Sodium Nitroprusside for Advanced Low-Output Heart Failure Mullens, Wilfried, MD; Abrahams, Zuheir, MD, PhD; Francis, Gary S., MD, FACC ...
Journal of the American College of Cardiology,
07/2008, Volume:
52, Issue:
3
Journal Article
Peer reviewed
Open access
Sodium Nitroprusside for Advanced Low-Output Heart Failure Wilfried Mullens, Zuheir Abrahams, Gary S. Francis, Hadi N. Skouri, Randall C. Starling, James B. Young, David O. Taylor, W. H. Wilson Tang ...Inotropic drugs are often preferred over vasodilators in patients with end-stage, low-output heart failure. We reviewed consecutive patients admitted between 2000 and 2005 with acute decompensated heart failure with a cardiac index ≤2 l/min/m2 . Compared with control patients, treatment with sodium nitroprusside was associated with greater improvement in hemodynamics, higher rates of transitioning oral vasodilators at discharge, and lower rates of all-cause mortality and all-cause mortality/cardiac transplant without increase in rehospitalization, inotropic use, or worsening renal function.
Prognostic Value and Echocardiographic Determinants of Plasma Myeloperoxidase Levels in Chronic Heart Failure W. H. Wilson Tang, Wilson Tong, Richard W. Troughton, Maureen G. Martin, Kevin Shrestha, ...Allen Borowski, Sue Jasper, Stanley L. Hazen, Allan L. Klein We examined the relationship between plasma myeloperoxidase (MPO) levels and both echocardiographic indices of systolic and diastolic performance, and overall prognosis, in patients with chronic systolic heart failure. Elevated plasma MPO levels correlated with increasing stages of diastolic dysfunction as well as with increasing severity of right ventricular dysfunction, especially in patients with more advanced systolic dysfunction. Plasma MPO levels were an independent predictor of long-term adverse clinical outcomes (death, cardiac transplantation, or heart failure hospitalization) after adjustment for age, left ventricular ejection fraction, plasma B-type natriuretic peptide, creatinine clearance, or diastolic stage.
Objectives The aim of this study was to investigate the use of durable mechanical circulatory support (MCS) in patients with chemotherapy-induced cardiomyopathy (CCMP) and determine their outcomes ...and survival in comparison to that of other patients with end-stage heart failure treated similarly. Background Patients with end-stage heart failure as a result of CCMP from anthracyclines are often precluded from heart transplantation because of a history of cancer. In such patients, durable MCS may offer an important chance for life prolongation. Yet, there are no data to support the use of MCS in this increasingly prevalent group of patients. Methods We searched 3,812 MCS patients from June 2006 through March 2011 in the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) database for the diagnosis of CCMP. We compared characteristics, outcomes, and survival between CCMP patients and patients with nonischemic cardiomyopathy and ischemic cardiomyopathy. Results Compared with patients with nonischemic cardiomyopathy and ischemic cardiomyopathy, patients with CCMP were overwhelmingly female (72% vs. 24% vs. 13%, p = 0.001), had MCS more often implanted as destination therapy (33% vs. 14% vs. 22%, p = 0.03), required more right ventricular assist device support (19% vs. 11% vs. 6%, p = 0.006), and had a higher risk of bleeding (p = 0001). Survival of CCMP patients was similar to that of other groups. Conclusions CCMP patients treated with MCS have survival similar to other MCS patients despite more frequent need for right ventricular assist device support and increased bleeding risk.
An organized and directed approach to a thorough review of evidence has resulted in the production of clinical practice guidelines that assist clinicians in selecting the best management strategy for ...an individual patient. ...clinical practice guidelines can provide a foundation for other applications, such as performance measures, appropriate use criteria, and both quality improvement and clinical decision support tools. A person is deemed to have a significant interest in a business if the interest represents ownership of >=5% of the voting stock or share of the business entity, or ownership of >=$10,000 of the fair market value of the business entity; or if funds received by the person from the business entity exceed 5% of the person's gross income for the previous year. Names are listed in alphabetical order within each category of review.According to the ACCF/AHA, a person has a relevant relationship IF: a) The relationship or interest relates to the same or similar subject matter, intellectual property or asset, topic, or issue addressed in the document; or b) The company/entity (with whom the relationship exists) makes a drug, drug class, or device addressed in the document, or makes a competing drug or device addressed in the document; or c) The person or a member of the person's household, has a reasonable potential for financial, professional or other personal gain or loss as a result of the issues/content addressed in the document.AAFP indicates American Academy of Family Physicians; ACCF, American College of Cardiology Foundation; ACCP, American College of Chest Physicians AHA, American Heart Association; DSMB, data safety monitoring board; EP, electrophysiology; HRS, Heart Rhythm Society; ISHLT, International Society for Heart and Lung Transplantation; UCLA, University of California, Los Angeles; and VA, Veterans Affairs.
Objectives We sought to assess the diagnostic accuracy and incremental prognostic value of delayed hyper-enhancement cardiac magnetic resonance (DHE-CMR) compared with electrocardiographic and ...transthoracic echocardiographic (TTE) parameters in such patients. Background Utility of DHE-CMR in the diagnosis of patients with suspected cardiac amyloidosis (CA) has recently been demonstrated, but its incremental prognostic utility is unclear. Methods Forty-seven consecutive patients (mean age 63 years, 70% men, 55% New York Heart Association functional class >II) with suspected CA who underwent electrocardiography (ECG), TTE, DHE-CMR, and biopsy (38 endomyocardial, 9 extracardiac) were studied. Low voltage on ECG was defined as S-wave in lead V1 + R-wave in lead V5 or V6 <15 mm. TTE parameters, including deceleration time, E/E′ ratio, and diastolic grade were recorded. CMR was considered positive with diffuse DHE of the subendocardium extending to adjacent myocardium. All-cause mortality was ascertained. Results In the study population, 59% had low voltage on ECG, 30% had abnormal deceleration time ≤150 ms, 38% had E/E′ ratio >15, and 47% had advanced (pseudonormal or restrictive) diastology. The diagnostic accuracy of DHE-CMR in patients undergoing endomyocardial biopsy was as follows: sensitivity 88%, specificity 90%, positive predictive value 88%, and negative predictive value 90%. On multivariable logistic regression testing of the diagnostic ability of various noninvasive imaging parameters, only DHE-CMR was significant (Wald chi-square statistic 9.6, p < 0.01). At 1-year post-biopsy, there were 9 (19%) deaths. On Cox proportional hazards analysis, only positive DHE-CMR was a predictor of 1-year mortality (Wald chi-square statistic 4.91, p = 0.03). Conclusions A characteristic DHE-CMR pattern is more accurate for diagnosis and is a stronger predictor of 1-year mortality in patients with suspected CA as compared with other noninvasive parameters.
Measurement of impedance is becoming increasingly available in the clinical setting as a tool for assessing hemodynamics and volume status in patients with heart failure. The 2 major categories of ...impedance assessment are the band electrode method and the implanted device lead method. The exact sources of the impedance signal are complex and can be influenced by physiologic effects such as blood volume, fluid, and positioning. This article provides a critical review of our current understanding and promises of impedance measurements, the techniques that have evolved, as well as the evidence and limitations regarding their clinical applications in the setting of heart failure management.
Abstract Background New urinary biomarkers, such as neutrophil gelatinase-associated lipocalin (NGAL), kidney injury molecule-1 (KIM-1), and interleukin-18 (IL-18), are proposed to allow a more ...reliable early diagnosis and prognosis of acute kidney injury (AKI) in acute decompensated heart failure (ADHF). Our aim was to compare the predictive value of urinary NGAL, KIM-1, and IL-18 for the occurrence of AKI, persistent renal impairment, and mortality in ADHF. Methods and Results Eighty-three patients admitted for ADHF were analyzed. Urinary creatinine (Cr), NGAL, KIM-1, and IL-18 were measured at baseline. Serum Cr was measured daily during the next 4 days and again at outpatient follow-up after 6 months. Mortality data were prospectively collected. Urinary NGAL, KIM-1, and IL-18 were modestly correlated with each other (Spearman ρ ≤0.61) and poorly correlated with estimated glomerular filtration rate (eGFR; Spearman ρ ≤0.28). None predicted AKI, defined as a 25% decrease in eGFR, during the index hospitalization, but urinary IL-18/Cr was the strongest predictor of persistently elevated serum Cr ≥0.3 mg/dL after 6 months compared with baseline (area under the receiver operating characteristic curve 0.674; P = .013). Urinary IL-18 was also significantly associated with all-cause mortality (hazard ratio 1.48, 95% confidence interval 1.16–1.87; P = .001). Conclusions Like urinary NGAL, urinary KIM-1 and IL-18 are relatively modest predictors of AKI in ADHF. Among these novel renal biomarkers examined, further investigations regarding the prognostic value of urinary IL-18 are warranted.
Evaluation and Long-Term Prognosis of New-Onset, Transient, and Persistent Anemia in Ambulatory Patients With Chronic Heart Failure W. H. Wilson Tang, Wilson Tong, Anil Jain, Gary S. Francis, C. ...Martin Harris, James B. Young We reviewed records of 6,159 consecutive ambulatory patients with chronic heart failure followed up at a single center between 2001 and 2006, and found the prevalence of anemia (hemoglobin <12 g/dl for men, <11 g/dl for women) to be 17.2%. At 6-month follow-up, new-onset anemia developed in 16% of patients without prior anemia, whereas 43% patients with anemia at baseline had resolution of their hemoglobin levels. Higher total mortality rates were evident in patients with persistent anemia (58% vs. 31%, p < 0.0001) or with incident anemia (45% vs. 31%, p < 0.0001) compared with those with without anemia at 6 months.
Both urine and serum neutrophil gelatinase-associated lipocalin (NGAL) reflect active chronic kidney disease and predict acute kidney injury. However, a direct comparison of these markers in acute ...decompensated heart failure has not been performed. We prospectively evaluated 93 patients admitted with acute decompensated heart failure and treated with intravenous furosemide and measured both systemic (serum) and urine NGAL levels and their corresponding markers of estimated glomerular filtration rate, natriuresis (urine sodium), and diuretic response (net output, urine sodium/furosemide ratio). In our study cohort, the median urine and serum NGAL level was 34 ng/ml (interquartile range 24 to 86) and 252 ng/ml (interquartile range 175 to 350), respectively. The urine and serum NGAL levels correlated modestly (r = 0.37, p <0.001). Higher urine (but not systemic) NGAL correlated with the markers of impaired natriuresis and reduced diuresis (p <0.005 for all). In contrast, higher serum NGAL demonstrated a stronger relation with reduced glomerular filtration function (p <0.0001). Both markers predicted acute kidney injury (urine NGAL, odds ratio 1.7, p = 0.035; serum NGAL, odds ratio 1.9, p = 0.009). In conclusion, in patients with acute decompensated heart failure, urine NGAL levels reflect renal distal tubular injury with impaired natriuresis and diuresis, and systemic NGAL levels demonstrate a stronger association with glomerular filtration function. Both systemic and urine NGAL predict worsening renal function.
Patients who underwent orthotopic heart transplant (OHT) can develop vasoplegia, which is associated with high mortality and morbidity. Herein we examine the pre-operative risk in OHT recipients at ...our institution.
We reviewed peri-operative data from 311 consecutive adult patients who underwent OHT between January 2003 and June 2008. Vasoplegia was defined as persistent low systemic vascular resistance, despite multiple intravenous pressor drugs at high dose, between 6 and 48 hours after surgery.
In our cohort of 311 patients, 35 (11%) patients developed vasoplegia syndrome; these patients were more likely to be UNOS Status 1A, with a higher body surface area (1.8 ± 0.25 vs 1.63 ± 0.36, p = 0.0007), greater history of thyroid disease (38.2% vs 18.5%, p = 0.0075) and a higher rate of previous cardiothoracic surgery (79% vs 48%, p = 0.0006). Pre-operatively, they were more frequently treated with aspirin (73% vs 48%, p = 0.005) and mechanical assist devices (ventricular assist devices VADs: 45% vs 17%, p < 0.0001; total artificial hearts: 8.6% vs 0%, p < 0.0001), and less treated with milrinone (14.7% vs 45.8%, p = 0.0005). Bypass time (118 ± 37 vs 142 ± 39 minutes, p = 0.0002) and donor heart ischemic time (191 ± 46 vs 219 ± 51 minutes, p = 0.002) were longer, with higher mortality (3.2% vs 17.1%, p = 0.0003) and morbidity in the first 30 days after transplant. In the multivariate analysis, history of thyroid disease (odds ratio OR = 2.7, 95% CI 1.0 to 7.0, p = 0.04) and VAD prior to transplant (OR = 2.8, 95% CI 1.07 to 7.4, p = 0.03) were independent risk factors for development of vasoplegia syndrome.
High body mass index, long cardiopulmonary bypass time, prior cardiothoracic surgery, mechanical support, use of aspirin, and thyroid disease are risk factors associated with development of vasoplegia syndrome.
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