Heartdrug : excellence in cardiovascular trials最新文献

{"title":"Rate versus Rhythm Control – An Open and Shut Case?","authors":"G. Tomaselli","doi":"10.1159/000073238","DOIUrl":"https://doi.org/10.1159/000073238","url":null,"abstract":"Accessible online at: www.karger.com/hed Atrial fibrillation (AF) and heart failure (HF) are the cardiovascular epidemics of the 21st century. AF is the most common sustained arrhythmia in man and is a significant cause of health care expenditure in the industrialized world. Although predominantly an arrhythmia of the aged (110% of individuals over the age of 65 years will experience AF), both the AF itself and the clinical context in which it occurs are very heterogeneous. The prevalence and persistence of AF and the relative inefficacy of pharmacotherapy have complicated the management of this rhythm disturbance and have motivated the search for alternative methods to manage patients. Catheter-based techniques are increasingly utilized rhythm and rate control therapeutic modalities in patients with AF [e.g. 1, 2]. Finally, the risk of thromboembolism adds to the complexity and patient dissatisfaction associated with treatment of AF. In the past several years four randomized clinical trials (AFFIRM, Dutch RACE, PIAF and STAF) have been published that demonstrate the equivalence (or noninferiority) of rate versus rhythm control strategies on mortality and other major trial endpoints [3–6]. In general the rate control therapeutic approaches were associated with a trend toward lower mortality, a reduced frequency of hospitalization and a lower incidence of drug-associated side effects. Case closed, right? Not so fast. The populations in these trials share a number of demographic features that may limit the generalizability of these data to all patients with AF. First, the mean age of patients in all of these trials exceeded 65 years. Second, patients in AF with their ventricular rate controlled were minimally symptomatic. Third, in most cases, patients had a prior clinically recognized episode of AF. Fourth, the efficacy of pharmacological rhythm control was at best marginal, thus patients were subjected to the risk of antiarrhythmic drugs with only marginal therapeutic benefit. As a corollary it is not surprising that patients in the rhythm control arms of these trials suffered thromboembolic complications at rates comparable to patients managed with rate control strategies. The limited efficacy of rhythm control strategies is in part responsible for the increased hospitalization rate in this group; patients were admitted to hospital for antiarrhythmic drug therapy, cardioversion and decompensation of underlying structural heart disease. Contemporary methods such as radiofrequency catheter ablation may afford improved rhythm control [1, 2] allowing for the constitution of a true rhythm control group. Landolina et al. [7] nicely summarize the limitations of a broad general application of rate control as a first-line management approach to AF. In addition they report a small prospective nonrandomized study of younger patients with advanced HF that suggests that a rhythm control strategy has a reasonable chance of success and may have a salutary effe","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"519 1","pages":"125 - 126"},"PeriodicalIF":0.0,"publicationDate":"2003-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000073238","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65183426","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Early Drug Therapy and In-Hospital Mortality following Acute Myocardial Infarction","authors":"P. Erne, D. Radovanović, P. Urban, J. Stauffer, O. Bertel, F. Gutzwiller","doi":"10.1159/000073838","DOIUrl":"https://doi.org/10.1159/000073838","url":null,"abstract":"Background: Early drug therapy in patients with ST-elevation infarction is essential for improved short- and long-term outcomes. Most of the drugs used currently have been extensively studied in the era prior to reperfusion therapies, and thus it is important to assess the value of these drugs in today’s clinical practice and compare the results with those of randomized trials. Objectives: The study assessed the effects of age, gender, risk factors, reperfusion therapy and early drug therapy in patients with acute myocardial infarction with ST elevation or new left bundle-branch block on in-hospital mortality. Methods: The analysis of drug administration and in-hospital mortality is based on the AMIS Plus project, a registry of acute coronary syndromes in Switzerland since 1997. Data from 7,279 patients admitted to participating hospitals between 1997 and 2002 were analyzed, and the effect of factors and drug therapies on in-hospital mortality was assessed by logistic regression analysis. Results: Age and diabetes were identified as factors associated with a higher likelihood of in-hospital mortality, while a significant and important reduction of in-hospital mortality was due to the use of thrombolytic therapy or primary percutaneous coronary intervention (PCI) [relative risk reduction (RRR) of 31%, odds ratio (OR) and 95% confidence interval: 0.69; 0.54–0.87; p = 0.002 for thrombolysis, RRR of 34%; OR 0.66; 0.44–0.99; p = 0.044 for PCI]. Early administration of aspirin or ADP antagonists is associated with a risk reduction of in-hospital mortality by 36% (OR 0.63; 0.45–0.89; p = 0.009) and 50% (OR 0.49; 0.35–0.70; p < 0.001), respectively. The use of unfractionated heparin did not reduce in-hospital mortality. Administration of ACE inhibitors, nitrates or beta-blockers reduced the relative risk of in-hospital death by 40% (OR 0.60; 0.49–0.75; p = 0.009), 42% (OR 0.58; 0.46–0.72; p < 0.001) and 54% (OR 0.46; 0.37–0.57; p < 0.001), respectively. Less frequent use of reperfusion therapies and beta-blockers was documented for older patients. Gender was not a determining factor for in-hospital survival. Conclusion: Early administration of aspirin or ADP inhibition with ticlopidine or clopidogrel as well as the early use of beta-blockers, nitrates and ACE inhibitors had a beneficial effect on in-hospital mortality in the reperfusion era with either thrombolytics or PCI. The association of a beneficial effect of ADP inhibition was more pronounced than that found in randomized trials for non-ST-elevation infarction. However, it cannot be excluded that patients with a lower risk for in-hospital death who were selected for early invasive assessment received more frequently ADP inhibitors and that this influenced this beneficial effect. Diabetes and age had negative effects on in-hospital mortality, and both reperfusion therapy and beta-blockers were much less frequently used in elderly patients.","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"134 - 140"},"PeriodicalIF":0.0,"publicationDate":"2003-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000073838","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65190663","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Emerging Role of the Urotensin II System in Cardiovascular Disease","authors":"H. Krum, A. Kompa, R. Hannan, W. Thomas","doi":"10.1159/000072742","DOIUrl":"https://doi.org/10.1159/000072742","url":null,"abstract":"Urotensin II is a potent 11-amino-acid vasoconstrictor peptide. The discovery of its endogenous receptor has led to renewed interest in its role in human cardiovascular physiology and pathophysiology. The cardiovascular actions of urotensin II are complex and include direct effects on the vasculature, systemic hemodynamic effects and effects on the myocardium, including actions on contractility, myocyte hypertrophy and extracellular matrix deposition. Plasma levels of urotensin have been found to be elevated in patients with chronic heart failure, diabetes mellitus and chronic renal disease. These elevations raise the possibility that urotensin II might be involved in the pathogenesis and/or progression of these disease states. Highly selective urotensin II antagonists have been developed, which should help to definitively clarify the role of urotensin II in these and other conditions.","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"153 - 158"},"PeriodicalIF":0.0,"publicationDate":"2003-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000072742","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65180226","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Value of N-Terminal proBNP in the Diagnosis of Left Ventricular Systolic Dysfunction in Primary Care Patients Referred for Echocardiography","authors":"F. Gustafsson, Jørn Badskjær, Frank Stensgaard Hansen, Allan H. Poulsen, P. Hildebrandt","doi":"10.1159/000073839","DOIUrl":"https://doi.org/10.1159/000073839","url":null,"abstract":"Background: Echocardiography is the method of choice to detect left ventricular systolic dysfunction (LVSD), but access to this examination is limited. Therefore, simpler diagnostic tests would be of clinical importance. Objectives: We sought to evaluate the performance of a new N-terminal pro-brain natriuretic peptide (NT-proBNP) analysis in diagnosing LVSD in primary care patients with a provisional diagnosis of heart failure referred for echocardiography. Methods: Serum levels of NT-proBNP were measured with an immunoassay and left ventricular ejection fraction (LVEF) was assessed by echocardiography in 367 patients. Results: Mean age of the patients was 68.8 years (39.0–84.0 years), and 54% were female. Ten percent of the patients had LVEF <0.40. Depending on which cutoff values were used, NT-proBNP analysis detected patients with LVEF <0.40 with a sensitivity of 91–100% and specificity of 46–60%. If the limit for LVSD was set to 0.30, the sensitivity was 100% and the specificity ranged from 44 to 58%. The area under the receiver operating characteristics curves for detecting LVEF ≤0.30 and LVEF ≤0.40 was 0.93 and 0.87, respectively. Conclusion: Irrespective of which cut off value is used, normal NT-proBNP levels effectively rule out LVSD in primary care patients referred for echocardiographic evaluation of possible heart failure.","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"141 - 146"},"PeriodicalIF":0.0,"publicationDate":"2003-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000073839","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65190835","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Congress Calendar","authors":"","doi":"10.1159/000074945","DOIUrl":"https://doi.org/10.1159/000074945","url":null,"abstract":"","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"171 - 172"},"PeriodicalIF":0.0,"publicationDate":"2003-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000074945","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65200073","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"N-Terminal ProBNP: Marker of Systolic Dysfunction or Nonspecific Indicator of Cardiac Disease?","authors":"T. Omland","doi":"10.1159/000073237","DOIUrl":"https://doi.org/10.1159/000073237","url":null,"abstract":"Accessible online at: www.karger.com/hed The clinical diagnosis of heart failure may represent a considerable challenge, particularly in the obese, in women and in the elderly [1]. Because contemporary heart failure therapy has been shown to significantly reduce mortality and the number of hospital readmissions, an early and correct diagnosis is crucial. The cost and potential side effects associated with heart failure therapy also means that overtreatment should best be avoided. The clinical syndrome of chronic congestive heart failure is often the end stage of progressive left ventricular dysfunction and is commonly preceded by an asymptomatic or oligosymptomatic latent phase. Congestive heart failure is frequently caused by systolic dysfunction of the left ventricle, but a considerable proportion of patients do have preserved systolic function [2]. Echocardiography is routinely performed by cardiologists to establish the diagnosis of impaired left ventricular systolic function, but this method requires expensive equipment and skilled operators and is not always readily available. During the past few years, B-type natriuretic peptide (BNP) and the N-terminal fragment of its prohormone, N-terminal proBNP (NT-proBNP) have emerged as promising markers of ventricular dysfunction, and biochemical tests for rapid measurement of these substances have been developed. A point-of-care test for rapid analysis of BNP was first introduced in the year 2000. Very recently, fully automated analytic systems for the determination of BNP and NT-proBNP on large hospital platforms have also become commercially available. BNP was first identified in porcine brain in 1988 [3], but was subsequently found to be present in ventricular myocardium, which is now known to be the main source of circulating BNP [4]. The main secretory stimulus for BNP (and NT-proBNP) appears to be stretch of cardiomyocytes rather than transmural pressure load [5]; circulating levels of BNP and NT-proBNP are increased in conditions characterized by volume overload and correlate with indices of hemodynamic status and ventricular function [6–8]. Although these peptides share many properties, some differences may have clinical implications. BNP is the biologically active hormone, whereas NTproBNP appears to be biologically inactive. The in vivo half-life of BNP is approximately 20 min, whereas the half-life of NT-proBNP has been estimated to be approximately 60–120 min [9]. Accordingly, BNP levels may change more rapidly than those of NT-proBNP following therapeutic interventions which affect cardiac filling [10]. Conversely, NT-proBNP may more accurately reflect the average, long-term hemodynamic status of the patient. Although both BNP and NT-proBNP have been demonstrated to be stable in full blood at room temperature for at least 24 h, the in vitro stability of NT-proBNP in serum or plasma appears to be superior to that of BNP [11]. BNP is cleared from the circulation via binding to specific","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"122 - 124"},"PeriodicalIF":0.0,"publicationDate":"2003-06-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000073237","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65182994","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intraoperative Stress Echocardiography","authors":"R. Jeger, M. Filipovic, P. Buser, M. Seeberger","doi":"10.1159/000071994","DOIUrl":"https://doi.org/10.1159/000071994","url":null,"abstract":"Echocardiography at rest is used to detect both chronic and acute coronary artery disease (CAD). It can also be used to identify mechanical complications of myocardial infarction and provides prognostic information by analyzing systolic and diastolic ventricular function. Segmental wall motion abnormalities (SWMA) are characteristic of scarred or ischemic tissue. Stress testing, e.g. dobutamine stress echocardiography (DSE), is able to detect and assess the severity of CAD. Low-dose DSE detects viable but not contractile myocardium in patients with SWMA at rest, whereas high-dose DSE reveals demand ischemia in patients without SWMA at rest. Perioperatively, echocardiography is usually performed by the transesophageal approach. It is used to monitor high-risk cardiac patients during cardiac and noncardiac surgery, to establish or confirm a cardiovascular pathology in emergency cases, to guide therapy in intraoperative hemodynamic instability and to assess the results of reconstructive cardiac surgery. Intraoperative transesophageal DSE (TEDSE) is a safe and accurate test with a high sensitivity and specificity to detect demand ischemia. It can be used for risk stratification in urgent noncardiac surgery and in patients with an increased risk of cardiac complications. Furthermore, intraoperative TEDSE can guide therapeutic management during and after coronary bypass grafting by the assessment of myocardial viability and coronary flow reserve. Finally, TEDSE can serve as a research tool to evaluate demand ischemia in CAD with a high sensitivity and specificity.","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"87 - 96"},"PeriodicalIF":0.0,"publicationDate":"2003-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000071994","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65173728","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Investigation and Treatment of Subclinical Coronary Atherosclerosis","authors":"J. Davies, P. Weissberg","doi":"10.1159/000071027","DOIUrl":"https://doi.org/10.1159/000071027","url":null,"abstract":"The first manifestation of atherosclerosis is commonly sudden death. Yet despite the fact that the disease has a long asymptomatic phase, diagnostic tests and treatments are largely only available to patients with symptoms. In this review, we discuss recent advances in technology and understanding of the disease process that are providing novel ways to identify patients at risk of having or developing asymptomatic atherosclerosis. We then review some of the disease-modifying drugs, such as antiplatelet agents, cholesterol-lowering drugs, and angiotensin-converting enzyme inhibitors, that can be used to reduce the risk of major adverse clinical events.","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"97 - 106"},"PeriodicalIF":0.0,"publicationDate":"2003-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000071027","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65166729","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Good News!","authors":"D. Diers","doi":"10.1159/000071991","DOIUrl":"https://doi.org/10.1159/000071991","url":null,"abstract":"","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"65 - 66"},"PeriodicalIF":0.0,"publicationDate":"2003-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000071991","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65173956","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Add-On Benefit to Coronary Artery Bypass Grafting of Treatment with Ramipril for Major Cardiac Events and Left Ventricular Remodeling in Intermediate-Risk Patients","authors":"L. Kjøller-Hansen, J. Thiis, R. Steffensen, P. Grande","doi":"10.1159/000071992","DOIUrl":"https://doi.org/10.1159/000071992","url":null,"abstract":"Background: It is not yet settled whether there is an add-on benefit to coronary artery bypass grafting (CABG) of treatment with an angiotensin-converting enzyme (ACE) inhibitor in patients with only moderately impaired left ventricular function and no clinically recognized heart failure. Objective: To assess whether treatment with an ACE inhibitor improves the clinical outcome and left ventricular remodeling after CABG in such intermediate-risk patients. Methods: At a median of 7 days after CABG, 130 patients with a mean left ventricular ejection fraction (LVEF) of 0.42 (SD 0.06), no recent myocardial infarction and no clinically recognized heart failure were randomized to and commenced treatment with ramipril or placebo (target dose 10 mg) and were subsequently followed for a median of 33 months (range 12–46 months). A preoperative and at least one postoperative echocardiogram were obtained in 108 patients. Results: Ramipril reduced the incidence of the triple composite end point of cardiac death, acute myocardial infarction and development of clinical heart failure (relative risk 0.41, 95% confidence interval 0.18–0.97; p = 0.045). Ramipril also had a beneficial effect on the change in left ventricular end-systolic volume index from preoperatively (ramipril group –0.22 ml/m2 and placebo group +4.90 ml/m2, p = 0.036), but did not reduce the incidence of recurrent angina. Multivariate analyses revealed that the beneficial effects with ramipril were independent of baseline variables including the LVEF. Patients who suffered the triple composite end point had a lower health-related quality of life score, dyspnea-fatigue rating and exercise capacity during the study period. Conclusion: These results suggest an add-on benefit of ramipril for major cardiac events and remodeling after CABG in intermediate-risk patients and therefore may justify recommendation of treatment with ramipril after CABG in such patients.","PeriodicalId":87985,"journal":{"name":"Heartdrug : excellence in cardiovascular trials","volume":"3 1","pages":"73 - 81"},"PeriodicalIF":0.0,"publicationDate":"2003-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.1159/000071992","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"65174094","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}