Обзор американских кардиологических журналов за неделю (ссылки)

[Chevychelov]

Title: Recommendations for Interpretation of 12-Lead Electrocardiogram in the Athlete
Topic: Arrhythmias
Date Posted: 1/8/2010
Author(s): Corrado D, Pelliccia A, Heidlbuchel H, et al.
Citation: Eur Heart J 2009;Dec 22:[Epub ahead of print].
Clinical Trial: No
Perspective: The following are 10 points to remember from this position paper formulated by the European Society of Cardiology:

1. Electrocardiographic findings that are common and training-related and that do not require additional evaluation are sinus bradycardia, 1° atrioventricular block (AVB), incomplete right bundle branch block (BBB), early repolarization, and isolated voltage criteria for left ventricular hypertrophy (LVH).

2. Uncommon and training unrelated electrocardiographic findings that mandate further evaluation include T-wave inversion, ST-segment depression, pathological Q waves, atrial enlargement, a hemiblock, right ventricular hypertrophy, a BBB, or a Brugada-pattern of ST-segment elevation.

3. Training-related electrocardiographic findings are more common in men than women, athletes of African descent, and high-endurance athletes such as cyclists.

4. Sinus rates <30 bpm and sinus pauses >2 seconds are common in highly trained athletes, particularly during sleep.

5. A normal chronotropic response to exertion and the absence of bradycardia-related symptoms distinguishes training-related sinus bradycardia from sinus node dysfunction.

6. 1° AVB and Mobitz I 2° AVB are common, but Mobitz II 2° AVB or 3° AVB should not be assumed to be training-related and require evaluation.

7. Early repolarization in Caucasian athletes most commonly consists of upwardly concave ST-segments and tall and peaked T waves; in black athletes, there often is convex ST-segment elevation and negative T waves, mimicking a Brugada pattern.

8. In the presence of voltage criteria for LVH, pathological hypertrophy should be suspected if there is left atrial enlargement, left-axis deviation, repolarization abnormalities, or pathological Q waves.

9. T-wave inversion ≥2 mm in ≥2 adjacent leads should prompt evaluation for structural heart disease.

10. Electrophysiological testing for risk stratification with possible catheter ablation is appropriate in athletes with ventricular pre-excitation. Fred Morady, M.D., F.A.C.C.

Title: Improved Survival Among Patients With Eisenmenger Syndrome Receiving Advanced Therapy for Pulmonary Arterial Hypertension
Topic: Arrhythmias
Date Posted: 1/11/2010
Author(s): Dimopoulos K, Inuzuka R, Goletto S, et al.
Citation: Circulation 2010;121:20-25.
Clinical Trial: No
Study Question: Advanced therapy (AT) for pulmonary arterial hypertension (PAH) in the context of congenital heart disease improves pulmonary hemodynamics, functional class, and the 6-minute walk test. Has there been an effect of AT on survival in the Eisenmenger syndrome?
Methods: Data on all Eisenmenger patients attending a single center over the past decade were collected. Survival rates were compared between patients on and off AT with the use of a modified version of the Cox model, which treats modern AT as a time-varying covariate. Baseline differences were adjusted for the use of propensity scores.
Results: A total of 229 patients (ages 34.5 ± 12.6 years; 35.4% male) were included. The majority had complex anatomy, and 53.7% were in New York Heart Association (NYHA) class ≥III at baseline. Mean resting oxygen saturation was 84.3%. Sixty-eight patients (29.7%) either were on AT or had AT initiated during follow-up. During a median follow-up of 4.0 years, 52 patients died, only 2 of them while on AT. Patients on AT were at a significantly lower risk of death, both unadjusted and after adjustment for baseline clinical differences by propensity score regression adjustment (C statistic = 0.80; hazard ratio, 0.16; 95% confidence interval, 0.04-0.71; p = 0.015) and propensity score matching (hazard ratio, 0.10; 95% confidence interval, 0.01-0.78; p = 0.028). Despite being older and sicker, only 2 of the 68 patients who received AT for a median period of 2.4 years died, compared with 50 deaths in those not receiving AT.
Conclusions: Advanced treatment for PAH in a contemporary cohort of adults with Eisenmenger syndrome was associated with a lower risk of death. Survival benefits should be considered together with improved hemodynamics and functional class when decisions are made about treatment in this population.
Perspective: The prostanoids, endothelin antagonists, and phosphodiesterase-5 inhibitors (advanced therapies) have each alone and in combination been effective at improving quality of life in PAH. A meta-analysis of randomized controlled trials of PH-specific therapies in various types of PAH recently showed a 43% reduction in overall mortality rate, but did not include the Eisenmenger syndrome. Placebo-controlled trials in congenital heart disease are limited, and placebo-controlled trials to assess the effects on mortality rate would be considered unethical. The survival advantage of those treated with advanced therapy in this single center as measured by the hazard ratio is over ninefold, despite the fact that patients receiving the novel drugs were more often NYHA class IV, older, and had more syncope. Melvyn Rubenfire, M.D., F.A.C.C.