Etiology of Anemia in Patients With Advanced Heart Failure
John N. Nanas, Charis Matsouka, Drosos Karageorgopoulos, Anastasia Leonti, Elias Tsolakis, Stavros G. Drakos, Eleftheria P. Tsagalou, George ...D. Maroulidis, George P. Alexopoulos, John E. Kanakakis, Maria I. Anastasiou-Nana
Thirty-seven patients, mean age 57.9 ± 10.9 years, with end-stage congestive heart failure and anemia were prospectively investigated to define the causes of anemia. Iron deficiency anemia was confirmed by bone marrow aspiration in 27 patients (73%), 2 patients (5.4%) had dilutional anemia, and 1 patient (2.7%) had drug-induced anemia. No specific cause was identified in 7 patients (18.9%) who were considered to have “anemia of chronic disease.” In conclusion, in this group of patients, iron deficiency was the most common cause of anemia. Thus, the iron status of patients with end-stage chronic congestive heart failure should be thoroughly evaluated and corrected before considering other therapeutic interventions.
We prospectively investigated the causes of anemia in patients with advanced congestive heart failure (CHF).
Anemia is common in patients with advanced CHF, and its etiology is generally considered to be multifactorial. However, despite its importance, precise information is lacking regarding the prevalence of putative etiologic factors.
Patients who were hospitalized for decompensated advanced CHF and who were stabilized after their initial treatment underwent evaluation of “clinically significant” anemia, defined as a hemoglobin content <12 g/dl for men and <11.5 g/dl for women. Patients with a serum creatinine concentration >3 mg/dl or patients with concurrent diseases that are known to cause anemia were not included. The initial evaluation included measurements of vitamin B12, folic acid, thyroid-stimulating hormone, erythropoietin, lactate dehydrogenase, Coombs test, multiple fecal occult tests, and bone marrow aspiration. Patients without diagnosis by these methods underwent red cell mass measurement with 51Cr assay.
The mean age of the 37 patients was 57.9 ± 10.9 years and mean left ventricular ejection fraction 22.5 ± 5.9%. Iron deficiency anemia was confirmed by bone marrow aspiration in 27 patients (73%), 2 patients (5.4%) had dilutional anemia, and 1 patient (2.7%) had drug-induced anemia. No specific cause was identified in 7 patients (18.9%) who were considered to have “anemia of chronic disease.” Serum ferritin for the iron-deficient patients was not a reliable marker of iron deficiency in this population.
In this group of patients, iron deficiency was the most common cause of anemia. The iron status of patients with end-stage chronic CHF should be thoroughly evaluated and corrected before considering other therapeutic interventions.
Background Left ventricular assist devices (LVAD)-induced unloading appear to cause reverse cardiac remodeling. However, its effect on arrhythmogenicity is a controversial issue, and prospective data ...are lacking. We sought to investigate the impact of LVAD-induced unloading on the electrical properties of the failing heart. Methods We prospectively studied the effects of LVAD therapy on QRS, QT, and QTc durations and ventricular arrhythmias from electrocardiograms and 24-hour ambulatory electrocardiograms recorded before and during 6 months of mechanical support in 12 LVAD patients and 7 other patients with advanced nonischemic cardiomyopathy untreated with LVAD. Results After 1 week of LVAD support, QTc duration had decreased from 479 ± 79 ms to 411 ± 57 ms ( p = 0.037), and QRS duration from 150 ± 46 ms to 134 ± 32 ms ( p = 0.029). At 6 months, QTc was found to be 372 ± 56 ms ( p = 0.046 versus baseline, 15% shortening) and QRS 118 ± 25 ms ( p = 0.028 versus baseline, 11% shortening). A strong correlation was found between QTc shortening and increase in left ventricular ejection fraction and decrease in left ventricular filling pressures. After 2 months of LVAD support, premature ventricular contractions had decreased from 3,507 ± 4,252 to 483 ± 417 in 24 hours ( p = 0.043), ventricular couplets from 82 ± 99 to 29 ± 25 in 24 hours ( p = 0.05), and ventricular runs from 9 ± 8 to 10 ± 9 (not significant). No patient died suddenly or suffered a symptomatic arrhythmic event during follow-up. No significant electrocardiographic, functional, or hemodynamic change was observed in the 7 patients untreated with LVAD. Conclusions The LVAD support caused progressive shortening of QTc and QRS intervals, consistent with reverse remodeling of the failing heart's electrical properties, accompanied by a decrease in frequency of ventricular arrhythmias.
Abstract A significant proportion of patients placed on long-term mechanical circulatory support for end-stage heart failure can be weaned from mechanical assistance after functional recovery of ...their native heart (“bridge to recovery”). The pathophysiological mechanisms implicated in reverse remodeling that cause a sustained functional myocardial recovery have recently become the subject of intensive research, expected to provide information with a view to accurately identify reliable prognostic indicators of recovery. In addition, this kind of information will enable changes in the strategy of myocardial recovery by modifying the duration and scale of the unloading regimen or by combining it with other treatments that promote reverse remodeling.
Thirty-six consecutive patients in New York Heart Association functional class IV, who were resistant to 24-hour continuous dobutamine infusion, were treated with continuous infusions of dobutamine ...10 μg/kg/min for ≥48 hours (group I, n = 18), followed by weekly intermittent 8-hour infusions or more often if needed. In group II (n = 18), after the initial 24-hour infusion of dobutamine, a 24-hour levosimendan infusion was added followed by biweekly 24-hour infusions. The addition of intermittent levosimendan infusions prolonged the survival of patients with advanced heart failure refractory to intermittent dobutamine infusions (45-day survival rates were 6% and 61% in groups I and II, respectively; p = 0.0002, log-rank test).
Background:
Patients with chronic heart failure (CHF) present with exercise‐induced hyperpnea, but its pathophysiological mechanism has not been thoroughly investigated. We aimed to determine the ...relationship between exercise‐induced hyperpnea, resting haemodynamic measurements and the validity of ventilatory response (VE/VCO2 slope) as a mortality predictor in CHF patients.
Methods:
Ninety‐eight CHF patients (90M/8F) underwent a symptom‐limited treadmill cardiopulmonary exercise test (CPET). Right heart catheterization and radionuclide ventriculography were performed within 72 h of CPET.
Results:
Twenty‐seven patients died from cardiac causes during 20±6 months follow‐up. Non‐survivors had a lower peak oxygen consumption (VO2p), (16.5±4.9 vs. 20.2±6.1, ml/kg/min, p=0.003), a steeper VE/VCO2 slope (34.8±8.3 vs. 28.9±4.8, p<0.001) and a higher pulmonary capillary wedge pressure (PCWP) (19.5±8.6 vs. 11.7±6.5 mm Hg, p=0.008) than survivors. By multivariate survival analysis, the VE/VCO2 slope as a continuous variable was an independent prognostic factor (χ2: 8.5, relative risk: 1.1, 95% CI: 1.03–1.18, p=0.004). Overall mortality was 52% in patients with VE/VCO2 slope ≥34 and 18% in those with VE/VCO2 slope <34 (log rank: 18.5, p<0.001). In a subgroup of patients (VO2p: 10–18 ml/kg/min), VE/VCO2 slope was a significant predictor of mortality (relative risk: 6.2, 95% CI: 1.7–22.2, p=0.002). Patients with high VE/VCO2 slope had higher resting PCWP (19.9±9.1 vs. 11.3±5.7 mmHg, p<0.001) and VE/VCO2 slope correlated significantly with PCWP (r: 0.57, p<0.001).
Conclusions:
The VE/VCO2 slope, as an index of ventilatory response to exercise, improves the risk stratification of CHF patients. Interstitial pulmonary oedema may be a pathophysiological mechanism of inefficient ventilation during exercise in these patients.
Background: Recent progress has been made in the understanding of the cellular and molecular mechanisms of growth hormone action and of its effects on cardiac tissue. The aim of this study was to ...measure growth hormone concentrations, along with various other hormones, in patients with stable chronic congestive heart failure due to idiopathic dilated cardiomyopathy.
Methods: The study included 23 ambulatory men, 51.2±9.3 years of age, on standard medical therapy for heart failure due to idiopathic dilated cardiomyopathy. All patients underwent clinical and laboratory evaluations, including echocardiogram, radionuclide ventriculography, right heart catheterization, coronary angiography, and right ventricular endomyocardial biopsy. Serum or plasma concentrations of growth, thyroid, sex and adrenal hormones were measured in all patients and compared with those found in 20 age-matched healthy men.
Results: Growth hormone, insulin-like growth factor I, and free testosterone values in patients with idiopathic dilated cardiomyopathy and heart failure were 0.37±0.2 ng/ml, 123.7±50 ng/ml and 48.6±23.8 pmol/l, respectively, versus 0.5±0.4 ng/ml (
P<0.01), 236.3±66.4 ng/ml (
P<0.001) and 105±17 pmol/l (
P<0.01), respectively, in the healthy age-matched individuals. All other hormone concentrations were comparable in both groups.
Conclusions: Chronic heart failure due to idiopathic dilated cardiomyopathy is associated with a significant decrease in growth hormone, insulin-like growth factor I, and testosterone concentrations, probably due to chronic disease.
Autonomic nervous system dysfunction is common in congestive heart failure (CHF) and is believed to predispose patients to an increased risk of death. This study aimed to assess the prognostic ...significance of heart rate variability (HRV) measurements in conjunction with scintigraphic imaging using metaiodobenzylguanidine (MIBG) labeled with iodine-123 (I-123-MIBG), which detects abnormalities in autonomic nervous activity, in patients with stable CHF during optimal medical treatment. The study population included 52 patients (56 ± 12 years of age) with a mean left ventricular ejection fraction of 31 ± 12%. All underwent I-123-MIBG scanning and 24-hour ambulatory electrocardiographic monitoring for the analysis of HRV on entrance into the study. The heart/mediastinum MIBG uptake ratio was calculated. HRV analysis included the assessment of time- and frequency-domain variables. During the 2-year follow-up, 14 patients (27%) died. MIBG uptake at 1 hour was less (1.39 ± 0.10) in nonsurvivors than in survivors (1.50 ± 0.16; p = 0.013). In univariate Cox regression analysis, MIBG uptake was a significant prognostic factor (p = 0.038, hazard ratio HR 0.017, 95% confidence interval CI 0.00 to 0.79). Time- and frequency-domain variables were similar in survivors and nonsurvivors. However, high-frequency power was associated with an increased risk for sudden death (HR 0.310, 95% CI 0.101 to 0.954, p = 0.041) but not with all-cause mortality. In conclusion, cardiac I-123-MIBG imaging identifies patients with CHF at high risk of dying and may be a more reliable predictor of overall mortality than HRV.
A 60-year-old male patient with ischemic cardiomyopathy experienced an electrical storm 1 month after implantation of an internal cardioverter-defibrillator. Recurrent life-threatening episodes of ...ventricular tachycardia persisted despite maximal antiarrhythmic theraphy with amiodarone, metoprolol and mexiletine. After a total of more than 500 cardioversions, all antiarrhythmic medications were withdrawn, and the nonselective beta-blocker propranolol was initiated. Electrical stability was achieved and the patient was discharged on propranolol 400 mg/day. Two months later, a second arrhythmia cluster occurred that was controlled by the addition of amiodarone. The patient remains free of arrhythmia 15 months after the event with the combination of propranolol and amiodarone.
Wegener’s granulomatosis is a systemic necrotizing vasculitis that usually involves the kidneys, typically causing segmental necrotizing glomerulonephritis. An association between Wegener’s ...granulomatosis and renal cell carcinoma was recently reported. We describe a case of Wegener’s granulomatosis presenting as a renal mass in a 72-year-old woman. Histologic examination of the mass revealed granulomatous inflammation, an extremely rare manifestation of this disease. We also review the incidence of renal mass in Wegener’s granulomatosis and highlight the importance of excluding the coexistence of renal cell carcinoma.
Anemia in Chronic Heart Failure Drakos, Stavros G.; Anastasiou‐Nana, Maria I.; Malliaras, Konstantinos G. ...
Congestive heart failure (Greenwich, Conn.),
March/April 2009, Letnik:
15, Številka:
2
Journal Article
Recenzirano
Anemia is frequently observed in patients with chronic heart failure and is increasingly recognized as an important and treatable condition. The present review will summarize the current knowledge of ...the prevalence, causative factors, and pathophysiologic correlates of anemia in chronic heart failure. Despite increasing knowledge of anemia there are very few evidence‐based recommendations for treatment. Potential benefits of therapy with supplemental hematinics such as iron, subcutaneous erythropoiesis–stimulating agents, or both will also be discussed.
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