, and Angiotensin-Converting Enzyme Inhibitors (ACEIs) plus doxorubicin. Pooled Odds Ratio (OR) of 0.043 with a 95% credible interval (CrI) between 0.005 and 0.22 indicated that the dexrazoxane plus epirubicin reduced the number of cardiac events compared with doxorubicin. Furthermore, doxorubicin and epirubicin represented the most effective interventions with a 52% probability of success. Also, the best treatment for reducing Congestive Heart Failure (CHF) was dexrazoxane plus epirubicin with a probability of 43%. For the Left Ventricular Ejection Fraction (LVEF) reduction outcome, ACEIs plus doxorubicin was ranked first with a success probability of 61.2% and they could significantly prevent the reduction in LVEF compared with LD, epirubicin, or doxorubicin. Our data suggested that angiotensin-converting enzyme inhibitors and dexrazoxane plus epirubicin were the most effective interventions for preventing cardiotoxicity and CHF. However, ACEIs plus doxorubicin was the best treatment for preventing LVEF reduction.

P1150BURDEN OF SYMPTOMS EVALUATION AND DETERMINANTS IN PERITONEAL DIALYSIS PATIENTS USING ESAS-R AND IPOS RENAL SCORE

Abstract Background and Aims CKD patients are known to have a substantial burden of symptoms. Effort towards treatment modifications aiming to improve the quality of life in ESRD patients is growing among clinicians. ESAS-r and IPOS renal score are well known among conservative and palliative care physicians, used to evaluate the burden of symptoms in their renal patients. However, there are few studies including patients in chronic peritoneal dialysis. Using these tools, we aim to evaluate the symptoms and determine patient and treatment-related conditions associated with their burden in a PD population. Method We have conducted 73 phone interviews to the prevalent PD population in our centre. ESAS-r and IPOS renal (3-days patient version) questionnaires were answered by each patient/family caregiver. The population was then characterized according to gender, race, age, PD technique and duration, number of daily exchanges, patient autonomy, diabetes mellitus and cancer status, Charlson score and number of cardiac events and hospitalizations since PD beginning. Statistical analysis of data was carried out using SPSS®. Results We obtained a total of 63 answers to both questionnaires. Three were answered by a family caregiver. 60.3% of the patients were male, mean age 53 (±14.9) years. 15.9% were on automated PD, with mean number of daily exchanges of 3.45 (±0.7) and mean PD duration of 25.7 (±33.5) months. 38,1% were diabetic, six (9.5%) patients had cancer and mean Charlson score was 4.24 (±1.8). Only 3 patients were caregiver dependent for treatment. 31.3% had at least one hospitalization since PD beginning. Each patient reported a mean 3.1 (±2) number of symptoms on ESASr: renal. Mean IPOS-renal score was 9.5 (±6.4). In univariate analysis (t-student test), greater IPOS-renal score was associated with female gender only (p = 0.056; CI -0.07-6.1). In multivariate analysis (linear regression) the number of symptoms reported by each patient on ESASr renal was associated with number of hospitalizations during PD time (B = 0.46; CI(95%) 0.18-0.75; p = 0.02) in model adjusted to time of PD. Conclusion The majority of variables analysed do not have an association with IPOS renal score. The number of hospitalizations was associated with greater burden of symptoms, adjusted to PD time. Oddly, Charlson score, diabetes mellitus and cancer status had no relation to the symptoms reported or IPOS renal score. More modifiable patient and treatment-related variables can be studied to better characterize which interventions may ease the burden of symptoms in PD patients. Patients can answer these questionnaires periodically to help clinicians understand weather treatment modifications have a positive impact on their well-being.

Round-off decision-making: Why do triage nurses assign STEMI patients with an average priority?

Patients with suspected ST elevation myocardial infarction should be classified with a high-priority triage level in the Emergency Department. Accurate triage can reduce mortality and morbidity in ST elevation myocardial infarction patients. Yet, half of these patients were given a low-priority score, especially the average classification (P3 on a P1–P5 scale). AimTo identify and clarify significant factors in the triage process that result in P3 assignment for patients with ST Elevation Myocardial Infraction diagnosis. MethodsA retrospective-archive study was conducted at a tertiary hospital from January 2015 to November 2017. We collected and measured patients’ characteristics, Emergency Department setting variables, and hospitalization characteristics. Data files were extracted from the electronic database (n = 140). ResultsThe results show several key factors that affect the decision to assign P3 in the triage process. Analysis of patients’ sociodemographic characteristics show that being female (OR = 1.96, P = .05) or having Arab ethnicity (OR = 2.19, P = .01) is significant to P3 assignment. Number of cardiac events (P = .02) is the only noteworthy cardiologic comorbidity of all that were reviewed.A connection was observed between a patient being classified as average urgency and poor treatment outcomes, namely for the variables time to physician, total time in the Emergency Department, door-to-balloon time, and in-hospital mortality. ConclusionAverage classification demonstrates the extreme risk involved in the triage process. Our research provides considerable data to identify factors that affect the decision to classify patients as P3.

A model for delivering survivorship care: Integrating the oncology and the primary care setting: Follow-up of the first cohort of patients.

40 Background: In our Institution, we started a survivorship care program that integrates survivors’ health care provided by the oncologist and the primary care physician (PCP).We present the follow-up analysis of the first cohort of patients (pts) enrolled from April to July 2015. Methods: We included adult pts affected by hematologic or solid tumors without evidence of disease from at least 5 years (yrs). They are referred to the PCP with a survivorship care plan. An online platform for cancer survivors (CS) and their PCPs will be available. Progression free survival (PFS), overall survival (OS) and treatment related clinical events were calculated after 17 months from the start of the project. Results: We analyzed data from 269 CS. The median age was 67 yrs, they were mainly females (77%). The most frequent histological types were breast (157), colorectal (37), and hematologic (30) tumors. 189 pts had an early stage disease. 161 pts received chemotherapy with 95 pts receiving anthracycline-based-chemotherapy (ABC), 86% at a cumulative dose > 240 mg/mq. 154 pts underwent radiation therapy (RT), 94% at a dose > 30 Gy. 58 pts received both ABC and RT. The 10-yr cumulative risk of secondary cancer (SC) was 4% with a median latency period from the first cancer diagnosis of 11.3 yrs. 15-yr OS was 98% (one patient died of myocardial infarction), and 15-yr PFS was 96%. The 10-yr cumulative risk of late cardiologic toxicity (LCT) was 11% and 37 pts developed cardiologic complications with a median latency period from treatment of 10.5 yrs. The adhesion to the survivorship care plan was 84%. 13% of pts returned to our Center. The main non-clinical reason for returning was the lack of confidence in PCP. No association was observed between ABC and/or RT exposure and LCT or SC development. Conclusions: In this cohort of patients a high risk of LCT was observed. The risk and latency of SC was similar to the ones reported in literature. The number of cardiac events and SC is too low to give solid conclusions about the association with therapeutic exposure. So far, the compliance of patients and PCPs with the program was high. More data and longer follow-up period are necessary to confirm the accuracy of this model of care.

Management of ventricular arrhythmias in suspected channelopathies.

Although structural heart disease remains the predominant substrate for ventricular arrhythmia, channelopathies including long QT syndrome (LQTS), short QT syndrome (SQTS), Brugada syndrome (BrS), catecholaminergic polymorphic ventricular tachycardia (CPVT), and early repolarization syndrome (ERS) are less common but important contributing entities. These etiologies require specific therapies potentially contrary to empirical management of arrhythmias associated with structural heart disease. Conventional therapy including antiarrhythmic drug therapy may not only fail to resolve unstable arrhythmias but worsen them. Additionally, channelopathy patients with implantable cardioverter defibrillators (ICD) and arrhythmic storms represent a major challenge, and the acute care team needs to be cognizant of unique circumstances that require specific acute therapies beyond empirical advanced life support algorithm recommendations.1 Successful and considered acute management of ventricular arrhythmias is contingent on a number of variables, including knowledge of the cardiac substrate or potential substrate; form, mechanism, and precipitants of ventricular arrhythmias; and acute effect of potential therapies. In the longer term, an understanding of the natural history of the channelopathy along with the efficacy of long-term therapy will lead to superior outcomes. This review will present the risk of ventricular arrhythmias associated with these uncommon entities, the evolving understanding of the mechanism of arrhythmia, and the mechanistic basis of therapies along with a clinical approach to summarize the evidence pertaining to acute and long-term management. Patients with a prolonged QT interval are at risk of sudden cardiac death (SCD) due to Torsade de Pointes (TdP; Figure 1). Most patients with congenital LQTS are asymptomatic and diagnosed incidentally on electrocardiogram screening or following family screening. However, syncope, aborted SCD, or SCD may be the first presentation. Most arrhythmic events in congenital LQT1 occur during physical or emotional stress, at rest or in association with sudden auditory stimulation in LQT2, and during sleep or rest in LQT3 …

Left Cardiac Sympathetic Denervation in Long QT Syndrome

Background— Long QT syndrome (LQTS) is a potentially lethal but highly treatable cardiac channelopathy. Treatment options include pharmacotherapy, device therapy, and left cardiac sympathetic denervation (LCSD). Here, we sought to determine the characteristics of LQTS patients who have had ≥1 LQTS-related breakthrough cardiac event (BCE) after LCSD. Methods and Results— We performed retrospective chart review for 52 consecutive patients (24 males; mean age at diagnosis, 10.0±10 years; mean QTc, 528±74 ms) with LQTS who underwent LCSD between 2005 and 2010 (mean age at LCSD, 14.1±10 years) and have been followed up for 3.6±1.3 years. A BCE was defined as either (1) an appropriate ventricular fibrillation-terminating implantable cardioverter defibrillator shock or (2) arrhythmogenic syncope, seizures, or aborted cardiac arrest after LCSD. Thirty-three patients (61%) had LCSD as primary prevention because of either high-risk assessment or β-blocker intolerance. So far, 12 of 52 (23%) patients (7 males) have experienced ≥1 BCE post LCSD. The clinical phenotype of patients with BCEs was significantly more severe than patients without a BCE. No BCEs were seen in patients undergoing LCSD for β-blocker intolerance (0/12 versus 17/40; P <0.001). Conclusions— Although a marked reduction in number of cardiac events is usually seen after LCSD, ≈50% of high-risk LQTS patients have experienced ≥1 post-LCSD breakthrough. Therefore, LCSD must not be viewed as curative or as an alternative in implantable cardioverter defibrillator for high-risk patients. Prophylactic LCSD may provide another option to counter a suboptimal quality of life resulting from medication-related side effects.

Is the mid-term outcome of free right internal thoracic artery with a proximal anastomosis modification inferior to in situ right internal thoracic artery?

We investigated the mid-term results of free right internal thoracic artery (RITA) grafts used in an aorto-coronary fashion with a modified proximal anastomosis. The subjects were 214 patients who underwent coronary artery bypass grafting with anastomosis to the left circumflex arteries using the RITA as a free graft (Group A: 158 patients) or an in situ graft (Group B: 56 patients). In Group A, the proximal end of the free RITA was anastomosed onto the ascending aorta interposing free graft tissue or to part of its own tissue as a cuff. The number of RITA anastomoses was 1.38±0.50 in Group A and 1.04±0.19 in Group B (P<0.001). The relationship between perioperative variables and mid-term outcomes was assessed using Cox proportional hazard models. Survival was not associated with the way the RITA graft was performed (Hazard Ratio 5.26, 95% CI 0.52-53.1, P=0.159), however, the number of cardiac events was decreased in Group A (Hazard Ratio 2.55, 95% CI 1.03-6.33, P=0.043). The graft patency was evaluated in 187 of 214 patients, and at 1, 3 and 5years was 97.0, 97.0 and 97.0% in Group A, and 97.9, 92.5 and 80.5% in Group B (P=0.378), respectively. By modifying the proximal anastomosis of the free RITA, cardiac events may be decreased, while survival and graft patency comparable with in situ RITA can be obtained, and a significantly larger number of targets can be revascularized.

Case-controlled study of critical care or surgical ward care after elective open colorectal surgery

Evidence for the benefit of critical care after surgery is limited. This study assessed the value of immediate admission to the critical care unit (CCU) after open colorectal surgery. Patients aged over 45 years were screened with a cardiopulmonary exercise test to determine their anaerobic threshold. Less fit patients defined by an anaerobic threshold below 11 ml oxygen per kg per min were assigned to either critical care or surgical ward care. Those with an anaerobic threshold of 11 ml oxygen per kg per min or above were assigned to ward care. The outcome measure was the number of cardiac events. Of 153 patients who underwent exercise testing, 55 had an anaerobic threshold of at least 11 ml oxygen per kg per min (ward care) and 98 had a threshold of less than 11 ml oxygen per kg per min, of whom 39 were allocated to ward care and 51 to critical care. Median length of CCU stay was 31 (range 5-46) h. More cardiac events occurred in patients allocated to ward care (7 of 39) than in those allocated to critical care (0 of 51): absolute difference 18 (95 per cent confidence interval 10 to 26) per cent (P = 0·002). There were no cardiac events in patients with an anaerobic threshold of 11 ml oxygen per kg per min or higher. Patients with an anaerobic threshold of at least 11 ml oxygen per kg per min and those with a threshold below 11 ml oxygen per kg per min managed in the CCU had fewer cardiac events.

Significance of LDL-C lowering therapy in diabetic patients

Diabetes is considered to be a risk factor equivalent of pre-existing coronary heart disease for the development of future myocardial infarction and cardiovascular death. In addition to improved glucose control, the increased risk of coronary disease in diabetics makes intensive lipid-lowering treatment necessary. A number of studies have demonstrated that lipid-lowering therapy in diabetes is effective in decreasing the number of cardiac events. The most important objective in the treatment of diabetes is to reduce LDL-C to a target of <100 mg/dl. Different types of lipid-lowering drugs are available. Statins are the current lipid-lowering drugs of choice to reduce LDL-C. However, some questions remain unanswered. This article will describe and discuss the significance of LDL-C lowering therapy in subjects with diabetes.

FGF-16 is a target for adrenergic stimulation through NF- B activation in postnatal cardiac cells and adult mouse heart

The fibroblast growth factor (FGF) family plays an important role in cardiac growth and development. However, only FGF-16 RNA levels are reported to increase during the perinatal period and to be expressed preferentially in the myocardium, suggesting control at the transcriptional level and a role for FGF-16 in the postnatal heart. Beyond the identification of two TATA-like elements (TATA1 and TATA2) in the mouse FGF-16 promoter region and the preferential cardiac activity of TATA2, there is no report of Fgf-16 gene regulation. Assessment of promoter sequences, however, reveals putative nuclear factor-kappaB (NF-kappaB) elements, suggesting that Fgf-16 is regulated via NF-kappaB activation and thereby implicated in a number of cardiac events. Thus, the Fgf-16 gene was investigated as a target for NF-kappaB activation in cardiac cells. Assessments of Fgf-16 promoter activity were made using truncated and transfected hybrid genes with NF-kappaB inhibitors and/or beta-adrenergic stimulation via isoproterenol (IsP) treatment (a known NF-kappaB activator) in culture, and on endogenous mouse and human Fgf-16 genes in situ. The mouse Fgf-16 promoter region was stimulated in response to IsP treatment, but this response was lost with NF-kappaB inhibitor pretreatment. Deletion analysis revealed IsP responsiveness linked to sequences between TATA2 and TATA1 and, more specifically, a NF-kappaB element upstream and adjacent to TATA1 that associates with NF-kappaB p50/p65 subunits in chromatin. Finally, TATA1 and the proximal NF-kappaB element are conserved in the human genome and responsive to IsP. The mouse and human Fgf-16 gene is a target for NF-kappaB activation in the postnatal heart.

Prehospital HMG Co-A Reductase Inhibitor Use and Reduced Mortality in Ruptured Abdominal Aortic Aneurysm

Conclusion: In patients with ruptured abdominal aortic aneurysms prehospital statin use appears to be associated with increased survival. Summary: One of the pleotrophic effects of statins appears to be reduction of inflammatory mediators. These mediators include heat shock proteins, tumor necrosis factor α, multiple interleukins, nuclear factor κ b, as well as nitric oxide. Statins likely have free radical scavenger activity. Statins also appear to exert anti-inflammatory and antioxidant affects that improve mortality in septic shock populations and patients with severe sepsis who were taking statins appear to develop septic shock less frequently. Theoretically, similar shock mechanisms could be active in the setting of a ruptured abdominal aortic aneurysm (rAAA). The authors performed a retrospective review of their patients with rAAAs from January 2000 to December 2008. They compared hospital and ICU lengths of stay, cardiac morbidity, and number of cardiac events per patient between survivor groups with and without pre hospital statin use. Mortality, cardiac morbidity, and gender were also compared. The Physiologic Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) was also calculated for all patients analyzed. There are 121 records screened with 40 patients excluded due to the presence of active cancer, chronic immune suppression or living wills or advanced directives against live sustaining treatment,. There were no statistically significant differences between statin users and non-users with respect to age, gender and POSSUM scores. Mortality in the group without pre hospital statin use was 63.8%. In the group with pre hospital statin use mortality was 34.8% (p=0.018, odds ratio 0.30 to 0.11). Hospital and ICU lengths of stay, cardiac morbidity, and number of cardiac events per patient were not statistically different among survivors. Comment: This study provides further evidence for the ever-widening pleotrophic effects of statin medications. It does have several limitations including its small sample size and the fact that endovascular repair of ruptured aneurysms and the use of statins increased over the study period. Patients were included in this study if they used any statin at any dose for any period of time up to their time of admission for rAAA. What is now needed is prospective studies on dose related response and time delays in the generation of the pleotrophic effects of statin medications.

Prehospital HMG Co-A Reductase Inhibitor Use and Reduced Mortality in Ruptured Abdominal Aortic Aneurysm

The compounds 3-hydroxy-3-methyl-glutaryl-CoA reductase inhibitors (HMG Co-A reductase inhibitors, statins) are popular medications for the control of elevated serum cholesterol. Recent evidence has demonstrated a survival benefit to patients who take statins in the premorbid period with severe sepsis, septic shock, or severe trauma. We hypothesized that a similar benefit would be seen in patients with ruptured abdominal aortic aneurysm. We completed a retrospective review of patients with ruptured abdominal aortic aneurysm in our institution from January 2000 to December 2008. We compared age, gender, mortality rates, and Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM) scores for all patients who met inclusion and exclusion criteria. We compared hospital and ICU lengths of stay, cardiac morbidity, and number of cardiac events per patient between survivor groups with and without prehospital statin use. We compared mortality, cardiac morbidity, and gender using the Pearson chi-square test, Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity scores and age using the Student's t-test and lengths of stay using the Mann Whitney-U test. Mortality in the group without prehospital statin use was 63.8%, and in the group with prehospital statin use was 34.8% (p=0.018, odds ratio 0.30 to 0.11). Physiologic and Operative Severity Score for the enumeration of Mortality and Morbidity scores were similar between survivor groups with and without statin use and nonsurvivor groups with and without statin use. Hospital and ICU lengths of stay, cardiac morbidity, and number of cardiac events per patient were not statistically different among survivors. Prehospital statin use appears to be associated with a significant survival benefit in the ruptured abdominal aortic aneurysm population.

HDL therapy for cardiovascular diseases: the road to HDL mimetics

3-Hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) are currently the drug of choice for the clinical management of elevated low-density lipoprotein (LDL) cholesterol. Although statin treatment provides an overall improvement in outcomes, clinical trial data reveal a significant number of cardiac events despite reaching targeted LDL levels. A low serum high-density lipoprotein (HDL) cholesterol level is an independent predictor of cardiovascular risk. Accordingly, there has been interest in determining whether HDL elevation, in addition to LDL lowering, further reduces risk in patients with coronary artery disease. Several commonly prescribed lipid-lowering therapies modestly raise HDL, but their use may be limited by the development of adverse reactions. Emerging data suggest that HDL quality and function may also be significantly reduced by atherosclerosis and other inflammatory diseases. The goal of this review is to discuss the current status of HDL therapeutics, with emphasis on a novel class of agent, the apolipoprotein A-I mimetic peptides, which improve the functional properties of HDL cholesterol.

Long-term cost-benefit ratio of cardiac rehabilitation after percutaneous coronary intervention

Objective — Cardiac rehabilitation (CR) has been shown to reduce short-term mortality and morbidity after percutaneous coronary intervention (PCI). Nonetheless, the long-term effects of CR after PCI and its cost-benefit ratio are not well studied.This study analyses the effect of multidisciplinary, hospital-based, ambulatory CR on long-term health-related costs after PCI.Methods and results — 213 patients were studied after PCI: 133 patients referred to cardiac rehabilitation were compared with 80 patients who were referred for PCI from another hospital, where no rehabilitation was available. The hospital files of these patients were studied and the patient and/or his/her general practitioner were contacted by telephone after a follow-up of approximately 4.5 years. All cardiovascular events (recurrent angina, coronary revascularization, acute myocardial infarction, and death) were noted and their cost to the community was calculated. Compared to no CR, CR resulted in a significant reduction of hospitalizations for angina (75% vs. 45%), and coronary revascularizations (17% vs. 7%).There was a significant increase in the incidence of myocardial infarction (2.5% vs. 7.5%).The intervention group experienced a total of 0.93 events/patient, as compared to 1.52 events/patient in the control group.The total health care cost (including the cost of CR) at 4.5 years of follow-up was lower in the rehabilitation group compared to the control group (4,862 €/patient vs. 5,498 €/patient).Conclusion — Cardiac rehabilitation after PCI not only significantly reduces the number of cardiac events, but, despite the additional cost due to CR, results in cost savings from the Belgian health care payer’s perspective.

Congenital long QT syndromes: clinical features, molecular genetics and genetic testing

Congenital long QT syndrome (LQTS) is a primary electrical disease characterized by a prolonged QT interval in the surface electrocardiogram and increased predisposition to a typical polymorphic ventricular tachycardia, termed Torsade de Pointes. Most patients with LQTS are asymptomatic and are diagnosed incidentally based on an electrocardiogram. Symptomatic patients may suffer from severe cardiac events, such as syncope and/or sudden cardiac death. Autosomal dominant forms are caused by heterozygous mutations in genes encoding the components of the ion channels. The autosomal recessive form with congenital deafness is also known as Jervell and Lang-Nielsen syndrome. It is caused by homozygous mutations or certain compound heterozygous mutations. Depending on the genetic defects, there are differences in the age of onset, severity of symptoms, and number of cardiac events and event triggers. With advances in gene technology, it is now feasible to perform genetic testing for LQTS, especially for those with family history. Identification of the mutation will lead to better management of symptoms and more targeted treatment, depending on the underlying genetic defect, resulting in a reduction of mortality and cardiac events.

Metabolic syndrome criteria: ready for clinical prime time or work in progress?The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

This editorial refers to ‘Impact of statins in microalbuminuric subjects with the metabolic syndrome: a substudy of the PREVEND Intervention Trial’† by C.A. Geluk et al. , on page 1314 Geluk et al. 1 describe a subgroup analysis of the PREVEND trial in which they tested whether pravastatin reduced risk for major adverse cardiac events in micro-albuminuric patients with and without the metabolic syndrome defined by the National Cholesterol Education Program (NCEP) Adult Treatment Panel (ATP III) criteria.2 Although pravastatin did not reduce incidence of adverse cardiac events in the total cohort,3 an impressive 60% relative risk reduction was noted in the subgroup with both micro-albuminuria and metabolic syndrome [hazard ratio (HR) 0.39, 95% confidence interval (CI) 0.17–0.89], whereas micro-albuminuric individuals without metabolic syndrome did not appear to benefit. The higher event rate in the former group concurs with other evidence indicating a more ‘malignant’ outcome when micro-albuminuria accompanies other risk factors (e.g. endothelial dysfunction4) than when it occurs in isolation. The investigators suggested that their study supports the use of statins in micro-albuminuric subjects with metabolic syndrome to reduce incidence of major coronary events. So what does this mean for clinicians in practice? Should we advocate that metabolic syndrome status be recorded in all micro-albuminuric patients, and that differential treatment with statins of micro-albuminuric patients with and without metabolic syndrome become routine practice? To address these issues, several aspects of the currently reported findings would benefit from further comment. First, the total number of cardiac events in this study numbered <50, relatively modest compared with major statin trials. Therefore, one explanation for lack of apparent statin benefit in subjects with micro-albuminuria but without … *Corresponding author. Tel: +44 141 211 4312; fax: +44 141 553 2558. E-mail address : nsattar{at}clinmed.gla.ac.uk

Hormone replacement therapy and cardiovascular disease.

This year's work on hormone replacement therapy (HRT) and cardiovascular disease has been remarkable for the publication of the first randomised controlled trial of HRT use, the Heart Estrogen Replacement Study (HERS). The findings go against not only the trend of previous observational epidemiological studies, but also against findings in the very many studies which have previously shown and continue to show this year a beneficial effect of HRT on a large variety of cardiovascular risk factors, including endothelial function, here reviewed. The aspect of the effect of HRT on clotting variables is clearly crucial given the increased risk of venous thrombosis, and also increased number of cardiac events in the first 4 months of the HERS. Prothrombotic factors increase with age in women, and HRT alters these, particularly fibrinogen, factor VII, and PAI (less change with transdermal HRT) and antithrombin III. In normal women therefore the balance should be towards fibrinolysis rather than coagulation. Work has been presented in abstract for clarifying the effects of HRT on coagulation markers and grasping the problem of differences according to its route of administration. The full publications on this work are expected shortly. We are still awaiting evidence from randomized controlled trials of HRT in primary prevention; one is now recruited but will not report until 2005.