Jindrich Spinar

Heart failure (HF) with reduced (HFrEF) or mildly reduced ejection fraction (HFmrEF) frequently coexists with atrial fibrillation (AF), leading to worse prognosis and greater therapeutic complexity. Although beta-blockers (BBs) are a cornerstone of HF treatment, their benefit in patients with AF remains unclear. We analyzed 1088 patients with stable chronic HF and left ventricular ejection fraction < 50% enrolled in the multicentre FAR NHL registry. Patients were stratified by the presence of AF and achieved BB dose: low ( < 25%), medium (25-49%), or high (≥50% of target). The primary endpoint was a composite of all-cause mortality, hospitalization for acute HF, left ventricular assist device (LVAD) implantation, or heart transplantation. AF was present in 379 patients (34.5%). BBs were prescribed to 94% of patients, but only 17% achieved high-dose therapy. The event rate was higher in AF patients (28.0%) than in those without AF (20.5%, p = 0.005). High BB dose was independently associated with a lower risk of the primary endpoint (HR 0.62, 95% CI 0.48-0.80; p < 0.001), consistently across both rhythm group. Higher BB doses were associated with improved outcomes in patients with chronic HF, regardless of AF status. These real-world data support up-titration of BBs as a key component in optimized guideline-directed therapy, even in patients with coexisting AF.

We investigated the associations between obesity, cardiorenal events, and benefits of dapagliflozin in patients with type 2 diabetes mellitus (T2DM). DECLARE–TIMI 58 randomized patients with T2DM and either atherosclerotic cardiovascular (CV) disease or multiple risk factors to dapagliflozin vs. placebo. Patients were stratified by body mass index (BMI, kg/m²): normal (18.5 to 2; P < 0.001 for all). Dapagliflozin reduced body weight by similar relative amounts consistently across BMI categories (percent difference: −1.9 to −2.4%). Although relative risk reductions in CV and renal-specific composite outcomes with dapagliflozin did not significantly differ across the range of BMI (P for interaction ≥0.20 for all outcomes), obese patients (BMI ≥ 30 kg/m²) tended to derive greater absolute risk reduction in HHF and AF/AFL (P for interaction 0.02 and 0.09, respectively) than non-obese patients. In DECLARE–TIMI 58, patients with T2DM and higher BMI were more likely to have HHF and AF/AFL. Whereas relative risk reductions in CV and renal outcomes with dapagliflozin were generally consistent across the range of BMI, absolute risk reduction in obesity-related outcomes including HHF and AF/AFL tended to be larger in obese patients with T2DM. URL: https://www.clinicaltrials.gov. Unique identifiers: NCT01730534. In the DECLARE–TIMI 58 trial, patients with type 2 diabetes mellitus and higher body mass index were more likely to have hospitalization for heart failure and atrial fibrillation or flutter, and obese patients tended to derive greater absolute risk reduction in obesity-related outcomes, hospitalization for heart failure and atrial fibrillation or flutter from dapagliflozin although relative risk reductions in all the outcomes were consistent across the range of body mass index. AF/AFL, atrial fibrillation or atrial flutter; BMI, body mass index; HF, heart failure; HR, hazard ratio.

Cardiogenic shock (CS) is the most life-threatening manifestation of acute heart failure. Its complexity and high in-hospital mortality may justify the need for invasive monitoring with a pulmonary artery catheter (PAC). Patients with CS included in the CardShock Study, an observational, prospective, multicenter, European registry, were analyzed, aiming to describe the real-world use of PAC, evaluate its impact on 30-day mortality, and the ability of different hemodynamic parameters to predict outcomes. Pulmonary artery catheter was used in 82 (37.4%) of the 219 patients. Cardiogenic shock patients who managed with a PAC received more frequently treatment with inotropes and vasopressors, mechanical ventilation, renal replacement therapy, and mechanical assist devices (P < .01). Overall 30-day mortality was 36.5%. Pulmonary artery catheter use did not affect mortality even after propensity score matching analysis (hazard ratio = 1.17 [0.59-2.32], P = .66). Cardiac index, cardiac power index (CPI), and stroke volume index (SVI) showed the highest areas under the curve for 30-day mortality (ranging from 0.752-0.803) and allowed for a significant net reclassification improvement of 0.467 (0.083-1.180), 0.700 (0.185-1.282), 0.683 (0.168-1.141), respectively, when added to the CardShock risk score. In our contemporary cohort of CS, over one-third of patients were managed with a PAC. Pulmonary artery catheter use was associated with a more aggressive treatment strategy. Nevertheless, PAC use was not associated with 30-day mortality. Cardiac index, CPI, and SVI were the strongest 30-day mortality predictors on top of the previously validated CardShock risk score.

Purpose: Single center retrospective analysis of complications of catheter ablation for paroxysmal atrial fibrillation (PAF).

Background: Long-term efficacy of catheter ablation for atrial fibrillation (AF) greatly declines with time.

To evaluate whether patients with late complications of pacemakers or implantable cardioverter-defibrillators have hypersensitivity reactions to some of the materials used in generators or in electrodes, or to environmental metal burden. The cohort consisted of 20 men and 4 women (mean age: 62.3 ± 17.2 years) who had a history of late complications of implanted devices. The control group involved 25 men and 8 women (mean age: 64.6 ± 14.0 years) who had comparable devices, but no history of late complications. Lymphocyte transformation test was used to evaluate hypersensitivity to eight metal pollutants (antimony, manganese, mercury, molybdenum, nickel, platinum, tin, and titanium) selected by results of questionnaires on environmental burden, and by material analysis of generators and electrode surfaces. Exposures to metal pollutants were approximately the same in patients and in controls. Titanium alloy used in generators contained at least 99.32% of titanium and trace levels of other metals; higher levels of tin and platinum were detected in electrode surfaces. Hypersensitivity reactions to mercury and tin were significantly more frequent in patients than in controls (patients and controls: mercury: 68.2 and 31.1%, respectively; P = 0.022; tin: 25.0 and 3.2%, respectively; P = 0.035). In contrast, hypersensitivity to manganese was significantly more frequent in controls than in patients (patients and controls: 13.6 and 50.0%, respectively; P = 0.008). Our findings suggest a possible relation between hypersensitivity to metals used in implantable devices or to environmental metal burden and the occurrence of their late complications.

Objectives: Mortality in cardiogenic shock complicating acute coronary syndrome is high, and objective risk stratification is needed for rational use of advanced therapies such as mechanical circulatory support. Traditionally, clinical variables have been used to judge risk in cardiogenic shock. The aim of this study was to assess the added value of serial measurement of soluble ST2 and amino-terminal pro-B-type natriuretic peptide to clinical parameters for risk stratification in cardiogenic shock. Design: CardShock (www.clinicaltrials.gov NCT01374867) is a prospective European multinational study of cardiogenic shock. The main study introduced CardShock risk score, which is calculated from seven clinical variables at baseline, and was associated with short-term mortality. Setting: Nine tertiary care university hospitals. Patients: Patients with cardiogenic shock caused by acute coronary syndrome (n=145). Interventions: In this substudy, plasma samples from the study patients were analyzed at eight time points during the ICU or cardiac care unit stay. Additional prognostic value of the biomarkers was assessed with incremental discrimination improvement. Measurements and Main Results: The combination of soluble ST2 and amino-terminal pro-B-type natriuretic peptide showed excellent discrimination for 30-day mortality (area under the curve, 0.77 at 12 hr up to 0.93 at 5–10 d after cardiogenic shock onset). At 12 hours, patients with both biomarkers elevated (soluble ST2, ≥ 500 ng/mL and amino-terminal pro-B-type natriuretic peptide, ≥ 4,500 ng/L) had higher 30-day mortality (79%) compared to those with one or neither biomarkers elevated (31% or 10%, respectively; p < 0.001). Combined measurement of soluble ST2 and amino-terminal pro-B-type natriuretic peptide at 12 hours added value to CardShock risk score, correctly reclassifying 11% of patients. Conclusions: The combination of results for soluble ST2 and amino-terminal pro-B-type natriuretic peptide provides early risk assessment beyond clinical variables in patients with acute coronary syndrome–related cardiogenic shock and may help therapeutic decision making in these patients.

Purpose: To assess possible left ventricular (LV) structural changes that might be behind long-lasting arrhythmia-induced cardiomyopathy related to long-standing persistent atrial fibrillation (LSPAF), delayed-enhancement magnetic resonance imaging (DE-MRI) in detecting abnormal LV tissue was performed in LSPAF patients with severe depression of LV ejection fraction (LVEF). Methods: Of 210 consecutive patients with first LSPAF ablation in years 2006-12, 41 (20%) subjects (58 ± 9 years, 12% females) presented with consistent LVEF ≤40% for 23 ± 20 pre-ablation months. Resting/peak heart rates of 97 ± 18/152 ± 26 bpm were significantly higher for only resting heart rate as compared to LSPAF patients with normal LVEF. In years 2014-5, the patients were contacted to undergo DE-MRI. Results: At the end of 59 ± 18 month follow-up (1.6 ± 0.6 procedures/patient) 39 (95%) patients were in stable SR and LVEF was ≤40% in 7 (17%) patients. At 1 year post-ablation, LVEF improved from baseline by 22 ± 8% (increase to ≥50% in 85% patients), accompanied by improvement in NT-proBNP (-711 ± 562 pg/ml), VO2 max (+3.9 ± 5.1 mL/kg/min), and quality of life (all p < 0.00001). DE-MRI was not available in 18 patients (death 2, ICD 7, PM 2, claustrophobia 3, declined 3). DE-MRI performed 54 ± 17 (25-89) months after initial ablation in remaining 23 patients with SR proved durable ablation effect on LVEF (57 ± 9% by MRI vs. 59 ± 5% by echocardiography at 1 year) with LVEF impairment from ≥50 to ≤40% (54 to 29%) in 1 patient with no DE deposit. Discrete LV DE deposits were found in basal septum (n = 3), basal lateral wall (n = 1), and anterolateral papillary muscle (n = 1) in 3 patients (LVEF 62, 67, and 55%, respectively). Conclusion: Successful LSPAF ablation reversed related long-lasting LVEF depression in a majority of patients. The adverse LV response to arrhythmia was not related to concealed intramural structural (e.g. post-myocarditis) changes.