Wednesday, January 30, 2013
Echo - Coronary artery dimensions in Non-Kawasaki febrile children
CIRCULATION CARDIOVASCULAR IMAGING.112.000159
Published online before print January 28, 2013,
doi: 10.1161/CIRCIMAGING.112.000159
Coronary Artery Dimensions in Febrile Children without Kawasaki Disease
Juan-Carlos G. Muniz1, Kirsten Dummer1, Kimberlee Gauvreau1, Steven D. Colan1, David R. Fulton1 and Jane W. Newburger1*
Background—Coronary artery (CA) dilatation on echocardiography is a criterion for treatment with intravenous immunoglobulin for incomplete Kawasaki disease (KD). However, CA dimensions for febrile children are unknown. We compared CA dimensions in children with febrile illnesses other than KD to those of normal afebrile children and to KD patients.
Methods and Results—We performed echocardiograms in 43 patients who met the following inclusion criteria: (1) age 3 months to 18 years, (2) daily fever >38 °C for ≥96 hours, and (3) a diagnosis other than KD.
These subjects had mean CA z-scores greater than normative values (LMCA=0.66±0.75, P<0 .001="" ca="" lad="0.35±1.0," maximum="" p="0.03)." rca="0.28±0.81," z-score="" zmax="">2 was found in 2 subjects (osteomyelitis, Mycoplasma pneumonia).
Among demographic and laboratory measures, only higher platelet count was associated with greater LAD z-scores (P=0.004) and zMax (P=0.03).
Non-KD febrile subjects, compared to 144 KD patients, had smaller CA z-scores (P=0.04, P<0 .001="" 2.0="" 20="" 25="" 32="" 84="" 95="" 98="" a="" all="" and="" blood="" cell="" count="" cut-off="" distinguishing="" erythrocyte="" febrile="" for="" from="" had="" in="" kd="" lad="" lmca="" lower="" non-kd="" of="" p="" patients="" platelet="" rate="" rca="" respectively="" sedimentation="" sensitivity="" specificity="" was="" white="" zmax="2.5,">
Conclusions—This pilot study found that mean CA dimensions in children with non-KD febrile illnesses are larger than those in normative afebrile subjects but smaller than dimensions in patients with KD. Future studies should augment the available data on CA dimensions in children with more severe febrile illnesses.
Serial BNP - Useful or Not?
Circulation. 2013; 127: 509-516
Controversies in Cardiovascular Medicine
Are Serial BNP Measurements Useful in Heart Failure Management?
Serial Natriuretic Peptide Measurements Are Not Useful in Heart Failure Management: The Art of Medicine Remains Long
Akshay S. Desai, MD, MPH
Introduction
Natriuretic peptides, including B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP), have emerged as powerful markers of cardiovascular risk in patients with heart failure.1 Circulating natriuretic peptide (NP) levels add incremental prognostic value to standard clinical risk stratification algorithms for both ambulatory and hospitalized heart failure patients, with a steady increase in the risk of mortality and recurrent heart failure hospitalization as NT-proBNP levels rise above 1000 pg/mL. A systematic review of 19 studies of patients with heart failure demonstrated that for every 100-pg/mL rise in BNP concentration, there was a corresponding 35% increase in the relative risk of death...
Circulation. 2013; 127: 500-508
Are Serial BNP Measurements Useful in Heart Failure Management?
Serial Natriuretic Peptide Measurements Are Useful in Heart Failure Management
James L. Januzzi, Jr, MD; Richard Troughton, MD, PhD
Introduction
We have been asked to take the position that serial natriuretic peptide (NP) testing is useful for heart failure (HF) management. To do so, we primarily draw on our experience as physicians with active clinical practices replete with patients suffering from the diagnosis but also from our in-depth knowledge of NP testing and its strengths and weaknesses...
Controversies in Cardiovascular Medicine
Are Serial BNP Measurements Useful in Heart Failure Management?
Serial Natriuretic Peptide Measurements Are Not Useful in Heart Failure Management: The Art of Medicine Remains Long
Akshay S. Desai, MD, MPH
Introduction
Natriuretic peptides, including B-type natriuretic peptide (BNP) and N-terminal-proBNP (NT-proBNP), have emerged as powerful markers of cardiovascular risk in patients with heart failure.1 Circulating natriuretic peptide (NP) levels add incremental prognostic value to standard clinical risk stratification algorithms for both ambulatory and hospitalized heart failure patients, with a steady increase in the risk of mortality and recurrent heart failure hospitalization as NT-proBNP levels rise above 1000 pg/mL. A systematic review of 19 studies of patients with heart failure demonstrated that for every 100-pg/mL rise in BNP concentration, there was a corresponding 35% increase in the relative risk of death...
Circulation. 2013; 127: 500-508
Are Serial BNP Measurements Useful in Heart Failure Management?
Serial Natriuretic Peptide Measurements Are Useful in Heart Failure Management
James L. Januzzi, Jr, MD; Richard Troughton, MD, PhD
Introduction
We have been asked to take the position that serial natriuretic peptide (NP) testing is useful for heart failure (HF) management. To do so, we primarily draw on our experience as physicians with active clinical practices replete with patients suffering from the diagnosis but also from our in-depth knowledge of NP testing and its strengths and weaknesses...
Thursday, January 24, 2013
Echo Assessment of LV diastolic function in Children
CIRCULATION: CARDIOVASCULAR IMAGING
Published online before print January 23, 2013,
doi: 10.1161/CIRCIMAGING.112.000175
Interpretation of Left Ventricular Diastolic Dysfunction in Children with Cardiomyopathy by Echocardiography: Problems and Limitations
Andreea Dragulescu, Luc Mertens and Mark K. Friedberg (Toronto)
Background:
Left ventricular diastolic dysfunction(DD) is a key determinant of outcomes in pediatric cardiomyopathy(CM), but remains very challenging to diagnose and classify. Adult paradigms and guidelines relating to DD are currently applied in children. However, it is unknown whether these are applicable to children with CM. We investigated the assessment of DD in children with CM using adult and pediatric echocardiographic criteria and tested whether recent adult guidelines are applicable to this population.
Methods and Results:
Three investigators independently classified diastolic function in 4 study groups: controls; dilated(DCM), hypertrophic(HCM) and restrictive(RCM) cardiomyopathy. Agreement between investigators, failure to classify DD and the reasons for diagnostic failure were determined. The usefulness of individual echo parameters to diagnose and classify DD was assessed. 175 children (0-18yrs) were studied. DD diagnostic criteria were discrepant in the majority of patients. Delayed relaxation was diagnosed in only 14% of HCM patients and never in DCM and RCM, with 50% of those patients having co-existing findings of elevated filling pressures. Many key parameters, such as mitral and pulmonary venous Doppler were not informative. Agreement between investigators for grading of diastolic dysfunction was poor (36% of CM patients).
Conclusions:
Assessment of DD in childhood cardiomyopathy seems inadequate using current guidelines. The large range of normal pediatric reference values allows diagnosis of diastolic dysfunction in only a small proportion of patients. Key echo parameters to assess DF are not sufficiently discriminatory in this population and discrepancies between criteria within individuals prevent further classification and result in poor inter-observer agreement.
Wednesday, January 23, 2013
CPR Duration and Outcome in Children
Circulation 2013 - Epub on Jan 22, 2013
Duration of Cardiopulmonary Resuscitation and Illness Category Impact Survival and Neurologic Outcomes for In-hospital Pediatric Cardiac Arrests
Renee I. Matos et al.
Background-Pediatric cardiopulmonary resuscitation (CPR) for >20 minutes has been considered futile after pediatric in-hospital cardiac arrests. This concept has recently been questioned.
Methods and Results - 3419 children from 328 US and Canadian sites (Get With The Guidelines-Resuscitation sites). In-hospital cardiac arrests between January 2000 and December 2009.
Patients were stratified into 5 patient illness categories: surgical cardiac, medical cardiac, general medical, general surgical, and trauma.
Survival to discharge was 27.9%, but only 19.0% of all cardiac arrest patients had favorable neurological outcomes.
Between 1 and 15 minutes of CPR, survival decreased linearly by 2.1% per minute, and rates of favorable neurological outcome decreased by 1.2% per minute.
Adjusted probability of survival was 41% for CPR duration of 1 to 15 minutes and 12% for >35 minutes.
Among survivors, favorable neurological outcome occurred in 70% undergoing <15 60="" and="" cpr="" minutes="" of="" undergoing="">35 minutes.
Compared with general medical patients, surgical cardiac patients had the highest adjusted odds ratios for survival and favorable neurological outcomes, 2.5 (95% confidence interval, 1.8-3.4) and 2.7 (95% confidence interval, 2.0-3.9), respectively.
Conclusions-CPR duration was independently associated with survival to hospital discharge and neurological outcome. Among survivors, neurological outcome was favorable for the majority of patients. Performing CPR for >20 minutes is not futile in some patient illness categories.
Duration of Cardiopulmonary Resuscitation and Illness Category Impact Survival and Neurologic Outcomes for In-hospital Pediatric Cardiac Arrests
Renee I. Matos et al.
Background-Pediatric cardiopulmonary resuscitation (CPR) for >20 minutes has been considered futile after pediatric in-hospital cardiac arrests. This concept has recently been questioned.
Methods and Results - 3419 children from 328 US and Canadian sites (Get With The Guidelines-Resuscitation sites). In-hospital cardiac arrests between January 2000 and December 2009.
Patients were stratified into 5 patient illness categories: surgical cardiac, medical cardiac, general medical, general surgical, and trauma.
Survival to discharge was 27.9%, but only 19.0% of all cardiac arrest patients had favorable neurological outcomes.
Between 1 and 15 minutes of CPR, survival decreased linearly by 2.1% per minute, and rates of favorable neurological outcome decreased by 1.2% per minute.
Adjusted probability of survival was 41% for CPR duration of 1 to 15 minutes and 12% for >35 minutes.
Among survivors, favorable neurological outcome occurred in 70% undergoing <15 60="" and="" cpr="" minutes="" of="" undergoing="">35 minutes.
Compared with general medical patients, surgical cardiac patients had the highest adjusted odds ratios for survival and favorable neurological outcomes, 2.5 (95% confidence interval, 1.8-3.4) and 2.7 (95% confidence interval, 2.0-3.9), respectively.
Conclusions-CPR duration was independently associated with survival to hospital discharge and neurological outcome. Among survivors, neurological outcome was favorable for the majority of patients. Performing CPR for >20 minutes is not futile in some patient illness categories.
Outcome of Arterial Switch Operation for d-TGA
Circulation. 2013; 127: 331-339
Cardiovascular Outcomes After the Arterial Switch Operation for D-Transposition of the Great Arteries
Paul Khairy, MD, PhD et al. Boston.
Single-institution retrospective cohort study (1983-1999). n=400.
Overall, 400 patients, 154 (38.3%) with a ventricular septal defect, 238 (59.5%) with an intact septum, and 9 (2.3%) with a Taussig-Bing anomaly, were followed for a median of 18.7 years. In perioperative survivors, overall and arrhythmia-free survival rates at 25 years were 96.7±1.8% and 96.6±0.1%, respectively.
Late mortality was predominantly a result of sudden deaths and myocardial infarction.
At 25 years, 75.5±2.5% remained free from surgical or catheter-based reintervention.
Freedom from an adverse cardiovascular event was 92.9±1.9% at 25 years. Independent predictors were a single right coronary artery (hazard ratio, 4.58; 95% confidence interval, 1.32-15.90), P=0.0166) and postoperative heart failure (hazard ratio, 6.93; 95% confidence interval, 1.57-30.62; P=0.0107).
At last follow-up, the left ventricular ejection fraction was 60.3±8.9%, 97.3% had class I symptoms, and 5.2% obstructive coronary artery disease. Peak oxygen uptake was 35.1±7.6 mL/kg/min (86.1±15.1% predicted), with a chronotropic index <80 10.3="" 3.2="" 3.4="" 34.2="" 6.6="" and="" at="" in="" least="" mild="" moderate="" more="" neoaortic="" present="" pulmonary="" regurgitation="" respectively="" stenosis="" than="" were="">
Conclusions—Long-term and arrhythmia-free survival is excellent after arterial switch operation. Although sequelae include chronotropic incompetence and neoaortic, pulmonary, and coronary artery complications, most patients maintain normal systolic function and exercise capacity.
Cardiovascular Outcomes After the Arterial Switch Operation for D-Transposition of the Great Arteries
Paul Khairy, MD, PhD et al. Boston.
Single-institution retrospective cohort study (1983-1999). n=400.
Overall, 400 patients, 154 (38.3%) with a ventricular septal defect, 238 (59.5%) with an intact septum, and 9 (2.3%) with a Taussig-Bing anomaly, were followed for a median of 18.7 years. In perioperative survivors, overall and arrhythmia-free survival rates at 25 years were 96.7±1.8% and 96.6±0.1%, respectively.
Late mortality was predominantly a result of sudden deaths and myocardial infarction.
At 25 years, 75.5±2.5% remained free from surgical or catheter-based reintervention.
Freedom from an adverse cardiovascular event was 92.9±1.9% at 25 years. Independent predictors were a single right coronary artery (hazard ratio, 4.58; 95% confidence interval, 1.32-15.90), P=0.0166) and postoperative heart failure (hazard ratio, 6.93; 95% confidence interval, 1.57-30.62; P=0.0107).
At last follow-up, the left ventricular ejection fraction was 60.3±8.9%, 97.3% had class I symptoms, and 5.2% obstructive coronary artery disease. Peak oxygen uptake was 35.1±7.6 mL/kg/min (86.1±15.1% predicted), with a chronotropic index <80 10.3="" 3.2="" 3.4="" 34.2="" 6.6="" and="" at="" in="" least="" mild="" moderate="" more="" neoaortic="" present="" pulmonary="" regurgitation="" respectively="" stenosis="" than="" were="">
Conclusions—Long-term and arrhythmia-free survival is excellent after arterial switch operation. Although sequelae include chronotropic incompetence and neoaortic, pulmonary, and coronary artery complications, most patients maintain normal systolic function and exercise capacity.
Valsartan in Systemic RV
Circulation. 2013; 127: 322-330
Effect of Valsartan on Systemic Right Ventricular Function
A Double-Blind, Randomized, Placebo-Controlled Pilot Trial
Teun van der Bom, MD et al. Netherland.
Methods and Results—Multicenter, double-blind, parallel, randomized controlled trial of angiotensin II receptor blocker valsartan 160 mg twice daily compared with placebo in patients with a systemic right ventricle caused by congenitally or surgically corrected transposition of the great arteries.
The primary end point was change in right ventricular ejection fraction during 3-year follow-up, determined by MRI or CT. Secondary end points were change in right ventricular volumes and mass, peak, and quality of life. Primary analyses were performed on an intention-to-treat basis.
A total of 88 patients (valsartan, n=44; placebo, n=44) were enrolled in the trial. No serious adverse effects occurred in either group. There was no significant effect of 3-year valsartan therapy on systemic right ventricular ejection fraction (treatment effect, 1.3%; 95% confidence interval, −1.3% to 3.9%; P=0.34), maximum exercise capacity, or quality of life. There was a larger increase in right ventricular end-diastolic volume (15 mL; 95% confidence interval, 3–28 mL; P<0 .01="" 2="" 95="" and="" confidence="" g="" group.="" group="" in="" interval="" mass="" p="0.01)" placebo="" than="" the="" valsartan="">
Conclusions—There was no significant treatment effect of valsartan on right ventricular ejection fraction, exercise capacity, or quality of life. Small but significant differences between valsartan and placebo were present for change in right ventricular volumes and mass.
Effect of Valsartan on Systemic Right Ventricular Function
A Double-Blind, Randomized, Placebo-Controlled Pilot Trial
Teun van der Bom, MD et al. Netherland.
Methods and Results—Multicenter, double-blind, parallel, randomized controlled trial of angiotensin II receptor blocker valsartan 160 mg twice daily compared with placebo in patients with a systemic right ventricle caused by congenitally or surgically corrected transposition of the great arteries.
The primary end point was change in right ventricular ejection fraction during 3-year follow-up, determined by MRI or CT. Secondary end points were change in right ventricular volumes and mass, peak, and quality of life. Primary analyses were performed on an intention-to-treat basis.
A total of 88 patients (valsartan, n=44; placebo, n=44) were enrolled in the trial. No serious adverse effects occurred in either group. There was no significant effect of 3-year valsartan therapy on systemic right ventricular ejection fraction (treatment effect, 1.3%; 95% confidence interval, −1.3% to 3.9%; P=0.34), maximum exercise capacity, or quality of life. There was a larger increase in right ventricular end-diastolic volume (15 mL; 95% confidence interval, 3–28 mL; P<0 .01="" 2="" 95="" and="" confidence="" g="" group.="" group="" in="" interval="" mass="" p="0.01)" placebo="" than="" the="" valsartan="">
Conclusions—There was no significant treatment effect of valsartan on right ventricular ejection fraction, exercise capacity, or quality of life. Small but significant differences between valsartan and placebo were present for change in right ventricular volumes and mass.