Beta blocker use in subjects with type 2 diabetes mellitus and systolic heart failure does not worsen glycaemic control

<p>Abstract</p> <p>Background</p> <p>The prognostic benefits of beta-blockers (BB) in patients with systolic heart failure (SHF) are known but despite this, in patients with diabetes they are underutilized. The aim of this study was to assess the effect of beta-blockers (BB) on glycaemic control in patients with Type 2 Diabetes (T2DM) and systolic heart failure (SHF) stratified to beta-1 selective (Bisoprolol) vs. nonselective BB (Carvedilol).</p> <p>Methods</p> <p>This observational, cohort study was conducted in patients with T2DM and SHF attending an Australian tertiary teaching hospital's heart failure services. The primary endpoint was glycaemic control measured by glycosylated haemoglobin (HbA1c) at initiation and top dose of BB. Secondary endpoints included microalbuminuria, changes in lipid profile and estimated glomerular filtration rate (eGFR).</p> <p>Results</p> <p>125 patients were assessed. Both groups were well matched for gender, NYHA class and use of guideline validated heart failure and diabetic medications. The mean treatment duration was 1.9 ± 1.1 years with carvedilol and 1.4 ± 1.0 years with bisoprolol (<it>p </it>= ns). The carvedilol group achieved a reduction in HbA1c (7.8 ± 0.21% to 7.3 ± 0.17%, <it>p </it>= 0.02) whereas the bisoprolol group showed no change in HbA1c (7.0 ± 0.20% to 6.9 ± 0.23%, <it>p </it>= 0.92). There was no significant difference in the change in HbA1c from baseline to peak BB dose in the carvedilol group compared to the bisoprolol group. There was a similar deterioration in eGFR, but no significant changes in lipid profile or microalbuminuria in both groups (<it>p </it>= ns).</p> <p>Conclusion</p> <p>BB use did not worsen glycaemic control, lipid profile or albuminuria status in subjects with SHF and T2DM. Carvedilol significantly improved glycemic control in subjects with SHF and T2DM and this improvement was non significantly better than that obtained with bisoprolol. BB's should not be withheld from patients with T2DM and SHF.</p

Omecamtiv mecarbil in chronic heart failure with reduced ejection fraction, GALACTIC‐HF: baseline characteristics and comparison with contemporary clinical trials

Aims: The safety and efficacy of the novel selective cardiac myosin activator, omecamtiv mecarbil, in patients with heart failure with reduced ejection fraction (HFrEF) is tested in the Global Approach to Lowering Adverse Cardiac outcomes Through Improving Contractility in Heart Failure (GALACTIC‐HF) trial. Here we describe the baseline characteristics of participants in GALACTIC‐HF and how these compare with other contemporary trials. Methods and Results: Adults with established HFrEF, New York Heart Association functional class (NYHA) ≥ II, EF ≤35%, elevated natriuretic peptides and either current hospitalization for HF or history of hospitalization/ emergency department visit for HF within a year were randomized to either placebo or omecamtiv mecarbil (pharmacokinetic‐guided dosing: 25, 37.5 or 50 mg bid). 8256 patients [male (79%), non‐white (22%), mean age 65 years] were enrolled with a mean EF 27%, ischemic etiology in 54%, NYHA II 53% and III/IV 47%, and median NT‐proBNP 1971 pg/mL. HF therapies at baseline were among the most effectively employed in contemporary HF trials. GALACTIC‐HF randomized patients representative of recent HF registries and trials with substantial numbers of patients also having characteristics understudied in previous trials including more from North America (n = 1386), enrolled as inpatients (n = 2084), systolic blood pressure &lt; 100 mmHg (n = 1127), estimated glomerular filtration rate &lt; 30 mL/min/1.73 m2 (n = 528), and treated with sacubitril‐valsartan at baseline (n = 1594). Conclusions: GALACTIC‐HF enrolled a well‐treated, high‐risk population from both inpatient and outpatient settings, which will provide a definitive evaluation of the efficacy and safety of this novel therapy, as well as informing its potential future implementation

What factors affect the development, progression and outcome of aortic stenosis?

© 2013 Dr. Leighton Geoffrey KearneyWith the aging population, the number and complexity of patients with aortic stenosis (AS) being referred for consideration of aortic valve replacement (AVR) is increasing. Selection of appropriate candidates for AVR can be difficult as the relative prognostic importance of increasing age, haemodynamic severity and comorbidity in patients with AS is not well understood. In addition, traditional risk assessment with AS severity, symptomatic status and left ventricular ejection fraction (LVEF) has limitations and new objective markers of cardiovascular (CV) risk are required to assist with management decisions. This thesis consists of three overall studies: 1) The natural history of AS in elderly patients over long-term follow up study (Chapter 3); 2) The prospective AS cohort study (Chapters 4-7); and 3) The prospective AVR cohort study (Chapter 8). “The natural history of AS in elderly patients over long-term follow up study” (Chapter 3) aimed to document the natural history of AS with regards to haemodynamic progression, adverse cardiac events and survival in a cohort of 239 elderly patients over eighteen years of follow up. Predictors of rapid haemodynamic progression included severe renal impairment, a history of anaemia, advanced aortic valve (AV) calcification and moderate to severe AS. Survival rates were reduced across the spectrum of AS severity; however, patients who developed severe symptomatic AS and underwent AVR, experienced excellent long-term survival. Survival was strongly dependent upon age and comorbidity, with the age-adjusted Charlson comorbidity index (age-CCI) proving a strong independent predictor of all-cause mortality. “The prospective AS cohort study” (Chapters 4-7) evaluated the role of novel non-invasive cardiac imaging techniques and biomarkers in the assessment and risk stratification of AS in 146 patients over a median follow up of two years. The main aims of this study were: 1) To compare traditional versus novel trans-thoracic echocardiography (TTE) and cardiac magnetic resonance imaging (cMRI) techniques for the evaluation of AS severity (Chapter 4); and 2) To assess the capacity of novel TTE (Chapter 5), cMRI (Chapter 6) and biomarker parameters (Chapter 7) to detect clinical and subclinical left ventricular (LV) dysfunction and predict adverse clinical outcomes in patients with AS. Of the AS severity parameters assessed, energy loss index (ELI) demonstrated the strongest association with adverse clinical outcomes. cMRI successfully evaluated AV morphology and AS severity, although cMRI specific thresholds for a diagnosis of severe AS are recommended. Overall, global longitudinal strain (GLS) and plasma brain natriuretic peptide (BNP) were the most promising risk markers in patients with AS. GLS and plasma BNP demonstrated significant associations with haemodynamic severity, detected sub-clinical LV dysfunction and independently predicted adverse clinical outcomes. Myocardial fibrosis imaging with cMRI provided insights into the detrimental effects of chronic pressure overload and the quantitative fibrosis burden predicted major adverse cardiac events (MACE). The primary aim of “The prospective AVR cohort study” (Chapter 8) was to document the prevalence and predictors of adverse outcomes twelve months post AVR for severe AS (Study 8A). Persistent adverse cardiac remodeling, LV dysfunction and symptoms were common post AVR, although outcomes were more favourable in patients who received AVR prior to the development of adverse cardiac changes. Impaired GLS was a strong predictor of MACE and persistent symptoms post AVR. In a separate sub-study cMRI safely evaluated AV prosthesis function with reasonable accuracy (Study 8B). Overall, this thesis supports the routine calculation of the age-CCI and incorporation of the ELI, GLS and plasma BNP into risk stratification algorithms alongside traditional risk factors in patients with AS. This approach would enhance discussions regarding the potential risks and benefits of AVR in patients with haemodynamically significant AS and may assist with identifying the optimal timing for intervention

CardiSort: a convolutional neural network for cross vendor automated sorting of cardiac MR images

Objectives: To develop an image-based automatic deep learning method to classify cardiac MR images by sequence type and imaging plane for improved clinical post-processing efficiency. Methods: Multi-vendor cardiac MRI studies were retrospectively collected from 4 centres and 3 vendors. A two-head convolutional neural network ('CardiSort') was trained to classify 35 sequences by imaging sequence (n=17) and plane (n=10). Single vendor training (SVT) on single centre images (n=234 patients) and multi-vendor training (MVT) with multicentre images (n = 479 patients, 3 centres) was performed. Model accuracy was compared to manual ground truth labels by an expert radiologist on a hold-out test set for both SVT and MVT. External validation of MVT (MVTexternal) was performed on data from 3 previously unseen magnet systems from 2 vendors (n=80 patients). Results: High sequence and plane accuracies were observed for SVT (85.2% and 93.2% respectively), and MVT (96.5% and 98.1% respectively) on the hold-out test set. MVTexternal yielded sequence accuracy of 92.7% and plane accuracy of 93.0%. There was high accuracy for common sequences and conventional cardiac planes. Poor accuracy was observed for underrepresented classes and sequences where there was greater variability in acquisition parameters across centres, such as perfusion imaging. Conclusions: A deep learning network was developed on multivendor data to classify MRI studies into component sequences and planes, with external validation. With refinement, it has potential to improve workflow by enabling automated sequence selection, an important first step in completely automated post-processing pipelines.Comment: Published in European Radiology 202

Early outcomes following integration of computed tomography (CT) coronary angiography service in an established cardiology practice in disease management

Background Computed tomography coronary angiography (CTCA) is an established modality for the diagnosis and assessment of cardiovascular disease. However, price and space pressure have mostly necessitated outsourcing CTCA to external radiology providers. Advara HeartCare has recently integrated CT services within local clinical networks across Australia. This study examined the benefits of the presence (integrated) or absence (pre-integrated) of this “in-house” CTCA service in real-world clinical practice. Methods De-identified patient data from electronic medical records were used to create an Advara HeartCare CTCA database. Data analysis included clinical history, demographics, CTCA procedure, and 30-day outcomes post-CTCA from two age-matched cohorts: integrated (n = 495) and pre-integrated (n = 456). Results Data capture was more comprehensive and standardised across the integrated cohort. There was a 21% increase in referrals for CTCA from cardiologists observed for the integration cohort vs. pre-integration [n = 332 (72.8%) pre-integration vs. n = 465 (93.9%) post-integration, p \u3c 0.0001] with a parallel increase in diagnostic assessments including blood tests [n = 209 (45.8%) vs. n = 387 (78.1%), respectively, p \u3c 0.0001]. The integrated cohort received lower total dose length product [Median 212 (interquartile range 136–418) mGy∗cm vs. 244 (141.5, 339.3) mGy∗cm, p = 0.004] during the CTCA procedure. 30-days after CTCA scan, there was a significantly higher use of lipid-lowering therapies in the integrated cohort [n = 133 (50.5%) vs. n = 179 (60.6%), p = 0.04], along with a significant decrease in the number of stress echocardiograms performed [n = 14 (10.6%) vs. n = 5 (11.6%), p = 0.01]. Conclusion Integrated CTCA has salient benefits in patient management, including increased pathology tests, statin usage, and decreased post-CTCA stress echocardiography utilisation. Our ongoing work will examine the effect of integration on cardiovascular outcomes

Distribution and Prognostic Significance of Left Ventricular Global Longitudinal Strain in Asymptomatic Significant Aortic Stenosis An Individual Participant Data Meta-Analysis

International audienceOBJECTIVES In this individual participant data meta-analysis on left ventricular global longitudinal strain (LVGLS), our objective was to 1) describe its distribution; 2) identify the most predictive cutoff values; and 3) assess its impact on mortality in asymptomatic patients with significant aortic stenosis (AS) and preserved left ventricular ejection fraction (LVEF). BACKGROUND The evidence supporting the prognostic role of LVGLS in asymptomatic patients with AS has been obtained from several relatively small studies. METHODS A literature search was performed for studies published between 2005 and 2017 without language restriction according to the following criteria "aortic stenosis" AND "longitudinal strain." The corresponding authors of selected studies were contacted and invited to share their data that we computerized in a specific database. The primary endpoint was all-cause mortality. RESULTS Among the 10 studies included, 1,067 asymptomatic patients with significant AS and LVEF >50% were analyzed. The median of LVGLS was 16.2% (from 5.6% to 30.1%). There were 91 deaths reported during follow-up with median of 1.8 (0.9 to 2.8) years, resulting in a pooled crude mortality rate of 8.5%. The LVGLS performed well in the prediction of death (area under the curve 0.68). The best cutoff value identified was LVGLS of 14.7% (sensitivity, 60%; specificity, 70%). Using random effects model, the risk of death for patients with LVGLS 2.5 (hazard ratio 2.62; 95% confidence interval 1.66 to 4.13; p = 60% (p = 0.001). CONCLUSIONS This individual participant data meta-analysis demonstrates that in asymptomatic patients with significant AS and normal LVEF, impaired LVGLS is associated with reduced survival. These data emphasize the potential usefulness of LVGLS for risk stratification and management of these patients. (C) 2019 the American College of Cardiology Foundation. Published by Elsevier. All rights reserved

The work of health visitors and school nurses with children with psychological and behavioural problems

&lt;b&gt;Aim&lt;/b&gt;. This paper is a report of a study to describe the workload of health visitors and school nurses in relation to children and young people with psychological, emotional or behavioural problems, and to identify perceived challenges, obstacles and sources of satisfaction associated with this aspect of their work. &lt;b&gt;Background&lt;/b&gt;. There is little published information on the work performed by non-specialist community nurses with children and young people who have psychological, emotional and behavioural problems. &lt;b&gt;Method&lt;/b&gt;. We analysed data from a survey conducted in 2002 – 2003 of 1049 Scottish professionals working with children and young people. Data included quantitative responses and free-text describing the cases seen by respondents. Responses from a sub-sample of 71 health visitors and 100 school nurses were analysed using a combination of descriptive statistics and analysis of themes emerging from the text. &lt;b&gt;Findings&lt;/b&gt;. Although community-based nurses saw a relatively small number of children with psychological, emotional or behavioural problems each week, dealing with these problems took up a disproportionate amount of time. The commonest types of problem were self-harm, externalizing behaviours and family difficulties. Few respondents had received specific training in child and adolescent mental health but most expressed a wish to receive such training. &lt;b&gt;Conclusion&lt;/b&gt;. The work of health visitors and school nurses in caring for children with mental health problems is substantial and important. Development of their public health role should not be at the expense of this important contribution. There is a need for rigorous evaluation of nursing mental health interventions among children and young people