Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access
Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc
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Original Article

Volume 12, Number 2, February 2020, pages 100-107

Favorable Effects of Sacubitril/Valsartan on the Peak Atrial Longitudinal Strain in Patients With Chronic Heart Failure and a History of One or More Episodes of Atrial Fibrillation: A Retrospective Cohort Study

Figures

Figure 1.
Figure 1. Examples of the longitudinal strain of the LA using 2-dimensional speckle tracking imaging. The strain (%) of the six individually colored LA segments and mean value of all segments (dotted line) from 4-chamber and 2- chamber views are shown in (a) and (b). The PALS (mean value) refers to the mean LA peak strain value during systole. LA: left atrium; PALS: peak atrial longitudinal strain.
Figure 2.
Figure 2. During 1 year of continuous treatment respectively with sacubitril/valsartan or conventional therapy consisting of ACEI or ARBs, there are favorable effects on the mean values of PALS. In fact, the variations that occur on average after 1 year of treatment for each of the two therapeutic regimens have all a positive sign and indicate the achievement of statistical significance in both therapeutic regimens, but more marked in the sacubitril/valsartan group, whose P value (Wilcoxon test) is < 0.0001 versus a P value (Wilcoxon test) = 0.0254 detected in the group subject to conventional therapy. PALS: peak atrial longitudinal strain; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker.
Figure 3.
Figure 3. One of the main aims of the study was to verify whether the administration of sacubitril/valsartan (sac/v) maintained for 1 year is effective in improving the PALS in patients at risk for atrial fibrillation (AF) episodes. For this purpose it was necessary to recruit retrospectively a sufficient number of patients that had experienced at least one episode of AF successfully converted with the use of electrical or pharmacological cardioversion. According to the rules that apply to the administration of sac/v, the recruited patients had to suffer from chronic II - III NYHA class heart failure. Based on clinical considerations that were not always expressed in the clinical records, some patients were assigned to sac/v as a substitute of the traditional therapy with ACEI or ARBs, whereas others practiced the conventional therapy. The figure highlights that patients assigned to sac/v (green dots) have significantly greater increase in PALS (P (ANOVA) < 0.001) compared to patients subjected to conventional therapy (red dots). A line conjoins the mean changes in PALS of the two groups. PALS: peak atrial longitudinal strain; AF: atrial fibrillation; NYHA: New York Heart Association; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; ANOVA: analysis of variance.
Figure 4.
Figure 4. The atrial fibrillation (AF) relapses in patients subjected to conventional therapy are compared with those of patients who experienced therapy with sacubitril/valsartan to replace ACEI or ARBs. All of the patients were enrolled retrospectively and had to have suffered from at least one episode of AF converted to sinus rhythm with electrical or pharmacological cardioversion. The count of AF episodes recorded during 1 year of conventional therapy or sacubitril/valsartan regimen shows the above reported results, as visually represented by the colored bars (see also the Results section in the text). On the whole, a superior incidence of AF relapses is noticeable in the group of “conventional therapy”, which encompasses also the cases of patients with multiple episodes; whereas sacubitril/valsartan regimen comprises only four patients whose AF burden reaches the threshold of two AF episodes during 1 year. Thus, an incisive action against the occurrence of AF in chronic heart failure patients is inferable in the cohort treated with sacubitril/valsartan. AF: atrial fibrillation; ACEI: angiotensin-converting enzyme inhibitor; ARB: angiotensin receptor blocker; pts: patients.

Table

Table 1. Comparison of Demographics and Clinical, Laboratory, and Echocardiographic Features of Patients Examined in the Retrospective Study According to Whether or Not a CHF Patient Was Treated With Sacubitril/Valsartan
 
Patients (n = 40) treated with sacubitril/valsartanPatients (n = 40) treated with conventional therapy, i.e., ACEI or ARBs (without sacubitril/valsartan)P value
ACEI: angiotensin-converting enzyme inhibitor; ARBs: angiotensin receptor blockers; SD: standard deviation; BMI: body mass index; SBP: systolic blood pressure; HF: heart failure; CMP: cardiomyopathy; CABG: coronary artery bypass graft; DM: diabetes mellitus; COPD: chronic obstructive pulmonary disease; ICD: implantable cardioverter defibrillator; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic diameter; BNP: B-type natriuretic peptide.
Baseline demographics
  Age (years, mean ± SD)76 ± 5.575 ± 7.50.4985
  Male sex % (n)70% (28)67.5% (27)1.0000
  BMI on admission (kg/m2, mean ± SD)28.2 ± 6.8727.2 ± 50.4589
  Heart rate at the first visit (beats/min, mean ± SD)90 ± 1985 ± 200.2552
  Heart rate after 6 months (beats/min, mean ± SD)64 ± 1880 ± 200.0003
  SBP at the first visit (mm Hg, mean ± SD)115 ± 26125 ± 300.1152
  SBP after 6 months (mm Hg, mean ± SD)110 ± 21115 ± 180.2564
Comorbidities
  Ischemic etiology of HF, % (n)45% (18)45% (18)0.8222
  Valvular etiology of HF, % (n)15% (6)17.5% (7)1.0000
  CMP-induced HF, % (n)27.5% (11)30% (12)1.0000
  Other cause of HF, % (n)12.5% (5)7.5% (3)0.7094
  CABG, % (n)22.5% (9)35% (14)0.3231
  History of hypertension, % (n)57.5% (23)52.5% (21)0.8222
  DM on insulin, % (n)22.5% (9)27.5% (11)0.7963
  COPD, % (n)12.5% (5)12.5% (5)0.7353
  ICD, % (n)10% (4)10% (4)0.7094
Hematochemical variables
  NT-pro BNP at the first visit (pg/mL, mean ± SD)800.84 ± 123756.22 ± 1290.0594
  NT-pro BNP after 12 months (pg/mL, mean ± SD)290.5 ± 90.1591.47 ± 213.81< 0.0001
  Serum creatinine (mL/dL, mean ± SD)1.46 ± 0.551.6 ± 0.40.0981
  Serum Na+ at the first visit (mEq/L, mean ± SD)136 ± 1.55137 ± 2.50.0166
  Serum Na+ after 12 months (mEq/L, mean ± SD)138.5 ± 10138.4 ± 8.60.9526
  Serum K+ at the first visit (mEq/L, mean ± SD)4.5 ± 0.64.7 ± 0.90.1851
  Serum K+ after 12 months (mEq/L, mean ± SD)4.8 ± 0.654.1 ± 0.85< 0.0001
Echocardiographic data at the first visit
  LVEF (%, mean ± SD)39.71 ± 4.7838 ± 5.440.1365
  LVESD (mm, mean ± SD)58 ± 1059 ± 140.7142
  E/A ratio (mean ± SD)3 ± 1.253.4 ± 1.350.1731
  Deceleration time (ms, mean ± SD)136 ± 22145 ± 250.0914