2002 ACC/AHA guideline versus clinician judgment as diagnostic tests for chest pain.

PURPOSE: Hospital admissions for chest pain are frequent and costly. The use of objective criteria to determine the need for hospitalization may save money. Here we compare the 2002 American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of patients with unstable angina and nonST-segment elevation myocardial infarction to clinical judgment as diagnostic tests to predict which patients with chest pain will develop positive cardiac troponin-I. METHODS: Researchers conducted a retrospective chart review of patients admitted to a military community hospital for chest pain over a 2-year period. The study determined sensitivity and specificity for both the ACC/AHA guidelines and consensus of clinical judgment to predict which subjects would develop positive cardiac troponin-I. RESULTS: Positive cardiac troponin-I was very low (7 of 386). Both the ACC/AHA guidelines and clinical judgment had sensitivities of 100% (95% CI, 65-100) to predict positive cardiac troponin-I. The ACC/AHA guideline was 13% specific (95% CI, 12-13), with clinical judgment at 48% (95% CI, 47-48). Classification as low risk had a high negative predictive value (ACC/AHA guideline, 1.00 [95% CI, 0.95-1.00]; clinical judgment, 1.00 [95% CI, 0.99-1.00]). CONCLUSION: Patients categorized as low risk by either method could probably be discharged from the emergency department without developing positive troponin-I.     

Update on infective endocarditis

Infectious Endocarditis is a disease almost invariably fatal if it is not treated in the proper manner. A review is presented of the cardiac abnormalities and procedures associated with its development as well as the most recent classification of the different modalities of endocarditis. The clinical manifestation, the causative organisms and diagnostic procedures are summarized. The American Heart Assciation and the American College of Cardiology (AHA/ACC) recommendations for management of native valve endocarditis, infective endocarditis in drug users, prosthetic valve endocarditis and culture negative endocarditis are summarized. The conditions that justify surgical interventions are also presented.     

The role of aldosterone-antagonists in the treatment of congestive heart failure

The role of aldosterone-antagonists in the treatment of congestive heart failure. Despite the advances of the treatment of congestive heart failure, nearly half of the patients diagnosed with this disease five years ago are alive today. Experimental and human studies have demonstrated, that under special pathologic condition, the heart extracts aldosterone, and aldosterone extraction in the heart stimulates increased collagen turnover culminating in ventricular remodeling. Aldosterone blockade has been shown to be effective in reducing total mortality and hospitalization for heart failure in patients with systolic left ventricular dysfunction due to chronic heart failure (RALES study with spironolactone) and in patients with systolic left ventricular dysfunction post acute myocardial infarction (EPHESUS study with eplerenone). These clinical studies have shown that mineralocorticoid receptor activation remains important despite the use of angiotensin converting enzyme inhibitor or angiotensin receptor blocking agent and a beta blocker. In the ACC/AHA (and in the European and Hungarian) guidelines for the evolution and management of chronic heart failure, the indication of spironolactone was defined of Class Ila, Level of Evidence: B in CHF of stage C. The eplerenone (in US: INSPRA) was approved for the management of CHF patients after myocardial infarction with ejection fraction < 40%. Eplerenone, compared with spironolactone, is associated with a lower incidence of gynecomastia and other sex hormone-related adverse effect (breast pain, menstrual abnormalities). The spironolactone should not be used in patients with a creatinine above 220 mikromol/l. Despite the guidelines recommendation, spironolactone has been widely used in patients without consideration of their functional class or ejection fraction, without optimization of background treatment with ACE inhibitors and beta-blockers.     

The role of ACE inhibitors and angiotensin receptor blockers in the treatment and prevention of chronic heart failure

The incidence of heart failure is increasing and its prevalence is high, ranging from 1% to 2% in middle aged patients to more than 10% in older patients. Several pharmacologic approaches developed during the past 15 years, have had at least in clinical trials a significant impact on progression of heart failure mortality. The effect of ACE-inhibitors has been documented extensively during the last 15 years. They offered 15% decrease in hospitalization for moderate heart failure and, depending on the severity of the disease, produced a 16% to 31% reduction in mortality. Angiotensin receptor blockers provide unique pharmacological mechanism, and have demonstrated high tolerability in large trials. According to the new ACC/AHA guidelines for the evaluation and management of heart failure, the results of evidence based studies using ACE-inhibitor and angiotensin blocker therapies were analyzed by the author.     

风湿性心脏病合并心脏恶液质综合征的外科治疗

目的　探讨风湿性心脏病合并心脏恶液质综合征的外科治疗方法和特点。方法　对 1996年 4月至 2 0 0 2年12月符合心脏恶液质综合征诊断标准的 18例风湿性心脏病患者外科治疗的临床资料进行回顾性分析 ,其中二尖瓣置换术 14例 ,二尖瓣及主动脉瓣置换术 4例 ,18例均同时进行 De Vega三尖瓣成形术。结果　术后主要并发症为低心排综合征及在此基础上并发的多脏器功能衰竭 ,早期死亡 4例 ,均为多脏器功能衰竭。结论　外科治疗可提高风湿性心脏病合并心脏恶液质综合征病人的治疗成功率和长期存活率 ,正确恰当的围术期处理是手术成功的关键。     

Comanagement of patients with congestive heart failure by family physicians and cardiologists: frequency, timing, and patient characteristics

BACKGROUND: Many patients with congestive heart failure (CHF) receive care solely from a primary care physician, while some receive care from both a primary care physician and a cardiologist. Patients in the latter type of care relationships have not been described. The principal objectives of our study were to determine what percentage of patients with CHF are comanaged, the characteristics of comanaged CHF patients, and when in the natural history of CHF this relationship is initiated. METHODS: A retrospective record review was conducted of all patients who met the modified Framingham criteria for the diagnosis of CHF in a large community-based family practice office. Comanagement was defined as an ongoing relationship with a cardiologist characterized by a minimum of one visit to the cardiologist's office in the year of evaluation. We divided the natural history of CHF into 4 stages to describe the timing of the initial referral to the cardiologist: I Prediagnosis; II Diagnosis; III Progression; and IV Terminal. RESULTS: Of 151 patients identified with CHF, 36% of the patients were comanaged by a primary care physician and a cardiologist. The comanagement relationship often began early in the development of CHF, 20% at stage I and 54% at stage II. The patients who were comanaged were younger, predominately men, had a greater frequency of myocardial infarction, were more likely to have decreased systolic function, were on more cardiac medications, and had fewer hospitalizations for CHF exacerbations compared with CHF patients managed solely by family physicians. CONCLUSIONS: Comanagement of patients with CHF is a common occurrence, and comanaged CHF patients have distinct characteristics from those managed solely by family physicians. These results have implications for the quality and cost of caring for patients with CHF and suggest that more detailed study is required.     

别嘌呤醇治疗对伴高尿酸血症慢性心衰患者心功能的影响

[目的]探讨高尿酸血症的慢性心衰患者,别嘌呤醇治疗对其心功能的影响。[方法]56例心功能II～III级慢性心衰患者分为别嘌呤醇治疗组和对照组。所有对照组患者均于入院后给予常规抗心衰治疗,治疗组在对照组治疗基础上加用别嘌呤醇300mg/d,治疗12周。分别检测治疗前、后血尿酸、左心室舒张末期内径和左心室射血分数的变化。[结果]与治疗前相比,别嘌呤醇组治疗后左心室舒张末期内径明显降低,左心室射血分数升高(P﹤0.05)。与对照组相比,别嘌呤醇组治疗后左心室舒张末期内径,左心室射血分数的改善更为明显(P﹤0.05)。[结论]别嘌呤醇能降低体内氧化应激水平,改善心功能。     

心力衰竭患者B型钠尿肽及其肌钙蛋白Ⅰ和超敏C反应蛋白水平的变化

目的:观察慢性心力衰竭(CHF)患者心肌损伤指标肌钙蛋白I(cTnI)和炎症指标超敏C反应蛋白(hs-CRP)含量变化并探讨其与CHF不同类型及B型钠尿肽(BNP)之间的关系。方法:选择经临床确诊的CHF患者160例(NYHAⅠ-Ⅳ级),健康对照者150名,无CHF的心血管患者142例。用免疫荧光定量分析法测定其全血hs-CRP和BNP水平,微粒子酶促化学发光免疫分析法测定其血清cTnI水平,并进行对比分析。结果:CHF患者组全血BNP和hs-CRP水平均显著高于无CHF的心血管患者组和健康对照组,血清cTnI值CHF患者组亦均显著高于无CHF的心血管患者组和健康对照组(P均<0.01)。且随心功能NY-HA分级的增高,全血BNP水平逐渐升高,组间差别均有统计学意义,而全血hs-CRP与血清cTnI水平随心功能NYHA分级的增高,组间差别均无统计学意义(P均>0.05),但均较健康对照组升高。结论:慢性心力衰竭疾病过程中存在着心肌损伤和炎症,表明心肌损伤和炎症是这种疾病病理生理过程的重要成分,但这种心肌损伤和炎症与心功能NYHA分级和障碍程度无关。     

Activité physique,nutrition, et insuffisance cardiaque chronique

Chronic heart failure (CHF) is a highly prevalent syndrome and a burden for public health. Malnutrition, including its most severe form, cardiac cachexia, is an independent factor of mortality and morbidity. During the course of CHF, there is a loss of muscle mass and an impaired oxidative capacity of muscular mitochondria, together with a shift of type I oxidative to type II non-oxidative muscular fibers. These muscle changes are multifactorial, and result in physical exercise deconditioning. In CHF with reduced left ventricular ejection fraction, exercise training (ET) is well tolerated and improves exercise capacity, quality of life, and cardiovascular-related mortality. ET integrated into a global cardiac rehabilitation program is recommended by academic societies for CHF therapy. Cardiac rehabilitation centres offer ET programs combined with therapeutic education. In CHF-related malnutrition, ET or nutrition support alone, although insufficiently documented, seems to be ineffective. Specific care programs of multimodal rehabilitation enclosing ET, oral nutritional supplements, omega-3 polyunsaturated fatty acids, and anabolizing androgens, could improve exercise capacity and clinical outcome in undernourished patients with moderate to severe CHF. The clinical trial NUTRICARD (ClinicalTrial.gov NCT #01864733) supported in part by the French Society for Clinical Nutrition and Metabolism (SFNEP) is currently testing this hypothesis.     

Physician adherence to preventive cardiology guidelines for women.

Despite the publication of the American Heart Association/American College of Cardiology (AHA/ACC) "Guide to Preventive Cardiology for Women" primary care screening and treatment of women at risk for coronary heart disease risk is not optimal. The purpose of this article is to apply a framework of physician behavior to describe specific challenges in implementing clinical practice guidelines for women's cardiovascular health in the primary care setting. Specifically, we illustrate 1) underlying barriers to adherence, 2) attempts and interventions to overcome these barriers, and 3) future areas of research to improve physician adherence to guidelines for the prevention and treatment of heart disease in women.     

Macro- and micronutrients in patients with congestive heart failure, particularly African-Americans

Not all patients with heart failure, defined as a reduced ejection fraction, will have an activation of the RAAS, salt and water retention, or the congestive heart failure (CHF) syndrome. Beyond this cardiorenal perspective, CHF is accompanied by a systemic illness that includes oxidative stress, a proinflammatory phenotype, and a wasting of soft tissues and bone. A dyshomeostasis of calcium, magnesium, zinc, selenium, and vitamin D contribute to the appearance of oxidative stress and to compromised endogenous defenses that combat it. A propensity for hypovitaminosis D, given that melanin is a natural sunscreen, and for secondary hyperparathyroidism in African-Americans make them more susceptible to these systemic manifestations of CHF-a situation which is further threatened by the calcium and magnesium wasting that accompanies the secondary aldosteronism of CHF and the use of loop diuretics.     

Comparison of Cardiac Risk Scores among the East Mediterranean and South Asian Population

BackgroundCardiovascular disease (CVD) is a global burden particularly in developing countries necessitates the periodical monitoring for these vulnerable population. This study aimed to compare four tools to measure the CVD risk between the East Mediterranean and South Asian population.MethodsThis retrospective analysis included 139 patients from East Mediterranean (n=90) and South Asians (n=49) ethnicity who were admitted during the one-year period in a multi-specialty tertiary care hospital located in Tabuk, Saudi Arabia. Four different tools currently in use across the world were used to analyses the CVD risk.ResultsAtherosclerotic Cardiovascular Disease (ASCVD) from American College of Cardiology/American Heart Association (ACC/AHA) was found to be significant (P=0.0000) than World Health Organization/International Society of Hypertension (WHO/ISH) and Framingham Risk Score (FRS) European SCORE (Systematic Coronary Risk Evaluation) memo card from European Society of Cardiology risk prediction charts. Meanwhile, FRS looks equally good as it detects 44.89% of South Asian study population with >10% CVD risk while ACC/AHA detects 46.93%.ConclusionThe present study recommends ACC/AHA cardiac risk estimator to identify the CVD risk in East Mediterranean population. However, the South Asian population needed a population-based tool to assess the accurate CVD risk.     

心衰患者室性心律失常的发生及其预后分析

目的探讨充血性心力衰竭严重程度与室性心律失常的关系及3年内死亡率分析。方法应用24h动态心电图记录分析88例充血性心力衰竭患者(按NYHA心功能分级均在Ⅱ~Ⅳ级),比较各组心律失常发生率并对心功能分级和心律失常程度进行相关性分析。随访44例心力衰竭患者为期3年并比较各组的生存情况。结果心功能Ⅱ级、Ⅲ级和Ⅳ级患者室性心律失常的发生率分别为42.9%、65.7%和88.0%。随着心功能级别的增加,室性心律失常的发生率越高(p=0.003)。心功能分级和心律失常程度之间经Spearman秩相关分析,具有相关性(rs=0.315,p=0.017),心功能分级越高,心律失常程度越严重。3年随访结果显示,各组生存率间有显著性差异(p<0.05),心功能越差,生存率越低。结论充血性心力衰竭越重,室性心律失常发生率越高,程度越严重,其生存率越差。     

小剂量多巴胺治疗老年慢性心力衰竭疗效分析

目的　观察小剂量多巴胺对老年充血性心力衰竭 (CHF)患者的心功能影响 ,探讨该药在CHF治疗中的应用价值。方法　将 1 0 2例老年CHF患者随机分为 2组。其中A组 5 0例在洋地黄、利尿剂和血管扩张剂治疗的基础上 ,加用小剂量多巴胺注射液静滴 ;B组 5 2例仅给洋地黄、利尿剂和血管扩张剂。 2组均连续用药 2周。用药前后进行多普勒超声心动图检查。结果　A组治疗后患者心排量、心脏指数和射血分数均明显增加。与治疗前比较 ,差异有显著性 (P <0 .0 1或 0 .0 5 ) ;与B组比较差异亦有显著性 (P <0 .0 5 )。A组的临床显效率和总有效率分别为 5 2 .0 %和 90 .0 % ;B组为 2 8.8%和 6 7.4 % ,2组比较差异有显著性 (P <0 .0 5 )。治疗期间未见小剂量多巴胺不良反应。结论　小剂量多巴胺注射液有增强改善心功能的作用 ,是辅助治疗老年CHF的一种有效而安全的药物     

PUFA Supplementation and Heart Failure: Effects on Fibrosis and Cardiac Remodeling

Heart failure (HF) characterized by cardiac remodeling is a condition in which inflammation and fibrosis play a key role. Dietary supplementation with n-3 polyunsaturated fatty acids (PUFAs) seems to produce good results. In fact, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) have anti-inflammatory and antioxidant properties and different cardioprotective mechanisms. In particular, following their interaction with the nuclear factor erythropoietin 2 related factor 2 (NRF2), the free fatty acid receptor 4 (Ffar4) receptor, or the G-protein coupled receptor 120 (GPR120) fibroblast receptors, they inhibit cardiac fibrosis and protect the heart from HF onset. Furthermore, n-3 PUFAs increase the left ventricular ejection fraction (LVEF), reduce global longitudinal deformation, E/e ratio (early ventricular filling and early mitral annulus velocity), soluble interleukin-1 receptor-like 1 (sST2) and high-sensitive C Reactive protein (hsCRP) levels, and increase flow-mediated dilation. Moreover, lower levels of brain natriuretic peptide (BNP) and serum norepinephrine (sNE) are reported and have a positive effect on cardiac hemodynamics. In addition, they reduce cardiac remodeling and inflammation by protecting patients from HF onset after myocardial infarction (MI). The positive effects of PUFA supplementation are associated with treatment duration and a daily dosage of 1–2 g. Therefore, both the European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association (ACC/AHA) define dietary supplementation with n-3 PUFAs as an effective therapy for reducing the risk of hospitalization and death in HF patients. In this review, we seek to highlight the most recent studies related to the effect of PUFA supplementation in HF. For that purpose, a PubMed literature survey was conducted with a focus on various in vitro and in vivo studies and clinical trials from 2015 to 2021.     

Hospitalized congestive heart failure after renal transplantation in the United States

PURPOSE: African Americans have increased risk for congestive heart failure (CHF) compared to Caucasians in the general population, but the risk of CHF in African American renal transplant recipients has not been studied in a national renal transplant population. METHODS: Therefore, 33,479 renal transplant recipients in the United States Renal Data System (USRDS) from 1 July, 1994 to 30 June, 1997 were analyzed in an historical cohort study of the incidence, associated factors, and mortality of hospitalizations with a primary discharge diagnosis of CHF [International Classification of Diseases-9 (ICD9) Code 428.x]. RESULTS: African American renal transplant recipients had increased age-adjusted risk of hospitalizations for congestive heart failure compared to African Americans in the general population [rate ratio 4.60, 95% confidence interval (CI) 4.59-4.62]. In logistic regression analysis, African American recipients had increased risk of congestive heart failure after renal transplantation, independent of other factors. Among other significant factors associated with congestive heart failure, the strongest were graft loss and allograft rejection. No maintenance immunosuppressive medications were associated with CHF. In Cox regression analysis patients hospitalized for CHF had increased all-cause mortality compared with all other recipients (hazard ratio 3.69, 95% CI, 2.23-6.10), but African American recipients with CHF were not at significantly increased risk of mortality compared to Caucasian recipients with CHF. CONCLUSIONS: African Americans recipients were at high risk for CHF after transplant independent of other factors. The reasons for this increased risk should be the subject of further study. All potential transplant recipients should receive particular attention for the diagnosis and prevention of CHF in the transplant evaluation process, which includes preservation of allograft function.     

卡维地洛治疗充血性心力衰竭合并快速型心房纤颤的疗效观察

目的　观察卡维地洛治疗充血性心力衰竭 (CHF)合并快速型心房纤颤 (Af)的临床疗效。方法　将CHF并快速型Af患者 5 6例 ,随机分为治疗组、对照组各 2 8例。治疗组在常规治疗的基础上加用卡维地洛。对照组给予强心利尿等常规治疗。疗程均为 16周。结果　治疗组在临床疗效 (92 .86 % )、心电图疗效 (85 .72 % )以及心泵功能各项指标均明显优于对照组 (P <0 .0 1)。结论　卡维地洛治疗CHF并快速型Af,既能有效控制心室率 ,又能显著改善心功能。     

伊贝沙坦联合卡托普利治疗老年非瓣膜性心脏病慢性心力衰竭疗效观察

目的探讨伊贝沙坦联合卡托普利治疗老年非瓣膜性心脏病慢性心力衰竭(CHF)的临床疗效及安全性.方法51例非瓣膜性心脏病心功能Ⅱ～Ⅳ级(NYHA分级)的CHF患者联合应用伊贝沙坦和卡托普利治疗6个月,观察治疗前后心率(HR)、血压(BP)、血肌酐(Cr)、K 、超声心动图相关指标(包括左室质量指数LVMI)、6min步行试验(6-MWT)、心功能NYHA分级变化及心血管事件发生率.结果治疗6个月后,94.11%的患者心功能改善1～2级,LVEF及6-MWT显著增加(P＜0.001),左室舒张末期内径(LVEDd)、左室收缩末期内径(LVESd)、LVMI及HR、BP均显著降低(P＜0.01);血K 略有升高(P＜0.05),但HR、BP及血K 均在正常范围内;血浆Cr无显著变化(P＞0.05);疗程期间4例(7.84%)发生心血管事件,1例死亡,1例缺血性脑卒中,2例心衰恶化再次住院.结论伊贝沙坦联合卡托普利治疗老年非瓣膜性心脏病CHF患者,可有效逆转心室重塑,改善心脏功能,提高运动耐量且未见明显副作用.     

连续性血液净化治疗肾前性氮质血症(附8例分析)

目的探讨连续性血液净化(CBP)对肾前性氮质血症的治疗效果。方法回顾性分析肾前性氮质血症患者8例,均给予CBP治疗,方案为日间连续性静脉静脉血液透析滤过(CVVHDF)。结果入选患者诱因包括肾病综合征、急性(或慢性基础急性加重)左心功能衰竭、营养不良性低白蛋白血症、肝硬化失代偿期。经CBP治疗后除肝硬化失代偿期患者外,其余7例患者肾功能改善,尿量恢复正常。心功能衰竭患者心功能改善。肝硬化失代偿期患者尿量及肾功能无改善。结论CBP对肾病性低蛋白血症及心源性低灌注所致肾前性氮质血症可能具有较好的效果。     

最新血压标准变化下高血压与心血管疾病关联

目的 本文探究了2020 ISH高血压指南与2017 ACC/AHA高血压指南定义下的血压标准与天津市老年人特别是原定义为高值血压现定义为正常血压人群的心血管疾病发生风险的关联,为进一步评价2020 ISH新指南定义标准在预防心血管疾病的应用中提供参考。方法 基于2014年进入天津市居民健康档案队列,通过整群抽样,选取天津市部分地区60岁以上191 043名老年人的血压测量随访数据。血压诊断采用2种标准:2017 ACC/AHA高血压指南、2020 ISH高血压指南。统计学方法采用卡方检验、独立样本t检验及Cox比例风险模型。结果 介于120/80 mm Hg与130/85 mm Hg之间的血压值在2017年ACC/AHA指南中为高值血压,但在2020年ISH新的血压指南中为正常血压。此区间的51 605名老年人群发生主要心血管事件的风险HR=1.248,95%CI: 1.187～1.313,高于两个标准下均为正常血压的人群,HR有统计学意义。结论 位于120/80～130/85 mm Hg区间的107 575名人群可能会增加CVD发生风险,仍需密切关注。应基于我国实际人口发展状况,采取高血压防线关口前移策略,通过控制发病率降低实现更加有效的防治。