Elektriksel kardiyoversiyon uygulanan atriyal fibrilasyonlu olgularda sinüs ritminin sağlanması için gereken kardiyoversiyon enerjisiyle sol atriyum ve sol atriyal apendiks doku doppler bulguları arasındaki ilişki

Amaç: Bu çalışmada kardiyoversiyon (KV) uygulanacak atriyal fibrilasyonlu (AF) hastalarda KV başlangıç enerjisinin belirlenmesinde kullanılabilecek sol atriyum (SA) ve sol atriyal apendiks (SAA) doku Doppler görüntüleme (DDG) bulgularını saptamayı ve AF tekrarı ile ilişkili ekokardiyografik değişkenleri tanımlamayı amaçladık. Gereç ve yöntem: Çalışmaya elektriksel KV ile sinüs ritmi sağlanan 27 hasta alındı. Çalışmaya dahil edilen hastaların transtorasik ekokardiyografi (TTE) ile SA çapları, alanları, hacmi ve hacim indeksi, sağ atriyum çapları, alanı ve hacmi ölçüldü. Doku Doppler görüntülemede ise SA 10 bölgeye (apikal dört boşluktan 5 ve iki boşluktan 5 bölgeye) ve sağ atriyum 3 bölgeye ayrılarak atriyal miyokart kasılma hızları değerlendirildi. Transözofajiyal ekokardiyografide ise SAA akım hızları, SAA maksimum ve minimum alanları, SAA alan değişimi, pulmoner ven akımları ve DDG ile 5 bölgeye (septal bazal ve orta, lateral bazal ve orta, tepe) ayrılarak SAA duvarının kasılma hızları değerlendirildi. Hastalara 50 J ile başlamak üzere sinüs ritmi sağlanana kadar 100 J, 150 J, 200 J antero-lateral, 5. ve son olarak ise 200 J anteriyor-posteriyor olmak üzere bifazik dogru akım KV yapıldı. Kardiyoversiyon ile sinüs ritmi sağlanan hastalar 1. ayda AF tekrarı açısından elektrokardiyografi ile tekrar değerlendirildi. Bulgular: Kardiyoversiyon başarı oranları, 50 J ile %20, 100 J ile % 56,6, 150 J ile %73,3, 200 J ile %90 saptandı. Kardiyoversiyon enerjilerine göre hastalar - 100 J ve >100 J enerjilerde başarılı olunanlar olarak 2 gruba ayrıldığında, yüksek enerji değerlerinde başarılı olunacağını gösteren bulgular olarak SAA septal duvar bazal D3 dalga hızı (p:0,005), SAA dolum hızı (p:0,008), SA anteriyor bazal duvar E' dalga hızı (p:0,009), SAA septal duvar orta D3 dalga hızı (p:0,025) saptandı. Kardiyoversiyon sonrası takipte hastaların %40,7’sinde (n:11) 1. ayda AF tekrarı saptandı. Atriyal fibrilasyon tekrarını öngören bulgular ise sağ atriyum mediyolateral çapının 4,27 cm (p:0,019), apikal dört bosluk görüntülerden SA mediyolateral çapının 4,87 cm (p:0,032), SA hacim indeksinin 42,5 ml/m² (p:0,034), SA hacminin 82,2 ml (p:0,038), SA apikal dört bosluk planimetrik alanının 22,25 cm² (p:0,043), sağ atriyum hacminin 53 ml (p:0,043) üzerinde olması ve SAA septal duvar bazal D3 dalga hızının 11,95 cm/sn altında olması (p:0,046) olarak belirlendi. Sonuç: Atriyal fibrilasyonda KV uygulanacak hastalarda konvansiyonel ekokardiyografik bulgular yanında DDG bulgularının da kullanılması, daha yüksek enerji değerlerine ihtiyaç duyulan hastaların seçiminde yardımcı olabilir. Böylece ilk şokta başarı şansı arttığından, uygulanan toplam enerji, sok sayısı ve anestezi süresinin azaltılması mümkün olacaktır. Ayrıca AF tekrarını artıran bulguların belirlenmesi ile KV sonrası ek tedavi gereksinimi olan ya da AF tekrarlama olasılığı yüksek ise ritim kontrolü yerine hız kontrolünün tercih edilmesi gereken olgular ayırt edilebilir

Suboptimal guideline adherence is associated with higher MortalitY and hospitalization Rates in patieNts with heArt failure and reduced ejection fraction: The SMYRNA Study

[No Abstract Available

Prognostic significance of medical therapy in patients with heart failure with reduced ejection fraction

Aims: The use of guideline-directed medical therapy (GDMT) among patients with heart failure (HF) with reduced ejection fraction (HFrEF) remains suboptimal. The SMYRNA study aims to identify the clinical factors for the non-use of GDMT and to determine the prognostic significance of GDMT in patients with HFrEF in a real-life setting. Methods and results: The SMYRNA study is a prospective, multicentre, and observational study that included outpatients with HFrEF. Patients were divided into three groups according to the status of GDMT at the time of enrolment: (i) patients receiving all classes of HF medications including renin-angiotensin system (RAS) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists (MRAs); (ii) patients receiving any two classes of HF medications (RAS inhibitors and beta-blockers, or RAS inhibitors and MRAs, or beta-blockers and MRAs); and (iii) either patients receiving class of HF medications (only one therapy) or patients not receiving any class of HF medications. The primary outcome was a composite of hospitalization for HF or cardiovascular death. The study population consisted of 1062 patients with HFrEF, predominantly men (69.1%), with a median age of 68 (range: 20–96) years. RAS inhibitors, beta-blockers, and MRAs were prescribed in 76.0%, 89.4%, and 55.1% of the patients, respectively. The proportions of patients receiving target doses of guideline-directed medications were 24.4% for RAS inhibitors, 11.0% for beta-blockers, and 11.1% for MRAs. Overall, 491 patients (46.2%) were treated with triple therapy, 353 patients (33.2%) were treated with any two classes of HF medications, and 218 patients (20.6%) were receiving only one class of HF medication or not receiving any HF medication. Patient-related factors comprising older age, New York Heart Association functional class, rural living, presence of hypertension, and history of myocardial infarction were independently associated with the use or non-use of GDMT. During the median 24-month period, the primary composite endpoint occurred in 362 patients (34.1%), and 177 of 1062 (16.7%) patients died. Patients treated with two or three classes of HF medications had a decreased risk of hospitalization for HF or cardiovascular death compared with those patients receiving ≤1 class of HF medication [hazard ratio (HR): 0.65; 95% confidence interval (CI): 0.49–0.85; P = 0.002, and HR: 0.61; 95% CI: 0.47–0.79; P < 0.001, respectively]. Conclusions: The real-life SMYRNA study provided comprehensive data about the clinical factors associated with the non-use of GDMT and showed that suboptimal GDMT is associated with an increased risk of hospitalization for HF or cardiovascular death in patients with HFrEF

Gender-related clinical and management differences in patients with chronic heart failure with reduced ejection fraction

WOS: 000588830800001PubMed: 33063424Aim Gender-related differences have been described in the clinical characteristics and management of patients with chronic heart failure with reduced ejection fraction (HFrEF). However, published data are conflictive in this regard. Methods We investigated differences in clinical and management variables between male and female patients from the ATA study, a prospective, multicentre, observational study that included 1462 outpatients with chronic HFrEF between January and June 2019. Results Study population was predominantly male (70.1%). in comparison to men, women with chronic HFrEF were older (66 +/- 11 years vs 69 +/- 12 years, P < .001), suffered more hospitalisations and presented more frequently with NYHA class III or IV symptoms. Ischaemic heart disease was more frequent in men, whereas anaemia, thyroid disease and depression were more frequent in women. No difference was seen between genders in the use rate of renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, or ivabradine, or in the proportion of patients achieving target doses of these drugs. Regarding device therapies, men were more often treated with an implantable cardioverter-defibrillator (ICD) and women received more cardiac resynchronisation therapy. Conclusion in summary, although management seemed to be equivalent between genders, women tended to present with more symptoms, require hospitalisation more frequently and have different comorbidities than men. These results highlight the importance of gender-related differences in HFrEF and call for further research to clarify the causes of these disparities. Gender-specific recommendations should be included in future guidelines in HFrEF

Adherence to guideline-directed medical and device Therapy in outpAtients with heart failure with reduced ejection fraction: The ATA study

Objective: Despite recommendations from heart failure guidelines on the use of pharmacologic and device therapy in patients with heart failure with reduced ejection fraction (HFrEF), important inconsistencies in guideline adherence persist in practice. The aim of this study was to assess adherence to guideline-directed medical and device therapy for the treatment of patients with chronic HFrEF (left ventricular ejection fraction ?40%). Methods: The Adherence to guideline-directed medical and device Therapy in outpAtients with HFrEF (ATA) study is a prospective, multicenter, observational study conducted in 24 centers from January 2019 to June 2019. Results: The study included 1462 outpatients (male: 70.1%, mean age: 67±11 years, mean LVEF: 30%±6%) with chronic HFrEF. Renin–angiotensin system (RAS) inhibitors, beta-blockers, mineralocorticoid receptor antagonists (MRAs), and ivabradin were used in 78.2%, 90.2%, 55.4%, and 12.1% of patients, respectively. The proportion of patients receiving target doses of medical treatments was 24.6% for RAS inhibitors, 9.9% for beta-blockers, and 10.5% for MRAs. Among patients who met the criteria for implantable cardioverter–defibrillator (ICD) and cardiac resynchronization therapy (CRT), only 16.9% of patients received an ICD (167 of 983) and 34% (95 of 279) of patients underwent CRT (95 of 279). Conclusion: The ATA study shows that most HFrEF outpatients receive RAS inhibitors and beta-blockers but not MRAs or ivabradin when the medical reasons for nonuse, such as drug intolerance or contraindications, are taken into account. In addition, most eligible patients with HFrEF do not receive target doses of pharmacological treatments or guideline-recommended device therapy. (Anatol J Cardiol 2020; 24: 32-40) Keywords: adherence, chronic heart failure, device therapy, guidelines, pharmacological treatment, outpatient