Titration to target dose of bisoprolol vs. carvedilol in elderly patients with heart failure: the CIBIS-ELD trial

AIMS: Various beta-blockers with distinct pharmacological profiles are approved in heart failure, yet they remain underused and underdosed. Although potentially of major public health importance, whether one agent is superior in terms of tolerability and optimal dosing has not been investigated. The aim of this study was therefore to compare the tolerability and clinical effects of two proven beta-blockers in elderly patients with heart failure. METHODS AND RESULTS: We performed a double-blind superiority trial of bisoprolol vs. carvedilol in 883 elderly heart failure patients with reduced or preserved left ventricular ejection fraction in 41 European centres. The primary endpoint was tolerability, defined as reaching and maintaining guideline-recommended target doses after 12 weeks treatment. Adverse events and clinical parameters of patient status were secondary endpoints. None of the beta-blockers was superior with regards to tolerability: 24% [95% confidence interval (CI) 20-28] of patients in the bisoprolol arm and 25% (95% CI 21-29) of patients in the carvedilol arm achieved the primary endpoint (P= 0.64). The use of bisoprolol resulted in greater reduction of heart rate (adjusted mean difference 2.1 b.p.m., 95% CI 0.5-3.6, P= 0.008) and more, dose-limiting, bradycardic adverse events (16 vs. 11%; P= 0.02). The use of carvedilol led to a reduction of forced expiratory volume (adjusted mean difference 50 mL, 95% CI 4-95, P= 0.03) and more, non-dose-limiting, pulmonary adverse events (10 vs. 4%; P < 0.001). CONCLUSION: Overall tolerability to target doses was comparable. The pattern of intolerance, however, was different: bradycardia occurred more often in the bisoprolol group, whereas pulmonary adverse events occurred more often in the carvedilol group. This study is registered with controlled-trials.com, number ISRCTN34827306

Hand-held echo is not so handy in everyone’s hands: Misdiagnosing congenital septal defects in patients with heart murmurs

Introduction. Echocardiography is a highly operator-dependant technique which requires adequate training and skills that are frequently not present, considering the widespread use of cardiovascular ultrasound. This could particularly be true for hand-held echo devices which made echocardiography more accessible but are frequently used by non-cardiologists and non-experts. Outline of Cases. We present a 45-year-old female and a 37-year-old male with heart murmurs due to atrial and ventricular septal defect, respectively. Congenital septal defects were undiagnosed in both patients during several outpatient examinations due to challenging image acquisition. Careful re-evaluation revealed that, depending on the scanning technique, it was possible to detect or overlook the real cause of the murmur using either hand-held or high-end echo device. Conclusion. Our report underlines the need of adequate knowledge and training of medical professionals performing pocket-size hand-held echocardiography, since potential misdiagnoses may not be related to limited imaging capabilities of pocket-sized echo devices only, but also to inability of insufficiently trained users to obtain good quality images and interpret them adequately. [Projekat Ministarstva nauke Republike Srbije, br. 175099

Pseudopacemaker syndrome and marked first-degree atrioventricular block: Case report

Introduction. Pacemaker syndrome consists of the symptoms and signs present in the single chamber (VVI) pacemaker patient with electrode placed in the right ventricular apex. It is caused by inadequate timing of atrial and ventricular contractions. Pacemaker syndrome without a pacemaker (or pseudopacemaker syndrome) refers to occurrence of symptoms in the presence of marked first-degree atrioventricular (AV) block, when P wave is too close to the preceding QRS complex producing the same haemodynamic disturbance as artificial pacemaker cardiac stimulation with retrograde VA conduction. Case Outline. We present the patient with acute inferior myocardial infarction due to late bare metal stent thrombosis, treated with primary pectutaneous coronary intervention. Hospital course was complicated by complete heart block which was treated with temporary pacing. During the stand-by mode of temporary pacing, sinus rhythm with marked first-degree AV block (PQ interval 480 ms) was observed while the patients re-experienced the symptoms that were present prior to pacemaker implantation. Temporary pacing was continued for the next 24 hours when spontaneous shorteninig of PQ interval (250-270 ms) was noticed; since the patient was asymptomatic during the stand-by mode, the pacemaker electrodes were removed and the patient discharged 11 days after admission. Conclusion. Conduction disturbances, such as the varying degrees of AV blocks, are relatively common in acute inferior myocardial infarction. The first degree AV blok is usually asymptomatic and does not require treatment, unless when it is associated with pseudopacemaker syndrome. In that case, temporary pacing provides haemodynamic stability until conduction system recovers

Short QT interval is unreliable marker of anabolic androgenic steroid abuse in competitive athletes

Introduction. Previous animal and human studies provided the evidence that testosterone may affect ventricular repolarization by shortening of the QT interval. Synthetic derivatives of testosterone, modified to enhance its anabolic properties, are occasionally abused by some competitive athletes. Objective. We assessed whether the QT interval duration could discriminate androgenic anabolic steroids (AAS)-using strength athletes (SA) from drug-free endurance athletes (EA), by comparing 25 formulas for QT interval correction. Methods. We recruited 22 elite male athletes involved in long-term strength or endurance training and 20 sedentary controls. All elit

Severe short-lasting left ventricular dysfunction associated with a respiratory infection

Introduction. Since clinical and electrocardiographic features of various cardiac disorders may overlap, the differential diagnosis of left ventricular (LV) dysfunction may be difficult even for the most experienced physicians. Recent advances in cardiac imaging may help clinicians to establish an accurate diagnosis and initiate adequate treatment. The aim of this case report is to raise awareness of a very short-lasting LV dysfunction during respiratory infections and to underline the importance of multimodality imaging in this clinical setting. Case outline. A previously healthy 37-year-old male presented with atypical chest pain and ST-segment elevation in the inferolateral leads during severe mental stress and acute respiratory infection. Acute myocardial infarction, myocarditis, coronary vasospasm and stress cardiomyopathy were all considered as a differential diagnosis. A rapid onset of severe LV dysfunction and a complete recovery within 4 days was detected by echocardiography and further evaluated by multimodality imaging, including multislice computed tomography and cardiac magnetic resonance imaging. Conclusion. Severe, but very short-lasting LV dysfunction may be triggered by various causes, including upper respiratory tract infections. Since the symptoms of respiratory infections may obscure those of LV dysfunction, myocardial dysfunction in these patients may go undetected with possible serious consequences

Scintigraphy of the Domestic Dog Using [Tc-99m(Co)(3)(H2o)(3)]-C-60(Oh)(22-24)

In this study we performed the dynamic and static scintigraphy of the domestic dog, using the newly synthesized radiopharmaceutical, [Tc-99m(CO)(3)(H2O)(3)]-C-60(OH)(22-24). In the current study, an advanced one-step method for the functionalization of fullerenol by Tc-99m is described. Optical properties of as-prepared samples and the mechanism responsible for the functionalization were investigated using UV-VIS and FTIR spectroscopy, respectively. Also, the presence of the Tc complex on fullerenol was confirmed by using the energy dispersive X-ray spectroscopy, HPLC and MALDI TOF techniques. This simple and effective method of producing a new radiopharmaceutical is of interest not only for its application in various areas of technology and biology, but also for investigating its potential use in radiation technology for nanoengineering of materials. With dynamic scintigraphy, performed during 30 minutes (120 frames, 15 sec per frame), we obtained ratios of heart, liver and spleen counts: 222/249/168; 178/320/217; 120/348/239 respectively. By static scintigraphy after 1 hour, we detected the activity in heart, liver, spleen and intestines. After 4 hours, the radiopharmaceutical activity was detected in salivary glands. The detection after 21 hours showed the activity in kidneys and urinary bladder, while the activity in intestines was absent. After 24 hours, we detected the activity in liver, spleen, kidneys and urinary bladder. Pharmacokinetic investigations performed in this study are of key interest for the further fullerenol in vivo research

Influence of manual thrombus aspiration on left ventricular diastolic function in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention

Introduction. Data on effects of thrombus aspiration on left ventricular diastolic function in ST-elevation myocardial infarction (STEMI) population are scarce. Objective. We sought to compare echocardiographic indices of the diastolic function and outcomes in STEMI patients treated with and without manual thrombus aspiration, in an academic, high-volume percutaneous coronary intervention (PCI) center. Methods. A total of 433 consecutive patients who underwent primary PCI in 2011-2012 were enrolled in the study. Patients were not eligible for the study if they already suffered a myocardial infarction, had been previously revascularized, received thrombolytics, presented with cardiogenic shock, had significant valvular disease, atrial fibrillation or had previously implanted pacemaker. Comprehensive echocardiogram was performed within 48 hours. During follow-up patients’ status was assessed by an office visit or telephone interview. Results. Patients treated with thrombus aspiration (TA+, n=216) had similar baseline characteristics as those without thrombus aspiration (TA-, n=217). Groups had similar total ischemic time (319 ± 276 vs. 333±372 min; p=0.665), but TA+ group had higher maximum values of troponin I (39.5 ± 30.5 vs. 27.6 ± 26.9 ng/ml; p<0.001). The echocardiography revealed similar left ventricular volumes and systolic function, but TA+ group had significantly higher incidence of E/e’>15, as a marker of severe diastolic dysfunction (TA+ 23.1% vs. TA- 15.2%; p=0.050). During average follow-up of 14Ѓ}5 months, major adverse cardiac/ cerebral events occurred at the similar rate (log rank p=0.867). Conclusion. Thrombus aspiration is associated with a greater incidence of severe diastolic dysfunction in unselected STEMI patients treated with primary PCI, but it doesn’t influence the incidence of major adverse cardiovascular events. [Projekat Ministarstva nauke Republike Srbije, br. 175099