Echocardiographic indices of diastolic function in patients with heart failure: heart failure preserved versus reduced left ventricular ejection fraction

Introduction: Heart failure (HF) is a clinically defined syndrome in which patients have typical signs and symptoms due to an abnormality of cardiac structure or function. According to left ventricle ejection fraction (LVEF) HF can be classified as HF preserved LVEF (HFpEF) and HF reduced LVEF (HFrEF). Whether HF is presents and evolves as a single syndrome with HFpEF preceding HFrEF or as two independent syndromes is a matter of controversy.Aim: The purpose of this study was to examine the diastolic function using doppler and tissue doppler echocardiographic indices among patients with HFpEF and HFrEF.Methods: Study population consisted of 40 stable HF patients, under guideline recommended medical treatment, without exaggeration or hospitalization over the last 30 days that were evaluated at the outpatient clinic from 1/9/2009 till 30/7/2010. According to LVEF (dichotomous 45%) two groups were formed. Group A consisted the HFpEF group (n = 20, 11 males, mean age 62.8 ± 7.4 years, LVEF = 52.4 ± 5.7%) while group B consisted the HFrEF group (n=20, 15 males, mean age 63.3 ± 7.8 years, LVEF = 28.5 ± 5.8%). Control group consisted of 20 volunteers (11 males, mean age 57.8 ± 9.7 years, LVEF = 63/1 ± 7.1%) without history or signs/symptoms of HF.Results: Age, gender and NYHA class were not statistically different among both HF groups. Patients with HFrEF had statistically increased left ventricle (LV) dimensions and reduced wall thickness compared to those with HFpEF, however left atrial volume index (LAVI) and dimension were not different among both groups. Pulse doppler in mitral valve and pulmonary veins revealed reduced wave A duration and S wave velocity as well as increased IVRT in patients with HFrEF than those with HFpEF, while tissue doppler in mitral valve annulus revealed reduced both septal and lateral s' and lateral a' wave velocity in patients with HFrEF than those with HFpEF. Moreover, patients with HFpEF exhibited reduced lateral s' wave velocity compared to those in control group. Concerning diastolic dysfunction grading there was no difference between the two HF groups, however HF groups had worse grading compared to control group. Finally, BNP levels were greater in patients with HFrEF. LAVI and NYHA class in patients with HF seem to correlate with echocardiographic indices of diastolic function and BNP levels but not with LVEF.Conclusion: Diastolic function seems to be equally impaired in both HF types, considering the echocardiographic indices of diastolic function.Εισαγωγή: Η καρδιακή ανεπάρκεια (ΚΑ) με βάση το κλάσμα εξώθησης της αριστερή κοιλίας (ΚΕΑΚ) διακρίνεται σε ΚΑ με διατηρημένο (ΚΑδΚΕ) και με μειωμένο ΚΕΑΚ (ΚΑμΚΕ). Αντικρουόμενες είναι οι απόψεις για το πόσο η ΚΑδΚΕ αποτελεί ανεξάρτητη οντότητα της ΚΑ ή εξελίσσεται σε ΚΑμΚΕ, ενώ δεν έχει διευκρινιστεί κατά πόσο η διαστολική δυσλειτουργία αποτελεί κοινό στοιχείο των ασθενών με ΚΑ ανεξάρτητα του ΚΕΑΚ.Σκοπός: Η συγκριτική μελέτη με υπερηχοκαρδιογραφικούς δείκτες της διαστολικής λειτουργίας της αριστερής κοιλίας (ΑΚ) με τη χρήση παλμικού και ιστικού Doppler σε ασθενείς με ΚΑ.Μέθοδοι και Υλικό: Τον πληθυσμό της μελέτης αποτέλεσαν 40 ασθενείς με διαγνωσμένη ΚΑ, υπό φαρμακευτική αγωγή, χωρίς παρόξυνση και νοσηλεία τις τελευταίες 30 ημέρες, που προσήλθαν στα εξωτερικά ιατρεία από 1/9/2009 μέχρι και 30/7/2010. Διακρίθηκαν 2 ομάδες ανάλογα με το ΚΕΑΚ (διχοτόμος τιμή 45%). Η ομάδα Α (n = 20, 11 άντρες, 62,8 ± 7,4 ετών, ΚΕΑΚ = 52,4 ± 5,7%) περιλαμβάνει εκείνους με ΚΑδΚΕ και η ομάδα Β (n=20, 15 άντρες, 63,3 ± 7,8 ετών, ΚΕΑΚ = 28,5 ± 5,8%) περιλαμβάνει εκείνους με ΚΑμΚΕ. Την ομάδα ελέγχου (ομάδα C) αποτελούν 20 εθελοντές (11 άντρες, 57,8 ± 9,7 ετών, ΚΕΑΚ = 63,1 ± 7,1%) χωρίς διαγνωσμένη ΚΑ και χωρίς συμπτώματα ή/και σημεία ΚΑ.Αποτελέσματα: Οι δύο ομάδες της ΚΑ δε διαφέρουν στατιστικά σημαντικά ως προς την ηλικία, το φύλο και την τάξη κατά NYHA. Οι ασθενείς της ομάδας ΚΑμΚΕ έχουν στατιστικά αυξημένες διαστάσεις και λεπτότερα τοιχώματα της αριστερής κοιλίας σε σχέση με τους ασθενείς με ΚΑδΚΕ, χωρίς όμως να διαφέρουν οι διαστάσεις και ο όγκος του αριστερού κόλπου (LAVI) μεταξύ των δυο ομάδων. Στο παλμικό Doppler, στη μιτροειδή βαλβίδα και στις πνευμονικές φλέβες, παρατηρήθηκε μικρότερη διάρκεια του κύματος Α, μεγαλύτερη διάρκεια του χρόνου ισογκωτικής χάλασης και μικρότερη ταχύτητα του κύματος S στην ομάδα ΚΑμΚΕ σε σχέση με την ομάδα ΚΑδΚΕ, ενώ στο ιστικό doppler στο μιτροειδικό δακτύλιο (διαφραγματική και πλάγια θέση) εντοπίστηκαν χαμηλότερη ταχύτητα των κύματων s' και του κύματος a' στην πλάγια θέση στους ασθενείς με ΚΑμΚΕ σε σχέση με τους ασθενείς με ΚΑδΚΕ. Οι ασθενείς με ΚΑδΚΕ παρουσίαζαν χαμηλότερη ταχύτητα του κύματος s' στην πλάγια θέση σε σχέση με τα άτομα της ομάδας ελέγχου. Οι ασθενείς με ΚΑδΚΕ δε διέφεραν ως προς την ταξινόμηση της βαρύτητας της διαστολικής δυσλειτουργίας σε σχέση με τους ασθενείς με ΚΑμΚΕ, ενώ και οι δύο ομάδες της ΚΑ διέφεραν στατιστικά σημαντικά σε σχέση με την ομάδα ελέγχου. Τέλος, οι ασθενείς με ΚΑμΚΕ έχουν υψηλότερα επίπεδα BNP σε σχέση με εκείνους με ΚΑδΚΕ. Ο LAVI και η τάξη κατά ΝΥΗΑ στους ασθενείς με ΚΑ συσχετίζεται με υπερηχοκαρδιογραφικούς διαστολικούς δείκτες και τα επίπεδα του BNP, ενώ δεν ανιχνεύτηκε σημαντική συσχέτιση με το ΚΕΑΚ. Συμπέρασμα: Η διαστολική δυσλειτουργία φαίνεται να αποτελεί κοινό σημείο και στους δύο τύπους ΚΑ, όπως προκύπτει από τη σύγκριση των υπερηχοκαρδιογραφικών δεικτών διαστολικής λειτουργίας μεταξύ ασθενών με ΚΑδΚΕ και ασθενών με ΚΑμΚΕ

Wahania kursów walut i ich wpływ na zagregowany eksport na Ukrainie

This paper examines the effect of Exchange Rate Volatility (ERV) on the aggregate exports of Ukraine during the period of 1990 to 2013 using quarterly data. In the literature, it is found that exchange rate volatility causes a reduction in the overall level of trade. The paper tests this finding for Ukrainian foreign trade in the aforementioned period using the Autoregressive Distributed Lags (ARDL) method to co-integration. Overall, our findings suggest that there is a negative effect of ERV on Ukrainian exports. From a policy prospective, this result is important because it suggests that policy makers should consider the negative effect of ERV on exports when exercising exchange rate policy for balance of payment purposes

Cost-Effectiveness of Apixaban vs. Other New Oral Anticoagulants for the Prevention of Stroke: An Analysis on Patients with Non-Valvular Atrial Fibrillation in the Greek Healthcare Setting

Background and Objectives Three new oral anticoagulants (NOACs) are currently approved for stroke prevention and systemic embolism in patients with non-valvular atrial fibrillation (NVAF). The objective of this analysis was to assess the cost effectiveness of apixaban against other NOACs for the prevention of stroke in patients with NVAF in Greece. Methods A Markov model that evaluated clinical events, quality-adjusted life expectancy, and costs for patients treated with apixaban or other NOACs formed the basis of the analysis. Clinical events were modeled for a lifetime horizon, based on clinical efficacy data from an indirect comparison, using the ARISTOTLE, ROCKET-AF, and RE-LY clinical trials. Resource use associated with patient monitoring was elicited via a panel of experts (cardiologists and internists). Cost calculations reflect the local clinical setting and followed a third-party payer perspective (Euros, discounted at 3 %). Results Apixaban was projected to reduce the occurrence of clinical events and increase quality-adjusted life expectancy and incremental costs of treatment compared with other NOACs. Taking into account costs of medications, patient monitoring, and management of events, the incremental cost-effectiveness ratios for apixaban 5 mg twice daily vs. dabigatran 110 mg twice daily, dabigatran 150 mg twice daily, and rivaroxaban 20 mg once daily were estimated at (sic)9907/quality-adjusted life-year (QALY), (sic)13,727/QALY, and (sic)6936/QALY gained, respectively. Extensive sensitivity analyses indicated that results were robust over a wide range of inputs. Conclusions Based on the results of this analysis, apixaban can be a cost-effective alternative to other NOACs for the prevention of stroke in patients with NVAF in Greece

Long-term risk, clinical management, and healthcare resource utilization of stable patients with coronary artery disease and post-myocardial infarction in Greece - TIGREECE study

Background: In light of the scarcity of evidence, TIGREECE evaluated the clinical management and long-term outcomes of patients at high risk for an atherothrombotic event who have suffered a myocardial infarction (MI), managed by cardiologists/internists in routine hospital and private office settings in Greece. Methods: TIGREECE, a multicenter, 3-year prospective cohort study, enrolled patients ≥50 years old, with a history of MI 1–3 years before enrollment and with at least one of the following risk factors: age ≥65 years, diabetes mellitus requiring medication, second prior MI, multivessel coronary artery disease, and creatinine clearance 15–60 mL/min. The primary outcome was a composite of MI, unstable angina with urgent revascularization, stroke, or all-cause death. Results: Between 5 June 2014 and 25 July 2015, 305 eligible consented patients (median age: 67.3 years; 81.3% males; 14.8% active smokers; 80.7% overweight/obese) were enrolled; 52.5% had ≥2 qualifying risk factors. The median time from the index MI [ST-segment elevation myocardial infarction (STEMI) in 51.1%, non-STEMI in 33.1%] to enrollment was 1.7 years. Of the patients, 65.9% had been discharged on dual antiplatelet therapy. At enrollment, 94.4% were receiving antiplatelets: 60.0% single [acetylsalicylic acid (ASA): 43.3%; clopidogrel: 15.7%] and 34.4% dual (ASA + clopidogrel: 31.8%) therapy. The Kaplan–Meier estimated 3-year primary composite event rate was 9.3% [95% confidence interval (CI): 6.4–13.0), and the ischemic composite event rate was 6.7% (95% CI: 4.2–9.9). Conclusions: Study results indicate that in the routine care of Greece one in ten patients experience a recurring cardiovascular event or death, mainly of ischemic origin, 1–3 years post-MI

Association of asymmetric dimethylarginine levels with treadmill-stress-test-derived prognosticators

Background: Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide production. The purpose of this study was to assess the correlation between ADMA and treadmill stress test outcome parameters with known prognostic value, in patients with intermediate risk for coronary artery disease (CAD). Methods: Study participants were referred for treadmill exercise stress test (EST) due to symptoms of suspected CAD. Participants with prior history of CAD, cerebrovascular events, peripheral artery disease, systemic inflammatory disease or use of anti-inflammatory agents were excluded. ADMA levels were measured before EST. Results: The study prospectively enrolled 209 individuals (165 males, aged 58.1 +/- 10.9). A significant negative correlation was detected between ADMA and maximal exercise time (r= -0.556, p < 0.001), metabolic equivalents (METs) (r= -0.555, p < 0.001) and Duke treadmill score (DTS) (r= -0.347, p < 0.001). Subjects who exercised to >= 10 METs (n = 114) had lower ADMA levels than those who achieved < 7 METs (n = 30) (0.58 +/- 0.06 vs 0.87 +/- 0.08 mu mol/L, p < 0.001), and those with DTS < 5 (n = 63) had higher ADMA (0.75 +/- 0.19 vs 0.64 +/- 0.15 mu mol/L, p < 0.001) compared to those with DTS >= 5 (n= 146). In multivariable analysis, ADMA remained an independent predictor of DTS (R-2= 0.210; beta=-10.5; 95% confidence interval - 14.9 to - 6.2; adjusted p < 0.001) and METs (R-2 = 0.500; beta - 8.5; 95% confidence interval -9.7 to - 6.0; adjusted p < 0.001) after adjustment for age, BMI, gender, diabetes, smoking status, dyslipidemia, hypertension and family history of premature CAD. Conclusion: ADMA is correlated to EST parameters with proven prognostic value. This implies that ADMA itself might be a useful prognosticator in patients with suspected CAD. (C) 2014 The Canadian Society of Clinical Chemists. Published by Elsevier Inc. All rights reserved

An open-label, add-on study of pregabalin in patients with partial seizures: A multicenter trial in Greece

Introduction: Pregabalin efficacy and safety as an adjunctive treatment for partial seizures was evaluated using an open-label, flexible-dose. Study design: In 98 adults with refractory partial epilepsy taking 1-3 anti-epileptic drugs with >= 2 seizures during an 8-week baseline period. Methods: Pregabalin was increased to 3 per 28 days, respectively. The 50% and 75% responder rates were 41.94% (95% CI: 31.91-51.96) and 30.11% (95% CI: 20.78-39.43), respectively. Nineteen percent of subjects were seizure-free throughout the last 12 weeks. Pregabalin administration resulted in a significant reduction in anxiety (mean reduction in Hospital Anxiety and Depression Scale scores of 1.68 units, 95% CI: -2.60 to -0.76). Most patients were much improved or very much improved on Patient Global Impression of Change (53.8%) and Clinical Global Impression of Change (53.8%). The most frequently self-reported adverse events (AEs) were mild or moderate somnolence (20.4%) and dizziness (5.1%) with a low AE discontinuation rate (5.1%). Conclusions: The efficacy and side-effect profile of pregabalin were similar to previous pregabalin double-blind, controlled studies. Additionally, pregabalin, as an add-on treatment for partial epilepsy, exhibits significant anti-anxiety properties. (C) 2011 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved