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Severe frequent ventricular ectopy after exercise as a predictor of death in patients with heart failure
Adverse Effects of -Blocker Therapy for Patients With Heart Failure: A Quantitative Overview of Randomized Trials
Conclusions: The investigators concluded that AfricanAmerican patients with diastolic HF had a poorer prognosis than did whites with diastolic HF. Perspective: Further studies are required to determine whether these racial differences are simply due to the fact that the blood pressure is better controlled in one racial group. An interesting follow-up study would be a comparison of outcomes with the severity of hypertension. RB
Ko DT, Hebert PR, Coffey CS, et al. Arch Intern Med 2004;164: 1389 –94. Study Question: What are the adverse effects of beta-blocker therapy in heart failure (HF)? Methods: The MEDLINE database was used to identify HF trials of beta-blockers. Results of trials were combined, and estimates of risks were calculated using the random-effects model. Results: The risk of hypotension, dizziness and bradycardia was significantly increased [(11 per 1000; 95% confidence interval CI, 0 –22; 57 per 1000; 95% CI, 11–104 and 38 per 1000; 95% CI, 21–54), respectively]. There was no significant risk of fatigue. Furthermore, beta-blocker therapy was associated with a reduction in all-cause withdrawal of medications, a reduction in all-cause mortality, HF hospitalizations and worsening HF [(14 per 1000; 95% CI, ⫺2 to 29), (34 per 1000; 95% CI, 20 – 49), (40 per 1000; 95% CI, 22–58), (52 per 1000; 95% CI, 10 –94), respectively]. Conclusions: The researchers concluded that the benefits of beta-blocker therapy outweigh the side effects. Perspective: This is yet another study showing that lifesaving beta-blocker therapy should not be withheld in patients with HF because of potential adverse effects. If a physician is not comfortable initiating beta-blockers, the patient should be referred to a HF clinic for initiation of life-saving beta-blocker therapy. RB
Severe Frequent Ventricular Ectopy After Exercise as a Predictor of Death in Patients With Heart Failure O’Neill JO, Young JB, Pothier CE, Lauer MS. J Am Coll Cardiol 2004;44:820 – 6. Study Question: What is the prognostic importance of severe ventricular ectopy during recovery (SVER) after exercise in patients with systolic heart failure (HF)? Methods: Electrocardiographic data of 2123 patients with left ventricular ejection fraction ⬍35% who underwent exercise testing were studied for severe ventricular ectopy (defined as the presence of ventricular triplets, sustained or nonsustained ventricular tachycardia, ventricular flutter, polymorphic ventricular tachycardia, or ventricular fibrillation). All-cause mortality (those who underwent cardiac transplantation were omitted) was the primary end point. Results: Seven percent of patients (n⫽140) had SVER, and 530 deaths occurred over a mean follow-up duration of 2.9 years. The SVER was associated with increased mortality (3-year mortality rates of 37% vs. 22%, hazard ratio [HR] 1.76; 95% confidence interval [CI] 1.32–2.34; p⬍0.0001). After adjusting for confounders, SVER remained predictive of mortality (adjusted HR 1.48; 95% CI 1.10 –1.97; p⫽0.0089), unlike ventricular ectopics during exercise. Conclusions: The researchers concluded that severe ventricular ectopy after exercise was a predictor of death in HF. Perspective: This study cohort includes patients managed before beta-blockers and aldosterone receptor blockers were routinely used in the management of HF; therefore, we may see only a small number of patients with severe ventricular ectopy after exercise in current clinical practice. Nevertheless, the presence of severe ventricular ectopy after exercise should prompt the healthcare provider to ensure that patients are on optimal treatment for HF. RB
Racial Differences in the Outcomes of Patients With Diastolic Heart Failure East MA, Peterson ED, Shaw LK, Gattis WA, O’Connor CM. Am Heart J 2004;148:151– 6. Study Question: Is there any difference in the natural history of diastolic dysfunction between African-Americans and whites? Methods: All patients were identified from the Duke Cardiovascular Databank from 1984 to 1996. A total of 2740 white and 563 black patients with diastolic heart failure (HF) were identified in the databank. Kaplan-Meier and Cox proportional hazards models were used to perform unadjusted and adjusted 5-year survival-rate comparisons. Results: The investigators found that the survival rates were similar for both age groups (68% for African-Americans and 70% for whites). However, after adjusting for known risk factors, the mortality risk was significantly higher in African-Americans than in whites (hazard ratio [HR], 1.34; 95% CI, 1.13–1.60). Patients with nonischemic diastolic HF had the most prominent difference (HR, 1.6; 95% CI, 1.2–2.0) as compared with patients with ischemic HF (HR, 1.1; 95% CI, 0.9 –1.4).
Comprehensive Analysis of the Beta-Myosin Heavy Chain Gene in 389 Unrelated Patients With Hypertrophic Cardiomyopathy Van Driest SL, Jaeger MA, Ommen SR, et al. J Am Coll Cardiol 2004;44:602–10. Study Question: What is the prevalence and phenotype of -myosin heavy-chain gene (MYH7) mutations in unrelated patients with hypertrophic cardiomyopathy (HCM)?
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Conclusions: The investigators concluded that AfricanAmerican patients with diastolic HF had a poorer prognosis than did whites with diastolic HF. Perspective: Further studies are required to determine whether these racial differences are simply due to the fact that the blood pressure is better controlled in one racial group. An interesting follow-up study would be a comparison of outcomes with the severity of hypertension. RB
Ko DT, Hebert PR, Coffey CS, et al. Arch Intern Med 2004;164: 1389 –94. Study Question: What are the adverse effects of beta-blocker therapy in heart failure (HF)? Methods: The MEDLINE database was used to identify HF trials of beta-blockers. Results of trials were combined, and estimates of risks were calculated using the random-effects model. Results: The risk of hypotension, dizziness and bradycardia was significantly increased [(11 per 1000; 95% confidence interval CI, 0 –22; 57 per 1000; 95% CI, 11–104 and 38 per 1000; 95% CI, 21–54), respectively]. There was no significant risk of fatigue. Furthermore, beta-blocker therapy was associated with a reduction in all-cause withdrawal of medications, a reduction in all-cause mortality, HF hospitalizations and worsening HF [(14 per 1000; 95% CI, ⫺2 to 29), (34 per 1000; 95% CI, 20 – 49), (40 per 1000; 95% CI, 22–58), (52 per 1000; 95% CI, 10 –94), respectively]. Conclusions: The researchers concluded that the benefits of beta-blocker therapy outweigh the side effects. Perspective: This is yet another study showing that lifesaving beta-blocker therapy should not be withheld in patients with HF because of potential adverse effects. If a physician is not comfortable initiating beta-blockers, the patient should be referred to a HF clinic for initiation of life-saving beta-blocker therapy. RB
Severe Frequent Ventricular Ectopy After Exercise as a Predictor of Death in Patients With Heart Failure O’Neill JO, Young JB, Pothier CE, Lauer MS. J Am Coll Cardiol 2004;44:820 – 6. Study Question: What is the prognostic importance of severe ventricular ectopy during recovery (SVER) after exercise in patients with systolic heart failure (HF)? Methods: Electrocardiographic data of 2123 patients with left ventricular ejection fraction ⬍35% who underwent exercise testing were studied for severe ventricular ectopy (defined as the presence of ventricular triplets, sustained or nonsustained ventricular tachycardia, ventricular flutter, polymorphic ventricular tachycardia, or ventricular fibrillation). All-cause mortality (those who underwent cardiac transplantation were omitted) was the primary end point. Results: Seven percent of patients (n⫽140) had SVER, and 530 deaths occurred over a mean follow-up duration of 2.9 years. The SVER was associated with increased mortality (3-year mortality rates of 37% vs. 22%, hazard ratio [HR] 1.76; 95% confidence interval [CI] 1.32–2.34; p⬍0.0001). After adjusting for confounders, SVER remained predictive of mortality (adjusted HR 1.48; 95% CI 1.10 –1.97; p⫽0.0089), unlike ventricular ectopics during exercise. Conclusions: The researchers concluded that severe ventricular ectopy after exercise was a predictor of death in HF. Perspective: This study cohort includes patients managed before beta-blockers and aldosterone receptor blockers were routinely used in the management of HF; therefore, we may see only a small number of patients with severe ventricular ectopy after exercise in current clinical practice. Nevertheless, the presence of severe ventricular ectopy after exercise should prompt the healthcare provider to ensure that patients are on optimal treatment for HF. RB
Racial Differences in the Outcomes of Patients With Diastolic Heart Failure East MA, Peterson ED, Shaw LK, Gattis WA, O’Connor CM. Am Heart J 2004;148:151– 6. Study Question: Is there any difference in the natural history of diastolic dysfunction between African-Americans and whites? Methods: All patients were identified from the Duke Cardiovascular Databank from 1984 to 1996. A total of 2740 white and 563 black patients with diastolic heart failure (HF) were identified in the databank. Kaplan-Meier and Cox proportional hazards models were used to perform unadjusted and adjusted 5-year survival-rate comparisons. Results: The investigators found that the survival rates were similar for both age groups (68% for African-Americans and 70% for whites). However, after adjusting for known risk factors, the mortality risk was significantly higher in African-Americans than in whites (hazard ratio [HR], 1.34; 95% CI, 1.13–1.60). Patients with nonischemic diastolic HF had the most prominent difference (HR, 1.6; 95% CI, 1.2–2.0) as compared with patients with ischemic HF (HR, 1.1; 95% CI, 0.9 –1.4).
Comprehensive Analysis of the Beta-Myosin Heavy Chain Gene in 389 Unrelated Patients With Hypertrophic Cardiomyopathy Van Driest SL, Jaeger MA, Ommen SR, et al. J Am Coll Cardiol 2004;44:602–10. Study Question: What is the prevalence and phenotype of -myosin heavy-chain gene (MYH7) mutations in unrelated patients with hypertrophic cardiomyopathy (HCM)?
ACC CURRENT JOURNAL REVIEW Nov 2004
47