Evaluation of beta-blockers on left ventricular dyssynchrony and reverse remodeling in idiopathic dilated cardiomyopathy: A randomized trial of carvedilol and metoprolol

Background: The effect of b-blockage on cardiac dyssynchrony in idiopathic dilated cardio­myopathy (IDC) is unknown. This study evaluated the impact of carvedilol and metoprolol succinate on left ventricular (LV) dyssynchrony and reverse remodeling in IDC. Methods: In this small, prospective, double-blind study, we randomly assigned 81 IDC pa­tients to receive carvedilol or metoprolol succinate. Echocardiographic measurements (dyssyn­chrony, LV volumes and ejection fraction [EF]) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels were obtained at baseline and at first and sixth month of therapy. Results: A total of 74 (91%) patients completed all investigations at sixth month (38 and 36 taking carvedilol and metoprolol succinate, respectively). In the carvedilol group, reduction in LV end diastolic volume (D LVEDV at 6 months, 50 ± 15 mL to 40 ± 17 mL, p = 0.03) and increase in LVEF (D LVEF, 7 ± 2% to 5 ± 3%, p = 0.02) was higher compared to the meto­prolol group. Also improvement in inter-ventricular dyssynchrony achieved with carvedilol was higher than metoprolol (D interventricular delay at 6 months, 11 ± 8 ms to 6 ± 7 ms, p = 0.03). However, improvement in intraventricular dyssynchrony was similar in the two groups (D intraventricular delay, 9 ± 7 ms to 9 ± 6 ms, p = 0.91). Improvements in LV mechanical dyssynchrony and reverse remodeling achieved with both drugs were accompanied by reduction in NT-proBNP levels in both carvedilol and metoprolol groups (1614 ± 685 pg/mL to 654 ± ± 488 pg/mL and 1686 ± 730 pg/mL to 583 ± 396 pg/mL, respectively, p < 0.001 for both). Conclusions: Although reduction in LVEDV and increase in LVEF was higher with carvedilol, improvement in intraventricular dyssynchrony was similar in carvedilol and metoprolol groups.

Cost-effectiveness analysis of left atrial appendage occlusion compared with pharmacological strategies for stroke prevention in atrial fibrillation

Background Transcatheter left atrial appendage occlusion (LAAO) is a promising therapy for stroke prophylaxis in non-valvular atrial fibrillation (NVAF) but its cost-effectiveness remains understudied. This study evaluated the cost- effectiveness of LAAO for stroke prophylaxis in NVAF. Methods A Markov decision analytic model was used to compare the cost-effectiveness of LAAO with 7 pharmacological strategies: aspirin alone, clopidogrel plus aspirin, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban. Outcome measures included quality-adjusted life years (QALYs), lifetime costs and incremental cost-effectiveness ratios (ICERs). Base-case data were derived from ACTIVE, RE-LY, ARISTOTLE, ROCKET-AF, PROTECT-AF and PREVAIL trials. One- way sensitivity analysis varied by CHADS2 score, HAS-BLED score, time horizons, and LAAO costs; and probabilistic sensitivity analysis using 10,000 Monte Carlo simulations was conducted to assess parameter uncertainty. Results LAAO was considered cost-effective compared with aspirin, clopidogrel plus aspirin, and warfarin, with ICER of US$5,115,$2,447, and $6,298 per QALY gained, respectively. LAAO was dominant (i.e. less costly but more effective) compared to other strategies. Sensitivity analysis demonstrated favorable ICERs of LAAO against other strategies in varied CHADS2 score, HAS-BLED score, time horizons (5 to 15 years) and LAAO costs. LAAO was cost-effective in 86.24$50,000/QALY. Conclusions Transcatheter LAAO is cost-effective for prevention of stroke in NVAF compared with 7 pharmacological strategies. Condensed abstract The transcatheter left atrial appendage occlusion (LAAO) is considered cost-effective against the standard 7 oral pharmacological strategies including acetylsalicylic acid (ASA) alone, clopidogrel plus ASA, warfarin, dabigatran 110 mg, dabigatran 150 mg, apixaban, and rivaroxaban for stroke prophylaxis in non-valvular atrial fibrillation management

A population-based cohort study of 394,401 children followed for 10 years exhibits sustained effectiveness of scoliosis screening

© 2015 Elsevier Inc. All rights reserved. Background context: The value of scoliosis screening has been recently shown in a multicenter randomized controlled trial. However, the long-term sustainability of the clinical effectiveness of scoliosis screening as a routine health service remains unknown. Purpose: The aim of this study was to assess the sustainability of the clinical effectiveness of school scoliosis screening. Study design/setting: A large population-based cohort study with a 10-year follow-up was conducted. Patient sample: A total of 394,401 students who were in the fifth grade during the five academic years from 1995/1996 to 1999/2000 formed five consecutive annual cohorts. The students were eligible for the Hong Kong scoliosis screening program, with their screening history and medical records until their nineteenth birthdays being assessed. Outcome measures: The outcome measures considered in the study were development of adolescent idiopathic scoliosis by the 19 years of age and the Cobb angle. Methods: The clinical effectiveness of scoliosis screening was assessed by referral rate for radiographic diagnosis, sensitivity, specificity, and predictive values. Results: A total of 306,144 students (78%) participated in scoliosis screening, which used a two-tier system. The prevalence of curves of 20 or greater was 1.8% (95% confidence interval [CI], 1.7-1.8%), whereas the referral rate for radiography, the sensitivity, and the positive predictive value (PPV) for curves of 20 or greater were 4.1% (95% CI, 4.0-4.2%), 91% (95% CI, 90-92%), and 40% (95% CI, 39-41%), respectively. Across the five consecutive annual cohorts, the prevalence and sensitivity for curves of 20 or greater increased by 0.23% (95% CI, 0.21-0.25%; p<.001) and 0.76% (95% CI, 0.43-1.04%; p<.001) per year, respectively; however, the PPV was reduced by 1.71% (95% CI, 1.09-2.33%; p<.001) per year. Conclusions: This report describes the first large population-based study with a long-term follow-up indicating that a scoliosis screening program can have sustained clinical effectiveness in identifying patients with adolescent idiopathic scoliosis needing clinical observation. As the prevalence of adolescent idiopathic scoliosis increases, scoliosis screening should be continued as a routine health service in schools or by general practitioners if there is no scoliosis screening policy.postprin

Enhanced platelet activity in atrial septal defect

AimsEnhanced platelet activity assessed by mean platelet volume (MPV) was observed in pulmonary arterial hypertension. This study examined the presence of platelet activation in adults with atrial septal defect (ASD), its relationship with pulmonary vascular disease and its changes following device closure of the defects.MethodsA total of 76 consecutive patients received transcatheter ASD closure and 40 matched healthy volunteers were prospectively enrolled for blood tests and transthoracic echocardiography (patients: aged 3613, 37% men; controls: aged 368, 38% men). MPV, systolic pulmonary arterial pressures (PAP), and right ventricular end-diastolic diameters were collected before and after ASD closure in patients.ResultsThe mean MPV levels were significantly higher in patients than in controls (10.1 +/- 1.3 to 8.6 +/- 0.9fl; P<0.001) at baseline. A moderate, positive correlation was also observed between baseline MPV levels and systolic PAP (r=0.542, P<0.001) in patients. Both MPV levels, systolic PAP and right ventricular end-diastolic diameters reduced significantly 6 months following ASD closure. The 6-month MPV and systolic PAP values were comparable to those of the normals.ConclusionEnhanced platelet activity was present in ASD and associated with the presence of pulmonary vascular disease. This phenomenon was largely reversible following device closure of the defects

Recurrent laryngeal nerve palsy in well-differentiated Thryroid Carcinoma: clinicopathologic features and outcome study

Involvement of the recurrent laryngeal nerve (RLN) by well-differentiated thyroid carcinoma may not invariably lead to unilateral cord palsy, although the presence of RLN palsy is associated with locally advanced disease. The present study evaluates the clinicopathologic features and outcomes of patients surgically treated for well-differentiated thyroid carcinoma with documented nonfunctioning RLN at presentation. From 1970 to 2002, 20 of 709 patients undergoing surgical treatment for well-differentiated thyroid carcinoma were found to have ipsilateral unilateral cord palsy by routine preoperative laryngoscopy. There were 5 men and 15 women with a median age of 70 years. Nine patients (45%) did not have a clinically palpable thyroid mass, and hoarseness was the primary presenting symptom. All patients had histologically confirmed pT4 papillary thyroid carcinoma with a median size of 4 cm. Cervical nodal and pulmonary metastases were detected in 14 (70%) and 2 (10%) patients, respectively. The ipsilateral recurrent nerve was transected in all patients because of gross tumor involvement, and 19 patients underwent total or completion total thyroidectomy. Resection was incomplete in 15 patients, including 2 who underwent a debulking procedure and required reoperation for local control. Postoperative radioactive iodine ablation and external-beam irradiation were administered to 18 and 13 patients, respectively. Over a median follow-up of 4.5 years, 10 patients survived without evidence of recurrence, 5 died of disease recurrence, and 5 died of unrelated causes. The 5-year and 10-year cause-specific mortality was 17% and 42%, respectively. Patients developing distant metastasis at presentation or during follow-up had a significantly increased cause-specific mortality (p = 0.002). Preoperative RLN palsy can be the first symptom in patients with locally advanced papillary thyroid carcinoma. Despite the adoption of a relatively conservative surgical treatment, long-term survival can be achieved in selected patients

Effect of chronic afterload increase on left ventricular myocardial function in patients with congenital left-sided obstructive lesions

The effect of pressure-overloading distance on left ventricular (LV) function in patients with congenital aortic coarctation and aortic stenosis (AS) was investigated. LV long-axis motions were recorded using M-mode and tissue Doppler imaging (TDI) techniques in 46 consecutive patients with severe LV outflow tract obstruction (23 coaretation and 23 AS), and results were compared with those of 23 controls. TDI lateral and septal long-axis systolic velocities, early diastolic velocities, and M-mode systolic amplitudes were lower in patients with coarctation and AS than controls (lateral site long-axis systolic velocity 7.1 +/- 1.7 and 6.4 +/- 1.6 vs 9.7 +/- 1.7 cm/s, septal site long-axis systolic velocity 6.3 +/- 1.3 and 5.4 +/- 1.1 vs 7.7 +/- 1.3 cm/s; lateral site early diastolic velocity 10.5 +/- 2.2 and 8.2 +/- 2.6 vs 13.1 +/- 2.5 cm/s, septal site early diastolic velocity 7.4 +/- 1.9 and 6.0 +/- 1.8 vs 10.8 +/- 1.6 cm/s, lateral site M-mode systolic amplitude 1.4 +/- 0.2 and 1.3 +/- 0.2 vs 1.6 +/- 0.2 cm, septal site M-mode systolic amplitude 1.2 +/- 0.2 and 1.1 +/- 0.2 vs 1.4 0.2 cm, p < 0.01 for all). Compared with patients with coarctation, those with AS had lower TDI velocities, higher early LV filling velocity/long-axis diastolic velocity ratios, and a higher prevalence of long-axis incoordination. (p < 0.05 for all) despite similar LV mass index, ejection fraction, and systolic wall stress. In conclusion, LV long-axis function is impaired in patients with a chronic increase in afterload. Worse deterioration in LV function and higher prevalence of long-axis incoordination independent of LV outflow resistance is seen in patients with proximally increased LV afterload (AS) compared with distal disease (aortic coarctation). (c) 2007 Elsevier Inc. All rights reserved

Tenascin-C as Predictor of Left Ventricular Remodeling and Mortality in Patients

Background: Several cardiac biomarkers, especially brain natriuretic peptide (BNP) and N-terminal (NT)-proBNP, have been used as predictors of prognosis and negative remodeling in DCM. In the present study, we aimed to evaluate the prognostic value of tenascin-C in dilated cardiomyopathy (DCM) and whether it can be used to determine reverse remodeling in patients with DCM. Background: &nbsp; Several cardiac biomarkers, especially brain natriuretic peptide (BNP) and N-terminal (NT)-proBNP, have been used as predictors of prognosis and negative remodeling in DCM. In the present study, we aimed to evaluate the prognostic value of tenascin-C in dilated cardiomyopathy (DCM) and whether it can be used to determine reverse remodeling in patients with DCM. Methods: &nbsp; Sixty-six patients with DCM were followed up for 12 months after initiation of medical treatment including carvedilol, ramipril (candesartan if ramipril was not tolerated), spironolactone, and furosemide. Tenascin-C and NT-proBNP measurements and transthoracic echocardiography were performed at baseline and at 12 months. Results: &nbsp; At 12 months, a significant improvement in New York Heart Association class (2.57 &nbsp; T 0.6 vs. 1.87 T 0.5; P G 0.0001), left ventricular end-diastolic volume (217 &nbsp; T 47 vs 203 T 48; P G 0.0001), left ventricular ejection fraction (29.1 &nbsp; T 5.5 vs 30.9 T 3.8; P G 0.0001), NT-proBNP (2019 &nbsp; T 558 vs 1462 T 805; P G 0.0001), and tenascin-C (76 T 19 vs 48 &nbsp; T 28; P G 0.0001) values were observed, compared with baseline. Importantly, decrease in tenascin-C values were correlated with increase in left ventricular ejection fraction. Tenascin-C (odds ratio [OR], 1.896; &nbsp; G95% confidence interval [CI], 1.543Y2.670; P = 0.02), diabetes mellitus (OR, 2.456; G95% CI, 1.987 &nbsp; Y3.234; P = 0.01) and hypertension (OR: 2.106, &nbsp; G95% CI, 1.876Y2.897; P = 0.03) were independent predictors of mortality in patients with DCM. Conclusion: &nbsp; Reverse ventricular remodeling obtained with carvedilol, ramipril/candesartan, and spironolacton is associated with decreases in left ventricular end-diastolic volume, left ventricular end-systolic volume, tenascin-C levels, and NT-proBNP levels. Consequently, tenascin-C may be used to evaluate reverse remodeling in patients with DCM.</p