IMPROVING OUTCOME AFTER ACUTE MYOCARDIAL INFARCTION: WHAT IS THE ROLE OF ACE INHIBITORS?

SUMMARY Acute myocardial infarction continues to be the number 1 killer in industrialised countries. While the more widespread use of thrombolytic therapy has made a dramatic impact on patient survival, changes in long-term prognosis after discharge from hospital have not improved radically and 5-year mortality remains at over 30%. The single most important determinant of survival in the long term is left ventricular function. The process of ventricular dilatation and remodelling begins early after infarction. While such changes may initially go unrecognised clinically, without intervention progressive functional impairment will ensue and the majority of patients will develop signs and symptoms of heart failure, which carries a worse prognosis than many forms of cancer. ACE inhibitors act on both the haemodynamic and neurohormonal mechanisms in heart failure. Several large-scale clinical trials have clearly demonstrated that early use of these agents in stable patients who are not hypotensive or in cardiogenic shock can reduce significantly the development of heart failure and death. A strategy for the early initiation of ACE inhibitor therapy is proposed to improve survival in AMI patients.     

Essentials of the diagnosis of heart failure

Although heart failure is a common clinical syndrome, especially in the elderly, its diagnosis is often missed. A detailed clinical history is crucial and should address not only current signs and symptoms of heart failure but also signs and symptoms that point to a specific cause of the syndrome, such as coronary artery disease, hypertension or valvular heart disease. It is important to determine whether the patient has had a previous cardiac event, in particular a myocardial infarction. The physical examination should include Valsalva's maneuver, a test that is highly specific and sensitive for the detection of left ventricular systolic and diastolic dysfunction in patients with heart failure. An electrocardiograph and a chest radiograph should also be obtained. Two-dimensional echocardiography of the heart helps differentiate systolic from diastolic dysfunction. Coronary angiography is indicated in patients with heart failure and anginal chest pain and should be strongly considered in patients with an electrocardiogram suggestive of ischemia or myocardial infarction.     

妊娠合并心力衰竭的临床特点及分期护理干预

目的:探讨妊娠合并心力衰竭的临床特点及护理干预措施。方法:对1997年2月~2009年3月我院收治的20例妊娠合并心力衰竭患者的临床资料进行回顾性分析。结果:妊娠合并心力衰竭病例中,因妊娠高血压并发心力衰竭11例。产妇死亡1例。新生儿死亡2例,胎儿死亡1例。结论:妊娠高血压性心脏病、妊娠合并先心病是妊娠诱发心力衰竭的主要危险因素,应对孕产妇加强围产期保健、健康教育和心理支持,并根据临床血流动力学及孕产妇生理特点及早发现围生期各个阶段可能出现心力衰竭的征象,以降低心力衰竭的发生率,确保母婴安全。     

Symptomatic Pericardial Disease Associated with Patch Electrodes of the Automatic Implantable Cardioverter Defibrillator: An Underestimated Complication?

Constrictive pericarditis can be associated with ICD patch electrodes. During a mean follow-up of 24 months, in a population of 35 patients who received ICDs with a patch electrodes configuration, we identified three patients with clinical and hemodynamic signs compatible with this event. Patient 1, a 35-year-old male, underwent implantation of an ICD because of a primary electrical disease complicated by cardiac arrest. Fourteen months later he complained ofexertional dyspnea without any signs of heart failure. Right heart catheter- ization showed high filling pressures and diastolic dip and plateau in pressure curves. Thoracotomy and pericardia! exploration were performed. Three months after removal of the patches and insertion of an endocardial lead system, the patient had normal respiration. Patients 2 and 3, who suffered from coronary heart disease without heart failure, exhibited a hemodynamic profile suggestive of constrictive pericarditis: in one patient, 10 months after ICD implantation, associated with right heart failure; and in the other, 18 months after ICD implantation with left heart failure. Patch electrodes were removed in these two patients and replaced by endocardial lead electrodes with subsequent clinical improvement. It is concluded that constrictive pericarditis related to epicardial patch is not an uncommon occurrence during ICD therapy and should be considered in patients who show clinical signs of cardiac decompensation.     

Diagnosis and evaluation of heart failure

Heart failure is a common clinical syndrome characterized by dyspnea, fatigue, and signs of volume overload, which may include peripheral edema and pulmonary rales. Heart failure has high morbidity and mortality rates, especially in older persons. Many conditions, such as coronary artery disease, hypertension, valvular heart disease, and diabetes mellitus, can cause or lead to decompensation of chronic heart failure. Up to 40 to 50 percent of patients with heart failure have diastolic heart failure with preserved left ventricular function, and the overall mortality is similar to that of systolic heart failure. The initial evaluation includes a history and physical examination, chest radiography, electrocardiography, and laboratory assessment to identify causes or precipitating factors. A displaced cardiac apex, a third heart sound, and chest radiography findings of venous congestion or interstitial edema are useful in identifying heart failure. Systolic heart failure is unlikely when the Framingham criteria are not met or when B-type natriuretic peptide level is normal. Echocardiography is the diagnostic standard to confirm systolic or diastolic heart failure through assessment of left ventricular ejection fraction. Evaluation for ischemic heart disease is warranted in patients with heart failure, especially if angina is present, given that coronary artery disease is the most common cause of heart failure. (Am Fam Physician. 2012;85(12):1161-1168. Copyright ? 2012 American Academy of Family Physicians.).     

Indications for pediatric cardiology evaluation

Heart disease in infants and children may often lead to rapid decompensation. Early recognition by the primary physician is essential, since modern medicine and surgery can cure many heart defects. Main clinical signs are cyanosis, heart failure and/or abnormal auscultatory findings. Cyanosis appears shortly after birth or in small infants. In the newborn, cyanosis due to heart disease must be differentiated from pulmonary problems, sepsis or persistent pulmonary hypertension. Heart failure occurs more often in non cyanotic heart defects, mainly with left to right shunts. The main symptoms and signs of heart failure in the infant are briefly discussed. Abnormal auscultatory findings, usually murmurs, are the most common reason for referral to the paediatric cardiologist. However, most murmurs are "innocent" or "functional"; clues to their recognition are given. The present short review should help the primary physician to recognize signs of heart defects in infants and children so as to proceed with timely referral to the specialist.     

Heart failure with preserved systolic function: giving well-deserved attention to the "other" heart failure

Heart failure with preserved systolic function is common in patients hospitalized with decompensated heart failure and is associated with postdischarge morbidity and costs similar to patients with heart failure and systolic dysfunction. It is common in the older people, and hypertension and cardiac ischemia are often etiological factors. Nurses must be able to recognize left ventricular diastolic abnormalities and understand treatment priorities and treatment options on the basis of structural cardiovascular disease; etiology and risk factors; and signs, symptoms, and hemodynamic parameters. Currently, clinical treatments are on the basis of individual randomized clinical trials; however, there are general principles that should be followed during hospitalization and as part of general practice. As in the treatment of systolic heart failure, nurses have active roles in ensuring accurate assessment; optimal care planning; implementation of clinical, psychosocial; and education interventions; and timely and accurate evaluation so that patients have the best chance for successful hospital and postdischarge outcomes.     

Heart failure complicated by atrial fibrillation: mechanistic,prognostic, and therapeutic implications

Atrial fibrillation and congestive heart failure are two distinct clinical entities that are responsible for significant morbidity and mortality in the Western world. Hypertension, coronary artery disease, and nonischemic cardiomyopathy represent the most prevalent underlying pathologies of both diseases, implying a coincidence of both in many patients. The prevalence of atrial fibrillation with a progressive degree of congestive heart failure is increasing, as judged by New York Heart Association functional class. Moreover, the presence of congestive heart failure has been identified as one of the most powerful independent predictors of atrial fibrillation, with a sixfold increase in relative risk of its development. On the other hand, atrial fibrillation can cause or significantly aggravate symptoms of congestive heart failure in previously asymptomatic or well-compensated patients. In some patients, symptomatic dilated cardiomyopathy may develop over time entirely due to atrial fibrillation with rapid ventricular rates. Upon restoration of sinus rhythm, this type of "tachymyopathy" has been shown to be often reversible. Recent investigations of the physiologic and structural changes of the atrial myocardium ("electrical and structural remodeling") have shown that neurohumoral activation, fibrosis, and apoptosis are demonstrable with both diseases. On the other hand, experimental data suggest that the substrates of atrial fibrillation in congestive heart failure are different from those of pure atrial tachycardia-related forms of atrial fibrillation. This review highlights the clinical and pathophysiologic similarities and differences of atrial fibrillation and congestive heart failure relevant to the understanding, treatment, and prevention of these diseases in the population at risk.     

Prise en charge diagnostique et thérapeutique de l'hypertension artérielle pulmonaire

Pulmonary hypertension is a rare disease related to increased resistance in the pulmonary vascular bed. The disease leads spontaneously to right heart failure and death. A pathophysiological classification taking into account possible causal factors is available. Diagnosis rests on right heart catheterisation when clinical and paraclinical data suggest the diagnosis. To date, guidelines are available for severe forms of the disease. ICU management may be required for right heart failure. Despite the lack of consensus, management of patients with pulmonary hypertension resembles to this of patients with severe pulmonary embolism with right heart failure and the need for inotropic support.     

Role of Echocardiography in the Diagnosis of Heart Failure with Preserved Left Ventricular Systolic Function: Update 2013

Heart failure and its complications are significant causes of mortality and morbidity in most societies. Major parts of the studies that constitute the base of modern treatment of heart failure have been limited to the study of heart failure associated with reduced left ventricular ejection fraction (HFrEF). Only during the past 10–15 years, heart failure associated with preserved left ventricular ejection fraction (HFpEF) or primarily right-sided heart failure have come more into focus as our understanding of the critical role of other etiologies for the clinical syndrome of heart failure than a reduced left ventricular (LV) ejection fraction has increased. Furthermore, whilst the powerful prognostic role of a reduced LV ejection fraction has long since been well validated, only relatively recently it was realized that patients with heart failure symptoms and preserved LV ejection fraction also have a substantially impaired prognosis. Previously, these patients had often been dismissed as not having "real heart failure". In parallel, it has become clear that diagnoses like hypertensive heart disease, diabetic cardiomyopathy and heart failure associated with atrial fibrillation, among others, can be understood as forms of HFpEF.     

Beriberi heart disease in a schizophrenic with an unusual diet

A 37-year-old male presented with peripheral edema of sudden onset. Other signs of heart failure were absent. Subsequent evaluation revealed that the patient was a schizophrenic whose diet consisted almost entirely of carbohydrates. A clinical diagnosis of beriberi heart disease was made and the patient improved dramatically within several days of thiamine supplementation. The presentation of beriberi heart disease in developed countries is discussed. Emphasis is placed on food faddists and psychiatric patients in whom clinical findings may be subtle or absent.     

老年充血性心力衰竭364例临床分析

目的 探讨老年人充血性心力衰竭(CHF )的临床特点及治疗措施.方法 对364 例老年CHF 患者的临床资料进行回顾性分析.结果 冠心病、高血压病、肺心病为充血性心力衰竭的主要病因,肺部感染、急性冠状动脉综合征为主要诱因.误诊26 例(占7.14% ),并发症以心律失常及电解质紊乱为主.治疗有效率92.03%.结论 老年人CHF 的治疗应在消除诱因、治疗病因基础上,采用包括强心、利尿、改善心室重塑以及抗心律失常等综合措施.     

Congestive heart failure in children

Congestive heart failure in children is unusual as a presenting problem, and the nonspecific nature of the signs and symptoms in the pediatric population makes recognition difficult. Congenital heart disease is most common in the infant whereas older children most commonly develop congestive heart failure due to cardiomyopathy, myocarditis, electrolyte abnormalities, dysrhythmias, and, more rarely, endocarditis, and rheumatic carditis. Management focuses upon stabilization of the airway and ventilation while improving circulatory function. This is achieved by the use of inotropic agents, combined with attention to the volume and pressure overload, pulmonary problems, dysrhythmias, and ongoing follow-up.     

左西孟旦治疗顽固性心力衰竭的临床观察

目的观察静脉应用左西孟旦治疗顽固性心力衰竭的临床疗效及不良反应。方法选取顽固性心力衰竭患者36例,予常规治疗效果欠佳后给予静脉应用左西孟旦治疗,观察用药后48h生命体征、临床症状（特别是呼吸困难）、心功能等的改善及主要不良反应。结果用药后48h,患者临床状况、呼吸困难程度及心功能均有明显改善;不良反应主要头痛（6％）、低钾血症（8％）和室性早搏（6％）。结论顽固性心力衰竭患者静脉应用左西孟旦后,短期内可取得较好的临床效果,且安全性好。     

The heart disease of Friedreich's ataxia: a clinical and electrocardiographic study of 115 patients, with an analysis of serial electrocardiographic changes in 30 cases

One hundred and fifteen patients with carefully defined Friedreich's ataxia were assessed clinically and electrocardiographically for evidence of heart disease. Cardiac symptoms, of which dyspnoea and palpitations were the most frequent, occurred in less than 30 per cent. Abnormalities on clinical examination were present in a similar proportion; harsh systolic murmurs, ventricular hypertrophy and added heart sounds were the commonest of these. Cardiac failure and persistent arrhythmias were rare and occurred late in the evolution of the neurological disease. Two patients presented with heart disease before developing neurological symptoms. Cardiac signs and symptoms were uncommon in patients without electrocardiographic abnormalities. About two-thirds of the cases had definitely abnormal ECG recordings. The characteristic finding was of widespread T-wave inversion with ventricular hypertrophy. Serial ECGs, recorded over periods of up to 32 years, were available in 30 cases and showed that abnormalities may develop in patients with Friedreich's ataxia at any time up until 20 years after the onset of neurological symptoms. In four patients initial ECG abnormalities had either improved or disappeared subsequently.     

Brain natriuretic peptide-guided therapy in the inpatient management of decompensated heart failure

Heart failure is extremely prevalent and is associated with significant mortality, morbidity and cost. Studies have already established mortality benefit with the use of neurohormonal blockade therapy in systolic failure. Unfortunately, physical signs and symptoms of heart failure lack diagnostic sensitivity and specificity, and medication doses proven to improve mortality in clinical trials are often not achieved. Brain natriuretic peptide (BNP) has proven to be of clinical use in the diagnosis and prognosis of heart failure, and recent efforts have been taken to further elucidate its role in guiding heart failure management. Multiple studies have been conducted on outpatient guided management, and although still controversial, there is a trend towards improved outcomes. Inpatient studies are lacking, but preliminary data suggest various BNP cut-off values, as well as percentage changes in BNP, that could be useful in predicting outcomes and improving mortality. In the future, heart failure management will probably involve an algorithm using clinical assessment and a multibiomarker-guided approach.     

Approach to patients with heart failure and normal ejection fraction

Approximately 50% of patients with a firm clinical diagnosis of heart failure (HF) have a normal ejection fraction. Some patients have valvular disease, but most have underlying diastolic dysfunction that leads to pulmonary and systemic congestion and signs and symptoms of HF. Although diastolic HF is clinically and radiographically indistinguishable from HF with depressed left systolic ventricular function, knowledge of which patients are at risk of diastolic HF, the common clinical profiles, and the common echocardiographic findings enhances the clinician's ability to diagnose diastolic HF with confidence. The prognostic implications of a diagnosis of diastolic HF and the therapeutic approach to such patients are reviewed.     

Hypertrophic osteoarthropathy caused by PGE1 in a patient with congestive heart failure during cardiac rehabilitation

Continuous chronic drug infusion with PGE1 via a portable pump and neuromuscular electrical stimulation (NMES) help to improve the quality of life in patients with severe chronic heart failure waiting for a donor heart, as both treatments can be performed at home. We report a 56-year-old woman suffering from severe chronic heart failure, who was referred for a cardiac rehabilitation program because of progressive muscle weakness and weight loss. Due to her underlying heart disease she was unable to perform voluntary exercise. NMES of both knee extensor muscles was started. Under simultaneous chronic drug infusion with PGE1 via a portable pump the patient developed clinical signs of hypertrophic osteoarthropathy, which prevented her from continuing the rehabilitation program. X-ray examinations and bone scans concurred with the diagnosis of secondary hypertrophic osteoarthropathy. After the PGE1 dose had been reduced, the clinical signs of the osteoarthropathy resolved and the patient was able to continue the rehabilitation program with no difficulty. This case report underlines the importance of being aware of the potential side effects of modern cardiac drugs in the complex treatment of patients waiting for a donor heart.     

早期无创正压通气纠正急性左心衰竭所致严重低氧血症效果观察

目的观察早期无创正压通气（noninavasive positive pressure ventilation，NPPV）对急性左心衰竭所致严重低氧血症的治疗效果。方法40例急性左心衰（心功能Ⅳ）患者随机分为NPPV组和常规治疗组，两组均常规给予强心、利尿、镇静、扩血管等对症支持治疗，NPPV组在常规治疗的基础上采用双向气道正压呼吸机（BiPAP）经面罩双向正压通气治疗，常规治疗组则给予普通高浓度吸氧。观察治疗2小时后两组患者心率、呼吸、血压、脉搏、血氧饱和度（SaO2）、血气分析和临床症状体征的变化。结果NPPV组所有患者HR下降，呼吸困难症状缓解，生命体征平稳，PaO2、SaO2明显增高，缺氧程度得到有效改善，治疗总有效率100％（20／20）；常规治疗组总有效率70％（14／20）。结论重度左心衰患者在抗心衰药物治疗的同时使用BiPAP面罩双相气道正压无创通气可以较快纠正机体缺氧状况，改善心功能，缩短病程。