In-hospital bleeding in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) is associated with increased mortality risk [ 1 Suh J.W. Mehran R. Claessen B.E. et al. Impact of in-hospital major bleeding on late clinical outcomes after primary percutaneous coronary intervention in acute myocardial infarction the HORIZONS-AMI (Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction) trial. J Am Coll Cardiol. 2011; 58: 1750-1756 Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar , 2 Rao S.V. McCoy L.A. Spertus J.A. et al. An updated bleeding model to predict the risk of post-procedure bleeding among patients undergoing percutaneous coronary intervention: a report using an expanded bleeding definition from the National Cardiovascular Data Registry CathPCI Registry. JACC Cardiovasc Interv. 2013; 6: 897-904 Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar ]. Novel antiplatelet agents have been found superior over clopidogrel in reducing cardiovascular events, though still with an increased bleeding risk [ 3 Wiviott S.D. Braunwald E. McCabe C.H. et al. TRITON-TIMI 38 Investigators. Prasugrel versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2007; 357: 2001-2015 Crossref PubMed Scopus (5473) Google Scholar , 4 Wallentin L. Becker R.C. Budaj A. et al. PLATO Investigators. Ticagrelor versus clopidogrel in patients with acute coronary syndromes. N Engl J Med. 2009; 361: 1045-1057 Crossref PubMed Scopus (5419) Google Scholar , 5 Becker R.C. Bassand J.P. Budaj A. et al. Bleeding complications with the P2Y12 receptor antagonists clopidogrel and ticagrelor in the PLATelet inhibition and patient Outcomes (PLATO) trial. Eur Heart J. 2011; 32: 2933-2944 Crossref PubMed Scopus (292) Google Scholar ]. Not much information is available regarding prasugrel use in unselected patients with ACS [ [6] Damman P. Varenhorst C. Koul S. et al. Treatment Patterns and Outcomes in Patients Undergoing Percutaneous Coronary Intervention Treated With Prasugrel or Clopidogrel (from the Swedish Coronary Angiography and Angioplasty Registry [SCAAR]). Am J Cardiol. 2014; 113: 64-69 Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar ], whereas no ‘real world’ data for ticagrelor are available to date. In the context of the Greek Antiplatelet Registry (GRAPE) [ 7 Alexopoulos D. Goudevenos J.A. Xanthopoulou I. et al. on behalf of the GRAPE Investigators. Implementation of contemporary oral antiplatelet treatment guidelines in patients with acute coronary syndrome undergoing percutaneous coronary intervention: A report from the GReek AntiPlatelet rEgistry (GRAPE). Int J Cardiol. 2013; 168: 5329-5335 Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar , 8 Alexopoulos D. Xanthopoulou I. Deftereos S. et al. on behalf of the GRAPE Investigators. Contraindications/Special Warnings and Precautions for Use of Contemporary Oral Antiplatelet Treatment in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention. Circ J. 2013; 78: 180-187 PubMed Google Scholar ], we aimed to assess in-hospital bleeding, classified according to Bleeding Academic Research Consortium (BARC) classification [ [9] Mehran R. Rao S.V. Bhatt D.L. et al. Standardized bleeding definitions for cardiovascular clinical trials: a consensus report from the Bleeding Academic Research Consortium. Circulation. 2011; 123: 2736-2747 Crossref PubMed Scopus (2715) Google Scholar ] with all 3 available for use oral antiplatelet agents.

AimsLittle is known about the use of bivalirudin in real life. In the context of contemporary antiplatelet treatment, we aimed to assess bivalirudin treatment patterns and short-term (one-month) outcome.MethodsGreek Antiplatelet Registry (GRAPE) is a prospective, observational, multicenter cohort study of consecutive, moderate-to-high-risk acute coronary syndrome patients undergoing percutaneous coronary intervention (PCI). We assessed bivalirudin treatment patterns and predictive factors for its use. Combined in-hospital and one-month major adverse cardiovascular events (MACE, including death, myocardial infarction, urgent revascularization, and stroke), and bleeding events according to Bleeding Academic Research Consortium (BARC) criteria were analyzed after propensity matching.ResultsOf 2047 registered patients, 480 (23.4%) were treated with bivalirudin. Multivariate analysis (C statistic 0.77, 0.75-0.80 95% CIs, P<0.001) revealed as factors favoring bivalirudin use primary PCI, radial arterial access, presentation with positive biomarkers and use of novel P2Y12 inhibitor, whereas IIb/IIIa inhibitor administration did not. Regional trends also affected bivalirudin's choice. In 370 propensity-matched pairs of patients who received or not bivalirudin, MACE, BARC type 1, 2 and 3 did not differ between groups: 4.1%, 21.9%, 3.2%, 3.5% and 5.1%, 18.9%, 2.7%, 4.3%, respectively, P=nonsignificant for all.ConclusionsIn a real life, contemporary antiplatelet treatment registry, clinical, laboratory and logistic factors affect bivalirudin's choice, while there are no differences in one-month outcome between bivalirudin-treated and non-bivalirudin-treated patients.

The relationship between echocardiographically measured epicardial fat thickness (EFT) and plasma concentrations of leptin, ghrelin, and adiponectin has not been evaluated in patients with noncachectic heart failure (HF). Patients with noncachectic HF and age-and sex-matched controls did not differ significantly in EFT, whereas EFT values showed significant positive correlation with body mass index (BMI) in both groups and were negatively related with brain natriuretic peptide and positively with log leptin values in the HF group. In the control group, a positive correlation with high-sensitivity C-reactive protein (hsCRP) and a negative correlation with log ghrelin were found. In multivariable analysis, log leptin was a significant predictor of EFT in patients with HF, but this effect was not retained after adjusting for BMI. In contrast, log ghrelin and hsCRP were significant predictors of EFT in controls even after adjusting for BMI.

Heart failure (HF) is a leading cause of morbidity and mortality worldwide and, despite recent advances in therapy HF hospitalization rates remains unacceptably high. Prompt identification and optimal management of HF can affect long-term outcome. A valuable tool with diagnostic, prognostic, and treatment-guiding properties in this respect will be very useful, as exemplified by natriuretic peptides. However, natriuretic peptide levels show biological variation and are dependent on age, renal function, and body mass index. Recent advances in the field of molecular biology and HF pathophysiology have led to the discovery of other novel biomarkers that may have advantages. Among others, Galectin-3 (GAL3) and sST2 are 2 promising biomarkers that have been recently developed and can be used alone or in combination with natriuretic peptides in clinical practice. In the current paper, we review the existing data regarding GAL3 and sST2 in HF.

It has been widely suggested that depression negatively affects patients with cardiovascular disease. There are several pathophysiological mechanisms as well as behavioral processes linking depression and cardiac events. Improvements in nursing and medical care have prolonged survival of this patient population; however, this beneficial outcome has led to increased prevalence of depression. Since mortality rates in chronic heart failure patients remain extremely high, it might be as equally important to screen for depression and there are several valid and reliable screening tools that healthcare personnel could easily employ to identify patients at greater risk. Consultation should be provided by a multidisciplinary team, consisting of cardiologists, psychiatrists, and hospital or community nurses so as to carefully plan, execute, and evaluate medical intervention and implement lifestyle changes. We aim to systematically review the existing knowledge regarding current definitions, prognostic implications, pathophysiological mechanisms, and current and future treatment options in patients with depression and cardiovascular disease, specifically those with heart failure.

Heart failure (HF) is a growing epidemic with the annual number of hospitalizations constantly increasing over the last decades for HF as a primary or secondary diagnosis. Despite the emergence of novel therapeutic approached that can prolong life and shorten hospital stay, HF patients will be needing rehospitalization and will often have a poor prognosis. Telemonitoring is a novel diagnostic modality that has been suggested to be beneficial for HF patients. Telemonitoring is viewed as a means of recording physiological data, such as body weight, heart rate, arterial blood pressure, and electrocardiogram recordings, by portable devices and transmitting these data remotely (via a telephone line, a mobile phone or a computer) to a server where they can be stored, reviewed and analyzed by the research team. In this systematic review of all randomized clinical trials evaluating telemonitoring in chronic HF, we aim to assess whether telemonitoring provides any substantial benefit in this patient population.

Heart failure is a major public health problem and its management requires a significant amount of health care resources. Even with administration of the best available medical treatment, the mortality associated with the disease remains high. As therapeutical strategies for heart failure have been refined, the number of patients suffering from the disease has expanded dramatically. Although heart transplantation still represents the gold standard therapeutical approach, the implantation of mechanical circulatory support devices (MCSDs) evolved to a well-established management for this disease. The limited applicability of heart transplantation caused by a shortage of donor organs and the concurrent expand of the patient population with end-stage heart failure led to a considerable utilization of MCSDs. This paper outlines the current status of mechanical circulatory support.

Aim: The aims of this study were to evaluate: i) the prevalence of impaired coronary flow reserve (CFR), ii) the association of impaired CFR with indices of left ventricular function, and iii) the independent predictors of impaired CFR in a cohort of high-risk asymptomatic individuals. Methods: Ninety-nine consecutive individuals (age, 52.5 ± 13.2 years; 68% male; left ventricular ejection fraction, 62 ± 6%) with at least one major cardiovascular risk factor (49% hypertension, 23% diabetes mellitus, 42% hypercholesterolemia, 32% smoking) were evaluated. Based on CFR values, patients were divided into normal (CFR ≥2.5), borderline (2.5>CFR ≥2.0), and abnormal (CFR < 2.0). Left ventricular function was assessed with comprehensive transthoracic echocardiography. Results: Impaired CFR was identified in 39 individuals (borderline, n = 25; abnormal, n = 14). Isovolumic relaxation time was significantly increased for abnormal compared with normal CFR (94 ± 12 vs. 85 ± 11 msec, p < 0.05), as was the left atrial volume index (LAVI) (24 ± 7 cm3/m2 vs. 19.1 ± 5.2, p < 0.01). A stepwise linear regression analysis identified the LAVI and the deceleration time of E wave of transmitral flow as the only independent predictors of CFR value. An ordinal regression analysis model revealed two predictors of CFR categorization: diabetes mellitus (proportional odds ratio (POR) for CFR group deterioration, 4.55; 95% confidence interval (CI), 1.13–18.28; p = 0.033) and LAVI (POR, 1.11 per 1 cm3/m2 increment; 95% CI, 1.01–1.23; p = 0.034). Conclusions: CFR is often impaired among asymptomatic individuals with major cardiovascular risk factors and is associated with changes in left ventricular diastolic function and left atrial size. The prognostic importance of these early derangements should be assessed in prospective studies.

A 76-year-old Caucasian woman with a history of hepatitis C presented to our institution due to symptoms of worsening fatigue and peripheral oedema. She had signs of right heart failure and almost normal laboratory profile. Cardiac echocardiography revealed a hypertrophied left ventricle and the presence of a round mass in the right atrium. In …

Background Worsening renal function (WRF) and hypokalemia related to diuretic use for acute decompensated heart failure (ADHF) are common and associated with poor prognosis Low dose dopamine in fusion improves renal perfusion its effect on diuresis or renal function specifically in ADHF is not knownMethods and Results Sixty consecutive ADHF patients (age 75 7 +/- 11 2 years 51 7% female left ventricular ejection fraction 35 3 +/- 12 1%) were randomized after receiving a 40 mg intravenous furosemide bolus to either high dose furosemide (HDF 20 mg/h continuous infusion for 8 hours) or low-dose furosemide combined with low-dose dopamine (LDFD furosemide 5 mg/h plus dopamine 51 mu g kg(-1) min(-1) continuous infusion for 8 hours) Both strategies were compared for total diuresis WRF (defined as a rise in serum creatinine of > 0 3 mg/dL from baseline to 24 hours) electrolyte balance and 60-day postdischarge outcomes Mean hourly excreted urine volume (272 +/- 149 mL in HDF vs 278 +/- 186 mL in LDFD group P = 965) and changes in dyspnea score (Borg index -44 +/- 2 1 in HDF group vs -4 7 +/- 20 in LDFD group P = 575) during the 8 hours of protocol treatment were similar in the two groups WRF was more frequent in the HDF (n = 9 30%) than in the LDFD group (n = 2 67% P = 042) Serum potassium changed from 4 3 +/- 0 5 to 3 9 +/- 0 4 mEq/L at 24 hours (P = 003) in the HDF group and from 4 4 +/- 0 5 to 4 2 +/- 0 5 mEq/L at 24 hours (P = 07) in the LDFD group Length of stay and 60 day mortality or rehospitalization rates (all cause cardiovascular and worsening HF) were similar in the two groupsConclusions In ADHF patients the combination of low dose furosemide and low dose dopamine is equally effective as high dose furosemide but associated with improved renal function profile and potassium homeostasis

We assessed the association between (CA)n repeat polymorphism of angiotensinogen (AGT), 250 base pair (bp) insertion/deletion (I/D) of angiotensin-converting enzyme (ACE), tetranucleotide repeat polymorphism (TCTG)n of renin (REN), (CT)n repeat polymorphism of the natriuretic peptide receptor A (NPRA) genes, and the presence and extent of coronary artery disease (CAD) in Greek patients with a history of myocardial infarction (MI). A total of 158 post-MI patients referred for coronary angiography were compared with 144 controls. The SS genotype of the AGT gene was related with an increased risk for 3-vessel CAD (odds ratio [OR], 1.94; 95% confidence interval [CI], 1.05-3.61; P = .041), whereas the SL genotype was related with a decreased risk (OR, 0.44; 95% CI, 0.22-0.87; P = .019). Moreover, there was a trend for the SL genotype of the REN gene toward increased risk for CAD. There was a significant association between (CA)n polymorphism of the AGT gene and the extent of CAD in Greek patients with a history of MI.

2009;54;1747-1762 J. Am. Coll. Cardiol. George Louridas, and Javed Butler Filippos Triposkiadis, George Karayannis, Grigorios Giamouzis, John Skoularigis, Pathophysiology, and Clinical Implications The Sympathetic Nervous System in Heart Failure: Physiology, This information is current as of November 7, 2009 http://content.onlinejacc.org/cgi/content/full/54/19/1747 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Background: Worsening renal function (WRF) and hypokalemia related to diuretic use for acute decompensated heart failure (ADHF) are common and portend poor prognosis. Low dose dopamine infusion improves renal perfusion. Whether dopamine infusion improves diuresis and/or reduces renal complication in ADHF is not known.

Heart failure is a syndrome characterized initially by left ventricular dysfunction that triggers countermeasures aimed to restore cardiac output. These responses are compensatory at first but eventually become part of the disease process itself leading to further worsening cardiac function. Among these responses is the activation of the sympathetic nervous system (SNS) that provides inotropic support to the failing heart increasing stroke volume, and peripheral vasoconstriction to maintain mean arterial perfusion pressure, but eventually accelerates disease progression affecting survival. Activation of SNS has been attributed to withdrawal of normal restraining influences and enhancement of excitatory inputs including changes in: 1) peripheral baroreceptor and chemoreceptor reflexes; 2) chemical mediators that control sympathetic outflow; and 3) central integratory sites. The interface between the sympathetic fibers and the cardiovascular system is formed by the adrenergic receptors (ARs). Dysregulation of cardiac beta(1)-AR signaling and transduction are key features of heart failure progression. In contrast, cardiac beta(2)-ARs and alpha(1)-ARs may function in a compensatory fashion to maintain cardiac inotropy. Adrenergic receptor polymorphisms may have an impact on the adaptive mechanisms, susceptibilities, and pharmacological responses of SNS. The beta-AR blockers and the inhibitors of the renin-angiotensin-aldosterone axis form the mainstay of current medical management of chronic heart failure. Conversely, central sympatholytics have proved harmful, whereas sympathomimetic inotropes are still used in selected patients with hemodynamic instability. This review summarizes the changes in SNS in heart failure and examines how modulation of SNS activity may affect morbidity and mortality from this syndrome.

Systolic heart failure (HF) is a progressive disorder that often begins with asymptomatic left ventricular (LV) systolic dysfunction and culminates in symptoms from fluid overload and poor end-organ perfusion. The progression to symptomatic HF is accompanied by marked activation of neurohormonal and cytokine systems, as well as a series of adaptive LV anatomical and functional changes, collectively referred to as LV remodelling. However, the mechanisms underlying symptom appearance have not been delineated and the weight of experimental and clinical evidence suggests that the development of symptomatic HF occurs independently of the haemodynamic status of the patient. The left atrium is a muscular chamber strategically located between the left ventricle and the pulmonary circulation with important mechanical function (modulation of LV filling), which is closely coupled with its endocrine (atrial natriuretic peptide synthesis and secretion) and regulatory (contribution to the control of sympathetic activity and vasopressin release) functions. In this narrative review we provide evidence supporting the concept that left atrial dilation and systolic dysfunction (left atrial remodelling) contributes to the progression of asymptomatic LV dysfunction to chronic symptomatic systolic HF as it is a prerequisite for the development of the pulmonary congestion and marked neuronhormoral activity that characterize the symptomatic state.