2019 Vol. 16, No. 7
Background Coronary computed tomography angiography (CCTA) is often avoided in elderly patients due to a presumption that a high proportion of patients will have heavily calcified plaque limiting an accurate assessment. We sought to assess the image quality, luminal stenosis and utility of CCTA in elderly patients with suspected coronary artery disease (CAD) and stable chest pain. Methods Retrospective analysis of elderly patients (> 75 years) who underwent 320-detector row CCTA between 2012–2017 at MonashHeart. The CCTA was analysed for degree maximal coronary stenosis by CAD-RADS classification, image quality by a 5-point Likert score (1-poor, 2-adequate, 3-good, 4-very good, 5-excellent) and presence of artefact limiting interpretability. Results 1011 elderly patients (62% females, 78.8 ± 3.3 years) were studied. Cardiovascular risk factor prevalence included: hypertension (65%), hyperlipidaemia (48%), diabetes (19%) and smoking (21%). The CCTA was evaluable in 68% of patients which included 52% with non-obstructive CAD ( 50%) stenosis. Mean Likert score was 3.1 ± 0.6 corresponding to good image quality. Of the 323 (32%) of patients with a non-interpretable CCTA, 80% were due to calcified plaque and 20% due to motion artefact. Male gender (P = 0.009), age (P = 0.02), excess motion (P P = 0.03) were associated with non-interpretable CCTA. Conclusion Although CCTA is a feasible non-invasive tool for assessment of elderly patients with stable chest pain, clinicians should still be cautious about referring elderly patients for CCTA. Patients who are male, diabetic and >78 years of age are significantly less likely to have interpretable scans.
Background Cardiac resynchronization therapy (CRT) is a highly effective treatment in patients with a class I recommendation. However, a small proportion of the strictly selected patients still fail to respond. This study was designed to identify predictors of non-response in patients with class I indications for CRT and determine the non-response probability of the patients. Methods A total of 296 consecutive patients with a class I recommendation received CRT from January 2009 to January 2017 were retrospectively analyzed. Multivariate logistic regression analysis was performed to identify predictors for non-response (defined as cardiac death, heart transplantation, or HF hospitalization during 1-year follow-up). Results Among 296 patients, 30 (10.1%) met non-response. Multivariate analysis demonstrated that non-response to CRT was associated with a fragmented QRS (odd ratio (OR) = 2.86, 95% CI: 1.14–7.12; P = 0.025) and left ventricular end-diastolic dimension (LVEDD)≥77 mm (OR = 3.02, 95% CI: 1.17–7.82; P = 0.022). Patients with both of the predictors had a non-response probability of 46.2% (95% CI: 19.1%–73.3%). Conclusion In patients with left bundle branch block and wider QRS duration, the proportion of non-response to CRT is not low in real world. The presence of the dilated LVEDD or fragmented QRS is a strong predictor of non-response to CRT. The probability of non-response in the patients with the two predictors was 46.2%.
Objective To assess the prognostic utility of serum albumin among elderly patients admitted for acute decompensated heart failure (ADHF) in terms of all-cause mortality and also to identify the predictors of hypoalbuminemia. Methods Retrospective cohort study of 119 elderly patients admitted for ADHF. Elderly patients were defined as patients over the age of 65 years. The patients were followed up for approximately 11 years. Patients with advanced renal failure, liver disease not due to HF, cancer and other causes of low life expectancy were excluded. Hypoalbuminemia was defined as serum albumin ≤ 2.9 g/dL. Results The study was made up of 65 females and 54 males with age ranging from 65 to 96 years. Of the 119 elderly patients with ADHF, there were 26 deaths. A significantly higher proportion of patients in the mortality group had an admission serum albumin level of ≤ 2.9 g/dL than those surviving (P = 0.011). After Cox's logistic regression, low albumin (P = 0.016), elevated direct bilirubin (P = 0.03), age greater than 85 (P = 0.008), lack of use of beta blockers (P = 0.0001) and left ventricular ejection fraction less than 35% (P = 0.005) increased the risk of death. Elevated serum creatinine (P = 0.0357) was the only predictor of hypoalbuminemia following multiple linear regression. Conclusions Hypoalbuminemia may be an unrecognized marker of death in elderly patients with ADHF.
Objective To construct a prediction model based on metabolic profiling for predicting the response to cardiac resynchronization therapy (CRT). Methods Peripheral venous (PV) and coronary sinus (CS) blood samples were collected from 25 patients with heart failure (HF) at the time of CRT implantation, and PV blood samples were obtained from ten healthy controls. The serum samples were analyzed by liquid chromatography-mass spectrometry (LC-MS). As per the clinical and echocardiographic assessment at the 6-month follow-up, the HF patients were categorized as CRT responders and non-responders. Results HF patients had altered serum metabolomic profiles that were significantly different from those of the healthy controls. Differential metabolites were also observed between CRT responders and non-responders. A prediction model for CRT response (CRT-Re) was constructed using the concentration levels of the differential metabolites, L-arginine and taurine. The optimal cutoff value of the CRT-Re model was found to be 0.343 by ROC analysis (sensitivity, 88.2%; specificity, 87.5%; Area Under Curve (AUC) = 0.897, P = 0.002). The concentration levels of the differential metabolites, L-arginine and lysyl-gamma-glutamate, in PV serum were significantly correlated with that in CS serum (r = 0.945 and r = 0.680, respectively, all P Conclusions Our results suggest that serum-based metabolic profiling may be a potential complementary screening tool for predicting the outcome of CRT.
Background Febuxostat, a novel nonpurine selective inhibitor of xanthine oxidase (XO), may be used in the prevention and man-agement of atrial fibrillation (AF). The purpose of this study was to evaluate the effects of febuxostat on atrial remodeling in a rabbit model of AF induced by rapid atrial pacing (RAP) and the mechanisms by which it acts. Methods Twenty-four rabbits were randomly divided into four groups: sham-operated group (Group S), RAP group (Group P), RAP with 5 mg/kg per day febuxostat group (Group LFP), and RAP with 10 mg/kg per day febuxostat group (Group HFP). All rabbits except those in Group S were subjected to RAP at 600 beats/min for four weeks. The effects of febuxostat on atrial electrical and structural remodeling, markers of inflammation and oxidative stress, and signal-ing pathways involved in the left atrium were examined. Results Shortened atrial effective refractory period (AERP), increased AF induci-bility, decreased mRNA levels of Cav1.2 and Kv4.3, and left atrial enlargement and dysfunction were observed in Group P, and these changes were suppressed in the groups treated with febuxostat. Prominent atrial fibrosis was observed in Group P, as were increased levels of TGF-β1, Collagen I, and α-SMA and decreased levels of Smad7 and eNOS. Treatment with febuxostat attenuated these differences. Changes in inflammatory and oxidative stress markers induced by RAP were consistent with the protective effects of febuxostat. Conclusions This study is the first to find that febuxostat can inhibit atrial electrical and structural remodeling of AF by suppressing XO and inhibiting the TGF-β1/Smad signaling pathway.
Adverse drug reaction is defined by the World Health Organization as any response to a drug that is noxious and unintended and occurs at a dose normally used in man. Older people are at elevated risk of adverse drug reactions—because of changes in pharmacodynamics, con-current use of multiple medications and the related drug interactions. However, adverse drug reactions are significantly underestimated in the elderly population that is also exposed to inappropriate drugs. Amiodarone is an antiarrhythmic drug used commonly for the treatment of atrial fibrillation and is increasingly prescribed in older people. While amiodarone is an efficient drug for rhythm control, it's a carrier of different adverse reactions, and pro and cons must be carefully evaluated before its use especially in older people.