Search

Objectives/Hypothesis Sleep apnea is associated with hypertension and diabetes, putting these patients at high risk for developing cardiovascular disease. The goal of this study was to identify the individual cardiovascular risk profile and to detect premature and undiagnosed disease in patients with various degrees of sleep apnea. Study Design Cross-sectional. Methods Over a 6-month period, we consecutively characterized all patients referred to our sleep laboratory for an initial evaluation of sleep apnea. Clinical history; blood tests with oral glucose tolerance test, when appropriate; test for microalbuminuria; and an electrocardiogram (ECG) were performed. The Framingham general cardiovascular risk score was assessed in each patient. Results A total of 255 patients were evaluated. Of those, 190 (75%) were diagnosed with sleep apnea. Patients with sleep apnea had a significantly higher Framingham risk score than patients without sleep apnea. Adjusted for age and gender, severe sleep apnea was associated with a 60% increased cardiovascular risk compared with not having sleep apnea. In sleep apnea patients without previously diagnosed hypertension, an additional 45% had significant elevated blood pressure. Among sleep apnea patients without known diabetes, we tested 48% with a pathological glucose disposal. Twenty percent of sleep apnea patients without known heart disease had significant ECG changes. Conclusions High Framingham score, undiagnosed hypertension, and pathological glucose disposal were highly prevalent in patients with sleep apnea. Appropriate screening routines are important to detect cardiovascular risk factors in patients with sleep apnea. Level of Evidence 2b. Laryngoscope, 124:306-310, 2014 [ABSTRACT FROM AUTHOR]

Background: Advances in the understanding of mitral valve pathology have laid to mitral valve plasty (MPL) as the procedure of choice of all the mitral intervention as compared to mitral valve replacement (MVR). This study is aimed to compare the outcome mortality and reoperation and to estimate failure of repair between the two procedures during the follow up time. Material and methods: A cohort of 355 patients with mitral valve disease operated between January 1993 to January 2007 with closing date first of mars 2011. There were 214 MPL and 141 MVR at the Hospital discharge. This retrospective cohort had the design of exposed (MPL) versus non-exposed (MVR) with outcome total mortality and reoperation during follow up. Also echocardiography follow-up was undertaken to estimate the true long-term failure rate of repair. Results: The mean follow up was 5.3 years SE (3.82) maximum follow up was 14.1 years. Considering the patient time model the association between repair/replacement and total mortality RR = 0.43 95% (0.28-074) p = 0.002 controlling for the confounding effect of 3-vessels disease. Those results were confirmed by propensity score analysis. As far as outcome re-operation, presence of atrial fibrillation AF was an effect modifier indicating lower reoperation rate for MPL compared to MVR for patients without AF, RR = 0.32 95% CL (0.13-0.81) p = 0.017 while no difference in reoperation rates between MPL/MVR for patients with AF RR = 1.82 95% CL (0.52-6.4) p = 0.344. Echocardiography follows up showed incidence of moderate and severe recurrent mitral regurgitation was 1.34 per 100 patients years and 0.27 per 100 patients years during the follow-up time. Conclusion: In a cohort of patient with mitral valve disease undergoing MPL/MVR was examined. MPL was associated with better survival, and lower reoperation rate for patients without AF but same rate for patients with AF. We advocate more attention in controlling risk factors of AF in the clinical management of mitral disease. Long-term failure rate of MPL was low during follow up time. A replication of our results by a randomized clinical trial is mandatory. [ABSTRACT FROM AUTHOR]

Background Renal dysfunction is considered a confounding variable in the interpretation of B-type natriuretic peptides (BNPs) and their amino-terminal fragments (NT-ProBNP) in patients with heart failure (HF). Our aim was to investigate the prognostic utility of BNPs and NT-proBNP in HF outpatients with renal dysfunction, and compare the prognostic significance of the corresponding BNP/NT-ProBNP levels in patients with and without renal dysfunction. Methods A total of 2076 patients from 13 HF clinics in the Norwegian Heart Failure Registry were investigated. The BNP/NT-ProBNP levels were categorized centre-wise into four groups using the quartile limits found in patients with preserved renal function. Patients with renal dysfunction, i.e. glomerular filtration rate (GFR) ≤60 mL/min/1.73 m2, were then assigned to BNP groups 1–4 centre-wise according to their level of natriuretic peptides. Results Renal dysfunction was present in 37.5% of the patients, of whom the majority (59.1%) had levels of natriuretic peptide in the highest BNP group. Patients with renal dysfunction and BNP levels in the lower three BNP groups had similar 2-year survival as patients without renal dysfunction and comparable BNP levels [crude hazard ratio (HR) 1.25, 95% CI 0.82–1.89, P = 0.302, multiple adjusted HR 0.85, 95% CI 0.54–1.33, P = 0.457]. Beyond 2 years of follow-up, renal dysfunction predicted all-cause mortality irrespective of the level of natriuretic peptides at the start of follow-up. Conclusion In HF outpatients, the BNP/NT-ProBNP level predicted 2-year mortality irrespective of renal function and provided important prognostic information on patients with renal dysfunction. [ABSTRACT FROM PUBLISHER]

Objectives: The aim of this study was to evaluate the prognostic impact of anemia in outpatients with chronic heart failure attending specialized heart failure clinics and specifically to investigate its prognostic utility in patients with severe renal dysfunction or advanced heart failure. Background: Anemia is an independent prognostic marker in patients with heart failure. The effect of anemia on mortality decreases with increasing creatinine levels. Methods: Multivariate Cox regression analyses were used to investigate the prognostic effect of anemia in 4,144 patients with heart failure from 21 outpatient heart failure clinics in Norway. Severe renal failure was defined as estimated glomerular filtration rate ≤45 ml/min/1.73 m2 and advanced heart failure as New York Heart Association functional classes IIIb and IV. Results: Baseline anemia was present in 24% and was a strong predictor of all-cause mortality (adjusted hazard ratio [HR]: 1.30, 95% CI: 1.09 to 1.56, p = 0.004). Baseline anemia did not predict mortality in the 752 patients with severe renal dysfunction (adjusted HR: 1.08, 95 % CI: 0.77 to 1.51, p = 0.662) and the 528 patients with advanced heart failure (adjusted HR: 0.87, 95% CI: 0.56 to 1.34, p = 0.542). In the 1,743 patients who attended subsequent visits, sustained anemia independently predicted worse prognosis (adjusted HR: 1.47, 95% CI: 1.10 to 1.94, p = 0.008), whereas transient and new-onset anemia did not. Conclusions: According to our study, baseline anemia was not an independent predictor of all-cause mortality in outpatients with heart failure and accompanied severe renal dysfunction or advanced heart disease. Sustained anemia after optimizing heart failure treatment might imply worse prognosis independently of renal function and New York Heart Association functional class. [Copyright &y& Elsevier]

Background. Chronic heart failure (CHF) is associated with increased inflammation, and exercise training has in some studies been shown to have anti-inflammatory effect, although controversies exist. We investigated the effects of exercise training in CHF patients on markers of inflammation, and further explored any association between inflammation and the severity and etiology of the disease. Methods. Eighty patients in stable CHF were randomized to 4 months of group-based high intensity exercise training or to a control group. Physical capacity was measured by 6-minute walk test and cycle ergometer test. Blood samples were drawn at baseline, after 4 months and after 12 months follow-up for analyses of a range of biomarkers. Results. Physical capacity was significantly inversely related to CRP, IL-6, VCAM-1 and TGF-β, and NT pro-BNP levels were significantly correlated to CRP, TNF-α, IL-6, VCAM-1, ICAM-1 and TGF-β ( p < 0.05 for all). Patients with hypertension as etiology of CHF showed higher levels of CRP ( p < 0.01), IL-6 ( p == 0.05) and TNF-α ( p == 0.02) as compared to other etiologies. No significant differences in changes between the exercise group and the control group were obtained in any of the measured variables, except in patients with idiopathic dilated cardiomyopathy (IDCM), where significant reductions in CRP, ICAM-1, TGF-β and TNF-α levels were observed ( p < 0.05 for all). Conclusions. Measures of CHF severity were significantly correlated with several markers of inflammation. We could not demonstrate over-all anti-inflammatory effect of exercise in this population of CHF patients. However, the etiology of CHF affected the inflammatory profile and the effect of exercise training. [ABSTRACT FROM AUTHOR]

Abstract: Background: Hospitalization rates, morbidity and mortality are undesirably high in heart failure (HF) patients. An organized system of HF specialist outpatient care has been recommended, but the best way to implement such programmes is not clearly established. Aim: To evaluate HF patient characteristics, management and outcome in outpatient HF clinics. Methods: Data from HF patients at 24 hospital outpatient clinics were entered in a common database allowing each centre to monitor its own practice against the rest. Results: A total of 3632 patients were included. At the last registered visit, ACE inhibitors or angiotensin receptor blockers were prescribed for 87%; beta blockers, 83%; spironolactone, 33% and loop diuretics 87% of the patients. The number of hospital admissions and days stayed in hospital for cardiovascular reasons were significantly reduced (p <0.001). Mortality was high, 11.5 and 22% after one and two years, respectively. Conclusions: The use of evidence-based medication increased over time in HF clinics with the ability of the individual clinics to compare their treatment to other sites. Thus, establishment of specialized HF clinics managed in a registry network might improve the quality of care. [Copyright &y& Elsevier]

Objectives. Exercise training might improve cardiac function as well as functional capacity in patients with chronic heart failure (CHF). N-terminal pro-B-type natriuretic peptide (NT pro-BNP), is associated with the severity of the disease, and has been reported to be an independent predictor of outcome in CHF. We evaluated the effect of a four months group-based aerobic interval training program on circulating levels of NT pro-BNP in patients with CHF. We have previously reported improved functional capacity in 80 patients after exercise in this exercise program. Methods. Seventy-eight patients with stable CHF (21% women; 70±8 years; left ventricular ejection fraction 30±8.6%) on optimal medical treatment were randomized either to interval training (n=39), or to a control group (n=39). Circulating levels of NT pro-BNP, a six minute walk test (6MWT) and cycle ergometer test were evaluated at baseline, post exercise, and further after 12 months. Results. There were no significant differences in NT pro-BNP levels from baseline to either post exercise or long-term follow-up between or within the groups. Inverse correlations were observed between NT pro-BNP and 6MWT (r=−0.24, p=0.035) and cycle exercise time (r=−0.48, p<0.001) at baseline. But no significant correlations were observed between change in NT pro-BNP and change in functional capacity (6MWT; r=0.12, p=0.33, cycle exercise time; r=0.04, p=0.72). Conclusion. No significant changes in NT pro-BNP levels were observed after interval training, despite significant improvement of functional capacity. [ABSTRACT FROM AUTHOR]

Abstract: Background: Impaired renal function confers an adverse prognosis in patients with heart failure (HF). The aims of the present study were to identify factors associated with and predictive of impaired renal function and to assess the relationship between estimated glomerular filtration rate (eGFR) and all-cause mortality in outpatients with HF. Methods and Results: Baseline data on 3605 patients (median age 73 years, 70.1% men) from 24 outpatient HF clinics in Norway were analyzed. Median follow-up time was 9 months. Renal dysfunction (eGFR < 60 mL/min) was present in 44.9%. The population was randomized into equal-sized model-building and validation samples to enhance model stability. eGFR was an independent predictor of all-cause mortality (HR 0.94 per 5 mL/min increase, P = .001). Use of spironolactone (P = .002), higher blood pressure (P < .001), and lower hemoglobin levels (P = .002) were predictors of impaired renal function. Increasing doses of loop diuretics were strongly associated with eGFR at baseline (P < .001), but only tended to predict worsening renal function during follow-up (P = .08). Conclusions: Clinically significant reduction in renal function was prevalent in outpatients with HF, and was a strong predictor of all-cause mortality. Use of loop diuretics and spironolactone should be carefully evaluated as these agents may adversely affect renal function. [Copyright &y& Elsevier]

Objectives. Observational studies and surveys have shown that lipid-lowering treatment is not optimal neither with regard to number of patients treated nor with number of patients achieving recommended goals. To address this issue in the Nordic countries, we evaluated the published literature on lipid-lowering therapies in preventive cardiology in this region. Design. Nordic papers published from 2000 throughout 2006 dealing with lipid-lowering management in coronary heart disease prevention were identified. In total, 19 studies were analyzed. Results. Approximately half of the patients are inadequately treated and have not achieved recommended treatment goals of total cholesterol <5.0and LDL-cholesterol <3.0 mmol/L. Statins were prescribed most often in low or medium doses. The predictive factors for treatment were cholesterol level, risk of cardiovascular disease, previous cardiovascular disease, age, and gender. Conclusions. There is a considerable need to improve standards of preventive cardiology. Statins have to be given evidence based to achieve treatment goals according to lipid levels, and higher doses of statins or combination therapy with a statin and a cholesterol absorption inhibitor or niacin is often needed. [ABSTRACT FROM AUTHOR]

Objectives. The sympathetic nervous system is implicated in the development and maintenance of hypertension. However, the predictive impact of arterial plasma catecholamines has never been reported. We investigated arterial catecholamines and blood pressures (BPs) prospectively over 20 years in a group of well-characterized middle-aged men. Methods. Fifty-six of original 79 men were available for the follow-up. Multiple regression analysis was done with mean BP at follow-up as a dependent variable, and arterial plasma catecholamines and BP at baseline as independent variables. Results. Half of the originally normotensive men developed hypertension during follow-up. There were significant differences in the screening BP values measured at baseline between the new hypertensives and the sustained normotensives. Multiple regression analysis revealed arterial adrenaline at baseline as an independent predictor of mean BP at follow-up in the new hypertensives (β = 0.646, R 2 = 0.42, p = 0.007). Furthermore, arterial noradrenaline at baseline was a negative independent predictor of mean BP at follow-up in the sustained normotensives (β = -0.578, R 2 = 0.334, p = 0.020). Noradrenaline increased with age in the group as a whole (1318±373 vs 1534±505 pmol/l, p = 0.010) while adrenaline did not change. Conclusion. Our data suggest that arterial adrenaline is involved in the development of hypertension over 20 years in middle-aged men. Men with sustained normotension may have an inherent protection against sympathetic overactivity. Furthermore, screening BP at baseline in normotensive men differentiated between those who developed hypertension and those who remained normotensive at follow-up. [ABSTRACT FROM AUTHOR]

The article presents treatment recommendations for hypertensive patients with concomitant heart failure. It explains the reason hypertension is a major risk factor for the development of cardiac failure. It enumerates the compounds for the treatment of hypertension, post-myocardial infarction, and heart failure. It discusses the importance of diuretics in the symptomatic treatment of heart failure.

Objective: The aim of the present study was to evaluate the effect on insulin secretion and insulin sensitivity of hormone replacement therapy (HRT) with short-term unopposed transdermal 17β-estradiol and, after 1 year, when combined with intermittent medroxyprogesterone acetate (MPA). Methods: Ninety-nine postmenopausal women with coronary artery disease (CAD), but without diabetes mellitus, consecutively recruited from patients referred for invasive coronary investigations at a tertiary university clinic, were randomized to either HRT or a control group. Unopposed estradiol was given for 3 months, and MPA was added in cycles of 14 days every 3 months. Clinical investigations were undertaken at baseline and after 3 months and 12 months. Insulin sensitivity index (HOMA-IR) and insulin secretion (HOMA-BCF) were calculated using the homeostasis model assessment. Results: Compared with the control group, treatment with unopposed transdermal 17β-estradiol caused a significant decrease in HOMA-IR, that is, improved insulin sensitivity, but after combination with MPA and 12 months of HRT, no change was observed in HOMA-IR. Similarly, a transient decrease was observed for plasma levels of C peptide after unopposed 17β-estradiol. HOMA-BCF remained unchanged throughout the study period. Sex hormone-binding globulin (SHBG) was related to HOMA-IR but not to HOMA-BCF at baseline. The association with HOMA-IR grew stronger after unopposed transdermal estradiol. No deleterious effect of HRT on glucose metabolism was found in postmenopausal women with CAD. Conclusions: Short-term treatment with unopposed transdermal estradiol caused a decrease in insulin resistance, but long-term treatment after intermittent MPA was introduced had no effect on either insulin secretion or insulin resistance. [ABSTRACT FROM AUTHOR]

Background: B-type natriuretic peptide (BNP) measurements are useful for diagnosing congestive heart failure (CHF) in patients presenting to the Emergency Department with acute dyspnoe. Whether the diagnostic accuracy of BNP is affected by the age and gender of the patients remains unknown. Aims: To evaluate the accuracy of BNP testing for diagnosing CHF in an unselected group of patients admitted to the emergency department of a Norwegian teaching hospital with a principal complaint of shortness of breath and to assess whether the diagnostic accuracy of the test differs according to age and gender. Methods: BNP levels in plasma were determined by a point-of-care device upon arrival in 155 patients presenting with acute dyspnoe. The diagnostic ‘gold’ standard for CHF was adjudicated by two independent cardiologists who were blinded to the BNP data. Results: By univariate logistic regression analysis, BNP was strongly related to a diagnosis of CHF. In a multivariate model BNP provided additional prognostic information to patient age and gender, radiographic evidence of pulmonary congestion and cardiomegaly, and the presence of pulmonary rales and jugular vein distention by physical examination. There was no significant interaction between age and BNP or between gender and BNP with regard to the accuracy of diagnosing CHF. The area under the receiver–operating characteristics-curve was 0.86 (95% confidence interval 0.78–0.93) in women and 0.90 (0.82–0.97) in men. The area under the curves were 0.82 (0.73–0.92) and 0.88 (0.80–0.97) for patients (both genders) aged &ges;76 and <76 years, respectively. Conclusion: Point-of-care BNP measurement in the emergency department discriminates well between patients with dyspnoe of cardiac and non-cardiac origin regardless of age and gender. [Copyright &y& Elsevier]

First-degree relatives of patients with premature coronary heart disease (CHD) bear a substantial excessive risk of CHD; however, multiple barriers may prevent risk factor screening. We examined the feasibility of family screening in a university hospital setting. Consecutive men <55 and women <65 years old admitted to the cardiology ward for coronary angiography and/or angioplasty, acute coronary syndrome, or after coronary artery bypass surgery attended a follow-up clinic visit within 6 months. Of 600 probands with eligible siblings, 78% agreed to contact their siblings, and of 480 probands with eligible children, 93% agreed to contact their children. Proband characteristics that predicted (p <0.05) successful screening of children were female gender (odds ratio [OR] 2.0), nonimmigrants (OR 2.3), and low educational level (OR 1.7). Predictors of screening of siblings were age (OR 0.95), female gender (OR 2.0), nonimmigrants (OR 4.0), and cigarette smoker (OR 0.6). Sisters and daughters were more likely to complete screening than brothers and sons. Among screened brothers and sisters, 15% and 8% had CHD or a CHD risk equivalent, respectively; moreover, 71% and 46%, respectively, had ≥1 additional major CHD risk factor. Only 3% of sons and 2% of daughters had CHD or a CHD risk equivalent; however, 50% and 40%, respectively, had ≥1 additional CHD risk factor, primarily smoking. These findings indicate that most patients with premature CHD were willing to contact relatives for screening. Screening yielded a substantial percentage of relatives with additional CHD risk factors. [Copyright &y& Elsevier]

The Carvedilol Acute Myocardial Infarction Study (CAMIS) investigates cardiac remodeling in patients (n = 250) randomized to carvedilol vs atenolol and treated for 12 months after acute myocardial infarction. In a sub-study, we compared sympathetic, hemorrheological and vascular effects in small but particularly well-matched groups of participants who had been on reasonably equipotent but unchanged doses of carvedilol (n = 10) or atenolol (n = 10) for at least 4 weeks. Blood pressures (p < 0.05), plasma adrenaline (p = 0.034), plasma vasopressin (p = 0.022) and whole blood viscosity at shear rate 0.5 cp (p = 0.050), 1.1 cp (p = 0.023), 5.8 cp (p = 0.049) and 201 cp (p = 0.060) taken in the laboratory at baseline before 2 h of using the hyperinsulinemic, isoglycemic glucose clamp were lower on carvedilol. Plasma noradrenaline was lower on carvedilol at baseline and throughout the clamp (p < 0.0005). Forearm vascular resistance as measured by plethysmography during the clamp tended to be lower on carvedilol (p = 0.074). No significant difference was found between the groups in glucose disposal rate measured by clamp, maximal forearm blood flow and minimal forearm vascular resistance after 10 min of ischemia, or in ambulatory blood pressure and heart rate taken a few days later. Thus, potential benefits of carvedilol vs atenolol were seen in these post-infarction patients in a laboratory setting. These findings suggest that the inhibitory effects on the sympathetic nervous system and related blood viscosity are stronger with carvedilol than with atenolol. [ABSTRACT FROM AUTHOR]

Objective - To examine changing trends in the field of secondary prevention of atherosclerotic disease in Norwegian general practice. Design - A multipractice survey of consecutive patients with atherosclerotic disease consulting general practitioners in 1994/95 compared with a similar survey in 1996/97. Setting - Primary health care. Subjects - 707 patients attending 31 general practitioners in 1994/95 and 1353 patients attending 63 general practitioners in 1996/97. Main outcome measures - The patients were examined and interviewed for risk factors and pharmacological treatment. Results - In 1994/95, 18% of the patients had been prescribed a lipid-lowering agent as opposed to 55% in the later survey. Consequently, the average level of LDL cholesterol in the 1996/97 population was 19% lower than in the 1994/95 population (3.8 mmol/l vs 4.7 mmol/l), which may imply a marked risk reduction. Aspirin and beta-blockers were prescribed to approximately 50% of the patients in both surveys. Diabetic patients had the same drug prescription rate and lipid profile as non-diabetics. In both surveys, about 25% of the patients were smokers. Conclusion – Secondary prevention in the majority of patients with atherosclerotic disease though ameliorating is still unsatisfactory. More attention is needed to achieve and sustain treatment goals. [ABSTRACT FROM AUTHOR]

The objective of this study was to determine the frequency and profile of adverse reactions to antihypertensive drugs in an unselected group of drug-treated hypertensive patients. A questionnaire-based survey was carried out among 2586 drug-treated hypertensive patients who attended a general practitioner for clinical control. Adverse drug reactions reported spontaneously, upon general inquiry, upon specific questioning and as evaluated by a physician were used as the main outcome measures. The study shows that the percentage of patients who reported adverse drug reactions spontaneously, upon general inquiry and upon specific questioning were 16%, 24% and 62% respectively. Users of diuretics reported the lowest frequency of adverse reactions, whereas users of beta-blockers reported the highest frequency. In 7% of the patients, the adverse drug reactions were of such a nature that the physicians considered discontinuing the treatment. As a conclusion, the reported frequency of adverse drug reactions in antihypertensive treatment is high, but with significant differences between the various drug groups. Monotherapy is connected with far fewer adverse drug reactions than combination therapy. [ABSTRACT FROM AUTHOR]