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PubMed2003

Non-transplant surgery for heart failure and severe left ventricular dysfunction. Opportunities and limitations.

The need of alternatives to transplantation has lead to routinely reconsidering conventional surgery for selected patients with advanced heart failure. Although the recovery of ventricular contractility with revascularization sometimes restores ventricular function almost to normality while dramatically enhancing the quality of life, only a few patients with ischemic left ventricular dysfunction exhibit the amount of hibernating myocardium required for such a spectacular outcome taking place. Advanced remodeling is a further obstacle and is currently being addressed by means of operations designed to reduce ventricular volume and restore geometry. Hemodynamic measurements raise concerns, however, as to the diastolic function and the competence of the mitral valve late after reconstructive surgery. Finally, the repair of mitral valve regurgitation has produced interesting short-to-medium term results both in terms of survival and heart failure relief. Yet, their durability is uncertain, if not disappointing when the valvular disease has an ischemic etiology. Expectations of patients undergoing one of the aforementioned procedures, or a combination thereof, should not be averaged as they heavily depend on the specific patient profile under evaluation.

Cardiac Surgical Procedures↗
PubMed2006

Usefulness of bedside testing for brain natriuretic peptide to identify right ventricular dysfunction and outcome in normotensive patients with acute pulmonary embolism.

Echocardiographic right ventricular (RV) dysfunction is a well-established prognostic indicator in patients with acute pulmonary embolism. However, the possibility of implementing a rapid and effective triage with biohumoral markers such as brain natriuretic peptide (BNP) may be of value. Sixty-one patients with a first documented episode of acute pulmonary embolism without shock and previous left ventricular dysfunction were prospectively studied. All patients underwent echocardiography and rapid BNP testing on admission. Patients were followed up for in-hospital death, progression to shock, and nonfatal pulmonary embolism recurrence. Overall, 35 patients (57%) had echocardiographic evidence of RV dysfunction on admission, and its prevalence increased progressively with increasing levels of BNP. A BNP level <85 pg/ml was highly accurate in excluding RV dysfunction. No patient in the lower tertile of BNP values (1.1 to 85.0 pg/ml) had RV dysfunction, compared with 75% in the middle tertile (88.7 to 487.0 pg/ml) and 100% in the upper tertile (527 to 1,300 pg/ml). Overall, 11 patients (18%), belonging to the upper tertile, progressed to shock during admission, 4 of whom died. The association of RV dysfunction with a BNP level in the upper tertile (>or=527 pg/ml) showed incremental prognostic value over RV dysfunction alone (in-hospital death and progression to shock were 55% and 31%, respectively). In the present study, BNP represented a powerful predictor of in-hospital clinical deterioration, with substantial incremental prognostic value over echocardiography alone.

Acute Disease↗
PubMed2006

Predictors of left ventricular dysfunction in patients with first acute anterior myocardial infarction undergoing primary angioplasty.

BACKGROUND: The degree of left ventricular dysfunction determines the prognostic outcome of patients with acute myocardial infarction. OBJECTIVES: To define the clinical, angiographic and procedural variables related to LV dysfunction in patients with anterior wall AMI referred for primary percutaneous coronary intervention. METHODS: The sample included 168 patients treated by primary PCI for first anterior wall AMI. Clinical, demographic and medical data were collected prospectively into a computerized registry, and clinical outcome (death, reinfarction, major cardiovascular event) were evaluated during hospitalization and 30 days after discharge. Patients were divided into three groups by degree of LV dysfunction (mild, moderate, severe) and compared for clinical, angiographic and procedural variables. RESULTS: LV dysfunction was associated with pre-PCl renal failure (serum creatinine > 1.4 mg/dl), peripheral vascular disease, high peak creatine kinase level, longer door to balloon time, low TIMI flow grade before and after PCl, and use of an intraaortic balloon pump. On multivariate analysis adjusted for baseline differences, peak creatine kinase level (r = 0.3, P = 0.0001) and door to needle time (r = 0.2, P = 0.008) were the most significant independent predictors of moderate or severe LV dysfunction after anterior AMI. CONCLUSION: Abnormal LV function after first anterior AMI can be predicted by door to balloon time and the size of the infarction as assessed by creatine kinase levels. Major efforts should be made to decrease the time to myocardial reperfusion.

Angioplasty, Balloon, Coronary↗
PubMed1996

Metoprolol abolishes exercise-induced left ventricular dysfunction in patients with silent ischemia.

Left ventricular systolic function is reduced during episodes of silent ischemia in patients with coronary artery disease (CAD). Left ventricular ejection fraction (LVEF) is increased at least 5 absolute percent during exercise in most normal subjects; however, in patients with CAD, LVEF often remains unchanged or decreases. The anti-ischemic effect of beta-adrenergic receptor blockade is well documented, including a reduction of exercise-induced electrocardiographic ST depressions; however, the effect of these drugs on left ventricular volume changes during exercise in patients with silent ischemia is unknown. The aim of this study was to evaluate the effect of a cardio-selective beta-blocking agent, metoprolol, on rest and exercise LVEF in patients with silent ischemia, using radionuclide cardiography. Fifteen patients with silent ischemia completed a double-blind, placebo-controlled crossover study at rest and during submaximal exercise. LVEF remained unchanged during exercise in the placebo phase (56% to 58%; p = NS), but even though LVEF tended to decrease 56% during rest after metoprolol versus 52% after placebo (p = NS), the LVEF increase from rest to exercise resembled a normal LVEF response, 52% to 58% (p = 0.005). Exercise-induced electrocardiographic ST depressions were also reduced during metoprolol treatment. In patients with silent ischemia, the exercise-induced change in LVEF rises significantly during metoprolol treatment. The mechanism may be a reduction in myocardial ischemia as indicated by a reduction in ischemic electrocardiographic findings.

Adrenergic beta-Antagonists↗
PubMed2006

Value of gadolinium-enhanced magnetic resonance imaging in patients with Tako-Tsubo-like left ventricular dysfunction.

We present gadolinium-enhanced cardiac magnetic resonance imaging (CMRI) in Tako-Tsubo-like left ventricular dysfunction showing the findings in acute phase and in follow-up. Gadolinium-enhanced CMRI allows to distinguish between myocardial infarction and other myocardial alterations, e.g., myocarditis. CMRI may thus permit to non-invasively identify patients with Tako-Tsubo syndrome by ruling out myocardial infarction or myocarditis in the setting of wall motion abnormalities (WMA).

Aged↗
PubMed2002

Extracorporeal membrane oxygenation for unprotected left main stenting in a patient with totally occluded right coronary artery and severe left ventricular dysfunction.

We report a case of unprotected left main stenting in an elderly female with severe left ventricular dysfunction and a totally occluded right coronary artery using hemodynamic support with the Extracorporeal Membrane Oxygenator (ECMO). There were no procedural complications and at 6-month follow-up, the patient was doing well with no cardiovascular events. Stenting of unprotected left main and the use of ECMO in high-risk coronary intervention are reviewed.

Aged↗
PubMed1997

Comparison of mortality rates and progression of left ventricular dysfunction in patients with idiopathic dilated cardiomyopathy and dilated versus nondilated right ventricular cavities.

This study assesses the influence of right ventricular (RV) dilation on the progression of left ventricular (LV) dysfunction and survival in patients with idiopathic dilated cardiomyopathy (IDC). Using transthoracic echocardiography, we studied 100 patients with IDC aged 20 to 80 years (mean 55 +/- 14); 67% were men. In the apical 4-chamber view, diastolic LV and RV chamber area measurements classified patients into 2 groups: group RV enlargement+ (RV area/LV area > 0.5) included 54 patients; group RV enlargement- (no RV enlargement) had RV area/LV area < or = 0.5. Echocardiographic studies were repeated in all patients after a mean of 33 +/- 16 months. At the time of the initial study, the 2 groups did not differ in age, gender, incidence of atrial fibrillation and diabetes, left ventricular mass, and LV ejection fraction, but the RV enlargement+ group had more severe tricuspid regurgitation and less LV enlargement. After 47 +/- 22 months (range 12 to 96), patients in group RV enlargement+ had lower LV ejection fraction (29% vs 34%, p = 0.006) than patients with initial RV enlargement-. At clinical follow-up, mortality was higher (43%) in patients with initial RV enlargement+ than the RV enlargement- patients (15%), p = 0.002. For survivors, the mitral deceleration time averaged 157 +/- 36 ms; for nonsurvivors or patients who required transplant, the mitral deceleration time averaged 97 +/- 12 ms (p < 0.0001). With use of a multivariate Cox model adjusting for LV ejection fraction, LV size, and age, the relative risk ratio of mortality from initial RV enlargement+ was 4.4 (95% confidence limits 1.7 to 11.1) (p = 0.002). Thus, patients with significant RV dilation had nearly triple the mortality over 4 years and more rapidly deteriorating LV function than patients with less initial RV dilation. In IDC, RV enlargement is a strong marker for adverse prognosis that may represent a different morphologic subset.

Adult↗
PubMed2004

Role of angiotensin receptor blockers in patients with left ventricular dysfunction: lessons from CHARM and VALIANT.

The role of angiotensin receptor blockers (ARBs) in patients with left ventricular dysfunction has changed after the VALIANT and CHARM trials. CHARM proved that candesartan is a good alternative for patients with chronic heart failure who cannot tolerate ACE-inhibitors. Moreover, VALIANT demonstrated non-inferiority of valsartan compared to captopril in patients after an acute myocardial infarction. The add-on effects of an ARB on top of an ACE-inhibitor are somewhat less pronounced, although a reduction in the number of hospitalizations for heart failure seems a consistent finding.

Angiotensin II Type 1 Receptor Blockers↗
PubMed2000

Diffuse and severe left ventricular dysfunction induced by epicardial coronary artery spasm.

Endothelial dysfunction and effectiveness of treatment of calcium antagonists are suggestive of coronary artery spasm as an underlying disorder in dilated cardiomyopathy (DCM). The aim of this study is to determine whether or not the epicardial coronary artery spasm can induce severe cardiac dysfunction like DCM. Thirty-four consecutive patients with angiographically normal coronary arteries and diffuse left ventricular hypokinesis whose causes had been unknown underwent acetylcholine provocation test and left ventricular biopsy. Eight patients were excluded according to the clinical and laboratory data and biopsy findings suggesting myocarditis or other systemic diseases. According to the results of the acetylcholine provocation test, 17 patients were finally diagnosed as having DCM, and nine patients (35% of the study patients), who had acetylcholine-induced diffuse and multivessel coronary spasm, were diagnosed as having DCM-like vasospastic angina pectoris (VSA). Clinical and cardiac catheterization data including hemodynamics and biopsy findings were similar between the two groups except that left ventricular end-systolic volume was significantly greater in DCM than in DCM-like VSA. After the acetylcholine provocation test, DCM patients received both a beta blocker and an angiotensin-converting enzyme inhibitor, and DCM-like VSA patients received antianginal drugs. In echocardiographic findings at predischarge and those after 6-month drug treatment, both DCM-lke VSA and DCM showed significant reduction in end-diastolic and end-systolic diameters and significant increase in fractional shortening and ejection fraction, whereas changes in ejection fraction and fractional shortening were significantly greater in DCM-like VSA than those in DCM. Epicardial coronary artery spasm can induce diffuse and severe left ventricular dysfunction like DCM in VSA. Although antianginal drugs markedly improve left ventricular function of these patients, only the acetylcholine provocation test can identify DCM-like VSA.

Acetylcholine↗
PubMedDate not supplied

Using a 6-minute walk test to predict outcomes in patients with left ventricular dysfunction.

Maximal oxygen consumption (VO2MAX) is an independent variable that predicts outcomes in patients suffering from left ventricular dysfunction (LVD). Determining VO2MAX in a rehabilitation setting is not only costly and time-consuming but it would also be beyond many patients' physical abilities. This study's goal was to show that a simpler and less costly 6-minute walk test can predict mortality in patients with LVD. Sixty-six Phase 1 cardiac rehabilitation patients with LVD performed the 6-minute walk test upon admission and at discharge from a rehabilitation hospital. Upon discharge, the group that was able to walk significantly longer distances upon discharge had a higher survival rate 3 months after discharge. The 6-minute walk test can predict longer survival in patients with LVD and can provide valuable information for determining treatment plans, future prognosis, and home disposition of deconditioned LVD patients in a rehabilitation setting.

Aged↗
PubMed2002

[Clinical evaluation of the cause of left ventricular dysfunction in type 2 diabetes without significant cardiac disease].

OBJECTIVES: The relationship between left ventricular dysfunction and hypertension or proteinuria was evaluated in type 2 diabetic patients without significant cardiac disease to investigate the cause of diabetic cardiac dysfunction. METHODS: Twenty-one patients with type 2 diabetes mellitus (mean age 63.8 +/- 7.4 years) underwent left ventriculography and Doppler echocardiography to calculate the ejection fraction and E/A ratio (E/A). RESULTS: Thirteen patients had hypertension (61.9%) and six patients had proteinuria (28.6%). The E/A was 0.82 +/- 0.21 in all patients. The E/A in patients with hypertension or proteinuria was significantly less than in those without these diseases (0.74 +/- 0.18 vs 0.97 +/- 0.18, p = 0.011; 0.65 +/- 0.10 vs 0.89 +/- 0.20, p = 0.010, respectively). The ejection fraction was 73.3 +/- 7.2% in all patients. The ejection fraction in patients with proteinuria was significantly less than in those without proteinuria (67.6 +/- 10.0% vs 75.5 +/- 4.4%, p = 0.019), but there was no significant difference in ejection fraction between patients with and without hypertension. The duration of diabetes was significantly related to the ejection fraction (r = -0.436, p = 0.048) but not to the E/A. CONCLUSIONS: In patients with type 2 diabetes without significant cardiac disease, left ventricular diastolic function may be related to both hypertension and proteinuria and left ventricular systolic function may be related to proteinuria and duration of diabetes. Therefore, in addition to hypertension, complications of nephropathy or long duration of diabetes may be related to the cause of the diabetic cardiac dysfunction.

Diabetes Mellitus, Type 2↗
PubMed1992

Chronic coronary artery constriction leads to moderate myocyte loss and left ventricular dysfunction and failure in rats.

Coronary artery narrowing, ranging from 19% to 61%, was induced in rats and ventricular performance, myocardial damage, and myocyte hypertrophy were examined 1 mo later. Animals were separated into two groups, exhibiting ventricular dysfunction and failure, respectively. Dysfunction consisted of a 2.4-fold increase in left ventricular end diastolic pressure (LVEDP), 15% decrease in left ventricular peak systolic pressure (LVPSP), 24% reduction in developed pressure (DP), and a 16% depression in-dP/dt. Failure was defined on the basis of a 4.7-fold elevation in LVEDP, and a 26%, 47%, 45%, and 41% decrease in LVPSP, DP, +dP/dt, and -dP/dt. Moreover, in this group, right ventricular end diastolic and systolic pressures increased 5.5- and 1.2-fold. Left and right ventricular weights expanded 23% and 51% with dysfunction and 30% and 56% with failure. Left ventricular hypertrophy was characterized by ventricular dilation and wall thinning which were more severe in the failing animals. Foci of damage were found in both groups but tissue injury was more prominent in the endomyocardium and in failing rats. Finally, myocyte loss in the ventricle was 10% and 20% with dysfunction and failure whereas the corresponding enlargements of the unaffected myocytes were 34% and 53%. Thus, coronary narrowing led to abnormalities in cardiac dynamics with an increase in diastolic wall stress and extensive ventricular remodeling in spite of a moderate loss of myocytes and compensatory reactive hypertrophy of the viable cells.

Animals↗
PubMed2006

Total arterial revascularisation in left ventricular dysfunction.

The feasibility and safety of total arterial coronary revascularization with 2 arterial conduits in patients with impaired left ventricular function was evaluated. Data were prospectively collected on all patients with multiple vessel discase and moderately or severely impaired left ventricular function, who underwent coronary surgery with the intention of total arterial revascularization with 2 conduits between March 1995 and August 2002. One hundred and seventy-nine patients were included in the study. Acute coronary insufficiency was present in 3 patients and 43 had unstable angina. Severe left ventricular impairment was present in 29 patients. There were 17 redo operations including 3 redo-redo procedures. Eighty-two percent of patients had a Y graft configuration from the left internal mammary artery (right internal mammary artery 40.8%, radial artery 33.5%, other 7.8%). The perioperative mortality was 2.2%, myocardial infarction 1.7% and stroke 0.6%. Total arterial revascularization in patients with ischaemic left ventricular dysfunction can be safely performed with 2 arterial conduits. The radial artery provides conduit length greater than the right internal mammary artery and allows full revascularization despite left ventricular dilatation.

Adult↗
PubMed1999

Attenuation correction improves the detection of viable myocardium by thallium-201 cardiac tomography in patients with previous myocardial infarction and left ventricular dysfunction.

The aim of this study was to determine the influence of attenuation-corrected thallium-201 stress/redistribution/reinjection single-photon emission tomography (SPET) on the number of viable segments in patients with previous myocardial infarction and dysfunctional myocardium. Fifty-one patients with previous myocardial infarction and left ventricular dysfunction were included in the study. In all patients, 201Tl non-corrected (NC) and attenuation-corrected (AC) SPET was performed using a stress/redistribution/reinjection protocol followed by coronary angiography. A semiquantitative analysis was performed using polar maps for NC and AC stress, redistribution and reinjection short-axis and vertical long-axis (apex) slices. Severe (perfusion defect below 50%/maximal count rate: PD < 50), mild and moderate persistent defects for redistribution and reinjection were evaluated for both NC and AC studies. A total of 1581 segments were evaluated by semiquantitative segmental analysis for both NC and AC studies for each redistribution and reinjection map. In the redistribution maps, NC revealed a total of 352 segments and AC a total of 222 segments with impaired perfusion below 50% of the maximal count rate (PD < 50). The mean number of affected segments was 6.9 +/- 5.5 in the case of NC and 4.4 +/- 4.8 in the case of AC (P < 0.001). In the reinjection maps, NC revealed a total of 263 non-viable segments (PD < 50) and AC a total of 169 non-viable segments. The mean number of affected segments was 5.2 +/- 5.3 in the case of NC and 3.3 +/- 4.2 in the case of AC (P < 0.001). Recovery of function was better predicted by AC than by NC in 20% of patients in the follow-up group. Therefore, the use of attenuation correction influences the extent of viable segments by showing more viable segments in either redistribution or reinjection maps. 201Tl imaging without attenuation correction may underestimate the extent of tissue viability, which may contribute to the lower sensitivity compared to fluorine-18-fluorodeoxyglucose positron emission tomography, where attenuation correction is a routinely performed procedure.

Exercise Test↗
PubMed2000

A nonsurgical porcine model of left ventricular dysfunction. Validation of myocardial viability using dobutamine stress echocardiography and positron emission tomography.

BACKGROUND: Although several short-term animal models of stunning and hibernation have been studied extensively, it has been difficult to produce a consistent animal model of chronic hibernation. The aim of the present study was to develop a nonsurgical porcine stent model of coronary stenosis in order to investigate the relationship between chronic dysfunctional myocardium and viability using 2D-echo, dobutamine stress echo (DSE) and positron emission tomography (PET). METHODS AND RESULTS: Focal progressive coronary stenosis was induced by implantation of an oversized stent in the left anterior descending (LAD) and/or circumflex (LCX) coronary artery in a total of 115 pigs, according to various experimental protocols: copper stent in the LAD (group I, n = 5); noncoated stainless steel stent in the LAD combined with balloon overstretch (group II, n = 7); poly(organo)phosphazene-coated stent in the LAD (group III, n = 77); and poly(organo)phosphazene-coated stent in both the LAD and the LCX (group IV, n = 26). Occurrence of left ventricular dysfunction was evaluated weekly by 2D-echo. At the time of left ventricular dysfunction the presence of viable myocardium within the dysfunctional region was investigated with DSE and PET, and confirmed by histology. The degree of coronary artery stenosis was measured by quantitative coronary angiography and morphometry. Severe coronary artery stenosis in the presence of dysfunctional, but viable, myocardium was induced in groups III and IV (47% and 11% of the animals, respectively). CONCLUSIONS: The authors developed a nonsurgical porcine stent model of progressive coronary stenosis using an oversized polymer-coated stent resulting in chronically decreased myocardial function, with residual inotropic reserve and viable myocardium. This condition may arise from repetitive periods of ischemia, or from sustained hypoperfusion, or a combination of these processes eventually leading to myocardial hibernation.

Journal Article↗
PubMed2006

Association of subclinical right ventricular dysfunction with obesity.

OBJECTIVES: The purpose of this research was to identify the determinants of right ventricular (RV) dysfunction in overweight and obese subjects. BACKGROUND: Right ventricular dysfunction in obese subjects is usually ascribed to comorbid diseases, especially obstructive sleep apnea. We used tissue Doppler imaging to identify the determinants of RV dysfunction in overweight and obese subjects. METHODS: Standard and tissue Doppler echocardiography was performed in 112 overweight (body mass index [BMI] 25 to 29.9 kg/m2) or obese (BMI >30 kg/m2) subjects and 36 referents (BMI <25 kg/m2), including 22 with obstructive sleep apnea but no obesity. Tissue Doppler was used to measure RV systolic (s(m)) and diastolic (e(m)) velocities and strain indexes. RESULTS: Obese subjects with BMI >35 kg/m2 had reduced RV function compared with referent subjects, evidenced by reduced s(m) (6.5 +/- 2.4 cm/s vs. 10.2 +/- 1.5 cm/s, p < 0.001), peak strain (-21 +/- 4% vs. -28 +/- 4%, p < 0.001), peak strain rate (-1.4 +/- 0.4 s(-1) vs. -2.0 +/- 0.5 s(-1), p < 0.001), and e(m) (-6.8 +/- 2.4 cm/s vs. -10.3 +/- 2.5 cm/s, p < 0.001), irrespective of the presence of sleep apnea. Similar but lesser degrees of reduced systolic function (p < 0.05) were present in overweight (BMI 25 to 29.9 kg/m2) and mildly obese (BMI 30 to 35 kg/m2) groups. Differences in RV e(m), s(m), and strain indexes were demonstrated between the severely versus overweight and mildly obese groups (p < 0.05). Body mass index remained independently related to RV changes after adjusting for age, log insulin, and mean arterial pressures. In obese patients, these changes were associated with reduced exercise capacity but not the duration of obesity and presence of sleep apnea or its severity. CONCLUSIONS: Increasing BMI is associated with increasing severity of RV dysfunction in overweight and obese subjects without overt heart disease, independent of sleep apnea.

Adult↗
PubMed1998

[Ebstein's anomaly associated with left ventricular dysfunction: a case report].

A 66-year-old man presented with Ebstein's anomaly associated with left ventricular dysfunction. He had been followed since 40 years of age for cardiomegaly and arrhythmia, and experienced episodes of orthopnea at the age of 64. He was referred to our hospital in April 1997 because of lower extremity edema. Physical examination revealed dilated external jugular vein, tenderness of the right hypocondorium, and lower extremity edema. Electrocardiography confirmed atrial fibrillation. Transthoracic echocardiography revealed bilateral atrial and ventricular dilation, and paradoxical septal movement. The apical four-chamber view demonstrated 15 mm apical displacement of the septal leaflet. Color Doppler echocardiography revealed moderate tricuspid regurgitation. Transesophageal echocardiography revealed low echoic and hypoplastic tricuspid valve. Left ventriculography showed diffuse hypokinesis, and the ejection fraction was 49%. The coronary artery was normal. Atrial septal defect was not detected. Diffuse fibrosis, which may be found in the hearts of patients with Ebstein's anomaly at autopsy may have been responsible for the left ventricular depressed systolic function in this patient.

Aged↗
PubMed1996

Effect of d-sotalol on mortality in patients with left ventricular dysfunction after recent and remote myocardial infarction. The SWORD Investigators. Survival With Oral d-Sotalol.

BACKGROUND: Left ventricular dysfunction after myocardial infarction is associated with an increased risk of death. Other studies have suggested that a potassium-channel blocker might reduce this risk with minimal adverse effects. We investigated whether d-sotalol, a pure potassium-channel blocker with no clinically significant beta-blocking activity, could reduce all-cause mortality in these high-risk patients. METHODS: Patients with a left ventricular ejection fraction of 40% or less and either a recent (6-42 days) myocardial infarction or symptomatic heart failure with a remote (> 42 days) myocardial infarction were randomly assigned d-sotalol (100 mg increased to 200 mg twice daily, if tolerated) or matching placebo twice daily. FINDINGS: After 3121 of the planned 6400 patients had been recruited, the trial was stopped. Among 1549 patients assigned d-sotalol, there were 78 deaths (5.0%) compared with 48 deaths (3.1%) among the 1572 patients assigned placebo (relative risk 1.65 [95% CI 1.15-2.36], p = 0.006). Presumed arrhythmic deaths (relative risk 1.77 [1.15-2.74], p = 0.008) accounted for the increased mortality. The effect was greater in patients with a left ventricular ejection fraction of 31-40% than in those with lower ( <or= 30%) ejection fractions (relative risk 4.0 vs 1.2, p = 0.007). INTERPRETATION: Among the 1549 patients evaluated, administration of d-sotalol was associated with increased mortality, which was presumed primarily to be due to arrhythmias. The prophylactic use of a specific potassium-channel blocker does not reduce mortality, and may be associated with increased mortality in high-risk patients after myocardial infarction.

Administration, Oral↗