The effect of preoperative statin therapy on cardiovascular outcomes in patients undergoing infrainguinal vascular surgery

BACKGROUND: Patients undergoing vascular surgery are at increased risk for perioperative cardiovascular (CV) complications. Our goal was to determine the effect of preoperative statin therapy on perioperative cardiac and vascular outcomes, and long-term survival in patients undergoing infrainguinal vascular bypass surgery. METHODS: We retrospectively reviewed consecutive infrainguinal vascular bypass surgeries on 446 patients performed between 1995-2001 at the University of Chicago Medical Center. Information was collected on preoperative statin and beta-blocker use, baseline characteristics, perioperative cardiac and major vascular complications, and length of stay (LOS). Long-term survival was assessed using the Social Security Death Index (SSDI). RESULTS: Thirty day perioperative complications included all-cause mortality (2.5%), CV mortality (1.8%), myocardial infarction (MI) (4.7%), stroke (1.1%), and major peripheral vascular complications (12.8%), and the composite of cardiac and vascular complications [combined CV complications] (17.9%). Statin therapy was associated with fewer combined CV complications (6.9% vs 20.1%, p=0.008), and a shorter LOS (6.4 vs 9.7 days, p=0.007). On multivariate logistic regression analysis, adjusting for significant baseline characteristics including beta-blocker use, statin therapy was independently associated fewer combined CV complications (odds ratio (OR) 0.36, 95% confidence interval (CI) 0.14-0.93, p=0.035) and a shorter LOS (OR 1.49, 95% CI 1.14-1.95, p=0.003). In a mean follow up period of 5.5 years, 215 deaths (48%) occurred. Statin therapy was independently associated with improved long-term survival (OR 0.52, 95% CI 0.32-0.84, p<0.004), after adjusting for significant baseline characteristics. CONCLUSION: Preoperative statin therapy is associated with fewer combined perioperative cardiac and major vascular complications, a shorter length of stay, and improved long-term survival in patients undergoing infrainguinal vascular bypass surgery.     

Nitroprusside and regional vascular capacitance in patients with severe congestive heart failure.

BACKGROUND. This study investigates the effects of sodium nitroprusside on regional vascular capacitance in eight patients with severe congestive heart failure (New York Heart Association class IV) and pulmonary hypertension. METHODS AND RESULTS. Regional relative blood volumes in the splanchnic and pulmonary region were determined by equilibrium blood pool scintigraphy. Hepatic venous wedge pressure and the mean of pulmonary artery and pulmonary capillary wedge pressure were used to represent the distending pressures of the splanchnic and pulmonary capacitance vessels, respectively. The dose of sodium nitroprusside was increased stepwise until systolic pulmonary artery pressure decreased below 50 mm Hg. This caused reductions in mean aortic pressure from 89 +/- 5 to 66 +/- 3 mm Hg (p less than 0.005), in pulmonary capillary wedge pressure from 31 +/- 1 to 16 +/- 2 mm Hg (p less than 0.001), and in hepatic venous wedge pressure from 10.0 +/- 1.0 to 5.9 +/- 0.6 mm Hg (p less than 0.005). Intestinal blood volume increased by 26 +/- 7% (p less than 0.005), whereas hepatic blood volume decreased by 9 +/- 3% (p less than 0.02). Pulmonary blood volume was unchanged. Analysis of intestinal and pulmonary vascular pressure-volume relations showed larger or equal blood volumes contained at lower distending pressures, indicating that sodium nitroprusside reduced smooth muscle tone of the capacitance vessels in these regions. The reduction of hepatic blood volume was compatible with passive expulsion of blood subsequent to reduced venous pressure. There was no change in the count rate from the spleen. CONCLUSIONS. Nitroprusside reduced venous pressure in patients with congestive heart failure by active relaxation of intestinal and pulmonary capacitance vessels. Hepatic vascular volume was probably reduced by a passive mechanism.     

Reflex cardiovascular control in congestive heart failure.

This article reviews evidence that the reflex control of the cardiovascular system provided by negative feedback mechanisms is impaired in congestive heart failure (CHF). The impairment involves vagal and sympathetic modulation of the heart exerted by arterial baroreceptors. It also affects baroreceptor control of blood pressure and peripheral vascular resistance, as well as the cardiopulmonary receptor's ability to modulate sympathetic activity. The degree of such impairment is most marked in severe CHF but is also apparent, to a minor degree, in mild heart failure. Reflex impairment is due to a reduction in the receptor signal, but other factor under investigation are probably also involved. Digoxin and other pharmacologic treatments of CHF improve reflex function, thereby facilitating a reduction in the elevated sympathetic activity and a stepping up of the reduced vagal activity typical of CHF. This may be relevant to a patient's prognosis.     

Preoperative levosimendan in heart failure patients undergoing noncardiac surgery

BACKGROUND: Heart failure (HF) is a major cause of perioperative morbidity and mortality in noncardiac surgery. Preoperative optimisation of these patients is, thus, of utmost importance. Levosimendan seems promising for patients undergoing cardiac surgery; however, its safety and efficacy in HF patients undergoing noncardiac surgery have not been evaluated. OBJECTIVE: To evaluate the effects of prophylactic preoperative levosimendan administration on left ventricular function in HF patients undergoing noncardiac surgery. METHODS: HF patients with ejection fraction <30%undergoing elective noncardiac surgery in 2005 were included in this prospective study. Patients were admitted to our surgical intensive care unit one day preoperatively. Under continuous haemodynamic monitoring, the treatment protocol consisted of an initial loading dose (24 microg/kg) for ten minutes followed by a continuous 24-hour infusion (0.1 microg/kg/min) at the end of which patients underwent surgery. Echocardiography was performed before infusion (day 0) and on the 7th postinfusion day (day 7). Measurements included left ventricular ejection fraction (LVEF), velocity time integral(VTI), pre-ejection period (PEP), ejection time (ET),maximum (Pmax) and minimum P(min) transvalvular aortic pressure gradient, and maximum (Vmax) and minimum V(min) aortic velocity. RESULTS: Twelve consecutive patients were enrolled.Levosimendan resulted in a significant increase in LVEF,VTI, P(max), P(min), V(max), and V(min) (p<0.01) and, moreover, a significant reduction in PEP, ET, and PEP/ET (p=0.04) on day 7 compared with day 0 values. No adverse reactions,complications or mortality occurred during 30-day follow-up. CONCLUSION: Prophylactic preoperative levosimendan treatment may be safe and efficient for perioperative optimisation of heart failure patients undergoing noncardiac surgery.     

充血性心力衰竭炎性细胞因子的改变

目的 :探讨充血性心力衰竭 (CHF)时肿瘤坏死因子 α(TNF α)、白细胞介素 6 (IL 6 )、白细胞介素 1β(IL 1β)和一氧化氮 (NO)的变化 ,及其与CHF关系。 方法 :CHF患者 4 5例和年龄匹配的对照者 17例 ,根据NY HA分级将CHF患者分成Ⅱ、Ⅲ、Ⅳ级 3组 ;根据体重分成恶病质组及非恶病质组。用酶联免疫法测定IL 6 ,用放射免疫法测定IL 1β、TNF α ,用比色法测定NO。 结果 :CHF组血清IL 6、IL 1β、TNF α和NO较对照组明显升高 ,IL 6、NO在心功能Ⅱ、Ⅲ、Ⅳ级时均显著升高 ,TNF α在Ⅲ、Ⅳ级时显著升高 ,而IL 1β在Ⅳ级时才显著升高。不同病因的CHF之间差异无统计学意义 ,恶病质组及非恶病质组之间差异也无统计学意义。血清TNF α与IL 6呈正相关 (r =0 .5 82 9,P <0 .0 1)。结论 :血清IL 6、IL 1β、TNF α、NO水平与CHF的严重程度密切相关 ,可作为判断CHF严重程度的指标 ;IL 6、IL 1β、TNF α在CHF的发生发展中可能起重要作用     

Psychosocial issues in patients with congestive heart failure

Psychosocial issues are important variables that need to be addressed in patients with congestive heart failure (CHF). Unfortunately, these issues are often overlooked. Depression and lack of social support have been shown to have a negative impact on patients with CHF. Patients with CHF who are depressed or who lack social support have been shown to have increased morbidity and hospital readmission rates, to be less adherent to their medical regimen, and to have an overall increase in cost of care. The variables are often interrelated, as high levels of social support may lessen the impact of depression on mortality. In addition, certain biologic factors may influence the impact of psychosocial factors in patients with CHF. This review addresses the effects of depression, treatment adherence, and social support in patients with CHF and suggests interventions targeted to these problems. Health care professionals must assess these issues in all patients with CHF, address their specific needs, and intervene appropriately when warranted.     

Hormonal profile in patients with congestive heart failure

BACKGROUND: Recent progress has been made in the understanding of the cellular and molecular mechanisms of growth hormone action and of its effects on cardiac tissue. The aim of this study was to measure growth hormone concentrations, along with various other hormones, in patients with stable chronic congestive heart failure due to idiopathic dilated cardiomyopathy. METHODS: The study included 23 ambulatory men, 51.2+/-9.3 years of age, on standard medical therapy for heart failure due to idiopathic dilated cardiomyopathy. All patients underwent clinical and laboratory evaluations, including echocardiogram, radionuclide ventriculography, right heart catheterization, coronary angiography, and right ventricular endomyocardial biopsy. Serum or plasma concentrations of growth, thyroid, sex and adrenal hormones were measured in all patients and compared with those found in 20 age-matched healthy men. RESULTS: Growth hormone, insulin-like growth factor I, and free testosterone values in patients with idiopathic dilated cardiomyopathy and heart failure were 0.37+/-0.2 ng/ml, 123.7+/-50 ng/ml and 48.6+/-23.8 pmol/l, respectively, versus 0.5+/-0.4 ng/ml (P<0.01), 236.3+/-66.4 ng/ml (P<0.001) and 105+/-17 pmol/l (P<0.01), respectively, in the healthy age-matched individuals. All other hormone concentrations were comparable in both groups. CONCLUSIONS: Chronic heart failure due to idiopathic dilated cardiomyopathy is associated with a significant decrease in growth hormone, insulin-like growth factor I, and testosterone concentrations, probably due to chronic disease.     

Cheyne-Stokes respiration in patients with congestive heart failure

Cheyne-Stokes Respiration (CSR) is a breathing pattern characterised by rhythmic oscillation of tidal volume with regularly recurring periods of hyperpnoea, hypopnoea and apnoea. CSR is no longer solely regarded as a symptom of severe congestive heart failure (CHF), but has been recognised as an independent risk factor for worsening heart failure and reduced survival in patients with CHF. CSR is associated with frequent awakening that fragment sleep and with concomitant sympathetic activation both of which may worsen CHF. Cheyne-Stokes Respiration is very common in patients with severe CHF and its prevalence may have been underestimated in the past due to technical limitations that precluded respiratory monitoring outside sleep laboratories. Since treatment of CSR appears to be beneficial and safe, patients at risk should be promptly diagnosed and treated. Treatment of CSR has been demonstrated to improve left ventricular ejection fraction and potentially prolongs survival in patients with severe CHF. This article briefly summarises the current knowledge of the patho-physiology, prevalence and therapy of Cheyne-Stokes respiration.     

Prostacyclin therapy in patients with congestive heart failure

The acute hemodynamic effects of intravenous prostacyclin (PGI₂), in doses of 22 ± 11 ng/kg per min were studied in nine patients with severe congestive heart failure refractory to digitalis and diuretic drugs. After prostacyclin infusion, mean (±standard deviation) pulmonary capillary wedge pressure decreased from 21.0 ± 7.9 to 15.0 ± 6.6 mm Hg (p < 0.001), mean arterial pressure from 98.9 ± 12.8 to 76.2 ± 7.0 mm Hg (p < 0.001), systemic vascular resistance from 2,574 ± 384 to > 1,368 ± 283 dynes s cm^?5 (p < 0.001), pulmonary vascular resistance from 1,008 ± 451 to 443 ± 135 dynes s cm^?5 (p < 0.001) and pulmonary arteriolar resistance from 330 ± 111 to 189 ± 73 dynes s cm^?5 (p < 0.001). Heart rate increased from 78 ± 21 to 82 ± 24 beats/min (p = not significant [NS]), cardiac index from 2.0 ± 0.37 to 3.2 ± 0.59 liters/min per m² (p < 0.001) and stroke index from 27.6 ± 8.69 to 42.0 ± 0.62 cc/m² (p < 0.001). With prostacyclin, moreover, coldness of the limbs and face disappeared, and patients felt warmth and mild flushing of the face. After prostacyclin, plasma norepinephrine levels, renin activity and aldosterone concentrations rose from 824 ± 375 to 880 ± 468 pg/ml (NS), 0.68 ± 1.36 to 0.95 ± 1.21 ng/ml per h (NS), and 6.64 ± 2.50 to 6.38 ± 2.88 ng/dl (NS), respectively, while plasma epinephrine increased from 140 ± 80 to 250 ± 154 pg/ml (p < 0.025).     

Sleep disorders in patients with congestive heart failure

PURPOSE OF REVIEW: This review of recent literature pertains to the growing evidence that obstructive sleep apnea contributes to the development of systemic hypertension and congestive heart failure. RECENT FINDINGS: There is irrefutable evidence that OSA causes systemic hypertension and that continuous positive airway pressure (CPAP) treatment of OSA causes a reduction in blood pressure. Moreover there is evidence that untreated OSA is associated with left ventricular diastolic and systolic failure and that treatment with CPAP improves systolic function. SUMMARY: OSA should be considered in patients with systemic hypertension or heart failure.     

慢性心力衰竭患者补体激活的临床研究

目的　探讨慢性心力衰竭 (心衰 )患者是否存在补体激活以及补体激活与心衰患者预后的关系。方法　检测 4 4例心衰患者 (心衰组 )和 16例性别、年龄匹配的健康人 (对照组 )血浆补体经典激活途径产物C4d、替代激活途径产物Bb、终末共同途径产物C3bc和补体激活终末复合物C5b 9浓度。心衰组平均随访 (13± 3)个月 ,观察患者是否因心功能恶化而住院治疗或因心功能恶化死亡。结果　 (1)心衰组血浆C4d、Bb、C3bc和C5b 9浓度均显著高于对照组 ;(2 )心衰组中 ,血浆C5b 9浓度低于中位数的心衰患者与血浆C5b 9浓度高于中位数的心衰患者相比 ,后者心功能较差 ,因心功能恶化住院和死亡的例数较多。结论　心衰患者补体系统被激活 ,血浆C5b 9浓度显著提高与心衰患者心功能和预后较差有关 ,提示补体可能成为治疗慢性心衰的一个新的靶点。     

Meta-analysis of cardiovascular outcomes with dronedarone in patients with atrial fibrillation or heart failure

Dronedarone is a benzofuran derivative approved by the Food and Drug Administration to decrease the risk of cardiovascular hospitalization in patients with paroxysmal or persistent atrial fibrillation (AF) and associated cardiovascular risk factors who are in sinus rhythm or will undergo cardioversion. There has been recent evidence to suggest that dronedarone may not have a favorable safety profile. We decided to evaluate all available evidence on the cardiovascular safety of this drug. A systematic search was made of the PubMed, CENTRAL, and EMBASE databases for randomized controlled trials from 1966 through 2011 comparing dronedarone to comparators in AF/heart failure. Intervention was dronedarone for AF for some studies and heart failure for others. Comparators included standard medical therapy and/or placebo and amiodarone for 1 study. Outcomes assessed were all-cause mortality, cardiovascular mortality, ventricular arrhythmias, embolic events, acute coronary syndrome, heart failure exacerbations, and hospitalization rates in the intervention versus comparator group at the end of ≥ 3 months of follow up with abstraction of data by 1 author. Seven randomized controlled trials were included in our analysis. Dronedarone use was associated with a trend toward worse all-cause and cardiovascular mortalities and increased heart failure exacerbations. It also showed numerically higher event rates for all other outcome events except acute coronary syndrome. Our pooled analysis showed increased all-cause and cardiovascular mortalities and increased heart failure exacerbations with use of dronedarone across a wide spectrum of populations. In conclusion, we recommend exercising caution using dronedarone, especially in patients with cardiovascular risk factors.     

Functional capacity in patients with congestive heart failure

BACKGROUND: Six-minute walk distance (6MWd) is related to activities of daily living and is also an independent predictor of prognosis in patients with congestive heart failure (CHF). Therefore, it is important to determine factors that contribute to the variability of this test. METHODS AND RESULTS: We assessed the relationship between 6MWd and peak aerobic capacity (VO2) and dynamic muscle strength in 180 patients with CHF (age, 66+/-10 years; 146 men, 34 women; ejection fraction, .29+/-0.08). We also hypothesized that a measure of work performed during the walk test (6MWw) would be a better indicator of exercise capacity than 6MWd. The 6MWd had weak to moderate correlations with dynamic muscle strength (r = 0.33 to 0.41) and peak VO2 (r = 0.48). However, 6MWw was strongly related to dynamic muscle strength (r = 0.63 to 0.70) and peak VO2 (r = 0.77). Multivariate analysis indicated that a model combining dynamic muscle strength and peak VO2 explained 69% of the variance in 6MWw, more than with peak VO2 alone (R2 = 0.59). CONCLUSIONS: Compared with 6MWd, 6MWw correlates significantly better with peak VO2 and dynamic muscle strength, suggesting that 6MWw may be a better reflection of a patient's exercise capacity. Furthermore, these results suggest that an exercise program combining both aerobic and strength training in patients with CHF may improve 6MWw and therefore 6MWd.     

Ultrafiltration in patients with hypervolemia and congestive heart failure

Fluid overload may occur in patients with myocardial dysfunction and different clinical problems. Myocoardial dysfunction may be a consequence of heart dilatation with reduced contractility, ventricular stiffness with diastolic dysfunction or the consequence of myocardial injury or circulating myocardial depressant factors as seen in sepsis. In all cases, cardiac support can be achieved by the optimization of fluid balance, the reduction in organ edema and the restoration of desirable levels of pre- and afterload. Several reports have shown that myocardial elastance can improve after hemofiltration with restoration of adequate fluid balance. In such conditions, continuous extracorporeal therapy may result in remarkable cardiovascular stability with maintenance of hemodynamic parameters, including mean arterial pressure, heart rate and systemic vascular resistance. Such stability, which is achieved through the slow continuous ultrafiltration and continuous refilling of the intravascular volume from the interstitium, enables the stability of the circulating blood volume and the preservation of organ perfusion. This is also crucial for renal recovery during acute renal failure.