BackgroundThe independent prognostic impact of diabetes mellitus (DM) and prediabetes mellitus (pre‐DM) on survival outcomes in patients with chronic heart failure has been investigated in observational registries and randomized, clinical trials, but the results have been often inconclusive or conflicting. We examined the independent prognostic impact of DM and pre‐DM on survival outcomes in the GISSI‐HF (Gruppo Italiano per lo Studio della Sopravvivenza nella Insufficienza Cardiaca‐Heart Failure) trial.Methods and ResultsWe assessed the risk of all‐cause death and the composite of all‐cause death or cardiovascular hospitalization over a median follow‐up period of 3.9 years among the 6935 chronic heart failure participants of the GISSI‐HF trial, who were stratified by presence of DM (n=2852), pre‐DM (n=2013), and non‐DM (n=2070) at baseline. Compared with non‐DM patients, those with DM had remarkably higher incidence rates of all‐cause death (34.5% versus 24.6%) and the composite end point (63.6% versus 54.7%). Conversely, both event rates were similar between non‐DM patients and those with pre‐DM. Cox regression analysis showed that DM, but not pre‐DM, was associated with an increased risk of all‐cause death (adjusted hazard ratio, 1.43; 95% CI, 1.28–1.60) and of the composite end point (adjusted hazard ratio, 1.23; 95% CI, 1.13–1.32), independently of established risk factors. In the DM subgroup, higher hemoglobin A1c was also independently associated with increased risk of both study outcomes (all‐cause death: adjusted hazard ratio, 1.21; 95% CI, 1.02–1.43; and composite end point: adjusted hazard ratio, 1.14; 95% CI, 1.01–1.29, respectively).ConclusionsPresence of DM was independently associated with poor long‐term survival outcomes in patients with chronic heart failure.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00336336.

The RCP estimates, during pacing, what the spontaneous MHR would be. Ventricular stimulation at the RCP causes a high P%, stabilising cardiac cycles with a modest increase in HR.

A case of asymptomatic left atrial wall rupture with pseudoaneurysm formation following coronary artery-bypass grafting (CABG) is illustrated. The patient was a 69-year-old man, who underwent a CABG in June 1994. During a routine postoperative transthoracic echocardiogram, a left atrium-adjacent cavity filled with high velocity fluid was seen. A pseudoaneurysm formation was suspected. Diagnosis was supported by transesophageal echocardiography and confirmed by cardiac MRI examination. The patient was not reoperated on for repair because of lack of symptoms and normal hernodynamic conditions. Transesophageal echocardiography was repeated forty days and eight months after CABG and revealed spontaneous disappearance of the left atrial pseudoaneurysm. At present (March 1996) the patient is as well as can be expected after CAJ3G and enjoys a good quality of life. Figure 1. Transthoracic echocardiogram. Apical four-chamber view. (A) A cavity adjacent to left atrium is seen (*). I n this early systolic frame, the left atrial wall is moderately collapsing. (B) Routine Color Doppler interrogation of mitral valve reveals flow signal within the cavity (arrow) and a mild mitral regurgitation. I n all figures, unless otherwise stated, flow signals mouing toward the transducer are shown in red, while those moving away are displayed in blue. DA = discending aorta; LA = left atrium; LV = left ventricle; M R = mitral regurgitation; RA = right atrium; RV = right ventricle.

Ultrasonography of the abdominal aorta should be performed as part of a complete echocardiographic study. As visualization may be difficult from the epi-mesogastric (E-M) window because of obesity or distension, we evaluated the feasibility of the right flank (RF) as an alternative acoustic window in 100 patients (62 male, 38 female, aged 7-83 years). Compared with the E-M window, our results showed that the right flank was significantly better in imaging of the infrarenal aorta: 89% (RF) vs 75% (E-M) (p < 0.05); right renal artery: 84% vs 71% (p < 0.05); and right renal artery Color Doppler: 84% vs 71% (p < 0.05). The Doppler sonification angle for the right proximal renal artery was 0 degrees-31 degrees (mean 12.7 degrees +/- 4.2 degrees) vs 64 degrees-76 degrees (mean 70.6 degrees +/- 4.1 degrees); for the left proximal renal artery 0 degrees-35 degrees (mean 23.1 degrees +/- 6.6 degrees) vs 62 degrees-73 degrees (mean 68.3 degrees +/- 4.2 degrees). Images obtained from the right flank were often of better quality than those obtained from the abdominal window because of a superior definition of acoustic interfaces and a better performance of Color Doppler sampling. Thus, the right flank could be considered a good alternative window for the echographic study of the abdominal aorta.

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