ABSTRACT
Background: Evidence for a link between periodontal disease and several systemic diseases is growing rapidly. The infectious and inflammatory burden of chronic periodontitis is thought to ...have an important systemic impact. Current evidence suggests that periodontitis is associated with an increased likelihood of coronary heart disease and may influence the severity of diabetes.
Scope: This paper represents a UK and Ireland cross-specialty consensus review, undertaken by a group of physicians and dentists. The consensus group reviewed published evidence (PubMed search for review and original articles), focusing on the past 5 years, on the contributory role of periodontal disease to overall health. In particular, evidence relating to a role for periodontal disease in cardiovascular disease and in diabetes was considered.
Findings: Initial studies of large epidemiological data sets have sought to find links between periodontitis and systemic disease outcomes, but a causal relationship still needs to be demonstrated between periodontal disease, cardiovascular disease and diabetes through prospective studies. There is a need for prospective studies assessing the association between periodontal disease and patients at particular risk of cardiovascular events which will allow assessment of both cardiovascular disease clinical endpoints and surrogate markers of cardiovascular risk. Of note, periodontal disease is also often more severe in subjects with diabetes mellitus, a group at already increased risk for cardiovascular events.
Conclusions: While further research is needed to define the population-attributable risk of periodontal disease to both cardiovascular diseases and to diabetes control and progression, health education to encourage better oral health should be considered as part of current healthy lifestyle messages designed to reduce the increasing health burden of obesity, cardiovascular disease and diabetes.
Aims To assess the prevalence of heart failure and asymptomatic left ventricular systolic dysfunction in the chronically paced population. Methods and Results Three hundred and seven patients were ...identified from attendance at routine pacemaker follow-up clinic. Subjects underwent a medical history and examination, 6-minute walk test and echocardiography. 94 (31%) had a left ventricular ejection fraction (LVEF) <40%, of whom 83 had symptoms of heart failure (70% NYHA II, 26% NYHA III and 4% NYHA IV). Heart failure was more prevalent in patients with single chamber compared to dual chamber pacemakers, (DDD(R) 18% vs 35% VVI(R), p<0.008), and those with chronic atrial fibrillation (AF) compared to those with sinus rhythm (42% vs 21%, p=0.003). Decreasing 6-minute walk distance, history of ischaemic heart disease and years of pacing were independently associated with the presence of heart failure (combined R=0.572, p<0.001). Conclusions Heart failure due to left ventricular systolic dysfunction is common in the paced population. Only a minority of these had a pre-existing diagnosis and a smaller proportion were on ‘optimal’ therapy. Echocardiographic screening of this high-risk population is justified to improve rates of diagnosis and treatment of heart failure.
This is a synopsis of presentations made at the American College of Cardiology (ACC) in 2001 summarising recent research developments relating to heart failure. Clinical studies of particular ...interest to physicians with an interest in heart failure and its prevention are reviewed. The COPERNICUS trial lends further support to the use of the beta-blocker, carvedilol, in severe heart failure and the CAPRICORN trial to its use in patients with post-infarction left ventricular systolic dysfunction. The MIRACLE study reinforces the evidence from three smaller trials that cardiac resynchronisation therapy is an effective treatment for the relief of symptoms in patients with severe heart failure and cardiac dyssynchrony. The STAF trial casts further doubt on the wisdom of cardioversion as a routine strategy for the management of chronic atrial fibrillation. The RITZ-2 trial suggests that an intravenous, non-selective endothelin antagonist is effective in improving haemodynamics and symptoms and possibly in reducing morbidity in severe heart failure. Observational studies in heart failure suggest that a moderate excess of body fat and elevated blood cholesterol may be desirable in patients with heart failure, challenging the current non-evidenced-based vogue for cholesterol lowering therapy in heart failure. The RENAISSANCE and RECOVER outcome studies of etanercept, a tumour necrosis factor (TNF) receptor analogue that blocks the effect of TNF, were stopped because of lack of evidence of benefit shortly after the ACC.
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BFBNIB, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
OBJECTIVE:To describe the UK experience with Renal Denervation (RDN).
DESIGN AND METHOD:RDN may lower blood pressure (BP) in people with resistant hypertension.The UK Renal Denervation Affiliation is ...an independent, investigator-led initiative. Each centre had done >5 cases. A standardised dataset was collected retrospectively, anonymised and submitted to the coordinating centre for analysis.
RESULTS:Results from 246 cases from 16 centres are reported. Average cases per centre was 15. Five different ablation technologies were usedunipolar catheters in 198 and multipolar in 48.Mean age was 56.7 years, 53% female, 87% Caucasian and 27% diabetes. Previous stroke/TIA - 24%; myocardial infarction - 15%; proteinuria - 26%.Patients were screened by a mean of 1.6 specialists with an interest in hypertension. 86% attended specialist hypertension clinics.On average 4.7 drugs were used before RDN; 95% were on 3+ drugs; 90% were on RAS blockers, 90% diuretics and 56% aldosterone antagonists at time of RDN.Pre-RDN mean office BP was 186/102 mmHg. Ambulatory blood pressure monitoring (ABP) data were available for 179 patients (73%). Average pre-RDN ABP wasdaytime - 170/98; night - 154/86.Average follow-up was 10.7 months. Mean Office BP post-RDN was 164/93, a fall of 22/9 mmHg (P < 0.001). In 24%, office SBP fell 40+ mmHg. On average, 0.8 drugs were withdrawn per patient and 0.3 drugs added between RDN and follow-up.Mean daytime ABP after RDN was 158/92 and nighttime ABP 145/81 - fall in daytime ABP was 12/6 (p < 0.001). 18% had a drop in day systolic ABP of >20 mmHg. A decrease in GFR >25% was seen at 10 months in 5% patients. Otherwise, no significant complications were seen.
CONCLUSIONS:In a cohort of 246 patients from 16 UK centres who had undergone renal denervation, a significant fall in blood pressure was observed. Office BP fell by 22/9 mmHg. Daytime ambulatory BP fell by 12/6 mmHg.Carefully selected patients with resistant hypertension exhibited significant BP reduction following RDN. This was a group with severe hypertension who had been well characterised in specialist hypertension clinics. Drug additions/withdrawals did not appear to explain the BP fall.
Objective: To assess the influence of acute α and β blockade on ventilation and symptoms of breathlessness during exercise in patients with chronic heart failure and in controls. Methods: 11 patients ...with chronic heart failure and 11 control subjects underwent repeated exercise testing with metabolic gas exchange after random, double blind administration of either an α blocker and placebo, a β blocker and a placebo, both an α blocker and a β blocker, or double placebo. Results: Patients had a lower peak oxygen consumption (mean (SD) 20.7 (4.9) v 37.6 (9.6) ml/kg/min, p < 0.0001) and a steeper slope relating ventilation to carbon dioxide production (VE/V̇co2 slope) (26.5 (4.1) v 37.1 (8.2), p = 0.0011), than controls. Blood pressure was lower following α and β blockade (p < 0.05) and the gradients of the slopes relating heart rate to oxygen consumption following the β blocker were reduced (p < 0.05). Exercise time and peak ventilatory variables following β or α blockers were unchanged. Ventilation was reduced during submaximal exercise following the active medications. Combined α and β blockade produced the greatest difference (p < 0.005), but the α and β blockers alone also reduced ventilation (p < 0.05). There was no difference in perceived exertion during exercise with any of the treatments. Conclusion: Acute sympathetic inhibition can reduce submaximal ventilation during exercise in patients with heart failure and control subjects, suggesting that autonomic nervous system activation has an important role in the abnormal ventilatory response to exercise in chronic heart failure.
Objective: To determine the pattern of the abnormal ventilatory response in heart failure and how it relates to symptoms by looking at tidal volume (Vt) and frequency (f) during exercise. Methods: 45 ...patients with heart failure and 21 controls underwent maximal treadmill based exercise testing with metabolic gas exchange analysis. The relation of ventilation (V̇E) to Vt was plotted to look for an inflection point where Vt failed to increase further. The slope of the relation before this inflection point was documented. Time to the inflection point, Vt, and f at the inflection point were recorded. The relation of symptom scores to f and V̇E was also examined. Results: Peak oxygen consumption (PV̇o2) (mean (SD)) was lower (19.7 (4.5) v 37.9 (8.6) ml/kg/min; p < 0001) and the ventilation to carbon dioxide production (V̇E/V̇co2) slope was steeper (40.0 (6.5) v 26.0 (1.6); p < 0.0001) in patients with heart failure than in the control group. The patients reached the inflection point of the V̇E/Vt slope sooner during exercise than the controls (271 (110) v 502 (196) seconds; p < 0.0001). Patients had a higher f and a smaller Vt at that point and throughout exercise until the peak where f was the same for patients and controls. Vt at the inflection point correlated with PV̇o2 (r = 0.67; p < 0.0001). Despite having an increased sensation of breathlessness for a given V̇E, patients were less symptomatic of f than controls. Conclusions: Patients with heart failure breathe at a higher f throughout exercise, reaching an apparent maximal Vt earlier. The Vt at an inflection point on the V̇E/Vt slope predicts PV̇o2.
This article continues a series of reports summarising recent research developments pertinent to the topic of heart failure. This is a summary of presentations made at Scientific Sessions of Heart ...Failure 2001, a meeting of the Working Group on Heart Failure of the European Society of Cardiology. Clinical studies of particular interest to people caring for patients with heart failure include CONTAK-CD, CHRISTMAS and further updates on OPTIME-CHF. A brief review of the current status of cardiac resynchronisation therapy is included.
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BFBNIB, FZAB, GIS, IJS, IZUM, KILJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK
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