Anemia in chronic heart failure--frequency and prognostic impact

Chronic heart failure (CHF) is an important public health care problem and a leading cause of morbidity and mortality world wide. Anemia is a common finding in CHF and known to cause heart failure. Patients with CHF are limited by exercise capacity and fatigue. A low hemoglobin concentration leads to impairment of both. With increasing severity of heart failure, anemia also becomes more frequent and clinically more relevant. There are many potential reasons for development of anemia in chronic heart failure like bone marrow depression, reduced intestinal iron uptake, and the dilution in consequence of sodium and water retention. However, the anemia seen in CHF is generally an "anemia of chronic illness". Furthermore, it has been shown that hemoglobin levels independently predict increased mortality in CHF.     

Use of diuretics in heart failure and cirrhosis

Sodium and water retention in cardiac failure and cirrhosis is pivotal in the morbidity and mortality of patients with these disorders. Moreover, the pathophysiology of these edematous disorders is quite similar. Both disorders have activation of the renin-angiotensin-aldosterone system, increased sympathetic activity, and nonosmotic stimulation of arginine vasopressin, which is initiated by unloading of the arterial baroreceptors; this occurs secondary to diminished cardiac output with heart failure and primary systemic arterial vasodilation with cirrhosis. With this common pathophysiology causing pulmonary congestion, ascites, and peripheral edema, diuretics are pivotal in the therapy of patients with heart failure and cirrhosis. Advanced cardiac failure and cirrhosis both show secondary hyperaldosteronism and impaired renal escape from the sodium-retaining effect of aldosterone. However, currently there are contradictory uses of mineralocorticoid-receptor antagonists in cardiac failure (non-natriuretic doses) versus cirrhosis (natriuretic doses). This disparity relates to the greater potential of hyperkalemia in cardiac failure patients receiving inhibitors of the renin-angiotensin-aldosterone system. This review discusses the beneficial and potentially deleterious effects of diuretic use in patients with cardiac failure and cirrhosis.     

Tolvaptan alleviates excessive fluid retention of nephrotic diabetic renal failure unresponsive to furosemide

Patients with diabetic nephropathy develop nephrotic syndrome and may show limited response to conventional therapy. They often require earlier initiation of renal replacement therapy because they become refractory to diuretics, and experience excessive fluid retention. We aimed to investigate the efficacy of tolvaptan, an oral arginine vasopressin type 2 receptor antagonist, in a case series of 14 severe diabetic renal failure patients who were severely refractory to maximal doses of furosemide and had excessive fluid retention despite preserved cardiac function and residual renal function. All 14 patients experienced immediate and sustained water diuretic effects, resulting in alleviation of congestive heart failure. None required initiation of renal replacement therapy. Tolvaptan promptly increased urine volume and free water clearance, reversed progressive fluid retention, and alleviated congestive heart failure. Thus, tolvaptan could serve as a potential adjunct therapy for severe diabetic renal failure patients with excessive fluid retention and congestive heart failure.     

Current treatment of chronic heart failure

Cardiovascular diseases including heart failure represent a common disease in patients referred for anesthesia.In most cases, heart failure is caused by left ventricular dysfunction due to coronary heart disease. The aims of the treatment of chronic heart failure are the relief of symptoms, the improvement of prognosis and the prevention of the progression of heart failure. The first-line treatment involves the underlying heart disease such as myocardial revascularisation procedures in coronary heart disease or the correction of valve diseases. The pharmacological therapy depends on the stage of heart failure and symptoms of the patient. Heart failure therapy includes ACE-inhibitors, betablockers, diuretics und digitalis. Nitrates can be prescribed in patients with symptomatic heart failure despite adequate therapy but calcium antagonists are not recommended. Repeated or prolonged treatment with positive inotropic agents like phosphodiesterase inhibitors or beta-adrenergic drugs increases mortality but this is commonly used in acute stages of heart failure refractory to treatment. Interactions of ACE-inhibitors or AT1- antagonists with anesthetic agents can lead to severe hypotension especially in hypovolemic patients. Whether those drugs should be continued perioperatively or not has been controversially discussed. The use of betablockers has a positive impact on cardiac morbidity and mortality during and early after surgery. Chronic treatment with diuretics can be associated with hypovolemia and an imbalance of electrolytes leading to hypotension and arrhythmia during anesthesia but careful evaluation prior to anesthesia can avoid such complications. The continuation of digitalis during anesthesia has been controversially discussed due to the various interactions with anesthetics.     

Renal hemodynamics in heart failure: implications for treatment

PURPOSE OF REVIEW: The purpose of this review is to describe the hemodynamic alterations in the kidney which occur in heart failure and to understand the cardiovascular and renal mechanisms responsible for these alterations. Implications for the clinical management of heart failure will be delineated on the basis of the pathophysiologic cardiorenal interactions. RECENT FINDINGS: Recent studies have shown that patients with heart failure exhibit abnormal cardiorenal hemodynamics on the basis of numerous pathophysiologic disturbances involving both the cardiovascular and renal systems. Macrovascular stiffening leads to microvascular damage with impairment of renal autoregulation. Diffuse neurohormonal activation occurs of multiple systems, particularly the renin-angiotensin-aldosterone system, sympathetic nervous system, arginine vasopressin system, endothelin system, and natriuretic peptide system, leading to an overall vasoconstrictive state promoting sodium and water retention and further impairment of cardiac function. Pharmacologic therapy directed at specific biochemical targets within these neurohormonal pathways has shown marked benefits in improving both the symptoms of heart failure and clinical outcomes. SUMMARY: Heart failure is characterized by abnormal cardiovascular hemodynamics, sodium and fluid retention, and diffuse neurohormonal activation, all of which affect the net renal hemodynamic state. An understanding of the pathophysiologic mechanisms is necessary to optimally manage patients with heart failure and help restore cardiorenal homeostasis.     

Drugs acting on the heart: heart failure and coronary insufficiency

Heart failure (HF) and coronary insufficiency are common among intensive care patients or those undergoing surgery. Both conditions can present as an acute decompensated state with high mortality or with a more stable, chronic course. Although similar drugs can be used to treat both conditions, an understanding of the respective pathological processes enables better targeting of treatment. Several drugs have been recently developed for HF and coronary insufficiency. It is increasingly appreciated that HF is not a single entity: the pathophysiology, treatment and prognosis depend on whether systolic or diastolic dysfunction predominates, and whether the condition is stable and compensated or acute and decompensated. Acute decompensated heart failure (ADHF) is treated with diuretics, vasodilators and positive inotropes in some cases. It is better to treat decompensated systolic HF with reduced left ventricular ejection fraction (LVEF; < 40%) with arterial dilators, whereas diastolic HF with intact LVEF responds better to venodilators. After an episode of ADHF, treatment for chronic HF (diuretics, angiotensin-converting enzyme inhibitors (ACEIs) and β-blockers unless contraindicated) should be initiated before hospital discharge and continued. ACEIs and β-blockers slow the progression of chronic HF and reduce mortality. Ischaemic heart disease is managed with nitrates, β-blockers, ACEIs, statins and anti-platelet drugs. In the acute coronary syndrome, thrombolytic agents are still used.     

Successful,Combined Long-term Treatment of Cerebral Candidiasis and Aspergillosis in a Liver Transplant Recipient: A Case Report

Invasive fungal infections, of which the most common are candidiasis and aspergillosis, are among the most important and fatal complications in solid organ transplantation. They continue to be a significant cause of morbidity and mortality in patients with involvement of the central nervous system (CNS) because of the poor CNS penetration of antifungal medications. Voriconazole yields fungicidal drug concentrations in the CNS, but its use is limited in solid organ transplant patients because of its metabolic interactions with immunosuppression. Here we report a case of invasive fungal infection in the CNS after an emergency liver transplantation due to hepatitis B virus–related acute liver failure. The patient was managed successfully with a long-term conservative medical treatment.     

When is it appropriate to use vasopressin receptor antagonists?

Hyponatremia is a common and challenging disorder. The mainstays of treatment until recently were water restriction and hypertonic saline. The first nonpeptide vasopressin receptor antagonist (VRA) is now approved by the US Food and Drug Administration for use in patients with euvolemic and hypervolemic hyponatremia. VRA induce urinary dilution with an aquaresis that leads to an increase in serum sodium concentration. In patients with heart failure, VRA modestly improve congestive symptoms but have no effect on short- or long-term mortality. Long-term effects have not been extensively studied, but serious adverse effects of VRA are rare, and the rate of rise in serum sodium that they produce seems unlikely to lead to osmotic demyelination. Beneficial effects beyond changing serum tonicity and alternative uses, such as in polycystic kidney disease, need further exploration. This commentary discusses the current and potential indications for use of VRA.     

Nephritic edema

Nephritic edema results from the primary retention of salt. Acute glomerulonephritis is the prototypical form of the disorder. The stimulus for the salt retention arises within the kidney by an unknown mechanism. As effective arterial blood volume (EABV) was normal at the start of the disease process, it becomes expanded as salt and water are added to it. The pathophysiological sequelae of this process are compared with those which follow the salt retention of congestive heart failure (CHF). The latter is a syndrome in which salt retention is secondary, driven by the contraction of EABV which is at the heart of CHF. Finally, mechanisms responsible for the salt retention of nephrosis are considered. It is possible, and even likely, that most patients with nephrotic edema have primary salt retention, rather than secondary edema. If this view is correct, salt is retained not because of urinary protein loss and its consequent hypoalbuminemia, but rather because of the glomerulopathy which caused the syndrome in the first place.     

Therapy of heart failure

The incidence and prevalence of heart failure is on the rise. It has become the single most expensive health care item in the United States and the number one discharge diagnosis in the elderly. The goals of therapy include both prevention and treatment of heart failure. In recent years research studies and randomized clinical trials have revolutionized the understanding of the pathophysiology and treatment of this disease. This article focuses on the medical management of chronic systolic heart failure based on the pathophysiology of the disease. Systolic heart failure is characterized by a decrease in left ventricular function and cardiac output, which results in activation of several neurohormonal compensatory systems. The long term effects of this neurohormonal activation leads to further deterioration of cardiac function. The use of hydralazine and nitrates to reduce the systemic vascular resistance was the first to show an improvement in mortality and morbidity. Then angiotensin converting enzyme inhibitors, by inhibiting the renin angiotensin system, demonstrated a greater improvement in mortality and morbidity. More recently the inhibition of the sympathetic stimulation with beta-blockers has been shown to have an additive effect on morbidity and mortality in combination with angiotensin-converting enzyme inhibitors. Digoxin and diuretics remain important for improving symptoms and decreasing hospitalizations but have not been shown to decrease mortality. The most recent advance in the treatment of cardiac failure is the demonstration that the aldosterone antagonists, spironolactone decreases morbidity and mortality.     

Acute Renal Failure in Hospitalized Patients in China: A Prospective Study

Acute renal failure (ARF) is a common complication in hospitalized patients, but little is known about the epidemiology of ARF in China. In this study, we performed a prospective examination of the cause, prognosis, and risk factors associated with ARF at a hospital in Shanghai, China. We considered all ARF patients who were admitted to our hospital from December 2003 to December 2006. Among the 320 ARF patients, 135 (42.2%) were over the age of 60. Sepsis, heart failure, and nephrotoxic drug use were the leading causes of ARF. The overall mortality rate was 31.9%, and mortality rate was significantly higher among the elderly. Logistic regression indicated that heart failure, respiratory failure, and malignant cancer were risk factors independently associated with poor prognosis. In this Shanghai hospital, there was a high incidence and mortality rate of patients hospitalized with ARF. The prognosis of patients who underwent renal replacement therapy was better than those who were treated more conservatively.     

Predicting the risk of death from heart failure after coronary artery bypass graft surgery

Heart failure is the most common cause of death among coronary artery bypass graft (CABG) patients. In addition, most variation in observed mortality rates for CABG surgery is explained by fatal heart failure. The purpose of this study was to develop a clinical risk assessment tool so that clinicians can rapidly and easily assess the risk of fatal heart failure while caring for individual patients. Using prospective data for 8,641 CABG patients, we used logistic regression analysis to predict the risk of fatal heart failure. In multivariate analysis, female sex, prior CABG surgery, ejection fraction <40%, urgent or emergency surgery, advanced age (70-79 yr and >80 yr), peripheral vascular disease, diabetes, dialysis-dependent renal failure and three-vessel coronary disease were significant predictors of fatal postoperative heart failure. A clinical risk assessment tool was developed from this logistic regression model, which had good discriminating characteristics (receiver operating characteristic clinical source = 0.75, 95% confidence interval: 0.71, 0.78). IMPLICATIONS: In contrast to previous cardiac surgical scoring systems that predicted total mortality, we developed a clinical risk assessment tool that evaluates risk of fatal heart failure. This distinction is relevant for quality improvement initiatives, because most of the variation in CABG mortality rates is explained by postoperative heart failure.     

The prognostic use of right heart catheterization data in patients with advanced heart failure: how relevant are invasive procedures in the risk stratification of advanced heart failure in the era of neurohormones?

BACKGROUND: Right heart catheterization long has been a routine investigation in advanced heart failure, and its measurements have been linked variably to prognosis. However, in the modern era, newer potential markers of prognosis are coming to light. This study reconsiders the use of right heart catheterization data and compares their use to that of N-terminal pro-brain natriuretic peptide (NT-proBNP), a neurohormone linked with prognosis in chronic heart failure. METHODS: We assessed prospectively the prognostic potential of baseline right heart catheterization data in 97 consecutive patients with advanced heart failure referred to the Scottish Cardiopulmonary Transplant Unit for consideration of cardiac transplantation. Patients underwent baseline routine investigation, including right heart catheterization and blood draws for NT-proBNP analysis. Patients were observed for a median of 370 days. RESULTS: The primary end-point of all-cause mortality was reached in 17 patients (17.5%), and the secondary end-point of all-cause mortality or urgent cardiac transplantation was reached in 21 (21.6%) patients. Univariate predictors of all-cause mortality included pulmonary artery systolic pressure (PASP), pulmonary artery wedge pressure (PAWP), and NT-proBNP concentration greater than their median values. Univariate predictors of the secondary end-point included right atrial pressure, PASP, PAWP, and NT-proBNP concentration greater than their median values, and left ventricular ejection fraction, cardiac output, and cardiac index less than their median values. In multivariate analyses, however, only NT-proBNP concentration remained an independent predictor of all-cause mortality. Both NT-proBNP concentration and PAWP were independent predictors of all-cause mortality and of the need for urgent cardiac transplantation. CONCLUSION: Baseline data from routine right heart catheterization are of limited prognostic use in advanced heart failure. A baseline NT-proBNP concentration is a superior, non-invasive method of risk stratification in this era of measuring neurohormones.     

Vasopressin antagonists: role in the management of hyponatremia

Hyponatremia is a common electrolyte disorder associated with potentially serious or life-threatening consequences. Serum osmolality and sodium concentration [Na+] are regulated by thirst, the hormone arginine vasopressin (AVP), and renal water and sodium handling. Hyponatremia is frequently caused by dysregulation of AVP, which accompanies disorders of water retention, such as congestive heart failure (CHF) and the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Clinical trials with AVP receptor antagonists have confirmed the important role of AVP in the pathophysiology of hyponatremia and suggest these agents are efficacious in treating hyponatremia associated with SIADH, cirrhosis, and CHF. Acting directly at AVP receptors in the renal tubules, these agents promote aquaresis - the electrolyte-sparing excretion of free water - in patients with hyponatremia. In clinical trials, AVP receptor antagonists have been shown to increase the serum [Na+] and urine output while decreasing urine osmolality.     

Role of iron deficiency and anemia in cardio-renal syndromes

Chronic heart failure is a common disorder associated with unacceptably high mortality rates. Chronic renal disease and anemia are two important comorbidities that significantly influence morbidity and mortality in patients with chronic heart failure (CHF). Progress in CHF again may cause worsening of kidney function and anemia. To describe this vicious cycle, the term cardio-renal anemia syndrome has been suggested. Iron deficiency is part of the pathophysiology of anemia in both CHF and chronic kidney disease, which makes it an interesting target for treatment of anemia in cardio-renal anemia syndrome. Recently, studies have highlighted the potential clinical benefits of treating iron deficiency in patients with CHF, even if these patients are nonanemic. This article summarizes studies investigating the influence of iron deficiency with or without anemia in chronic kidney disease and CHF and gives an overview of preparations of intravenous iron currently available.     

The management of female urinary retention

Female acute urinary retention (AUR) is relatively uncommon and often poorly managed. There are several common precipitants though much of the literature refers to female AUR as a psychogenic condition. The underlying abnormality is often detrusor failure, not outlet obstruction. Investigations should focus on identifying serious or reversible causes and should include a detailed history and physical examination, urine dipstick, culture and pelvic ultrasound. Patients should be catheterised and reversible causes should be treated. Women who fail to void after catheter removal should be taught ISC. Alpha-blockers are no better than placebo in the treatment of female AUR. There is no role for urethral dilatation. Patients with apparently idiopathic retention should be referred to a urologist with an interest in bladder dysfunction for consideration of urodynamics.     

The right heart and its distinct mechanisms of development, function, and failure

Congestive heart failure is the most common cause of hospitalization in the United States for people over the age of sixty-five. As the population ages, the morbidity and mortality from heart failure will become more prevalent. Left heart failure has been, and continues to be, extensively studied. However, a recent report from the National Heart, Lung, and Blood Institute suggests that the right heart has been relatively under-investigated, and unfortunately, most of the basic mechanisms of intracellular signaling within the right heart still remain poorly understood. Right heart failure is now being increasingly recognized as distinctly different from left heart failure, and an important mediator of overall cardiovascular collapse. The purpose of this review, therefore, is to discuss the current understanding of right heart cellular development, physiology, and pathophysiology, as well as to review therapeutic interventions that are both currently available and under investigation.     

The burden of acute renal failure in nonrenal solid organ transplantation

BACKGROUND: Recipients of nonrenal solid organ transplants are at risk for acute renal failure resulting from cardiac or hepatic failure, prolonged surgery, and nephrotoxic effects of immunosuppression. Single-center studies have suggested a variable incidence of acute renal failure in this population, with an associated increase in mortality. This study examines the incidence of acute renal failure and its associated mortality and morbidity in a modern multicenter cohort. METHODS: All adult liver, heart, and lung transplant recipients from 2002 were identified from the New York Statewide Planning and Research Cooperative System database. The impact of acute renal failure on mortality, length of stay, and charges was analyzed using multivariate regression models. RESULTS: Among 519 liver, heart, and lung transplant recipients, the incidence of acute renal failure was 25%, with 8% of patients requiring renal replacement therapy. Acute renal failure requiring renal replacement therapy was associated with increased mortality among both heart (odds ratio, 9.0; 95% confidence interval, 1.8-45.8) and liver transplant recipients (odds ratio, 12.1; 95% confidence interval, 3.9-37.3). This degree of acute renal failure also increased length of stay by nearly 3 weeks and charges by more than $115,000. Even among patients who did not require renal replacement, acute renal failure was strongly associated with increased mortality, length of stay, and charges. CONCLUSIONS: Acute renal failure remains a common complication of nonrenal solid organ transplantation and is associated with increased mortality, prolonged hospitalization, and significant financial costs.     

Management of pancreatic trauma.

Since 1950, 300 patients sustaining pancreatic injuries have been managed. Three-fourths of the injuries were due to penetrating trauma with a 20% mortality and one-fourth due to blunt trauma resulting in an 18% mortality. The pancreatic injury was responsible for death in only 3% of patients. Early onset of shock resulted in 38% mortality whereas only 4% of normotensive patients died. No patient died of an isolated pancreatic injury. Sepsis was the second most common cause of death following hemorrhage. Preoperative serum amylase was elevated more frequently following blunt trauma than penetrating trauma, but did not correlate with injury. There has been a tendency toward more frequent use of distal pancreatectomy for simple penetrating injuries without obvious ductal violation which increases operative time, blood loss and possible intra-abdominal abscess since resection usually requires splenectomy. Patients considered for an 80% distal resection are better managed with a Roux-en-Y limb to the distal pancreas since three patients developed diabetes following an 80% or greater resection. A conservative approach consisting of Penrose and sump drainage is adequate for most injuries.     

Pulmonalarterienkatheter

The indication for the use of the pulmonary artery catheter (PAC) in high-risk patients is still a matter of discussion. Observational studies suggested that the use of the PAC did not result in decreased mortality but may even lead to increased mortality and morbidity. Therefore, a number of randomized controlled trials have been performed throughout recent years in patients suffering from sepsis/ARDS, congestive heart failure, multi-organ failure and those undergoing high-risk non-cardiac surgery. The majority of recent randomized studies failed to demonstrate any benefit of the PAC with respect to mortality and morbidity. However, the use of the PAC was also regularly not associated with an increase in morbidity and/or mortality. This review gives an overview of measurement parameters obtained by the current generation of PACs, alternatives to the PAC and recent studies on the use of the PAC in clinical practice.