Pooled analyses of independent cohort studies confirmed the long-term prognostic value of cardiac mIBG uptake in patients with HF independently of other markers, such as NYHA functional class, BNP, and LVEF, and demonstrated that categoric assessments could be used to define meaningful thresholds for lethal event risk.

Many studies have shown that a one-time 123 I-metaiodobenzylguanidine ( 123 I-MIBG) scintigraphic study during a stable period is useful for determining the prognosis of patients with chronic heart failure (CHF). However, the findings from this imaging modality are well known to be improved by medical treatment for heart failure. Accordingly, this study was performed to determine whether serial 123 I-MIBG scintigraphic studies represent a reliable prognostic marker for patients with CHF. Methods: A total of 208 patients with CHF (left ventricular ejection fraction [LVEF] , 45%) and with no cardiac events for at least 5 mo were identified on the basis of a history of decompensated acute heart failure requiring hospitalization. The delayed percentage of denervation (% denervation), delayed heart-to-mediastinum count (H/M) ratio, and washout rate (WR) were determined from the patients' 123 I-MIBG images just before they left the hospital and after they had received 6 mo of treatment. The left ventricular end-diastolic volume (LVEDV), left ventricular end-systolic volume (LVESV), and LVEF were also determined by echocardiography at the same time points. Results: Of the 208 patients, 56 experienced fatal cardiac events during the study. The mean follow-up period was 4.45 6 1.82 y. The baseline H/M ratio and WR; follow-up % denervation, H/M ratio, and WR; D-% denervation, H/M ratio, and WR; baseline LVEF; follow-up LVEDV, LVESV, and LVEF; and D-LVEDV, D-LVESV, and D-LVEF were significantly worse in the cardiac death group. A Cox regression analysis showed that the D-WR was an independent predictor of cardiac death. Moreover, sudden death occurred in 13 of the 56 patients with cardiac death. A Cox regression analysis also showed that the D-WR was an incremental predictor of sudden death. The cardiac death-free rate and sudden death-free rate were significantly higher in patients with D-WR less than 25% and D-WR less than 22% than in patients with D-WR greater than or equal to 25% and D-WR greater than or equal to 22%. Conclusion: D-WR obtained from serial 123 I-MIBG scintigraphic studies can be useful for predicting cardiac death and sudden death in stabilized patients with CHF.

Spironolactone improves cardiac sympathetic nerve activity and LV remodeling in patients with DCM.

The activation of the renin-angiotensin-aldosterone system prevents the uptake of norepinephrine in the myocardium. However, the additive effects of combined spironolactone and candesartan on cardiac sympathetic nerve activity (CSNA) have not been determined. We investigated the effects of the angiotensin-receptor blocker candesartan alone and in combination with spironolactone on CSNA in patients with congestive heart failure (CHF). Methods: Fifty patients with CHF (left ventricular ejection fraction [LVEF] , 45%) were randomly assigned to candesartan plus spironolactone (group A; n 5 25) or to candesartan alone (group B; n 5 25). All patients were also treated with a loop diuretic. The delayed percent denervation, delayed heart-tomediastinum count (H/M) ratio, and washout rate (WR) were determined from 123 I-metaiodobenzylguanidine (MIBG) scintigraphy, and plasma brain natriuretic peptide (BNP) concentration was measured before and 6 mo after treatment. The LV enddiastolic volume (LVEDV), LV end-systolic volume (LVESV), and LVEF were also determined by echocardiography. Results: After 6 mo, all of these parameters were improved in both groups. However, the degree of change in the percent denervation was 214 6 12 in group A and 27 6 10 in group B (P , 0.05); the change in the H/M ratio was 0.19 6 0.18 in group A and 0.08 6 0.14 in group B (P , 0.05), the change in WR was 212% 6 8% in group A and 25% 6 13% in group B (P , 0.05), and the change in plasma BNP was 2100 6 83 pg/mL in group A and 243 6 97 pg/mL in group B (P , 0.05). The degree of change in LVEDV, LVESV, and LVEF in group A tended to be better than that in group B, but these changes were not statistically significant. Moreover, there were significant correlations between changes in the 123 I-MIBG scintigraphic findings and changes in the LVEDV (% denervation, r 5 0.692, P , 0.001; H/M ratio, r 5 20.437, P , 0.05; and WR, r 5 0.505, P , 0.01) or the LVESV (% denervation, r 5 0.663, P , 0.001; H/M ratio, r 5 20.438, P , 0.05; and WR, r 5 0.532, P , 0.01) in group A. In contrast, there was no relationship between these parameters in group B. Conclusion: These findings indicate that the combination of spironolactone and candesartan may be more beneficial for CSNA and LV performance than candesartan alone in patients with CHF.

Low BMI, eGFR, CLI, and diabetes are significant risk factors for mortality in PAD. The obesity paradox was verified and may be partly explained by low BMI mediated by malnutrition and systemic inflammation due to PAD or chronic obstructive pulmonary disease.