Effects of tumor necrosis factor gene polymorphisms on patients with congestive heart failure. VEST Investigators for TNF Genotype Analysis. Vesnarinone Survival Trial

BACKGROUND

Tumor necrosis factor-alpha (TNF-alpha) is known to be elevated in patients with congestive heart failure (CHF). Two biallelic polymorphisms have been identified in the TNF gene locus: one in the promoter region of TNF-alpha (TNFA1/2), and the other in the first intron of TNF-beta (TNFB1/2). Both TNFA2 and TNFB2 alleles are associated with high TNF-alpha production in vitro and susceptibility to inflammatory diseases. Given the importance of TNF-alpha in the pathogenesis of CHF, we studied the prevalence of TNF gene polymorphisms in CHF patients and the correlation of genotypes to in vivo TNF-alpha levels.

METHODS AND RESULTS

TNFA and TNFB genotypes were determined by the polymerase chain reaction-restriction fragment length polymorphism technique. There were no differences in the TNF allele frequencies between CHF (n=229; TNFA1/2=0.84/0.16, TNFB1/2=0.33/0.67) and control subjects (n=139; TNFA1/2=0.84/0.16, TNFB1/2=0.32/0.68). In 211 patients with CHF, circulating levels of TNF-alpha and the soluble receptors type I and type II were measured by ELISA: 6.18+/-3.59 pg/mL, 1768+/-761 pg/mL, and 4484+/-1750 pg/mL, respectively. There were no correlations between TNFA or TNFB genotypes and circulating levels of TNF-alpha or its soluble receptors in the CHF patients.

CONCLUSIONS

Despite their association with other inflammatory diseases, neither TNFA nor TNFB polymorphisms are related to the presence of CHF or the elevation of circulating TNF-alpha. Thus, other factors may be more important in determining the circulating levels of TNF-alpha in CHF.

Treatment of patients admitted to the hospital with congestive heart failure: specialty-related disparities in practice patterns and outcomes

OBJECTIVES

This study sought to define specialty-related differences in the care and outcome of patients admitted to the hospital with congestive heart failure (CHF).

BACKGROUND

Congestive heart failure is the leading diagnosis-related group (DRG) discharge diagnosis in the United States and accounts for an estimated annual hospital cost in excess of $7 billion. The clinical impact of aggressive CHF management and the importance of the subspecialist in guiding this care have not been evaluated.

METHODS

To define differences in physician practice patterns, we performed a chart review of consecutive patients admitted to a university teaching hospital with a primary DRG discharge diagnosis of CHF. We compared treatment and outcome of patients cared for by a generalist (n = 160) and those whose care was guided by a cardiologist (n = 138) during their index hospital period with CHF and over the next 6 months.

RESULTS

At our institution, > 50% of patients admitted to the hospital with CHF cared for by generalists alone had minimal (New York Heart Association functional class I or II) symptoms, compared with < 15% of those cared for by a cardiologist (p < 0.01). Although generalists' patients underwent significantly fewer in-hospital diagnostic tests and had shorter lengths of stay, they had a 1.7-fold increased risk of readmission for CHF within 6 months (p < 0.05). Six-month cardiac and all-cause mortality were not significantly different between the groups. The type of physician caring for the patient and a history of diabetes, previous CHF or myocardial infarction were independent predictors of readmission for CHF.

CONCLUSIONS

Involvement of a cardiologist in the care of patients admitted to the hospital with CHF is associated with increased use of diagnostic testing, longer hospital stays and improved clinical outcome. These results substantiate practice guidelines that suggest a role for cardiologists in the care of symptomatic patients with CHF.

Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy

BACKGROUND

Although an autoimmune pathogenesis has been postulated for dilated cardiomyopathy, immunosuppressive therapy has not been shown to be effective in clinical trials. Immune modulatory therapy with immune globulin is an effective therapy for Kawasaki disease in children, and recent data suggest that it improves ventricular function in children with new-onset dilated cardiomyopathies. The role of immune globulin therapy in adults with this disorder has not previously been evaluated.

METHODS AND RESULTS

Ten patients were treated with high-dose intravenous immune globulin infusions (2 g/kg). All were hospitalized with NYHA class III to IV heart failure, left ventricular ejection fraction (LVEF) < 0.40, and symptoms for < 6 months at the time of presentation. One patient died before the completion of therapy. The remaining 9 were discharged, and LVEF was reassessed 12 months after therapy. LVEF improved from 0.24 +/- 0.02 (mean +/- SEM) at baseline to 0.41 +/- 0.04 at follow-up (P = .003). All 9 patients improved functionally to NYHA class I to II, and there have been no subsequent hospitalizations for heart failure during the course of follow-up.

CONCLUSIONS

In this series of patients with new-onset dilated cardiomyopathy treated with high-dose immune globulin, LVEF improved 17 EF units. The effectiveness of intravenous immune globulin therapy in this disorder should be evaluated in a randomized, multicenter trial.

Strategies for pharmacologic modulation of the heart failure phenotype

The end-stage heart failure phenotype is characterized by marked dyspnea on exertion, edema, and overwhelming fatigue, and by a high incidence of sudden death. Patients who display the end-stage phenotype have transitioned from a normal phenotype with myocardial damage at a cellular level. This transition appears to be mediated by events at both the cellular and molecular levels. Until recently, it was generally believed that this transition was irreversible. However, recent clinical trials have demonstrated that the phenotype can be changed with pharmacologic agents. These agents have been demonstrated to improve exercise capability, increase ventricular function, and improve symptoms. Important recent studies have shown that pharmacologic agents can substantially alter the high mortality rates associated with the end-stage heart failure phenotype. As we learn more about the molecular and cellular events that initiate and support the transition from cardiac compensation to decompensation, we will be able to improve our pharmacologic targeting and, we hope, be able to delay the development of the end-stage heart failure phenotype to an even greater degree.

Health-oriented telecommunication: a community resource

Telecommunication networks that link medical information with the community can support home caregivers while providing skills training and crisis intervention to prevent unnecessary hospitalization. Health-oriented telecommunications direct the traditional focus from intervention to prevention. Consumers become empowered with knowledge allowing them to participate in their healthcare and lifestyle decisions.