Abstract Background Pulmonary hypertension due to left heart disease is very common. Our aim was to investigate the relationship of the severity of left ventricular diastolic dysfunction with ...precapillary and postcapillary pulmonary hypertension (PH) in an elderly heart failure (HF) population. Methods and Results A post hoc analysis of the Trial of Intensified Medical Therapy in Elderly Patients With Congestive Heart Failure data was done. Baseline transthoracic echocardiography was used to categorize diastolic function, estimate pulmonary artery pressure and pulmonary capillary wedge pressure, and calculate the transpulmonary pressure gradient (TPG). Among 392 HF patients, PH was present in 31% of patients with grade 1, in 37% of patients with grade 2, and in 65% of patients with grade 3 diastolic dysfunction; 54% of all HF patients with PH had a TPG >12 mm Hg, suggesting not only a postcapillary but also an additional precapillary component of PH. Survival was not related to the severity of diastolic dysfunction, but was worse in patients with PH (hazard ratio 1.63, 95% confidence interval 1.07–2.51; P = .024). Conclusions Our data indicate that HF patients with even mild diastolic dysfunction often have PH. Echocardiographic assessment suggest that the presence of PH might not simply be due to increased PCWP, but in part due to a precapillary component.
...the patient's ability to estimate his own daily "working" capacity seems to carry a higher prognostic value than that estimated from repeat functional exercise testing. ...1-year changes in peak ...aerobic capacity may still have a prognostic value in patients with HF.
Differentiation between precapillary and postcapillary pulmonary hypertension (PH) classically relies on mean pulmonary artery wedge pressure (mPAWP). The left ventricular end-diastolic pressure ...(LVEDP) is proposed as an equivalent alternative. However, mPAWP and LVEDP may differ substantially. We compared the impact of the choice of using the mPAWP vs the LVEDP on PH classification and mortality prediction in patients with severe aortic stenosis (AS) undergoing valve replacement.
In 335 patients with severe AS , both mPAWP and LVEDP were measured. A mean pulmonary artery pressure ≥ 25 mm Hg was used to define PH, and either mPAWP or LVEDP was used to differentiate between precapillary and postcapillary PH (≤ 15 vs > 15 mm Hg). Mortality after a median follow-up of 1484 days after aortic valve replacement was assessed.
Overall, mPAWP was lower than LVEDP (16 ± 8 mm Hg vs 21 ± 8 mm Hg; P < 0.001). Among 140 patients (42%) with PH, the PAWP-based classification revealed 76 (54% of those with PH) with isolated postcapillary PH, 48 (34%) with combined pre- and postcapillary PH, and 16 (12%) with precapillary PH. When the LVEDP was used, 59 patients (42%) were differently classified. These patients had higher mortality than those who were not differently classified hazard ratio 2.79 (95% confidence interval, 1.17-6.65); P = 0.02. Higher mPAWP was associated with increased mortality hazard ratio 1.07 (95% confidence interval, 1.03-1.11) per 1 mm Hg; P = 0.001, whereas higher LVEDP was not.
Use of LVEDP rather than mPAWP results in a divergent PH classification in nearly every second patient with severe AS. These patients have higher mortality after aortic valve replacement. The mPAWP, but not the LVEDP, predicts mortality.
La différentiation entre l’hypertension pulmonaire (HP) précapillaire et postcapillaire repose traditionnellement sur la pression artérielle pulmonaire d’occlusion moyenne (PAPOm). La pression télédiastolique du ventricule gauche (PTDVG) est proposée comme alternative équivalente. Toutefois, la PAPOm et la PTDVG peuvent largement différer. Nous avons comparé les répercussions du choix entre l’utilisation de la PAPOm vs l’utilisation de la PTDVG sur la classification de l’HP et la prédiction de la mortalité des patients atteints d’une sténose aortique (SA) grave qui subissaient un remplacement valvulaire.
Nous avons mesuré la PAPOm et la PTDVG de 335 patients atteints de SA grave. Nous avons utilisé une pression artérielle pulmonaire moyenne ≥ 25 mmHg pour définir l’HP, et utilisé la PAPOm ou la PTVDG pour différencier entre l’HP précapillaire et postcapillaire (≤ 15 mmHg vs > 15 mmHg). Nous avons évalué la mortalité après un suivi médian de 1 484 jours après le remplacement valvulaire aortique.
Dans l’ensemble, la PAPOm était plus faible que la PTVDG (16 ± 8 mmHg vs 21 ±8 mmHg; P < 0,001). Parmi les 140 patients (42 %) atteints d’HP, la classification en fonction de la PAPO a révélé 76 (54 % des patients atteints d’HP) patients atteints d’HP postcapillaire isolée, 48 (34 %) patients atteints d’HP précapillaire et postcapillaire combinée et 16 (12 %) patients atteints d’HP précapillaire. Lorsque nous avons utilisé la PTVDG, 59 patients (42 %) étaient classifiés différemment. La mortalité chez ces patients était plus élevée que chez les patients qui n’étaient pas classifiés différemment (rapport de risque 2,79 intervalle de confiance à 95 %, 1,17-6,65; P = 0,02). La PAPOm plus élevée était associée à une mortalité accrue (rapport de risque 1,07 intervalle de confiance à 95 %, 1,03-1,11 par 1 mmHg; P = 0,001), tandis que la PTVDG plus élevée ne l’était pas.
Le fait d’utiliser la PTVDG plutôt que la PAPOm entraîne une classification divergente de l’HP chez presque tous les deux patients atteints de SA grave. La mortalité après le remplacement valvulaire aortique de ces patients est plus élevée. La PAPOm, mais non la PTVDG, prédit la mortalité.
Abstract Background The accuracy of Doppler echocardiography to estimate key hemodynamic parameters in subjects with normal left ventricular ejection fraction (LVEF) has not been fully investigated. ...Methods and Results Thirty-six subjects with LVEF >50% (median age 62 years), with a broad clinical profile, underwent Doppler echocardiography immediately followed by right heart catheterization. Correlation coefficients between invasive and noninvasive right atrial pressure (RAP), systolic (sPAP) and mean (mPAP) pulmonary artery pressure, cardiac output (CO), and pulmonary vascular resistance (PVR) were 0.39, 0.70, 0.72, 0.57, and 0.60 ( P < .001 for all). There was no significant correlation between invasive and noninvasive (based on the peak early transmitral to peak early septal mitral annular velocity ratio) pulmonary capillary wedge pressure (PCWP; r = 0.23; P = .18). Bland-Altman plots revealed variable bias but with consistently large limits of agreement for all noninvasive parameters, particularly PCWP. Areas under the receiver operating characteristic curve for noninvasive sPAP, CO, PVR, and PCWP to predict an invasively assessed mPAP ≥25 mm Hg, cardiac index <2.5 L min−1 m−2 , PVR >3 Wood units, and PCWP ≤15 mm Hg, respectively, were 0.92, 0.83, 0.70, and 0.58. Conclusions Single Doppler echocardiography parameters are not accurate enough to reliably estimate key hemodynamic parameters, particularly PCWP, in subjects with normal LVEF.
Abstract Background Cardiopulmonary exercise testing is the method of choice for the differentiation of exercise intolerance. This study sought to assess the utility of B-type natriuretic peptide ...(BNP) and N-terminal-pro-B-type natriuretic peptide (NT-proBNP) for the identification of a cardiocirculatory exercise limitation. Methods In 162 patients undergoing cardiopulmonary exercise testing, rest and peak exercise BNP and NT-proBNP levels were measured. In 94 patients fulfilling criteria for appropriate effort and sufficient diagnostic certainty, the accuracy of BNP and NT-proBNP for the prediction of a cardiocirculatory limitation, as assessed based on clinical and exercise testing data, was determined. Results A cardiocirculatory limitation was identified in 27 (29%) patients. Median (interquartile range) resting BNP 162 (45-415) vs 39 (19-94) vs 24 (15-46) pg/mL; P <.001 and NT-proBNP 506 (129-1167) vs 77 (35-237) vs 34 (19-77) pg/mL; P <.001 were higher in patients with cardiocirculatory as compared with those with pulmonary limitation (n = 28) and those without cardiocirculatory or pulmonary limitation (n = 39). The area under the receiver operator characteristics curve for BNP and NT-proBNP to identify a cardiocirculatory limitation was 0.79 and 0.84, respectively ( P = .15 for comparison of the curves). Sensitivity and specificity of the optimal BNP cutoff of 85 pg/mL were 63% and 84%, respectively. Sensitivity and specificity of the optimal NT-proBNP cutoff of 223 pg/mL were 74% and 85%, respectively. Peak exercise biomarkers were not more accurate than resting levels. Conclusions Among patients referred for cardiopulmonary exercise testing for evaluation of unexplained exercise intolerance, BNP and NT-proBNP were similarly useful to identify those with a cardiocirculatory limitation.
Background Both heart and renal failure are characterised by increased systemic oxidative stress and endothelial dysfunction and occur in the cardiorenal syndrome (CRS). The aim of the present study ...was to assess the impact of N-acetylcysteine (NAC), a potent antioxidant, on endothelial function, B-type natriuretic peptide (BNP) and renal function in patients with CRS. Methods In a double blind, placebo controlled manner, we randomised nine stable outpatients with both heart failure (LVEF < 40% and NYHA class II or III) and renal failure (Cockroft Gault clearance of 20–60 ml/min) to placebo or NAC (500 mg orally twice daily) for 28 days followed by a wash out period (>7 days) and crossover to the other treatment. Results Eight patients completed the study and all data ( N = 9) was used in the analysis. Mean forearm blood flow improved significantly with NAC with mean ratio of improvement of 1.99 (SEM: ±0.49) for NAC and 0.73 (SEM: ±0.23) for placebo with a p -value of 0.047. There was no significant difference in BNP ( p = 0.25), renal function ( p = 0.71) or NYHA class ( p = 0.5). No deaths occurred during the trial. Conclusion In this pilot trial of patients with CRS, NAC therapy was associated with improved forearm blood flow. This may represent a general improvement in endothelial function and warrants further investigation of antioxidant therapy in these patients.
Highlights • Recurrent events are common in patients with heart failure, though hardly analyzed • Recurrent events may reveal effects not seen by time-to-first event analysis • Gap-time method may be ...helpful to analyses recurrent events
Abstract We present a 44-year-old man with invasive aortic and tricuspid valve endocarditis complicated by electrical storm, which was immediately diagnosed and successfully treated due to the ...patient's telemetry electrocardiogram (ECG). This case highlights a rare but potentially fatal complication in patients with invasive endocarditis and the need for very careful clinical evaluation and monitoring of these patients.
Myocardial and Systemic Iron Depletion in Heart Failure Maeder, Micha T., MD; Khammy, Ouda, BSci; dos Remedios, Cris, PhD ...
Journal of the American College of Cardiology,
07/2011, Letnik:
58, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Objectives This study sought to determine the potential pathophysiological link between anemia and disease severity, and adverse outcome in heart failure (HF). Background Anemia frequently ...accompanies advanced HF; however, the pathophysiological mechanism responsible for the association between anemia and more severe HF remains uncertain. We hypothesized that a depletion of myocardial iron content may provide the biological link. Methods Complementary clinical and basic studies were performed. Hemodynamic, biochemical, and echocardiographic investigations were performed in 9 healthy controls and 25 patients with advanced HF (left ventricular ejection fraction: 23 ± 10%). Tissue iron content and type 1 transferrin receptor (Tfr1) expression were assessed in human myocardial tissue, and the regulation of Tfr1 expression was studied in isolated cardiomyocytes. Results HF patients displayed evidence of iron deficiency as measured by lower serum iron (p < 0.05) and transferrin saturation (TFS) (p < 0.05). When subclassified according to the presence of anemia, TFS was lower in anemic compared with nonanemic HF patients, whereas TFS in nonanemic HF patients was intermediate. In association, myocardial iron content was reduced in HF versus non-HF samples (0.49 ± 0.07 μg/g vs. 0.58 ± 0.09 μg/g, p < 0.05), and there was a significant reduction (p < 0.05) in the myocardial mRNA expression of Tfr1, which plays a key role in cellular iron transport. In the context of HF, catecholamines and aldosterone both down-regulated Tfr1 expression in isolated cardiomyocytes. Conclusions This study suggests the presence of iron depletion in the failing human heart, providing a potential link for the association between anemia and adverse prognosis in HF.
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