Current Issue 1 June 2012 | Vol. 109, No. 11

Heart Failure

• Relation of Dosing of the Renin-Angiotensin System Inhibitors after Cardiac Resynchronization Therapy to Long-Term Prognosis

Dosing of angiotensin converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARBs) in patients with heart failure (HF) treated with cardiac resynchronization therapy (CRT) may affect long term outcomes. Retrospective data was collected at baseline and follow up for consecutive patients who had CRT implanted and attended the institutional specialist heart failure pacing clinic. The study end point was death from any cause or hospitalization for worsening heart failure 24 months after implantation. A total of 91 patients (72 male, 68±12 years old) with reduced left ventricular ejection fraction (24±6%) were included. At baseline 85 patients (93%) were on ACEi/ARBs. At 6 months 3 patients had died and 86/88 (98%) were on ACEi/ARBs. Doses were uptitrated from 55±35% of target dose (TD) at baseline, to 62±31%TD at month 6 (p=0.018), while blood pressure was unchanged. Patients treated with <50%TD of ACEi/ARBs (n=20) at month 6, had worse 24-month event free survival than those on 50-99%TD (n=38, log-rank p=0.011) or ≥100%TD (n=30, log-rank p=0.007). Failure to achieve a dose of ≥50%TD of ACEi/ARBs at 6 months post CRT implantation was an independent predictor of all-cause mortality or hospitalization (HR 3.99, 95% CI 1.66-9.62, p=0.002), after adjustment for potential confounders including age, estimated glomerular filtration rate, diabetes and NYHA class. In conclusion optimal dosing of ACEi/ARBs is an independent predictor of prognosis in patients with heart failure treated with CRT and it can be achieved by a structured follow up within a specialized HF pacing clinic.

Valvular Heart Disease

• Frequency and Causes of Stroke During or After Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) is invariably associated with the risk of clinically manifest transient or irreversible neurologic impairment. We sought to investigate the incidence and causes of clinically manifest stroke during TAVI. A total of 214 consecutive patients underwent TAVI with the Medtronic-CoreValve System between November 2005 and September 2011 in our institution. Stroke was defined by the Valve Academic Research Consortium recommendations. Its cause was established by (i) analysing the time of onset of symptoms, (ii) correlating the symptoms with computed tomography (CT) detected defects in the brain and (iii) by analysing the presence of potential co-existing causes of stroke in addition to a multivariable analysis to determine independent predictors. Stroke occurred in 19 patients (9%) and was major in 10 (5%), minor in 3 (1%) and transient (TIA) in 6 (3%). The onset of symptoms was early (≤24 hours) in 8 patients (42%) and delayed (>24 hours) in 11 (58%). Brain CT scan showed a cortical infarct in 8 patients (42%), a lacunar infarct in 5 (26%), hemorrhage in 1 (5%) but no abnormalities in 5 (26%). Independent determinants of stroke were new-onset atrial fibrillation after TAVI (OR: 4.4; 95% CI: 1.2-15.6) and baseline aortic regurgitation grade ≥III (OR: 3.2; 95% CI: 1.1-9.3). In conclusion, the incidence of stroke was 9% of which more than half occurred >24 hours after the procedure. New-onset atrial fibrillation was associated with a 4.4-fold increased risk of stroke. These findings indicate that improvements in postoperative care after TAVI are equally if not more important for the reduction of periprocedural stroke than preventive measures during the procedure.

Congential Heart Disease

• Social Burden and Lifestyle in Adults with Congenital Heart Disease

We aimed to evaluate how the presence and severity of congenital heart disease (CHD) influence social life and lifestyle in adult patients. A random sample (n=1,496) from CONCOR (n=11,047), the Dutch national registry of adult patients with CHD, completed a questionnaire on educational attainment, employment and marital status, and lifestyle (response 76%). The Utrecht Health Project provided a large reference group (n=6,810) of unaffected individuals. Logistic regression models were used for subgroup analyses and to adjust for age, gender and socioeconomic status where appropriate.Of all patients 51.5% were males; median age 39 years (interquartile range 29-51)) with mild (46%), moderate (44%), and severe (10%) CHD. Young (age <40 years) CHD patients were more likely to have achieved lower education (adjusted odds ratio (OR)=1.6 for males and 1.9 for females (both p<0.05)), were significantly more often unemployed (adjusted OR=5.9 and 2.0 for males and females respectively), and less likely to be in a relationship compared to the reference group (adjusted OR=8.5 for males and 4.5 for females). These poorer outcomes were seen in all severity groups. Overall, the CHD population smoked less (adjusted OR=0.5, p<0.05), had more sports participation (adjusted OR=1.2, p<0.05), and less obesity (adjusted OR=0.7, p<0.05) than the reference group. In conclusion, there was a substantial social disadvantage among adult patients with CHD, which was seen in all severity groups and primarily in young men. In contrast, adults with CHD had healthier lifestyles compared to the reference group.