The mutual relationship between heart failure and atrial fibrillation

Atrial fibrillation (AF) and Heart Failure (HF) are evolving epidemies, together responsible for substantial human suffering and health-care expenditure. The simultaneous co-existence of the two conditions is associated with higher mortality rates than those observed in individuals with only one or none of them. Patients with concomitant HF and AF suffer from even worse symptoms and poorer prognosis, yet evidence-based evaluation and management of this group of patients is lacking. In this review, we evaluate the common mechanisms for the development of AF in HF patients and vice versa, focusing on the evidence for potential treatment strategies. Recent data have suggested that these patients may respond differently if compared to those with HF or AF alone. These results highlight the clear clinical need to identify and treat these diseases according to best evidence, in order to prevent adverse outcomes and reduce the huge burden er that HF and AF are expected to have on global healthcare systems in the future

Takotsubo cardiomyopathy and sepsis: a systematic review

Takotsubo cardiomyopathy (TTC) is characterized by a systolic dysfunction localized in the apical and medial aspect of the left ventricle. It is usually related to physical or emotional stress. Recent evidence highlighting the role of infection led us to analyze the links between TTC and sepsis. A systematic review of the literature was undertaken to assess any trends in clinical findings, diagnosis, and outcomes in such patients. We identified 23 selected papers reporting a total of 26 patients, having sepsis, in whom TTC occurred. For each case, we collected data identifying population characteristics, source of sepsis, clinical disease description, and the results of cardiovascular investigations. The majority of patients were females (n = 16), mean age was 62.8 (14.0 standard deviation) years, and clinical outcome was favorable in 92.3% of the cases once the management of sepsis was initiated. A better understanding of the mechanisms of sepsis-associated TTC may generate novel strategies to treat the complications of this cardiomyopathy and may even help predict and prevent its occurrence

Effect of intravenous iron replacement therapy on exercise capacity in iron deficient anemic patients after cardiac surgery

Iron deficiency (ID) is recognized as an important comorbidity in patients undergoing cardiac surgery; however, it still remains under-diagnosed and under-treated in clinical practice. This study aims at comparing efficacy and the effects on exercise capacity of intravenous ferric carboxymaltose (FCM) versus ferric gluconate (FG) in patients with ID anemia (IDA) resulting from cardiac surgery. We retrospectively analyzed data from our records of in-hospital patients with IDA after cardiac surgery undergoing cardiac rehabilitation. Group I was treated with FG, group II with FCM. Efficacy measures included changes (baseline vs discharge) in hemoglobin (Hb) and in distance traveled at six-minutes walking test (6MWT). Data from 74 in-patients (mean age 67.5±10.4 years, 43% women) were analyzed. At discharge, patients treated with FCM showed higher levels of Hb (11.1±1.2g/dl vs 10.2±1.1 g/dl; p=0.001), greater distance traveled at 6MWT (279.2±108.8 meters vs 236.3±72.7 meters; p=0.048), and lower in-hospital rehabilitation length of stay (20.3±7 vs 25.3±11.7 days; p=0.043) as compared to FG group. At multivariate analysis, the most powerful predictors of Hb increase >1 g/dl at discharge were transferrin levels (p=0.019) and treatment with FCM (p100 meters) at discharge (p=0.13 and p=0.003, respectively). In patients with IDA following cardiac surgery, intravenous FCM is effective in restoring Hb levels and in improving exercise capacity after cardiac surgery

Prognostic Value of the 6-Min Walk Test After Open-Heart Valve Surgery: EXPERIENCE OF A CARDIOVASCULAR REHABILITATION PROGRAM

PURPOSE: This single-center retrospective analysis aimed to evaluate the prognostic relevance of 6-min walk test (6MWT) in patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery. METHODS: One hundred one patients able to perform a 6MWT within the first week of admission (time after surgery: 16 ± 8 d) were included (age 68 ± 11 y; 55% female; median left ventricular ejection fraction 55% [interquartile range: 50-60]; 51% after aortic valve surgery). Study endpoints were cardiovascular death and the combined outcome of cardiovascular death/cardiac hospitalization. Univariate and multivariate analyses were performed to analyze predictive value of the 6MWT. RESULTS: After a median follow-up of 27 mo, cardiovascular mortality was 9.9% while combined endpoint occurrence was 33%. Patients experiencing study endpoints had lower left ventricular ejection fraction, higher N-terminal prohormone of brain natriuretic peptide serum levels, and longer in-hospital stay (all P < .05). The 6MWT distance was a significant predictor of cardiovascular death (hazard ratio [HR] = 0.89, 95% CI: 0.81-0.97, P = .007) and cardiac hospitalizations (HR = 0.95, 95% CI: 0.90-0.99, P = .02). Even after adjusting for the relevant confounding variables of cardiovascular death and cardiac hospitalization, the adjusted HR = 0.88, 95% CI: 0.75-0.98, P = .028 and adjusted HR = 0.95, 95% CI: 0.90-0.99, P = .05, respectively. CONCLUSIONS: In patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery, 6MWT proved to be an independent prognostic tool, potentially allowing identification of high-risk patients for whom a more intensive and tailored in-hospital cardiovascular rehabilitation program should be designed and implemented in order to avoid unfavorable cardiovascular events

Impact of "Off-Label" Use of Ivabradine on Exercise Capacity, Gas Exchange, Functional Class, Quality of Life, and Neurohormonal Modulation in Patients With Ischemic Chronic Heart Failure

BACKGROUND: epidemiologic studies indicate that elevated heart rate (HR) is an independent risk factor for mortality and morbidity in patients (pts) with chronic heart failure (CHF). Clinical trials with β-blockers suggest that HR reduction is an important mechanism of their benefit in pts with stable CHF. Pharmacologic inhibition of the I(f) current now provides the opportunity of pure HR reduction. The purpose of this study was to evaluate the impact of ''Off-Label'' use of ivabradine on exercise capacity, gas exchange, functional class, quality of life, and neurohormonal modulation in pts with ischemic CHF. METHODS: between January 2008 and June 2008, a graded maximal exercise test with respiratory gas analysis and an endurance test with constant workload corresponding to 85% of the peak VO(2) at the baseline and after 3 months were performed, and at the same times, N-terminal probrain natriuretic peptide (NT-proBNP) levels were also measured, in 60 pts (45 M, 15 F, mean age 52.7 ± 5.3 years), with stable ischemic CHF, New York Heart Association (NYHA) functional classes II (n = 35)-III (n = 25), with left ventricular ejection fraction (LVEF) ≤ 40%, randomized to a ''off-label'' ivabradine use (n = 30) and a control group (n = 30). RESULTS: the exercise capacity increased from 14.8 ± 2.5 to 28.2 ± 3.5 min (P < .0001) and the peak oxygen consumption tended to improve from 13.5 ± 1.3 to 17.9 ± 2.4 mL/kg per minute (P < .0001) in ivabradine group. Oxygen consumption at the anaerobic threshold (AT) increased from 11.9 ± 1.4 to 15.3 ± 1.4 mL/kg per minute (P < .0001). NTproBNP levels decreased from 2356 ± 2113 pg/mL to 1434 ± 1273 pg/mL (P = .045). No significant differences were found in control group at 3 months. The positive ivabradine effects were also associated with an improvement in the NYHA functional class and quality of life. CONCLUSION: the ''Off-Label'' use of ivabradine significantly improves the exercise capacity, gas exchange, functional heart failure class, quality of life, and neurohormonal modulation in pts with ischemic CHF