BMC Cardiovascular Disorders - Latest Articles

A mHealth cardiac rehabilitation exercise intervention: findings from content development studies

Leila Pfaeffli — 2012-05-30T00:00:00Z

Background: Involving stakeholders and consumers throughout the content and study design ensuresinterventions are engaging and relevant for end-users. The aim of this paper is to present thecontent development process for a mHealth (mobile phone and internet-based) cardiacrehabilitation (CR) exercise intervention. Methods: An innovative mHealth intervention was developed with patient input using the followingsteps: conceptualization, formative research, pre-testing, and pilot testing. Conceptualization,including theoretical and technical aspects, was undertaken by experts. For the formativecomponent, focus groups and interviews with cardiac patients were conducted to discuss theirperceptions of a mHealth CR program. A general inductive thematic approach identifiedcommon themes. A preliminary library of text and video messages were then developed.Participants were recruited from CR education sessions to pre-test and provide feedback onthe content using an online survey. Common responses were extracted and compiled. Aniterative process was used to refine content prior to pilot testing and conduct of a randomizedcontrolled trial. Results: 38 CR patients and 3 CR nurses participated in the formative research and 20 CR patientsparticipated in the content preTestingParticipants perceived the mHealth program as aneffective approach to inform and motivate patients to exercise. For the qualitative study,100% (n = 41) of participants thought it to be a good idea, and 11% of participants felt itmight not be useful for them, but would be for others. Of the 20 participants who completedthe online survey, 17 out of 20 (85%) stated they would sign up to a program where theycould receive information by video messages on a website, and 12 out of 20 (60%) showedinterest in a texting program. Some older CR patients viewed technology as a potentialbarrier as they were unfamiliar with text messaging or did not have mobile phones. Steps toinstruct participants to receive texts and view the website were written into the studyprotocol. Suggestions to improve videos and wording of texts were fed back to the contentdevelopment team and refined. Conclusions: Most participants thought a mHealth exercise program was an effective way to deliverexercise-based CR. The results were used to develop an innovative multimedia exerciseintervention. A randomized controlled trial is currently underway.Trial registrationACTRN12611000117910

Association between human cartilage glycoprotein 39 (YKL-40) and arterial stiffness in essential hypertension

Wei-hong Ma — 2012-05-29T00:00:00Z

Background: YKL-40, a proposed marker of inflammation and endothelial dysfunction, is associated with atherosclerosis and an increased cardiovascular mortality in the general population. However, the relationship between YKL-40 and arterial stiffness in hypertensive patients has not been adequately assessed. Methods: The relationship between serum levels of YKL-40 and arterial stiffness was evaluated in 93 essential hypertensive subjects and 80 normal subjects. Essential hypertensive subjects were divided into two groups based upon urinary albumin-to-creatinine ratio (ACR): nonmicroalbuminuric group, (ACR <30 mg/g, n = 50) and microalbuminuric group (ACR [greater than or equal to]30 mg/g, n = 43). Large artery wall stiffness was assessed by measuring femoral arterial stiffness and carotid-femoral pulse wave velocity (cf-PWV). Serum levels of YKL-40 were determined by enzyme-linked immunosorbent assay (ELISA). Results: The study demonstrated that YKL-40,cf-PWV and femoral arterial stiffness were increased significantly (P<0.05) in the hypertensive group compared with normal controls. These measurements were also increased significantly (P<0.05) in the microalbuminuric group compared with the nonmicroalbuminuric group. YKL-40 was positively correlated with cf-PWV(r = 0.44, P = 0.000) and femoral arterial stiffness (r = 0.42, P =0.001). Multiple linear stepwise regression analysis showed that YKL-40 was the impact factor of arterial stiffness (P<0.05). Conclusion: YKL-40 levels are elevated in essential hypertension subjects with an independent association between increasing YKL-40 levels and increasing arterial stiffness. The study suggests it played a positive role of YKL-40 in the progressing vascular complications in patients with essential hypertension.

Local electrogram delay recorded from left ventricular lead at implant predicts response to cardiac resynchronization therapy: Retrospective study with 1 year follow up

Rostislav Polasek — 2012-05-20T00:00:00Z

Background: Considerable proportion of patients does not respond to the cardiac resynchronization therapy(CRT). This study investigated clinical relevance of left ventricular electrode localelectrogram delay from the beginning of QRS (QLV). We hypothesized that longer QLVindicating more optimal lead placement in the late activated regions is associated with thehigher probability of positive CRT response. Methods: We conducted a retrospective, single-centre analysis of 161 consecutive patients with heartfailure and LBBB or nonspecific intraventricular conduction delay (IVCD) treated with CRT.We routinely intend to implant the LV lead in a region with long QLV. Clinical response toCRT, left ventricular (LV) reverse remodelling (i.e. decrease in LV end-systolic diameter -LVESD [greater than or equal to]10%) and reduction in plasma level of NT-proBNP >30% at 12-month post-implantwere the study endpoints. We analyzed association between pre-implant variables and thestudy endpoints. Results: Clinical CRT response rate reached 58%, 84% and 92% in the lowest ([less than or equal to]105 ms), middle(106-130 ms) and the highest (>130 ms) QLV tertile (p < 0.0001), respectively. Longer QRSduration (p = 0.002), smaller LVESD and a non-ischemic cardiomyopathy (both p = 0.02)were also univariately associated with positive clinical CRT response. In a multivariateanalysis, QLV remained the strongest predictor of clinical CRT response (p < 0.00001),followed by LVESD (p = 0.01) and etiology of LV dysfunction (p = 0.04). Comparablepredictive power of QLV for LV reverse remodelling and NT-proBNP response rates wasobserved. Conclusion: LV lead position assessed by duration of the QLV interval was found the strongestindependent predictor of beneficial clinical response to CRT.

Effectiveness of two intensive treatment methods for smoking cessation and relapse prevention in patients with coronary heart disease: study protocol and baseline description

Nadine Berndt — 2012-05-15T00:00:00Z

Background: There is no more effective intervention for secondary prevention of coronary heart diseasethan smoking cessation. Yet, evidence about the (cost-)effectiveness of smoking cessationtreatment methods for cardiac inpatients that also suit nursing practice is scarce. This protocoldescribes the design of a study on the (cost-)effectiveness of two intensive smoking cessationinterventions for hospitalised cardiac patients as well as first results on the inclusion rates andthe characteristics of the study population. Methods: A quasi-experimental study design is used in eight cardiac wards of hospitals throughout theNetherlands to assess the (cost-)effectiveness of two intensive smoking cessation counsellingmethods both combined with nicotine replacement therapy. Randomization was conducted atthe ward level (cross-over). Baseline and follow-up measurements after six and 12 monthsare obtained. Upon admission to the cardiac ward, nurses assess patients' smoking behaviour,provide a quit advice and subsequently refer patients for either telephone counselling or faceto-face counselling. The counselling interventions have a comparable structure and contentbut differ in provider and delivery method, and in duration. Both counselling interventionsare compared with a control group receiving no additional treatment beyond the usual care.Between December 2009 and June 2011, 245 cardiac patients who smoked prior tohospitalisation were included in the usual care group, 223 in the telephone counselling groupand 157 in the face-to-face counselling group. Patients are predominantly male and have amean age of 57 years. Acute coronary syndrome is the most frequently reported admissiondiagnosis. The ultimate goal of the study is to assess the effects of the interventions onsmoking abstinence and their cost-effectiveness. Telephone counselling is expected to bemore (cost-)effective in highly motivated patients and patients with high SES, whereas faceto-face counselling is expected to be more (cost-)effective in less motivated patients andpatients with low SES.DiscussionThis study examines two intensive smoking cessation interventions for cardiac patients byusing a multi-centre trial with eight cardiac wards. Although not all eligible patients could beincluded and the distribution of patients is skewed in the different groups, the results will beable to provide valuable insight into effects and costs of counselling interventions varying indelivery mode and intensity.Trial registrationDutch Trial Register NTR2144

Idiopathic premature ventricular contractions and ventricular tachycardias originating from the vicinity of tricuspid annulus: Results of radiofrequency catheter ablation in thirty-five patients

Li Yue-Chun — 2012-05-02T00:00:00Z

Background: In recent years, catheter ablation has increasingly been used for ablation of idiopathicpremature ventricular complexes (PVCs) or ventricular tachycardias (IVTs). However, themapping and catheter ablation of the arrhythmias originating from the vicinity of tricuspidannulus (TA) may not be fully understood. This study aimed to investigate electrophysiologiccharacteristics and effects of radiofrequency catheter ablation (RFCA) for patients withsymptomatic PVCs and IVTs originating from the vicinity of TA. Methods: Characteristics of body surface electrocardiogram (ECG) and electrophysiologic recordingswere analyzed in 35 patients with symptomatic PVCs/ IVTs originating from the vicinity ofTA. RFCA was performed using pace mapping and activation mapping. Results: Among the 35 patients with PVCs/IVTs arising from the vicinity of TA, complete eliminationof PVCs/IVTs could be achieved by RFCA in 32 patients (success rate 91.43%) during amedian follow-up period of 21 months. PVCs/IVTs originating from the vicinity of TA haddistinctive ECG characteristics that were useful for identifying the precise origin. An rSpattern was recorded in lead V1 in 93.1% of patients with PVCs/IVTs from the free wall ofTA, vs 16.7% of patients with PVCs/IVTs from the septal TA, whereas a QS pattern in leadV1 occurred in 83.3% of patients with PVCs/IVTs from the septal TA vs 6.9% of patientswith PVCs from the free wall of the TA. The precordial R wave transition occurred by leadV3 or earlier in all patients with PVCs/IVTs originating from the septal portion of the TA, ascompared to transition beyond V3 in all patients with PVCs/IVTs from the free wall of theTA. Conclusions: RFCA is an effective curative therapy for symptomatic PVCs/IVTs originating from thevicinity of TA. There are specific characteristics in ECG and the ablation site could belocated by ECG analysis.

Age - related treatment strategy and long-term outcome in acute myocardial infarction patients in the PCI era

Petr Kala — 2012-04-25T00:00:00Z

Background: Older age, as a factor we cannot affect, is consistently one of the main negative prognosticvalues in patients with acute myocardial infarction. One of the most powerful factors thatimproves outcomes in patients with acute coronary syndromes is the revascularizationpreferably performed by percutaneous coronary intervention. No data is currently availablefor the role of age in large groups of consecutive patients with PCI as the nearly sole methodof revascularization in AMI patients. The aim of this study was to analyze age-relateddifferences in treatment strategies, results of PCI procedures and both in-hospital and longtermoutcomes of consecutive patients with acute myocardial infarction. Methods: Retrospective multicenter analysis of 3814 consecutive acute myocardial infarction patientsdivided into two groups according to age (1800 patients [less than or equal to] 65 years and 2014 patients > 65years). Significantly more older patients had a history of diabetes mellitus and previousmyocardial infarctions. Results: The older population had a significantly lower rate of coronary angiographies (1726; 95.9%vs. 1860; 92.4%, p < 0.0001), PCI (1541; 85.6% vs. 1505; 74.7%, p < 0.001), achievement ofoptimal final TIMI flow 3 (1434; 79.7% vs. 1343; 66.7%, p < 0.001) and higher rate ofunsuccessful reperfusion with final TIMI flow 0-1 (46; 2.6% vs. 78; 3.9%, p = 0.022). A totalof 217 patients (5.7%) died during hospitalization, significantly more often in the olderpopulation (46; 2.6% vs. 171; 8.5%, p < 0.001). The long-term mortality (data for 2847patients from 2 centers) was higher in the older population as well (5 years survival: 86.1%vs. 59.8%). Though not significantly different and in contrast with PCI, the presence ofdiabetes mellitus, previous MI, final TIMI flow and LAD, as the infarct-related artery, hadrelatively lower impact on the older patients. Severe heart failure on admission (Killip III-IV)was associated with the worst prognosis in the whole group of patients, though itssignificance was higher in the youngers (HR 6.04 vs. 3.14, p = 0.051 for Killip III and 12.24vs. 5.65, p = 0.030 for Killip IV). We clearly demonstrated age as a strong discriminator forthe whole population of AMI patients. Conclusions: In a consecutive AMI population, the older group (>65 years) was associated with a lesspronounced impact of risk factors on long-term outcome. To ascertain the coronary anatomyby coronary angiography and proceed to PCI if suitable regardless of age is crucial in allpatients, though the primary success rate of PCI in the older age is lower. Age, when viewedas a risk factor, was a dominant discriminating factor in all patients.

The prognostic importance of a history of hypertension in patients with symptomatic heart failure is substantially worsened by a short mitral inflow deceleration time

Charlotte Andersson — 2012-04-25T00:00:00Z

Background: Hypertension is a common comorbidity in patients with heart failure and may contribute todevelopment and course of disease, but the importance of a history of hypertension inpatients with prevalent heart failure remains uncertain. Methods: 3078 consecutively hospitalized heart failure patients (NYHA classes II-IV) were screenedfor the EchoCardiography and Heart Outcome Study (ECHOS). The left ventricular ejectionfraction (LVEF) was estimated by 2 dimensional transthoracic echocardiography in allpatients and a subgroup of 878 patients had additional data on pulsed wave Dopplerassessment of transmitral flow available. A restrictive filling (RF) was defined as a mitralinflow deceleration time [less than or equal to]140 ms. Patients were followed for a median of 6.8 (Inter QuartileRange 6.6-7.0) years and multivariable Cox regression models were used to assess the risk ofall-cause mortality associated with hypertension. Results: The study population had a mean age of 73 +/- 11 years. 39% were female, 27% had a historyof hypertension and 48% had a RF. Over the study period, 64% of the population died.Hypertension was not associated with increased risk of mortality, hazard ratio (HR) 0.95(0.85-1.05). LVEF did not modify this relationship (p for interaction = 0.7), but RF patternsubstantially influenced the outcomes associated with hypertension (p forinteraction < 0.001); HR 0.75 (0.57-0.99) and 1.41 (1.08-1.84) in patients without and withRF, respectively. Conclusions: In patients with symptomatic heart failure, a history of hypertension is associated with asubstantially increased relative risk of mortality among patients with a restrictive transmitralfilling pattern.

Associations among different functional and structural arterial wall properties and their relations to traditional cardiovascular risk factors in healthy subjects: a cross-sectional study

Mojca Lunder — 2012-04-25T00:00:00Z

Background: The arterial wall possesses several functional and structural properties that define arterialhealth. Once they become impaired, cardiovascular risk increases. We aimed to ascertain thepattern of correlations among different arterial wall properties and to explore their relations totraditional risk factors and cardiovascular risk stratification. To allow such an investigation amiddle-aged healthy population was recruited. Methods: This cross-sectional study included 100 healthy males (aged 41.9 +/- 6.4 years). Pulse wavevelocity (PWV), beta-stiffness and intima-media thickness (IMT) of the carotid artery, andbrachial artery flow-mediated dilation (FMD) were measured by a standardized ultrasoundapproach. Results: No correlation between FMD and IMT was found; only relatively poor correlations betweenPWV (or beta-stiffness) and FMD existed, as well as between PWV (or beta-stiffness) and IMT.PWV and beta-stiffness highly correlated. Unexpectedly, only weak associations between PWV,beta-stiffness, FMD, IMT and traditional risk factors were revealed. Hence, traditional riskfactors (mainly age) explained only 10-50% of variability for PWV, beta-stiffness, FMD andIMT. Although the subjects had low cardiovascular risk according to their Framingham score,their arterial wall properties were already impaired, particularly FMD. Conclusions: In healthy middle-age males we found: i) absent or poor correlations among arterial stiffness,IMT and endothelial function; ii) a low impact of traditional risk factors on the studiedvariables, and iii) the presence of impaired arterial wall properties despite low calculatedcardiovascular risk. These results provide a deepened understanding of arterial wallproperties and could help to improve cardiovascular risk stratification.

Cardiac tamponade related to a coronary injury by a pericardial calcification: an unusual complication

Anne Cypierre — 2012-04-25T00:00:00Z

Background: Cardiac tamponade is a rare but severe complication of pericardial effusion with a poor prognosis. Prompt diagnosis using transthoracic echocardiography allows guiding initial therapeutic management. Although etiologies are numerous, cardiac tamponade is more often due to a hemopericardium. Rarely, a coronary injury may result in such a hemopericardium with cardiac tamponade. Coronary artery aneurysm are the main etiologies but blunt, open chest trauma or complication of endovascular procedures have also been described.Case presentationA 83-year-old hypertensive man presented for dizziness and hypotension. The patient had oliguria and mottled skin. Transthoracic echocardiography disclosed a circumferential pericardial effusion with a compressed right atrium, confirmed by contrast-enhanced thoracic CT scan. A pig-tail catheter allowed to withdraw 500 mL of blood, resulting in a transient improvement of hemodynamics. Rapidly, recurrent hypotension prompted a reoperation. An active bleeding was identified at the level of the retroventricular coronary artery. The pericardium was thickened with several "sharping" calcified plaques in the vicinity of the bleeding areas. On day 2, vasopressors were stopped and the patient was successfully extubated. Final diagnosis was a spontaneous cardiac tamponade secondary to a coronary artery injury attributed to a "sharping"calcified pericardial plaque. Conclusion: Cardiac tamponade secondary to the development of a hemopericardium may develop as the result of a myocardial and coronary artery injury induced by a calcified pericardial plaque.

QRS pattern and improvement in right and left ventricular function after cardiac resynchronization therapy: a radionuclide study

Giulia Domenichini — 2012-04-11T00:00:00Z

Background: Predicting response to cardiac resynchronization therapy (CRT) remains a challenge. We evaluated the role of baseline QRS pattern to predict response in terms of improvement in biventricular ejection fraction (EF). Methods: Consecutive patients (pts) undergoing CRT implantation underwent radionuclide angiography at baseline and at mid-term follow-up. The relationship between baseline QRS pattern and mechanical dyssynchrony using phase analysis was evaluated. Changes in left and right ventricular EF (LVEF and RVEF) were analyzed with regard to baseline QRS pattern. Results: We enrolled 56 pts, 32 with left bundle branch block (LBBB), 4 with right bundle branch block (RBBB) and 20 with non-specific intraventricular conduction disturbance (IVCD). A total of 48 pts completed follow-up. LBBB pts had significantly greater improvement in LVEF compared to RBBB or non-specific IVCD pts (+9.6 ± 10.9% vs. +2.6 ± 7.6%, p = 0.003). Response (defined as ≥ 5% increase in LVEF) was observed in 68% of LBBB vs. 24% of non-specific IVCD pts (p = 0.006). None of the RBBB pts were responders. RVEF was significantly improved in LBBB (+5.0 ± 9.0%, p = 0.007), but not in non-specific IVCD and RBBB pts (+0.4 ± 5.8%, p = 0.76). At multivariate analysis, LBBB was the only predictor of LVEF response (OR, 7.45; 95% CI 1.80-30.94; p = 0.006), but not QRS duration or extent of mechanical dyssynchrony. Conclusions: Presence of a LBBB is a marker of a positive response to CRT in terms of biventricular improvement. Pts with non-LBBB pattern show significantly less benefit from CRT than those with LBBB.