Cardiology

Palazzuoli, A., G. Ruocco, M. Pellegrini, M. Beltrami, N. Giordano, R. Nuti and P. A. McCullough (2016). “Prognostic significance of hyperuricemia in patients with acute heart failure.” Am J Cardiol 117(10): 1616-1621.

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Serum uric acid (UA) is associated with death and hospitalization in chronic heart failure (HF). However, UA in acute HF has not been well studied with respect to its relation to renal dysfunction and vascular congestion. We measured admission serum UA along with baseline variables in 281 patients with acute HF screened from the Loop Diuretics Administration and Acute Heart Failure (Diur-HF) trial. Hyperuricemia was defined as serum UA >7 mg/dl in men and >6 mg/dl in women. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate <60 ml/min/1.73 m(2) before hospital admission. Death or HF hospitalization at 6 months was the primary outcome. The mean UA concentration was 6.4 +/- 2.5 mg/dl, and 121 patients (43.1%) were classified as hyperuricemic. UA values were significantly increased in patients with CKD compared to patients without CKD (6.8 +/- 2.7 vs 6.1 +/- 2.1 mg/dl; p = 0.02); however, UA was not associated with the development of acute kidney injury. Patients with hyperuricemia had greater degrees of pulmonary and systemic congestion than normouricemic patients (congestion score 3.5 vs 2.1, p <0.01). Hyperuricemia was associated with higher risk of death or HF rehospitalization (univariate hazard ratio 1.46 [1.02 to 2.10]; p = 0.04, multivariate hazard ratio 1.69 [1.16 to 2.45]; p = 0.005). In conclusion, hospitalized patients with acute HF, elevated UA levels were associated with both CKD and pulmonary congestion. After controlling for potential confounders, hyperuricemia was associated with rehospitalization and death at 6 months.

Kotecha, D., L. Manzano, H. Krum, G. Rosano, J. Holmes, D. G. Altman, P. D. Collins, M. Packer, J. Wikstrand, A. J. Coats, J. G. Cleland, P. Kirchhof, T. G. von Lueder, A. S. Rigby, B. Andersson, G. Y. Lip, D. J. van Veldhuisen, M. C. Shibata, H. Wedel, M. Bohm and M. D. Flather (2016). “Effect of age and sex on efficacy and tolerability of beta blockers in patients with heart failure with reduced ejection fraction: Individual patient data meta-analysis.” Bmj 353: i1855.

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OBJECTIVES: To determine the efficacy and tolerability of beta blockers in a broad age range of women and men with heart failure with reduced ejection fraction (HFrEF) by pooling individual patient data from placebo controlled randomised trials. DESIGN: Prospectively designed meta-analysis of individual patient data from patients aged 40-85 in sinus rhythm at baseline, with left ventricular ejection fraction <0.45. PARTICIPANTS: 13 833 patients from 11 trials; median age 64; 24% women. MAIN OUTCOME MEASURES: The primary outcome was all cause mortality; the major secondary outcome was admission to hospital for heart failure. Analysis was by intention to treat with an adjusted one stage Cox proportional hazards model. RESULTS: Compared with placebo, beta blockers were effective in reducing mortality across all ages: hazard ratios were 0.66 (95% confidence interval 0.53 to 0.83) for the first quarter of age distribution (median age 50); 0.71 (0.58 to 0.87) for the second quarter (median age 60); 0.65 (0.53 to 0.78) for the third quarter (median age 68); and 0.77 (0.64 to 0.92) for the fourth quarter (median age 75). There was no significant interaction when age was modelled continuously (P=0.1), and the absolute reduction in mortality was 4.3% over a median follow-up of 1.3 years (number needed to treat 23). Admission to hospital for heart failure was significantly reduced by beta blockers, although this effect was attenuated at older ages (interaction P=0.05). There was no evidence of an interaction between treatment effect and sex in any age group. Drug discontinuation was similar regardless of treatment allocation, age, or sex (14.4% in those give beta blockers, 15.6% in those receiving placebo). CONCLUSION: Irrespective of age or sex, patients with HFrEF in sinus rhythm should receive beta blockers to reduce the risk of death and admission to hospital.

Packer, M. (2016). “Love of angiotensin-converting enzyme inhibitors in the time of cholera.” JACC Heart Fail: April 2016 [Epub ahead of print].

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The highly acclaimed novel Love in the Time of Cholera by the Nobel Prize-winning Colombian author Gabriel García Márquez is a brilliant exploration of the complexity of love, specifically the struggle between our attraction to the ideal and depraved dimensions of love and the importance of passion and societal expectations in defining the attributes and personal rewards of love (1). Lovesickness is viewed as an illness, just as cholera is defined (from an intriguing Spanish perspective) as a passion, separate from its conventional consideration as a disease. The flow of the story (which evolves over decades) can be viewed simplistically, but that would be a mistake. The author himself has warned readers “you have to be careful not to fall into my trap” (1).

Fernandez, H. T., P. T. W. Kim and G. Testa (2016). “Adrenal cortical carcinoma with pulmonary emboli: A unique presentation of a rare tumor with extensive tumor thrombus and inferior vena cava extension.” International Journal of Hepatobiliary and Pancreatic Diseases 6: 30-33.

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Introduction: Adrenal cortical carcinoma (ACC) is rare, and presenting symptoms vary widely depending on functional or non-functional endocrine status. These tumors are most commonly treated with surgical resection and postoperative mitotane administration. Case Report: This is an unusual presentation of a 23-year-old female with no significant past medical history, admitted to the hospital with syncope and dyspnea. Computed tomography angiography (CTA) demonstrated extensive bilateral pulmonary embolisms, with an associated 16-cm assumed right lobe hepatic mass with suprahepatic vena cava tumor thrombus extension beyond the level of the hepatic veins. The patient underwent a complete resection of the right adrenal mass, with inferior vena cava resection, thrombectomy, and placement of caval interposition graft without the use of bypass. Pathology was consistent with adrenal cortical carcinoma. Conclusion: This case of an adrenal cortical carcinoma, with a rare presentation of bilateral pulmonary embolisms, was treated with a surgical R0 resection. This included a right adrenalectomy with IVC resection and interposition graft. Tumors with IVC involvement and tumor thrombus can be treated with surgical resection and IVC grafting, without the use of bypass.

Joseph, S. M., M. A. Brisco, M. Colvin, K. L. Grady, M. N. Walsh and J. L. Cook (2016). “Women with cardiogenic shock derive greater benefit from early mechanical circulatory support: An update from the cvad registry.” J Interv Cardiol 29(3): 248-256.

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OBJECTIVES: The aim of this analysis was to assess survival differences between men and women supported with Impella 2.5 (Abiomed Inc., Danvers) in the setting of acute myocardial infarction (AMI) complicated by cardiogenic shock (CS). BACKGROUND: Data on sex differences in outcomes of CS with mechanical circulatory support are sparse. METHODS: Patients enrolled in the cVAD Registry who underwent percutaneous coronary intervention (PCI) and Impella 2.5 support for CS complicating an AMI were included. Differences between men and women were examined. RESULTS: In total, 180 patients were analyzed. Women (n = 49, 27.2%) were older (71.0 +/- 12.8 years vs 63.8 +/- 13.0, P = 0.001), smaller (BSA 1.82 +/- 0.22 vs 2.04 +/- 0.24 m(2) , P < 0.001), and had a higher STS mortality risk score than men (27.9 +/- 17.0 vs. 20.8 +/- 16.8 P = 0.01). There was no difference in survival to discharge (P = 0.3). Patients receiving the Impella 2.5 pre-PCI had significantly lower inpatient mortality than those who received support post-PCI (P = 0.003). However, the magnitude of the survival benefit was significantly greater in women who received the Impella pre-PCI as compared to men. Overall, 68.8% of women survived with pre-PCI Impella 2.5 versus 24.2% post-PCI (P = 0.005) whereas 54.2% of men survived with pre-PCI Impella 2.5 versus 40.3% post-PCI (P = 0.1, p-interaction = 0.07). No differences in timing to intervention were found between men and women. CONCLUSIONS: Early initiation of hemodynamic support prior to PCI with Impella 2.5, in the setting of AMI complicated by CS, was associated with a greater survival benefit to hospital discharge in women compared to men, despite a higher predicted risk of mortality and a greater revascularization failure rate for women.