Echocardiographic diastolic function evolution in patients with an anterior Q-wave myocardial infarction: insights from the REVE-2 study.

International audienceBackground: Myocardial fibrosis plays a key role in the development of adverse left ventricular remodeling after myocardial infarction (MI). This study aimed to determine whether the circulating levels of BNP, collagen peptides, and galectin-3 are associated with diastolic function evolution (both deterioration and improvement) at 1-year after an anterior MI.Methods: The REVE-2 is a prospective multicenter study including 246 patients with a first anterior Q-wave MI. Echocardiographic assessment was performed at hospital discharge and ±1-year after MI. BNP, Galectin-3 and collagen peptides were measured ±1-month after MI. Left ventricular diastolic dysfunction (DD) was defined according to the presence of at least 2 criteria of echocardiographic parameters: septal e’6 mg/l (Odds Ratio, OR=5.29; 95%CI=1.05-26.66; p=0.044), Galectin-3>13 μg/l (OR=5.99; 95%CI=1.18-30.45; p=0.031), and BNP>82 ng/l (OR=10.25; 95%CI=2.36-44.50; p=0.002) quantified at 1-month post-MI were independently associated with 1-year DD. Follow-up of the 137 patients with DD at baseline among the 159 patients showed that 36 patients (26%) had a normalized diastolic function at 1-year post-MI. Patients with a BNP>82 ng/l were less likely to improve diastolic function (OR=0.06; 95%CI=0.01-0.28; p=0.0003).Conclusions. The present study suggests that circulating levels of PIIINP, Galectin-3 and BNP may be independently associated with new-onset DD in post-MI patients

Impact of Insulin Treatment on the Effect of Eplerenone:Insights From the EMPHASIS-HF Trial

BACKGROUND: Patients with heart failure with reduced ejection fraction (HFrEF) and insulin-treated diabetes have a high risk of cardiovascular complications. Mineralocorticoid receptor antagonists may mitigate this risk. We aim to explore the effect of eplerenone on cardiovascular outcomes and all-cause mortality in HFrEF patients with diabetes, including those treated with insulin in the EMPHASIS-HF trial (Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms). METHODS: The primary outcome was the composite of heart failure hospitalization or cardiovascular death. Cox models with treatment-by-diabetes subgroup interaction terms were used. RESULTS: The median follow-up was 21 (10-33) months. Of the 2737 patients included, 623 (23%) had non-insulin-treated diabetes, 236 (9%) had insulin-treated diabetes and 1878 did not have diabetes. Patients with insulin-treated diabetes were younger, more often women, with higher body mass index, waist circumference, more frequent ischemic heart failure cause, impaired kidney function, and longer diabetes duration. Compared with patients without diabetes, those with insulintreated diabetes had a 2-fold higher risk of having a primary outcome event. The hazard ratio (95% CI) for the effect of eplerenone, compared with placebo, on the primary outcome was 0.31 (0.19-0.50) in insulin-treated diabetes, 0.69 (0.500.93) in non-insulin-treated diabetes, and 0.72 (0.58-0.88) in patients without diabetes; interaction P=0.007. The annualized number needed-to-treat-to-benefit with regards to the primary outcome was 3 (95% CI, 3-4) in patients with insulin-treated diabetes, 16 (13-19) in patients with diabetes not receiving insulin, and 26 (24-28) in patients without diabetes. CONCLUSIONS: Patients with insulin-treated diabetes experienced a greater benefit from eplerenone than those with diabetes not treated with insulin and people without diabetes

Clinical Determinants and Prognostic Implications of Renin and Aldosterone in Patients with Symptomatic Heart Failure

Aims Activation of the renin-angiotensin-aldosterone system plays an important role in the pathophysiology of heart failure (HF) and has been associated with poor prognosis. There are limited data on the associations of renin and aldosterone levels with clinical profiles, treatment response, and study outcomes in patients with HF. Methods and results We analysed 2,039 patients with available baseline renin and aldosterone levels in BIOSTAT-CHF (a systems BIOlogy study to Tailored Treatment in Chronic Heart Failure). The primary outcome was the composite of all-cause mortality or HF hospitalization. We also investigated changes in renin and aldosterone levels after administration of mineralocorticoid receptor antagonists (MRAs) in a subset of the EPHESUS trial and in an acute HF cohort (PORTO). In BIOSTAT-CHF study, median renin and aldosterone levels were 85.3 (percentile(25-75) = 28-247) mu IU/mL and 9.4 (percentile(25-75) = 4.4-19.8) ng/dL, respectively. Prior HF admission, lower blood pressure, sodium, poorer renal function, and MRA treatment were associated with higher renin and aldosterone. Higher renin was associated with an increased rate of the primary outcome [highest vs. lowest renin tertile: adjusted-HR (95% CI) = 1.47 (1.16-1.86), P = 0.002], whereas higher aldosterone was not [highest vs. lowest aldosterone tertile: adjusted-HR (95% CI) = 1.16 (0.93-1.44), P = 0.19]. Renin and/or aldosterone did not improve the BIOSTAT-CHF prognostic models. The rise in aldosterone with the use of MRAs was observed in EPHESUS and PORTO studies. Conclusions Circulating levels of renin and aldosterone were associated with both the disease severity and use of MRAs. By reflecting both the disease and its treatments, the prognostic discrimination of these biomarkers was poor. Our data suggest that the "point" measurement of renin and aldosterone in HF is of limited clinical utility

Myocardial deformation in malignant mitral valve prolapse: A shifting paradigm to dynamic mitral valve–ventricular interactions

ObjectivesThis study sought to assess the value of myocardial deformation using strain echocardiography in patients with mitral valve prolapse (MVP) and severe ventricular arrhythmia and to evaluate its impact on rhythmic risk stratification.BackgroundMVP is a common valvular affection with an overly benign course. Unpredictably, selected patients will present severe ventricular arrhythmia.MethodsPatients with MVP as the only cause of aborted SCD (MVP-aSCD: ventricular fibrillation and monomorphic and polymorphic ventricular tachycardia) with no other obvious reversible cause were identified. Nonconsecutive patients referred for the echocardiographic evaluation of MVP were enrolled as a control cohort and dichotomized according to the presence or absence of premature ventricular contractions (MVP-PVC or MVP-No PVC, respectively). All patients had a comprehensive strain assessment of mechanical dispersion (MD), postsystolic shortening, and postsystolic index (PSI).ResultsA total of 260 patients were enrolled (20 MVP-aSCD, 54 MVP-PVC, and 186 MVP-No PVC). Deformation pattern discrepancies were observed with a higher PSI value in MVP-aSCD than that in MVP-PVC (4.6 ± 2.0 vs. 2.9 ± 3.7, p = 0.014) and a higher MD value than that in MVP-No PVC (46.0 ± 13.0 vs. 36.4 ± 10.8, p = 0.002). In addition, PSI and MD increased the prediction of severe ventricular arrhythmia on top of classical risk factors in MVP. Net reclassification improvement was 61% (p = 0.008) for PSI and 71% (p = 0.001) for MD.ConclusionsIn MVP, myocardial deformation analysis with strain echocardiography identified specific contraction patterns with postsystolic shortening leading to increased values of PSI and MD, translating the importance of mitral valve–myocardial interactions in the arrhythmogenesis of severe ventricular arrhythmia. Strain echocardiography may provide important implications for rhythmic risk stratification in MVP

Hyperkalaemia and hypokalaemia outpatient management: a survey of 500 French general practitioners

International audienceAims: How general practitioners (GPs) manage dyskalaemia is currently unknown. This study aimed at describing GP practices regarding hypokalaemia or hyperkalaemia diagnosis and management in their outpatients.Methods and results: A telephone survey was conducted among French GPs with a 20-item questionnaire (16 closed-ended questions and 12 open-ended questions) regarding their usual management of hypokalaemia or hyperkalaemia patients, both broadly and more specifically in patients with heart failure and/or chronic kidney disease and/or in patients treated with angiotensin-converting enzyme/angiotensin receptor blockers or mineralocorticoid receptor antagonists. We aimed to interview 500 GPs spread geographically throughout France. This descriptive survey results are presented as mean ± standard deviation (if normally distributed or as median and inter-quartile range if the distribution was skewed). Categorical variables are expressed as frequencies and proportions (%). A total of 500 GPs participated in the study. Dyskalaemia thresholds (for diagnosis and intervention) and management patterns were highly heterogeneous. The mean ± SD (range) potassium level leading to 'intervene' was 5.32 ± 0.34 mmol/L (4.5-6.5) for hyperkalaemia and 3.23 ± 0.34 mmol/L (2.0-6.5) for hypokalaemia. Potassium levels leading to refer the patient to the emergency department (ED) were 6.14 ± 0.55 (4.5-10) and 2.69 ± 0.42 mmol/L (1-4), respectively. Potassium binders (51-65%) or potassium supplements (67-74%) were frequently used to manage hyperkalaemia or hypokalaemia. GPs uncommonly referred their dyskalaemic patients to cardiologists or nephrologists (or to the emergency department, if the latter was deemed necessary owing to the severity of the dyskalaemia). We identified an association between the close vicinity of GP office from an ED and 'referring a heart failure patient' (19.2% with ED vs. 8.6% without ED) and referring a heart failure and chronic kidney disease patient on mineralocorticoid receptor antagonist (16.7% with ED vs. 9.3% without ED). Although the majority (67%) of GPs had an electrocardiogram on hand, it was rarely used (14%) in dyskalaemic patients. Subgroup analyses considering gender, age of the participating GPs, and high-income/low-income regions did not identify specific patterns regarding the multidimensional aspect of dyskalaemia management.Conclusions: Owing to the considerable heterogeneity of French GP practices toward dyskalaemia diagnosis and management approaches, there is a likely need to standardize (potentially enabled by therapeutic algorithms) practices

Red Cell Distribution Width in Patients with Diabetes and Myocardial Infarction: an analysis from the EXAMINE trial

International audienceBackground: Red blood cell distribution width (RDW) is a measure of size variability in the red blood cell population (anisocytosis). Increased RDW may arise from any condition that affects erythropoiesis or the survival of erythrocytes. RDW has been associated with poor prognosis in patients with type 2 diabetes (T2D). Whether RDW is a risk marker for adverse cardiovascular outcomes or also a marker of non-cardiovascular health concerns is of clinical importance.Aims: To determine the clinical correlates of increased RDW, its potential mechanistic association with multiple circulating biomarkers, and its prognostic value, in patients with (T2D) who had a recent acute coronary syndrome.Methods: We used time-updated Cox models applied to patients enrolled in the EXAMINE (Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care) trial.Results: A total of 5380 patients were included, the median age was 61 years and 32% were women. Patients with higher RDW were older, more frequently women, with longer duration of diabetes duration, and increased comorbidities. An RDW >16.1% (both baseline and time-updated) was independently associated with the study primary composite outcome of nonfatal myocardial infarction, nonfatal stroke or cardiovascular death (time-updated adjusted HR =1.36, 95%CI =1.16-1.61, p < 0.001), all-cause death (time-updated adjusted HR =2.01, 95%CI =1.60-2.53, p < 0.001), as well as mortality from non-CV causes (time-updated adjusted HR =2.67, 95%CI =1.72-4.15, p < 0.001). RDW had a weak-to-moderate correlation with hemoglobin and circulating markers that reflected inflammation, apoptosis, fibrosis and congestion. Alogliptin did not alter RDW values.Conclusions: RDW is a marker of disease severity associated with a multitude of poor outcomes, including both cardiovascular and non-cardiovascular death. RDW correlated modestly with inflammatory, pro-apoptotic, pro-fibrotic, and congestion markers, and its levels were not affected by alogliptin during the course of the trial. This article is protected by copyright. All rights reserved

Head-to-head comparison of image quality between brain 18F-FDG images recorded with a fully digital versus a last-generation analog PET camera

International audienceBackground: The quality of phantom images was previously shown to be higher on digital (Vereos Philips®) compared to analog PET (Ingenuity Philips®) cameras. This study aimed to determine the extent to which this difference still remains significant on normal brain 18 F-FDG PET images. Methods: Relative noise and contrast as well as border sharpness (a spatial resolution index) of central (striata) and peripheral (occiput) gray-matter structures were compared between 10 sets of normal brain 18 F-FDG PET images recorded and reconstructed on digital and analog last-generation PET cameras, together with a subjective visual analysis of image quality provided by experienced physicians. Results: Compared with analog PET, digital PET provided marked improvements in image quality parameters. The median relative noise was decreased (− 22%), while gray/white-matter contrast was increased (+ 27%/+ 41% for central/peripheral gray-matter structures), with these results being consistent with visual analysis. In addition, a clear enhancement in image sharpness was further documented for digital PET owing to the possible use of a 1-mm 3 voxel size (+ 24%/+ 21%). Conclusions: On normal brain 18 F-FDG images and compared with a last-generation analog PET, the fully digital PET camera offers marked improvements in image noise and contrast, as well as significant potential for further enhancing spatial resolution

Cardiovascular Comorbidities Are the Main Predictors of Cardiac Reverse Remodeling following Kidney Transplantation

International audienceBackground: End-stage renal disease is associated with cardiac remodeling, which is partly reversible after kidney transplantation (KT). We aimed to determine the association of cardiovascular comorbidities or kidney-related factors with cardiac reverse remodeling after KT.Methods: We performed echocardiography in 56 patients (aged 48 ± 15 years, mean ± SD) before and 24 months after undergoing their first KT. Echocardiograms were reviewed using a standardized process with blinding for the patient characteristics and evaluation timing. Multivariable linear regression analysis was used to evaluate the association between comorbidities and changes in cardiac structure and systolic/diastolic function.Results: Left ventricular mass index (LVMI) and diastolic parameters did not change significantly, while left ventricular ejection fraction (LVEF) increased from 63.9 to 69.6% (p = 0.046). Multivariable analysis revealed associations of histories of valvular heart disease with a smaller reduction in LVMI (β = -27.3, p = 0.04), of coronary artery disease or heart failure with a smaller increase in LVEF (β = 7.17, p = 0.02), and of diabetes mellitus with less improvement in E wave (β = -0.19, p = 0.05), e' (β = 4.15, p = 0.046), and E/e' (β = -5.00, p < 0.01).Conclusion: Cardiovascular comorbidities were -associated with less improvement in cardiac structure and function following KT. Our findings suggest that patients with CV comorbidities may experience limited "favorable" reverse cardiac remodeling following KT

Ventricular arterial coupling and cardiovascular risk among young adults: The African-PREDICT study

International audienceAims: Studies exploring ventricular-arterial coupling (VAC) parameters and their association with anthropometric and cardiovascular (CV) factors are sparse in young asymptomatic individuals. Here, we aim to provide in an asymptomatic group of young participants, descriptive data regarding VAC and to explore its associations with CV risk factors. Methods: For 631 (mean age 24±3 years; 51% female) individuals participating in the African-PREDICT cohort, VAC was determined by pulse wave velocity (PWV)/global longitudinal strain (GLS). Multivariable logistic and linear regression models were performed to explore the association between PWV/GLS and CV risk factors. Results: The mean value of PWV/GLS was 0.33±0.07 m/s %. Higher ratios of PWV/GLS were associated with older age, male sex and a higher prevalence of CV risk factors (i.e., higher blood pressure and hypertension, increased waist circumference, active smoking, higher plasma triglycerides, lower high-density lipoprotein cholesterol and an adverse urine albumin/creatinine ratio). Further, higher PWV/GLS was associated with echocardiographic measures such as decreased ejection fraction and increased left ventricle mass index. In fully adjusted logistic regression models, higher ratios of PWV/GLS were significantly associated with the prevalence of active smoking (OR 1.88; CI 1.36 - 2.58, p<0.001) and hypertension (OR 1.98; CI 1.40 - 2.80, p<0.001). Conclusions: We demonstrated that VAC mismatch reflected by higher values of PWV/GLS are significantly associated with CV risk factors in young adults. The results suggest that PWV/GLS might serve as a tool to improve the profiling of cardiovascular risk in young adults

Dyskalemia: a management problem for students.

International audienceBackground: Although dyskalemia is common, its management can be problematic for students and general practitioners, especially when it occurs in patients with heart and renal failure. The basic academic knowledge of general medicine students, who have often not yet encountered clinical situations of dyskalemia, remains unclear in this regard.Objectives: The purpose of this study was to evaluate the knowledge and reflexive practices of general medicine students in regard to dyskalemia.Methods: A cross-sectional survey, based on a self-questionnaire, of all of the students enrolled in general medicine studies at the Faculty of Medicine at the University of Nancy (France) at the end of their degree. The students were asked questions pertaining to specific clinical situations. The answers were compared to the information provided in the medical curriculum as well as to the relevant European guidelines.Results: We collected 290 of the questionnaires (participation rate: 81.2%). The hyper- and hypo-kalemia thresholds considered pathological (3.5-5.0 mmol/L) were known by 78% and 67% of the students, respectively. The perception of danger in case of severe hypokalemia was underestimated by 62.7% of them. In most cases, the proposed management of hyperkalemia in heart and renal failure did not comply with the relevant guidelines. The students tended to favor permanent discontinuation of the administration of converting enzyme inhibitors (ACE) and/or mineralocorticoid receptor antagonists (MRA) without considering the need for their reintroduction (51.6%). Sodium polystyrene sulfate was frequently seen as an appropriate first-line treatment for hyperkalemia (45%).Conclusions: The knowledge and competence of general medicine students appear to be lacking for hyperkalemia in heart and renal failure, and they are long way from full compliance with the relevant European guidelines. Exposure to complex clinical situations as part of the medical curriculum, therefore, seems essential to improve the way dyskalemia is managed in France