Inspiratory muscle strength and body composition in patients receiving total parenteral nutrition therapy

We examined the relationship between inspiratory muscle strength and body composition in 59 patients receiving total parenteral nutrition (TPN). Inspiratory muscle strength was assessed by measuring maximal inspiratory pressure (Pm) after a tidal expiration, with the patient supine and the nose occluded. Body composition was determined by multiple isotope dilution. Body cell mass (BCM) and extracellular mass were estimated by measuring total exchangeable potassium (Ke) and total exchangeable sodium (Nae), respectively; Nae/Ke, an index of the nutritional state, was calculated from these values. The effect of changes in muscle mass was evaluated in 29 of the patients by simultaneous determination of Pm and body composition, prior to and at 2-wk intervals during TPN therapy. The Pm was lower (mean +/- 1 SE:33.5 +/- 2.8 cm H2O) in malnourished patients than in those who were in the normal Nae/Ke range (45.3 +/- 4.8 cm H2O, p less than 0.05). Loss of strength was related to reduction in muscle mass because BCM was also reduced in malnourished patients (15.6 +/- 0.8 kg) when compared to those with normal Nae/Ke (19.3 +/- 0.9 kg), (p less than 0.05), and Pm was positively correlated with BCM (r = 0.27, p less than 0.01). Changes in BCM were accompanied by appropriate changes in Pm during the study period (r = 0.44, p less than 0.01); the majority (21 patients) showed improvement in both BCM and Pm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect on survival of acute myocardial infarction in Killip classes II or III patients undergoing invasive coronary procedures

The purpose of the present study was to determine whether patients with acute myocardial infarction (AMI) in Killip class II or III are likely to benefit from catheterization and coronary revascularization performed within 30 days of AMI. The study population was drawn from 2 national surveys performed during 1996 and 1998 in 26 coronary care units operating in Israel. Our analysis included 3,113 patients with AMI who were divided into 2 groups according to their admission Killip class: 2,484 patients (80%) in Killip class I, of whom 1,408 (57%) underwent cardiac catheterization and 1,076 were treated noninvasively; and 629 patients in Killip class II or III, of whom 314 (50%) underwent cardiac catheterization and 315 were managed conservatively. Patients in Killip class II or III who were treated invasively had lower mortality rates than their counterparts who were treated noninvasively at 30 days: 7.6% versus 15.6%, respectively (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.28 to 0.92), and thereafter from 30 days to 6 months, 4.3% versus 13.6%, respectively (OR 0.34, 95% CI 0.16 to 0.68). In Killip class I patients, an invasive versus noninvasive management was not associated with a better outcome at 30 days: 1.6% versus 3.2%, respectively (OR 0.58, 95% CI 0.32 to 1.05), but with similar mortality rates at 30 days to 6 months, 1.9% versus 2.0%, respectively (OR 1.46, 95% CI 0.79 to 2.74). Thus, the present study suggests that patients with AMI in Killip class II or III on admission may benefit from cardiac catheterization and revascularization performed within 30 days from admission, whereas patients with AMI in Killip class I are less likely to benefit from this approach.     

慢性心力衰竭患者的血清可溶性Fas配体和可溶性Fas受体

目的 分析血清可溶性Fas配体(sFasL)和可溶性Fas受体(sEas)与慢性心力衰竭(CHF)的相关性。方法采用酶联免疫吸附双抗体夹心法检测33例CHF患者(CHF组,心功能Ⅱ-Ⅳ级,NYHA)血清sFasL和sFas浓度,并与18例心功能Ⅰ级(NYHA)组比较。结果 CHF与心功能Ⅰ级间sFasL浓度无显著统计学差异[231.50±84.50(心功能Ⅱ级216.50±96.00,Ⅲ级226.80±85.70,Ⅳ级244.00±73.00)vs217.50±89.00pg/mL,P>0.05]。而CHF组血清sFas浓度显著高于心功能Ⅰ级组[1353.30±507.71(心功能Ⅱ级1154.85±371.20,Ⅲ级1412.88±493.62,Ⅳ级1875.67±806.10)vs983.11±461.26pg/mL,P<0.05]。结论 血清sFasL与CHF无相关性。而血清sFas与CHF存在显著相关性。且sFas浓度增高的程度与CHF的严重程度相平行,sFas浓度增高可能在CHF发病机制中起重要作用。     

Hemodynamic basis of the reduced oxygen uptake relative to work rate during incremental exercise in patients with chronic heart failure

BACKGROUND: The ratio of the increase in oxygen uptake to the increase in work rate (DeltaVO2/DeltaWR) during incremental exercise is reduced in patients with severe chronic heart failure (CHF). However, the pathophysiological basis of the reduced O2 uptake relative to work rate has not been elucidated. METHODS: To elucidate the hemodynamic basis of the reduced ratio of DeltaVO2/DeltaWR during exercise in severe CHF, 48 patients with CHF (15 patients in class I, 21 in class II and 12 in class III) performed maximal ergometer exercise with respiratory gas analysis. Cardiac output and systemic O2 extraction were measured at 1-min intervals during exercise. RESULTS: Both peak VO2 and peak cardiac output decreased as the severity of CHF advanced. Patients in class III showed significantly reduced DeltaVO2/DeltaWR than those in class I (8.2+/-0.9 vs. 9.8+/-1.5 ml/min/W, P<0.01). Cardiac output at rest was significantly lower, and O2 extraction at rest was significantly higher in class III than class I. The ratio of the increase in cardiac output to the increase in work rate (DeltaCO/DeltaWR) was significantly lower in class III than class I (42.5+/-14.5 vs. 60.6+/-10.3 ml/min/W), and the ratio of the increase in O2 extraction to the increase in work rate (DeltaO2 extraction/DeltaWR) was significantly higher in class III than class I (0.45+/-0.13 vs. 0.34+/-0.08%/W). The DeltaVO2/DeltaWR was significantly correlated with the DeltaCO/DeltaWR (r=0.67, P<0.01), and the DeltaCO/DeltaWR was inversely correlated with DeltaO2 extraction/DeltaWR (r=-0.65, P<0.01). CONCLUSIONS: Decreased O2 supply due to reduced cardiac output was not fully compensated by the increased O2 extraction. Reduced ratio of DeltaVO2/DeltaWR in advanced CHF reflected the severely attenuated cardiac output response to exercise.     

Bicyclo-prostaglandin E2 metabolite in congestive heart failure and relation to vasoconstrictor neurohumoral principles

Vasodilator prostaglandins may play a role in maintaining circulatory homeostasis in patients with congestive heart failure (CHF). Plasma levels of bicyclo-prostaglandin E2 metabolite (PGEm), a chemically stabilized degradation product of the vasodilator prostaglandin E2, were determined in 45 patients with chronic CHF (New York Heart Association class II, III or IV). Mean circulating levels of bicyclo-PGEm were significantly elevated in patients with functional class III (72 +/- 8 pg/ml) or IV CHF (77 +/- 10 pg/ml) compared with control subjects (49 +/- 3 pg/ml) and patients with functional class II CHF (49 +/- 4 pg/ml). Bicyclo-PGEm concentrations correlated with plasma renin activity (r = 0.68, p less than 0.001) and plasma angiotensin II (r = 0.56, p less than 0.001) and plasma noradrenalin levels (r = 0.34, p less than 0.05). An inverse correlation was found between serum sodium concentrations and levels of bicyclo-PGEm (r = 0.46, p less than 0.01) as well as plasma renin activity (r = 0.66, p less than 0.001). Thus, prostaglandin E2 levels in plasma are increased in patients with severe CHF.     

Usefulness of pulsed tissue Doppler imaging for evaluating systolic and diastolic left ventricular function in patients with AL (primary) amyloidosis

To clarify whether pulsed tissue Doppler imaging at multiple left ventricular LV sites could help to explain the mechanism of congestive heart failure (CHF) in patients with primary amyloidosis, we examined 86 consecutive patients with primary amyloidosis confirmed by biopsy (group I, 31 patients without cardiac involvement; group II, 31 patients with evidence of heart involvement but no CHF; and group III, 24 patients with heart involvement, clinical CHF, and normal fractional shortening >28%). Peak early diastolic myocardial velocities in group II were significantly lower than those in group I, and the values in group III were also significantly lower than those in group II at most sites. In contrast to diastolic abnormalities, peak systolic wall motion velocities in group III were significantly lower than those in group II, but there were no significant differences between groups I and II. Thus, cardiac amyloidosis is characterized by an initial impairment in early cardiac relaxation, whereas CHF is associated with an impairment of peak systolic wall motion velocities, most prominently seen in the longitudinal axis. This systolic dysfunction can be detected by pulsed tissue Doppler imaging, even when ejection fraction is in the normal range.     

Changes in the levels of plasma atrial natriuretic peptide, hemodynamic measurements, and the levels of vasoactive hormones during the clinical course of congestive heart failure

To investigate the mechanism for the release of human atrial natriuretic peptide (hANP) and the pathophysiological role of hANP in patients with congestive heart failure (CHF), plasma hANP levels in patients with dilated cardiomyopathy (DCM) or acute myocardial infarction (AMI) were determined serially, and the relationship between plasma ANP levels and hemodynamic measurements or various vasoactive hormones was analyzed during the clinical course of congestive heart failure. In 63 patients with either AMI or DCM, plasma hANP, plasma renin activity, aldosterone concentration, and catecholamines were measured over 4 weeks, during the course of CHF. Cardiac catheterization with a Swan-Ganz catheter was also performed. Plasma hANP in patients with DCM was elevated continuously during the clinical course. Plasma hANP levels in patients with AMI of Groups II and IV of Forrester's class decreased on days 7 and 14 and those in patients with AMI of Group I changed within normal limits. Plasma hANP levels were correlated positively with pulmonary artery pressure and pulmonary capillary wedge pressure in patients with AMI or DCM. Plasma renin activity, noradrenaline, and adrenaline levels were elevated in the acute phase of myocardial infarction and had a tendency to decrease upon improvement in clinical status. Plasma renin activity and noradrenaline level correlated positively with plasma hANP levels. These data indicate that plasma hANP levels are regulated by atrial distension and severity of cardiac impairment, and that plasma hANP and plasma renin activity or catecholamines correlated closely during the clinical course of CHF, indicating that these hormones may be involved in the volume and electrolytes status in CHF.     

Catabolism of adenine nucleotides favors adenosine production following exercise in patients with chronic heart failure

BackgroundAdenosine 5′-triphosphate is catabolized to adenosine 5′-monophosphate (AMP), which is further degraded by 2 pathways: deamination to inosine 5′-monophosphate and ammonia by AMP deaminase, or dephosphorylation to adenosine and inorganic phosphate by 5′-nucleotidase. Because adenosine is believed to be cardioprotective and we have reported that ammonia production decreased after exercise in patients with chronic heart failure (CHF), we determined if plasma adenosine levels after exercise increases in patients with CHF.Methods and ResultsMaximal ergometer exercise tests with expired gas analysis were performed in 51 patients with CHF (age = 61 ± 2 years, New York Heart Association [NYHA] class I/II/III = 19/18/14) and 20 age-matched normal controls. Serial changes in both plasma ammonia and adenosine levels were determined. The ratio for Δammonia to peak work rate became smaller (control, NYHA I/II/III: 0.59 ± 0.13/0.41 ± 0.06/0.37 ± 0.10/0.22 ± 0.11 μg/dL·watts, respectively) and the ratio for Δadenosine to peak work rate was significantly higher in class III CHF (control, NYHA I/II/III: 0.93 ± 0.21/0.86 ± 0.14/1.11 ± 0.27/2.92 ± 0.67 nmol/L·watts, respectively).ConclusionIn patients with CHF after exercise, the plasma levels of adenosine increased along with the decrease in the plasma levels of ammonia. Considering the physiologic cardioprotective actions of adenosine, the enhanced adenosine production after exercise may be an important adaptive response in patients with CHF.     

Exercise-induced rise in arterial potassium in patients with chronic heart failure.

OBJECTIVES: In patients with chronic heart failure (CHF), exercise is frequently associated with skeletal muscle fatigue and breathlessness due to heightened ventilatory response. The exercise-induced rise in potassium, which is released from the exercising skeletal muscle, has been implicated in ventilatory control during exercise. The aim of the present study was to determine whether the exercise-induced rise in arterial potassium is altered in patients with CHF and to examine the relationship between increased exercise ventilation and exercise-induced hyperkalemia in patients with CHF. METHODS AND RESULTS: We evaluated 88 patients with CHF (25 patients were in class I, 35 in class II, and 28 in class III according to the New York Heart Association functional classification) and 14 normal subjects. Subjects performed symptom-limited ergometer exercise while expired gas, arterial blood gas, and arterial potassium were analyzed. The increases in ventilation (deltaV(E)), effective alveolar ventilation (deltaVA), and carbon dioxide output (deltaV(CO2)) from rest to peak exercise decreased as the severity of CHF advanced. The ratio of deltaV(E) to deltaV(CO2) was significantly elevated in class III patients, although there was no difference in the ratio of deltaVA to deltaV(CO2) among the four groups. Rest and exercise arterial P(CO2) did not differ among the four groups and was controlled within the normal range. The increase in arterial potassium (deltaK+) from rest to peak exercise was markedly reduced as the severity of CHF advanced: (mean +/- SD) 1.70+/-0.32 mmol/L in normal subjects; 1.46+/-0.27 mmol/L in class I patients; 1.15+/-0.24 mmol/L in class II patients; and 0.78+/-0.24 mmol/L in class III patients. The ratios of deltaVA or deltaV(CO2) to deltaK+ were not different among the four groups. The ratio of deltaV(E) to deltaK+, however, was significantly greater in patients in class III than in normal subjects or patients in class I or II. CONCLUSIONS: The deltaK+ from rest to peak exercise was markedly reduced as the severity of CHF advanced. The increased exercise ventilation due to increased physiologic dead space in severe CHF was not accompanied by the corresponding augmentation of exercise-induced hyperkalemia. Exercise-induced hyperkalemia does not contribute to the increased ventilatory drive to keep normal arterial P(CO2) during exercise in the presence of increased physiologic dead space in severe CHF.     

Circulating forms of human atrial natriuretic peptide in patients with congestive heart failure

To elucidate the circulating forms of human atrial natriuretic peptide (hANP) in patients with congestive heart failure (CHF), plasma samples obtained from 36 patients with CHF were analyzed and compared with those from normal subjects. Plasma concentrations of hANP-like immunoreactivity (LI) from normal subjects and patients with mild CHF (class I), as classified by the New York Heart Association (NYHA) functional criteria, did not differ (15 +/- 1 vs. 16 +/- 1 pmol/L, mean +/- SE), whereas plasma levels of hANP-LI in patients with moderate and severe CHF significantly (P less than 0.01) increased in relation to the severity of CHF (class II, 44 +/- 4 pmol/L; class III, 116 +/- 24 pmol/L; class IV, 141 +/- 21 pmol/L). Reverse-phase HPLC and gel permeation chromatography coupled with RIA for hANP revealed that the circulating forms of hANP-LI consisted of alpha-hANP, beta-hANP, and gamma-hANP in CHF, whereas alpha-hANP predominated in normal plasma. The percentage of beta-hANP in total hANP-LI as calculated from the chromatograms by gel filtration was greater in severe CHF (NYHA class III and IV) than those in mild CHF (NYHA class I and II), and apparently exceeded those of other forms. Successful medical treatment for CHF resulted in a marked reduction of total plasma hANP-LI levels with a concomitant disappearance or reduction of beta-hANP in 14 patients examined. These data suggest that beta-hANP and gamma-hANP are secreted from the failing human heart, possibly resulting from the augmented synthesis and/or the altered processing of hANP precursor in cardiocytes, and that circulating beta-hANP may serve as a potential marker for the severity of CHF in man.     

Ambulatory prazosin treatment of chronic congestive heart failure: Development of late tolerance reversible by higher dosage and interrupted substitution therapy

To evaluate whether long-term administration of the oral vasodilator, prazosin, in the ambulatory therapy of chronic refractory congestive heart failure (CHF) results in gradual attentuation of its marked salutary peripheral circulatory relaxing actions, 16 coronary heart failure patients receiving chronic prazosin, 16 mg daily, were assessed for the development of vasodilator tolerance for 12 months. In six of these patients such tolerance was documented after 7 months which was readily surmountable, thereby allowing continuation of effective chronic prazosin therapy. Each of the six tolerance patients underwent four forearm plethysmography studies: prior to chronic prazosin (study I; 4.0 mg study dose), after 7 months prazosin (study II; 4.0 mg), repeated following 1 additional week on higher effective prazosin dose of 32 mg daily (study III; 8.4 mg), and following 2 weeks of prazosin withdrawal (study IV; 4.0 mg). The prazosin study dose increased forearm blood flow, decreased forearm vascular resistance and venous tone in studies I, III, and IV; these variables were unchanged by prazosin in study II. Despite vasodilator tolerance to the initial daily dosage at 7 months (study II), symptomatic effectiveness and improved cardiac performance were sustained throughout the entire 12 months of chronic prazosin therapy by increasing dosage (study III) and brief interruption of the vasodilator (study IV) (NYHA class IV pre-prazosin symptoms improved to class 2.7 at 3 months, class 2.4 at 6 months, and class 2.5 at 12 months chronic prazosin). This study showed that prazosin vasodilator tolerance occurred in approximately one third of CHF patients after several months of chronic prazosin therapy. More importantly, however, the present investigation demonstrated that chronic prazosin symptomatic efficacy can be maintained in such CHF patients by overcoming tolerance with higher effective prazosin dosage or brief prazosin discontinuation.     

Association of hyperadiponectinemia with severity of ventricular dysfunction in congestive heart failure.

BACKGROUND: Adiponectin, which is a collagen-like plasma protein produced by adipose tissue, has anti-atherogenic and anti-inflammatory effects. Plasma adiponectin levels in patients with congestive heart failure (CHF) were determined, as well as relationships between the plasma levels of adiponectin and other hormones. METHODS AND RESULTS: The study group comprised 90 patients with CHF and 20 control subjects, who were divided into 4 subgroups according to New York Heart Association (NYHA) functional class. Plasma levels of adiponectin, tumor necrosis factor (TNF)-alpha and brain natriuretic peptide (BNP) and cardiac hemodynamics were determined. Plasma adiponectin levels were significantly increased according to the severity of NYHA class in the patients with CHF; control: 6.2+/-1.0; NYHA I: 8.5+/-1.9, NYHA II: 12.0+/-2.2, NYHA III: 13.0+/-2.7, NYHA IV: 14.9+/-2.7 microg/ml (p=0.0008). Similarly, plasma BNP levels were significantly increased in accordance with the NYHA class. Plasma adiponectin levels correlated positively with BNP (r=0.40, p=0.0002) and TNF-alpha (r=0.49, p=0.0001), and correlated negatively with cardiac index (r=-0.27, p=0.05). In 24 of 46 patients in the NYHA III and IV subgroups, according to the prompt improvement in cardiac function, levels of both plasma adiponectin and BNP were significantly reduced (p<0.0001). CONCLUSION: Plasma adiponectin levels increased according to the severity of CHF and, moreover, they correlated with the plasma levels of BNP and TNF-alpha. These results indicate that augmented release of adiponectin is involved in the pathogenesis of CHF and further study is needed to elucidate its exact role.     

Predictors of appropriate defibrillator therapy among patients with an implantable defibrillator that delivers cardiac resynchronization therapy

INTRODUCTION: The purpose of this study was to determine predictors of appropriate implantable defibrillator (ICD) therapy among patients with heart failure who are treated with a cardiac resynchronization therapy-defibrillator (CRT-D). METHODS AND RESULTS: Patients enrolled in the Ventak CHF/Contak CD study were treated with a CRT-D device and were required to have NYHA class II-IV CHF, QRS duration > or = 120 msec, and a class I or II indication for an ICD. The study database was retrospectively analyzed during the 6-month postimplant period to identify predictors of appropriate ICD therapy. Five hundred and one of the 581 patients enrolled in the trial had successful device implantation and were included in this analysis. Patients were mostly male (83%), 66 +/- 11 years old, and had coronary artery disease (69%), a mean left ventricular ejection fraction (EF) = 0.22 +/- 0.07, and NYHA class II (33%), III (58%), or IV (9%) CHF symptoms. During 6 months of follow-up, 73 of 501 (14%) patients received an appropriate ICD therapy. Two independent predictors of appropriate therapy were identified: a history of a spontaneous, sustained ventricular arrhythmia (HR = 2.05; 95% CI = 1.31-3.20; P = 0.002) and NYHA class IV CHF (HR = 1.81; 95% CI = 1.10-2.96; P = 0.019). When patients with NYHA class II were excluded from analysis, a history of a sustained ventricular arrhythmia and the presence of NYHA class IV CHF symptoms remained as independent predictors of appropriate ICD therapy. CONCLUSIONS: In a select population of advanced heart failure patients receiving a CRT-D, NYHA class IV CHF was a powerful independent predictor of appropriate ICD therapy. Approximately one-quarter of the patients with NYHA class IV CHF who received a CRT-D device received an appropriate ICD therapy within 3 months after implant. Additional studies are needed to confirm an association between class IV CHF symptoms and an increased frequency of ICD shocks.     

应用细胞凋亡抑制因子评估心力衰竭患者心肌细胞凋亡水平

研究心力衰竭患者细胞凋亡抑制因子水平变化,评估衰竭心肌细胞凋亡状态。方法采取链霉亲和素－生物素ＥＬＩＳＡ法测定６０例心力衰竭患者和５２例正常对照组血清Ａｐｏ－１／Ｆａｓ,白细胞介素－６和肿瘤坏死因子α水平,并测定心力衰竭患者左室身血分数,了解ＥＦ变化与Ａｐｏ－１／Ｆａｓ间的关系。     

Relationship between inflammatory markers and clinical patterns of atrial fibrillation in patients with congestive heart failure

BACKGROUND: Occurence of atrial fibrillation (AF) adversely affects left atrial size and cardiac function. This arrhythmia is also associated with an increase of plasma CRP and fibrinogen concentration. It is not clear whether elevated levels of inflammatory markers in patients with congestive heart failure (CHF) are associated with AF, clinical symptoms or adverse cardiac remodelling. AIM: To investigate the association between levels of inflammatory markers and selected clinical and echocardiographic parameters as well as used treatment in the population of CHF patients with various forms of AF. METHODS: The cross-sectional study included 99 patients with CHF divided into 3 groups. Group I included patients with sinus rhythm. Group II consisted of patients admitted to hospital with AF and discharged with sinus rhythm (the category of paroxysmal and persistent AF). Group III comprised patients with permanent AF. In all patients plasma CRP and fibrinogen concentrations were measured and echocardiographic examination was carried out. Left atrial dimension (LA), ejection fraction (LVEF) and right ventricular systolic pressure (RVSP) were assessed. RESULTS: Mean CRP concentration in group III (5.83+/-5.36 mg/l) was significantly higher than in group I (p=0.001) and group II (p=0.033). In the group with permanent AF mean fibrinogen concentration was elevated to a higher level (391.0+/-77.3 mg/dl) than in group II (p=0.007) and group I (p=0.099). Mean LA and RV dimensions and RVSP in group III were significantly higher than in group I and group II. Multivariable analysis revealed that plasma CRP concentration was significantly associated with the presence of arterial hypertension (p <0.001) and LA enlargement (p=0.007). A significant association between fibrinogen level and CRP level (p=0.038), presence of permanent AF (p=0.045) and metabolic syndrome (p <0.05) was found. Values of ln CRP were significantly correlated with LA diameter (r=0.24; p=0.015). CONCLUSIONS: Increased plasma CRP level in patients with CHF were significantly associated with arterial hypertension and LA enlargement. Permanent form of AF and CRP level have been shown to be significantly associated with increased plasma fibrinogen concentration in the course of CHF.     

Effectiveness of Digitoxin versus Trichlormethiazide/Amiloride in Congestive Heart Failure NYHA Class II/III and Sinus Rhythm

Summary. The effects of digitoxin and/or diuretic agents were investigated in patients with congestive heart failure (CHF) in sinus rhythm with respect to changes in hemodynami parameters, cardiac dimensions, and bicycle ergometric exercise capacity. In a randomized, double-blind study, 16 male patients with CHF NYHA class II and III received a placebo for 1 week (baseline) and then were randomly allocated, double blind, to take either digitoxin (digitalis group, DI: N <5 8) or trichlormethiazide/amiloride (diuretic group, DG: N <5 8) for 3 weeks (VP I). The patients who were first treated with digitoxin received the diuretic agent for a further 3 weeks and vice versa (VP II). At baseline and after VP I and II, a physical examination, 2D echocardiography, and bicycle ergometry were performed. Heart rate (HR), systolic (BPs), and diastolic (BPd) blood pressure at rest, and BPs at 50 watts, were not significantly changed during the observation period. HR at 50 watts was decreased in DI (11.5 <6 10.1 beats/mh) after VP I and II, but not in DG. BPd was significantly reduced after VP II in DI (8.2 <6 4.6 mmHg) and in DG (9.3 <6 8.9 mmHg). DI presents at baseline significantly higher end-diastolic (LVEDV) and end-systolic (LVESV) left ventricular dimensions, whereas left atrial diameter (LA) and stroke volume (SV) and ejection fraction (LVEF) were not significantly different. After VP I, a significantly decreased LA was found in DI, but not in DG. After VP II, all cardiac dimensions were significantly reduced compared with the baseline in DI, whereas in DG only a decrease in LVESV was found. SV was significantly increased in DI, but not in DG after VP I. SV and LVEF were significantly improved in DI and in DG after VP II. Exercise capacity did not change significantly in DI and DG. Digitoxin in combination with trichlormethiazide/amiloride is effective in reducing primarly enlarged left atrial and left ventricular dimensions, and is sufficient to improve the impaired systolic left ventricular function in CHF of NYHA class II and III in sinus rhythm. However, a significant increase in exercise capacity was not found. Treatment with digitoxin seems to be more relevant as a monotherapy with trichlormethiazide/amiloride.     

Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2)

OBJECTIVES: The purpose of this study was to examine treatment and outcomes in patients admitted to the hospital with acute myocardial infarction (AMI) complicated by congestive heart failure (CHF). BACKGROUND: Although cardiogenic shock complicating AMI has been studied extensively, the hospital course of patients presenting with CHF is less well established. METHODS: The Second National Registry of Myocardial Infarction (NRMI-2) was analyzed to determine hospital outcomes for patients with ST-elevation AMI admitted with CHF (Killip classes II or III). RESULTS: Of 190,518 patients with AMI, 36,303 (19.1%) had CHF on admission. Patients presenting with CHF were older (72.6 +/- 12.5 vs. 63.2 +/- 13.5 years), more often female (46.8% vs. 32.1%), had longer time to hospital presentation (2.80 +/- 2.6 vs. 2.50 +/- 2.4 h), and had higher prevalence of anterior/septal AMI (38.8% vs. 33.3%), diabetes (33.1% vs. 19.5%), and hypertension (54.6% vs. 46.1%) (all p < 0.0005). Also, they had longer lengths of stay (8.1 +/- 7.1 vs. 6.8 +/- 5.3 days, p < 0.00005) and greater risk for in-hospital death (21.4% vs. 7.2%; p < 0.0005). Patients with CHF were less likely to receive aspirin (75.7% vs. 89.0%), heparin (74.6% vs. 91.1%), oral beta-blockers (27.0% vs. 41.7%), fibrinolytics (33.4% vs. 58.0%), or primary angioplasty (8.6% vs. 14.6%), and more likely to receive angiotensin-converting enzyme inhibitors (25.4% vs. 13.0%). Congestive heart failure on admission was one of the strongest predictors of in-hospital death (adjusted odds ratio 1.68; 95% confidence interval 1.62, 1.75). CONCLUSIONS: Patients with AMI presenting with CHF are at higher risk for adverse in-hospital outcomes. Despite this, they are less likely to be treated with reperfusion therapy and medications with proven mortality benefit.     

Relationships of the renin-angiotensin-aldosterone system and sodium balance to blood pressure regulation in chronic renal failure of polycystic kidney disease

In 5 patients with polycystic kidney disease and creatinine clearances ranging from 4 to 40 ml/min, relationships between changes in blood pressure, sodium balance, body fluid compartments, plasma renin activity (PRA), urinary aldosterone excretion, and plasma aldosterone concentrations were studied during periods of low, medium, and high sodium intake. Total body water (TBW), total exchangeable body sodium (TEBS), and extracellular volume (ECV) were measured by isotope dilution techniques, plasma volume with Evan's blue dye, and PRA and aldosterone by radioimmunoassay. Low sodium intake reduced kidney function, blood pressure, and serum sodium, while PRA reached its highest levels. Subsequent increases in sodium intake improved kidney function and increased blood pressure. Plasma volume increased slightly and ECV markedly, while PRA dropped to 15% of the value noted after the low sodium intake. TBW and TEBS showed inconsistent changes. Aldosterone changes correlated closely with PRA. Blood pressure showed a negative correlation with PRA, but a positive one with body weight and cumulative sodium balance, and with plasma and extracellular volumes. It is suggested that whereas renin and aldosterone are involved in the maintenance of circulatory homeostasis during sodium loss, sodium retention causes an increase in blood pressure by concomitant changes in body fluids.     

The significance of CA125 levels in patients with chronic congestive heart failure. Correlation with clinical and echocardiographic parameters

OBJECTIVE: To assess serum levels of carbohydrate antigen 125 (CA125) in patients with chronic congestive heart failure (CHF) and to assess any correlation with clinical symptoms and echocardiographic indices. PATIENTS AND METHODS: We enrolled 77 male patients (mean age: 73+/-10 years) admitted to the Cardiology Emergency Department (ED) with cardiac symptoms requiring hospitalization. Diagnosis of CHF was based upon medical history or initial echocardiographic evaluation on current admission. Serum CA125 was measured by an enzyme immunoradiometric assay, on admission and before discharge. RESULTS: The median overall CA125 value was 22.4 (11.5-48.9) U/ml. Serum CA125 levels were related to the severity of CHF [New York Heart Association (NYHA) class I: 19.2 (7.2-31) U/ml, NYHA class II: 17.6 (10-23) U/ml, NYHA class III: 32 (25-77) U/ml and NYHA class IV: 34.3 (18.6-77) U/ml (p<0.04)]. Patients in NYHA classes III and IV had significantly higher mean values of CA125, than patients in class II (p<0.005 and p<0.05, respectively). Moreover, patients with fluid congestion (pulmonary congestion, ankle edema) had higher levels of serum CA125 than patients without congestion (p=0.002 and p<0.03, respectively). Finally, levels of serum CA125 correlated weakly with right ventricular systolic pressure (RVSP) and renal function, while no significant correlation was found between CA125 and E wave deceleration time on Doppler echocardiography, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVEDD), liver function and the medical treatment prescribed. CONCLUSION: Serum CA125 is associated with the clinical severity of CHF and the symptoms and signs of fluid congestion and therefore may be a useful additional tool for the evaluation and clinical staging of these patients.     

Outcomes following surgical ventricular restoration for patients with clinically advanced congestive heart failure (New York Heart Association Class IV)

BackgroundIt has been well documented that survival in patients with advanced congestive heart failure (CHF) receiving medical therapy is worse with advancing stages of disease (New York Heart Association [NYHA] IV versus NYHA III). However, such comparisons are rare in the surgical treatments for CHF. Surgical ventricular restoration (SVR) is an accepted therapy for patients with ischemic cardiomyopathy after anterior wall myocardial infarction. We evaluated the impact of advanced stage of CHF (NYHA IV) on survival after SVR.Methods and ResultsA retrospective review was conducted of SVR patients at our institution between January 2002 and December 2005. Seventy-eight patients underwent SVR during the study period; 34 patients were NYHA IV and 44 patients were NYHA II/III before surgery. NYHA IV patients had significantly worse preoperative ejection fraction (EF), left ventricular end systolic volume index (LVESVI), and stroke volume index (SVI). Both groups demonstrated significant improvement in EF and LVESVI after SVR, and there were no differences between the groups with regard to postoperative EF, LVESVI, or SVI. There were 3 operative deaths in each group (P = 1.00). Sixty-five percent (P < .0001) of NYHA IV patients and 82% (P < .0001) of NYHA II/III patients improved to NYHA class I or II at follow-up. NYHA IV patients trended toward reduced Kaplan-Meier survival at 32 months (68% versus 88%, P = .08), although NYHA IV was not a significant predictor of mortality.ConclusionsNYHA IV patients demonstrate similar improvements in cardiac function with acceptable, although decreased, survival after SVR when compared with those with less severe clinical disease. These outcomes are superior to those reported for medical management, indicating that patients with clinically advanced CHF who are appropriate candidates should be considered for SVR irrespective of preoperative NYHA class.