Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) patients with heart failure and preserved left ventricular ejection fraction assigned to spironolactone ...did not achieve a significant reduction in the primary composite outcome (time to cardiovascular death, aborted cardiac arrest, or hospitalization for management of heart failure) compared with patients receiving placebo. In a post hoc analysis, an ≈4-fold difference was identified in this composite event rate between the 1678 patients randomized from Russia and Georgia compared with the 1767 enrolled from the United States, Canada, Brazil, and Argentina (the Americas).
To better understand this regional difference in clinical outcomes, demographic characteristics of these populations and their responses to spironolactone were explored. Patients from Russia/Georgia were younger, had less atrial fibrillation and diabetes mellitus, but were more likely to have had prior myocardial infarction or a hospitalization for heart failure. Russia/Georgia patients also had lower left ventricular ejection fraction and creatinine but higher diastolic blood pressure (all P<0.001). Hyperkalemia and doubling of creatinine were more likely and hypokalemia was less likely in patients receiving spironolactone in the Americas with no significant treatment effects in Russia/Georgia. All clinical event rates were markedly lower in Russia/Georgia, and there was no detectable impact of spironolactone on any outcomes. In contrast, in the Americas, the rates of the primary outcome, cardiovascular death, and hospitalization for heart failure were significantly reduced by spironolactone.
This post hoc analysis demonstrated greater potassium and creatinine changes and possible clinical benefits with spironolactone in patients with heart failure and preserved ejection fraction from the Americas.
http://www.clinicaltrials.gov. Unique identifier: NCT00094302.
The main objective was to assess the effects of abdominal breathing (AB) versus subject's own breathing on femoral venous blood flow (Qfv) and their repercussions on central hemodynamics at rest and ...during exercise contrasting healthy subjects versus heart failure (HF) patients. We measured esophageal and gastric pressure (PGA), Qfv and parameters of central hemodynamics in eight healthy subjects and nine HF patients, under four conditions: subject's own breathing and AB (∆PGA ≥ 6 cmH2O) at rest and during knee extension exercises (15% of 1 repetition maximum) until exhaustion. Qfv and parameters of central hemodynamics stroke volume (SV), cardiac output (CO) were measured using Doppler ultrasound and impedance cardiography, respectively. At rest, healthy subjects Qfv, SV, and CO were higher during AB than subject's breathing (0.11 ± 0.02 vs. 0.06 ± 0.00 L·min−1, 58.7 ± 3.4 vs. 50.1 ± 4.1 mL and 4.4 ± 0.2 vs. 3.8 ± 0.1 L·min−1, respectively, P ≤ 0.05). ∆SV correlated with ∆PGA during AB (r = 0.89, P ≤ 0.05). This same pattern of findings induced by AB was observed during exercise (SV: 71.1 ± 4.1 vs. 65.5 ± 4.1 mL and CO: 6.3 ± 0.4 vs. 5.2 ± 0.4 L·min−1; P ≤ 0.05); however, Qfv did not reach statistical significance. The HF group tended to increase their Qfv during AB (0.09 ± 0.01 vs. 0.07 ± 0.03 L·min−1, P = 0.09). On the other hand, unlike the healthy subjects, AB did not improve SV or CO neither at rest nor during exercise (P > 0.05). In healthy subjects, abdominal pump modulated venous return improved SV and CO at rest and during exercise. In HF patients, with elevated right atrial and vena caval system pressures, these findings were not observed.
e12216
Circulatory function of the diaphragm produces an increase in circulatory output. Moreover, the peripheral muscle contraction produces greater venous blood return due to increased blood expulsion. In this study, we focused on the effects of diaphragm contraction at rest and during knee extension exercise on venous return and central hemodynamics in healthy subjects and heart failure patients. These results help us understand the mechanisms of abdominal pump modulation on venous return in healthy subjects and under conditions of elevated pressure of the right atrium and the vena cava.
Summary Background & aims Patients with acute decompensated heart failure (ADHF) have exacerbation of symptoms and fluid retention, and high risk of re-hospitalizations and mortality. The aim of this ...study was to evaluate the role of phase angle at hospital admission as a prognostic marker of mortality in patients with ADHF. Methods Patients hospitalized for ADHF, with left ventricular ejection fraction (LVEF) <45% and BOSTON criteria ≥8 points were included. The patients were evaluated at hospital admission (first 36 h) and then followed up for assessment of outcomes. Phase angle was measured with tetra polar bioelectrical impedance device. Mortality data was obtained from an average of 24 months after discharge, from the medical records of the hospital and outpatient or telephone contact with patients or family members. The best-discriminatory level of phase angle was selected based on the ROC curve for mortality. Results Seventy-one patients were included and the majority was male (63%), with a mean age of 61 ± 12 years, ischemic etiology being the most prevalent (48%) and LVEF average of 26 ± 8%. Mortality was 49% at an average of 24 months after hospital discharge. The average phase angle at hospital admission was 5.6 ± 2°, and lower values were associated with higher mortality. Survivors were compared to died patients in the risk factor variables for mortality. In multivariate analysis adjusting for age, LVEF and urea, phase angle <4.8° was independently associated with increased mortality (HR 2.67; p = 0.015). Conclusions Phase angle seems to be a prognostic marker in patients with ADHF independently of other known risk factors.
Abstract Background The therapeutic applicability of echocardiographic evaluations remains poorly defined in heart failure (HF). We hypothesized that an individualized echocardiography-guided ...strategy would be feasible and significantly reduce morbidity compared with the conventional clinically oriented treatment. Methods and Results We conducted a single-center clinical trial comparing an echocardiography-guided strategy aimed at achieving a near-normal hemodynamic profile and a conventional clinically oriented strategy for HF management. The echocardiography-guided strategy was based on sequential echocardiograms to evaluate hemodynamically derived parameters. Pharmacologic therapy was guided according to a predefined protocol. The primary efficacy end point was time to the first event of combined all-cause mortality and all-cause hospitalization or emergency department visit up to 1 year of follow-up. We studied 96 outpatients with HF, enrolled from 1999 to 2003, with predominantly nonischemic cause and a mean left ventricular ejection fraction of 26% ± 6%. Event-free survival at a mean follow-up of 230 days was 58.5% with the echocardiography-guided strategy and 36.5% with the clinically based strategy (relative risk = 0.54, 95% confidence interval = 0.31–0.97, P = .04). More patients in the echocardiography-based group received high-dose loop diuretics (absolute difference of 19%, P = .02) and hydralazine (absolute difference of 30%, P < .001). Significant reductions of estimates of pulmonary artery systolic pressure (mean difference of −9 mm Hg, P = .02) and systemic vascular resistance index (mean difference of −700 dyn.sec.m2 .cm5 , P = .02) were observed in the echocardiography-guided group. Conclusion A hemodynamically oriented echocardiography-based strategy is feasible and decreases HF morbidity. This benefit could be attributed in part to the rational and individualized use of higher doses of diuretics and vasodilators.
FUNDAMENTOS: Síndrome Metabólica (SM) está associada com maior risco cardiovascular, porém não está claro se as alterações miocárdicas presentes nessa condição, como a disfunção diastólica, são ...consequência de mecanismos sistêmicos ou de efeitos diretos no miocárdio. OBJETIVOS: Comparar função diastólica, biomarcadores de atividade da Matriz Extracelular (MEC), inflamação e estresse hemodinâmico, em pacientes com SM e controles saudáveis. MÉTODOS: Pacientes com SM (n = 76) e controles saudáveis (n = 30) foram avaliados clinicamente e submetidos a exame ecocardiográfico e mensuração dos níveis plasmáticos de metaloproteinase-9 (MMP9), inibidor tecidual da metaloproteinase-1 (TIMP1), proteína C reativa ultrassensível (PCR-us), resistência insulínica (HOMA-RI) e NT-proBNP. RESULTADOS: O grupo SM apresentou menor onda E' (10,1 ± 3,0 cm/s vs. 11,9 ± 2,6 cm/s, p = 0,005), maiores valores para onda A (63,4 ± 14,1 vs. 53,1 ± 8,9 cm/s, p < 0,001), razão E/E'(8,0 ± 2,2 vs. 6,3 ± 1,2; p < 0,001), MMP9 (502,9 ± 237,1 vs. 330,4 ± 162,7 ng/mL, p < 0,001), PCR-us (p = 0,001) e HOMA-RI (p < 0,001), sem diferença nos níveis de TIMP1 e NT-proBNP. Na análise multivariada, apenas MMP9 foi independentemente associada a SM. CONCLUSÃO: Pacientes com SM apresentaram diferenças em medidas ecocardiográficas de função diastólica, na atividade da MEC, PCR-us e HOMA-RI em relação aos controles. Porém, somente MMP9 foi independentemente associada com SM. Esses achados sugerem que os efeitos precoces da SM sobre a atividade da MEC podem não ser detectados nas medidas ecocardiográficas de função diastólica usuais.
Abstract Background Physicians often overlook trepopnea as a symptom, and its prevalence and clinical repercussions are not usually described. We propose that trepopnea is a common symptom in heart ...failure (HF) and, because of patient avoidance of left lateral decubitus position, contributes to the greater prevalence of right-sided pleural effusion in patients with HF. Accordingly, this study aimed to determine trepopnea prevalence and to evaluate the association of trepopnea and the laterality of pleural effusion in decompensated HF. Methods Consecutive patients (n = 37) with decompensated HF and evidence of pleural effusion by chest x-ray were included. Data were collected at the emergency department by a standard clinical examination in which patients were specifically asked about the presence of trepopnea and preferred decubitus position while recumbent. Chest x-ray and echocardiographic parameters were recorded. Results Of the 37 patients, 19 (51%) reported trepopnea. Most patients presented with right-sided pleural effusion; only 2 patients (5.4%) presented with left-sided pleural effusion. Patients who reported trepopnea had predominant right-sided pleural effusion more frequently than patients without this symptom (73.7% vs 26.3%; P = .049). The participants that reported trepopnea or avoidance of left lateral decubitus position while recumbent or both had a greater probability of having predominant right-sided pleural effusion (likelihood ratio, 1.85; 95% confidence interval, 1.02-3.35). Conclusions Trepopnea is a common symptom in patients with decompensated HF and is associated with predominant right-sided pleural effusion in this population. Our results indicate that trepopnea may be a contributory factor for pleural effusion laterality in patients with decompensated HF.
Vitamin D deficiency is frequent among patients with heart failure (HF) and diabetes, disorders associated with exercise intolerance and muscle weakness. This study aims to search for associations ...between vitamin D sufficiency and physical function indexes in patients with HF and diabetes. A cross-sectional study of 146 HF patients, 39.7% with diabetes, at a Brazilian tertiary outpatient clinic was performed. Patients underwent clinical evaluation, 6-minute walk test (6 MWT), handgrip strength, physical activity level (IPAQ), and biochemical evaluations including serum 25-hydroxyvitamin D. Classification was done according to vitamin D status (≥30 ng/dL, sufficient) and presence/absence of diabetes in vitamin sufficient, no diabetes (DS-C, n=25), vitamin sufficient, diabetes (DS-DM, n=18), vitamin deficient, no diabetes (DD-C, n= 63), and vitamin deficient, diabetes (DD-DM, n=40). Patients age was 55.4 ± 8 yrs; 70.5% had vitamin D deficiency. Clinical characteristics were similar among groups. Total time expended in physical activity was similar among groups (P=0.26). DS-C covered higher distances in the 6 MWT (392 ± 60 m) versus DD-DM (309 ± 116 m); P=0.024. Handgrip strength was similar among groups but tended to lower levels in DD-DM (P=0.074) even after being adjusted to physical activity (P=0.069). Vitamin D deficiency can influence physical function in HF diabetic patients.
Scarce data are available to predict in-hospital mortality for decompensated heart failure (HF) in South American populations.
We evaluated 779 consecutive HF admissions defined by the Boston ...criteria in a tertiary care hospital. Stepwise logistic regression was used to determine independent correlates of in-hospital mortality, derived from 83 potential predictors collected on hospital admission. A clinical score rule (HF Revised Score) was created using the regression coefficient estimates derived from multivariate modeling. During hospital stay, 77 (10%) deaths occurred and 6 clinical characteristics were independently associated with in-hospital mortality: presence of cancer (
P < .001), systolic blood pressure ≤124 mm Hg (
P < .001), serum creatinine >1.4 mg/dL (
P = .02), blood urea nitrogen >37 mg/dL (
P = .03), serum sodium <136 mEq/L (
P = .03), and age >70 years old (
P = .03). Both the Acute Decompensated Heart Failure National Registry stratification algorithm and the proposed HF Revised Score performed adequately to predict in-hospital mortality (“c” statistics = 0.71 and 0.76, respectively). The newly proposed score, however, discriminated a very low-risk group (101 13%) in whom all patients were discharged home, representing patients admitted with none of the 6 predictors of risk.
HF risk stratification can be accurately accomplished during the first day of admission with simple and easily obtained clinical variables.
•A case of cardiac allograft vasculopathy (CAV) developed early post heart transplantation.•Acute ischemic pancreatitis ensued on the fifth postoperative day with recurrent relapses.•By 18 months ...posttransplant, coronary angiography showed severe multivessel CAV.•Pancreatitis pathogenesis and CAV development are related to inflammatory response.•A high-grade inflammatory state secondary to pancreatitis may have been a trigger for early severe CAV.
We present a case of severe accelerated cardiac allograft vasculopathy (CAV), an infrequent finding usually related to dismal prognosis, in a heart recipient with recurrent episodes of acute pancreatitis.
A 38-year-old male was transplanted owing to advanced heart failure related to nonischemic dilated cardiomyopathy. On the fifth day after transplantation, a nonbiliary acute ischemic pancreatitis occurred. Recurrent relapses ensued within the following year requiring hospital readmissions for both supportive and pain management. The patient developed graft dysfunction by the 18th month post-transplant with severe multivessel CAV. A trial of bortezomib and percutaneous coronary interventions with drug-eluting stents at coronary arteries were attempted but the patient died suddenly, before the scheduled staged percutaneous coronary intervention for the coronary total occlusion was performed.
The causal mechanisms of aggressive accelerated CAV are unclear, but it is suggested that important inflammatory and/or humoral responses may play a pivotal role in this life-threatening disease pathogenesis. Increased levels of biomarkers have been linked to advanced CAV, as well as pancreatitis pathogenesis, related to cytokine activation with remarkable systemic inflammatory response. Some of those inflammatory mediators have been reported as central in both pancreatitis and CAV, more specifically interleukin-6.
A pro-inflammatory state due to recurrent acute pancreatitis early after transplantation may have contributed to severely accelerated CAV development in the presented case. Comprehensive evaluation of risk factors may assist in close surveillance and targeted therapies in the management of this challenging post–heart transplant scenario.
Abstract Background Anemia is a common finding in heart failure (HF) patients and has been associated with increased morbidity and mortality. It is generally denominated as anemia of chronic disease ...(ACD), but the association with true ferropenic anemia is common. Many studies have investigated the effects of treating anemia in HF patients with either erythropoietin alone or combination of erythropoietin and intravenous iron. However, the effect of iron supplementation alone in HF patients with ACD, ferropenic anemia, or both is unknown. Methods and Results IRON-HF study is a multicenter, investigator initiated, randomized, double-blind, placebo controlled trial that will enroll anemic HF patients with relatively preserved renal function, low transferrin saturation, low iron levels, and low to moderately elevated ferritin levels. Interventions are iron sucrose intravenously 200 mg once per week for 5 weeks, ferrous sulfate 200 mg by mouth 3 times per day for 8 weeks, or placebo. The primary objective is to assess the impact of iron supplementation (intravenously or by mouth) compared with placebo in HF patients with anemia from deficient iron availability. The primary end point is variation of peak oxygen consumption assessed by ergospirometry over 3-month follow-up. Secondary end points include functional class, brain natriuretic peptide levels, quality of life scores, left ventricular ejection fraction, adverse events, HF hospitalization, and death. Conclusions The results of IRON-HF should help to clarify the potential clinical impact of mild to moderate anemia correction in HF patients.
PDF
