Altered intracellular Ca2+ regulation in chronic rat heart failure

intracellular Ca(2+) handling by the sarcoplasmic reticulum (SR) plays a crucial role in the pathogenesis of heart failure (HF). Despite extensive effort, the underlying causes of abnormal SR Ca(2+) handling in HF have not been clarified. To determine whether the diastolic SR Ca(2+) leak along with reduced Ca(2+) reuptake is required for decreased contractility, we investigated the cytosolic Ca(2+) transients and SR Ca(2+) content and assessed the expression of ryanodine receptor (RyR2), FK506 binding protein (FKBP12.6), SR-Ca(2+) ATPase (SERCA2a), and L-type Ca(2+) channel (LTCC) using an SD-rat model of chronic HF. We found that the cytosolic Ca(2+) transients were markedly reduced in amplitude in HF myocytes (DeltaF/F(0) = 12.3 +/- 0.8) compared with control myocytes (DeltaF/F(0) = 17.7 +/- 1.2, P < 0.01), changes paralleled by a significant reduction in the SR Ca(2+) content (HF: DeltaF/F(0) = 12.4 +/- 1.1, control: DeltaF/F(0) = 32.4 +/- 1.9, P < 0.01). Moreover, we demonstrated that the expression of FKBP12.6 associated with RyR2, SERCA2a, and LTCC was significantly reduced in rat HF. These results provide evidence for phosphorylation-induced detachment of FKBP12.6 from RyRs and down-regulation of SERCA2a and LTCC in HF. We conclude that diastolic SR Ca(2+) leak (due to dissociation of FKBP12.6 from RyR2) along with reduced SR Ca(2+) uptake (due to down-regulation of SERCA2a) and defective E-C coupling (due to down-regulation of LTCC) could contribute to HF.

Family influences on self-management among functionally independent adults with diabetes or heart failure: do family members hinder as much as they help?

OBJECTIVES

Among functionally independent patients with diabetes or heart failure, we examined family member support and family-related barriers to self-care. We then identified patient characteristics associated with family support and family barriers and how each was associated with self-management adherence.

METHODS

Cross-sectional survey of 439 patients with diabetes or heart failure (74% response rate).

RESULTS

75% of respondents reported supportive family involvement in self-care; however, 25% reported frequent family-related barriers to self-care. Women reported family support less often (64% v. 77%) and family barriers to self-care more often (30% v. 21%) than men. 78% of respondents reported involved family members nagged or criticized them about illness care. In multivariate models, low health literacy, partnered status and higher family function were associated with higher family support levels, while female gender, older age, higher education, and more depression symptoms were associated with family barriers to self-care. Family barriers were associated with lower disease care self-efficacy (p<0.01), and both barriers and family support were associated with patients' self-management adherence (both p<0.05).

DISCUSSION

Family members are highly involved in the self-care of these higher functioning patients. Interventions should help patients with chronic illness overcome family barriers to self-care and help families use positive and effective support techniques.

[Heart failure: a view from primary care]

OBJECTIVE

Our aim was to find out the situation of heart failure (HF) in primary care.

DESIGN

Cross-sectional multicentre study.

SETTING

Four primary health care centres and a hospital in an urban area of Barcelona.

PARTICIPANTS

From a registered population of 35,212 inhabitants older than 45 years, we studied all patients (333) diagnosed with HF in 2006 in primary care.

MEASUREMENTS

A standardised questionnaire was used to record demographic, clinical and treatment data.

RESULTS

There were 61.4% females. Mean age was 74.5 (standard deviation [SD]: 10) for men and 79 (SD: 9.8) for women. A total of 46% of patients had HF for <5 years. The comorbidity diagnosis and at the beginning of the study were: hypertension 65.4% and 73%, diabetes 33.6% and 40%, dyslipaemia 40% and 53%, coronary disease 30% and 27%, and valvular disease 23.7% and 27%, respectively. A total of 64% of patients had registered New York Heart Association functional class (48% class II, 30% III and 6.6% IV). Blood pressure was controlled in 36% men and 20.5% women (P=0.002); 75.4% had an electrocardiogram, 57% X-ray; 58% of men and 46% of women (P=0.02) had echocardiography. The most prescribed drugs were diuretics 85.3%, the least, beta blockers 27%.

CONCLUSIONS

Patients with HF in primary care are elderly females with a lot of comorbidities. We must be concerned by the suboptimal use of basic investigations (electrocardiogram and X-ray) and beta blocker treatments.

African-American women have a higher risk for developing peripartum cardiomyopathy

OBJECTIVES

The purpose of this study was to assess whether African-American women are at increased risk of having peripartum cardiomyopathy.

BACKGROUND

Peripartum cardiomyopathy is a heart disease of unknown cause that affects young women, often with devastating consequences. The frequency of peripartum cardiomyopathy varies markedly between African and non-African regions.

METHODS

A case-control study was performed at a regional center that provides medical care to a racially heterogeneous population. For each case, 3 healthy control patients were randomly selected who delivered babies within the same month.

RESULTS

African-American women had a 15.7-fold higher relative risk of peripartum cardiomyopathy than non-African Americans (odds ratio [OR]: 15.7, 95% confidence interval [CI]: 3.5 to 70.6). Other significant univariate risk factors were hypertension (OR: 10.8, 95% CI: 2.6 to 44.4), being unmarried (OR: 4.2, 95% CI: 1.4 to 12.3), and having had >2 previous pregnancies (OR: 2.9, 95% CI: 1.1 to 7.4). African-American ethnicity remained a significant risk factor for peripartum cardiomyopathy when other risk factors were considered in multivariable (OR: 31.5, 95% CI: 3.6 to 277.6) and stratified analyses (OR: 12.9 to 29.1, p < 0.001). Although the frequency of peripartum cardiomyopathy (185 of 100,000 deliveries) at this center was higher than in previous U.S. reports, it was comparable to the frequency in countries with more women of African descent (100 to 980 of 100,000). Analysis of other U.S. studies confirmed that the frequency of peripartum cardiomyopathy was significantly higher among African-American women.

CONCLUSIONS

African-American women have significantly higher odds of having peripartum cardiomyopathy that could not be explained by several other factors. Further research will be necessary to determine the potential environmental and/or genetic factors associated with African descent that confer this risk.

Uncoupled cardiac nitric oxide synthase mediates diastolic dysfunction

BACKGROUND

Heart failure with preserved ejection fraction is 1 consequence of hypertension and is caused by impaired cardiac diastolic relaxation. Nitric oxide (NO) is a known modulator of cardiac relaxation. Hypertension can lead to a reduction in vascular NO, in part because NO synthase (NOS) becomes uncoupled when oxidative depletion of its cofactor tetrahydrobiopterin (BH(4)) occurs. Similar events may occur in the heart that lead to uncoupled NOS and diastolic dysfunction.

METHODS AND RESULTS

In a hypertensive mouse model, diastolic dysfunction was accompanied by cardiac oxidation, a reduction in cardiac BH(4), and uncoupled NOS. Compared with sham-operated animals, male mice with unilateral nephrectomy, with subcutaneous implantation of a controlled-release deoxycorticosterone acetate pellet, and given 1% saline to drink were mildly hypertensive and had diastolic dysfunction in the absence of systolic dysfunction or cardiac hypertrophy. The hypertensive mouse hearts showed increased oxidized biopterins, NOS-dependent superoxide production, reduced NO production, and dephosphorylated phospholamban. Feeding hypertensive mice BH(4) (5 mg/d), but not treating with hydralazine or tetrahydroneopterin, improved cardiac BH(4) stores, phosphorylated phospholamban levels, and diastolic dysfunction. Isolated cardiomyocyte experiments revealed impaired relaxation that was normalized with short-term BH(4) treatment. Targeted cardiac overexpression of angiotensin-converting enzyme also resulted in cardiac oxidation, NOS uncoupling, and diastolic dysfunction in the absence of hypertension.

CONCLUSIONS

Cardiac oxidation, independently of vascular changes, can lead to uncoupled cardiac NOS and diastolic dysfunction. BH(4) may represent a possible treatment for diastolic dysfunction.

Association between depressive symptoms and fibrosis markers: the Cardiovascular Health Study

OBJECTIVE

Fibrosis plays an important role in heart failure (HF) and other diseases that occur more frequently with increasing age. Depression is associated with an increased risk of heart failure and other age-related diseases. This study examined the association between depressive symptoms and fibrosis markers in adults aged 65 years and above.

METHODS

Fibrosis markers and depressive symptoms were assessed in 870 participants (age=80.9+/-5.9 yrs, 49% women) using a case-control design based on heart failure status (307 HF patients and 563 age- and sex-matched controls, of whom 284 with CVD risk factors (hypertension, diabetes mellitus, or hypercholesterolemia) and 279 controls without these CVD risk factors). Fibrosis markers were procollagen type I (PIP), type I collagen (CITP), and procollagen type III (PIIINP). Inflammation markers included C-reactive protein, white blood cell counts and fibrinogen. Depression was assessed using the Center for Epidemiological Studies-Depression (CES-D) scale using a previously validated cut-off point for depression (CES-D > or = 8). Covariates included demographic and clinical variables.

RESULTS

Depression was associated with higher levels of PIP (median=411.0, inter-quartile range (IQR)=324.4-472.7 ng/mL vs. 387.6, IQR=342.0-512.5 ng/mL, p=0.006) and CITP (4.99, IQR=3.53-6.85 vs. 4.53, IQR=3.26-6.22 microg/L, p=0.024), but not PIIIINP (4.07, IQR=2.75-5.54 microg/L vs. 3.58, IQR=2.71-5.01 microg/L, p=0.29) compared to individuals without depression. Inflammation markers were also elevated in depressed participants (CRP, p=0.014; WBC, p=0.075; fibrinogen, p=0.074), but these inflammation markers did not account for the relationship between depression and fibrosis markers.

CONCLUSIONS

Depression is associated with elevated fibrosis markers and may therefore adversely affect heart failure and other age-related diseases in which extra-cellular matrix formation plays a pathophysiological role.

Medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with heart failure

BACKGROUND

Rehospitalization rates are higher in African American than Caucasian patients with heart failure (HF). The reasons for the disparity in outcomes between African Americans and Caucasians may relate to differences in medication adherence. To determine whether medication adherence is a mediator of the relationship between ethnicity and event-free survival in patients with HF.

METHODS AND RESULTS

Medication adherence was monitored longitudinally in 135 HF patients using the Medication Event Monitoring System. Events (emergency department visits for HF exacerbation, HF and cardiac rehospitalization, and all-cause mortality) were obtained by interview and hospital data base review. A series of regression models and survival analyses was conducted to determine whether medication adherence mediated the relationship between ethnicity and event-free survival. Event-free survival was significantly worse in African Americans than Caucasians. Ethnicity was a predictor of medication adherence (P=.011). African Americans were 2.57 times more likely to experience an event than Caucasians (P=.026). Ethnicity was not a predictor of event-free survival after entering medication adherence in the model (P=.06).

CONCLUSIONS

Medication adherence was a mediator of the relationship between ethnicity and event-free survival in this sample. Interventions designed to reduce barriers to medication adherence may decrease the disparity in outcomes.

Cadmium exposure in association with history of stroke and heart failure

BACKGROUND

It is unclear whether environmental cadmium exposure is associated with cardiovascular disease, although recent data suggest associations with myocardial infarction and peripheral arterial disease.

OBJECTIVE

The objective of this study was to evaluate the association of measured cadmium exposure with stroke and heart failure (HF) in the general population.

METHODS

We analyzed data from 12,049 participants, aged 30 years and older, in the 1999-2006 National Health and Nutrition Examination Survey (NHANES) for whom information was available on body mass index, smoking status, alcohol consumption, and socio-demographic characteristics.

RESULTS

At their interviews, 492 persons reported a history of stroke, and 471 a history of HF. After adjusting for demographic and cardiovascular risk factors, a 50% increase in blood cadmium corresponded to a 35% increased odds of prevalent stroke [OR: 1.35; 95% confidence interval (CI): 1.12-1.65] and a 50% increase in urinary cadmium corresponded to a 9% increase in prevalent stroke [OR: 1.09; 95% CI: 1.00-1.19]. This association was higher among women [OR: 1.38; 95% CI: 1.11-1.72] than men [OR: 1.30; 95% CI: 0.93-1.79] (p-value for interaction=0.05). A 50% increase in blood cadmium corresponded to a 48% increased odds of prevalent HF [OR: 1.48; 95% CI: 1.17-1.87] and a 50% increase in urinary cadmium corresponded to a 12% increase in prevalent HF [OR: 1.12; 95% CI: 1.03-1.20], with no difference in sex-specific associations.

CONCLUSIONS

Environmental exposure to cadmium was associated with significantly increased stroke and heart failure prevalence. Cadmium exposure may increase these important manifestations of cardiovascular disease.

Echocardiography as a guidance in CRT management: the GPS system in a labyrinth?

Although progress has been made to understand the factors for non-responsiveness, fine tuning and comprehensive strategies are needed to make echocardiography the GPS system in cardiac resynchronization. Taking the wrong turn in the labyrinth of dyssynchrony is expensive and time consuming without improving well being of the heart failure patient. Possibly other imaging techniques could help in fine tuning cardiac resynchronization.

Dietary glycemic index, dietary glycemic load, and incidence of heart failure events: a prospective study of middle-aged and elderly women

OBJECTIVE

Dietary glycemic index (GI) and glycemic load (GL), measures of the propensity of dietary carbohydrate to increase blood glucose, have been associated with risk of coronary heart disease, but their association with incidence of heart failure (HF) is unknown. The authors therefore assessed whether dietary GI and GL were associated with rates of HF events.

METHODS

The authors conducted a prospective, observational study of 36,019 women 48-83 years old without baseline HF, diabetes, or myocardial infarction who were participants in the Swedish Mammography Cohort, a prospective cohort study. Diet was measured using food-frequency questionnaires. Women were followed from January 1, 1998, through December 31, 2006, for HF hospitalization or death through the Swedish inpatient and cause-of-death registers. Cox proportional hazards models adjusted for age and other risk factors were used to estimate incidence rate ratios (RRs) and 95% confidence intervals (CIs).

RESULTS

Over 9 years of follow-up, 639 of 36,019 women died of HF (n = 54) or were hospitalized for HF for the first time (n = 585). The authors did not find statistically significant associations between dietary GI and HF events (RR comparing highest to lowest quartile = 1.12, 95% CI = 0.87-1.45, p for trend = 0.31) or between dietary GL and HF events (RR comparing highest to lowest quartile = 1.30, 95% CI = 0.87-1.93, p for trend = 0.16). Results were not significantly different in normal weight and overweight women.

CONCLUSIONS

In this population, dietary GI did not appear to be associated with incident HF events. There was a suggestion of an association between dietary GL and HF, which did not reach statistical significance.

The dietary quality of persons with heart failure in NHANES 1999-2006

BACKGROUND

Dietary quality may impact heart failure outcomes. However, the current status of the dietary quality of persons with heart failure has not been previously reported.

OBJECTIVE

To describe sodium intake, patient factors associated with sodium intake and overall dietary quality in a national sample of persons with heart failure.

DESIGN

Analysis of repeated cross-sectional probability sample surveys using data from National Health and Nutrition Examination Surveys (NHANES) of 1999-2000, 2001-2002, 2003-2004 and 2005-2006.

PARTICIPANTS

The study sample consisted of 574 persons with self-reported heart failure (mean age = 70 years; 52% women).

MEASUREMENTS

Diet of each survey participant was assessed using single 24 hour recall. Dietary nutrients of interest included sodium, the mainstay of heart failure dietary recommendations, and additionally potassium, calcium, magnesium, fish oils, saturated fat and fiber. Specific dietary goals were based on established guidelines.

RESULTS

Mean sodium intake was 2,719 mg, with 34% consuming less than 2,000 mg per day. Patient factors associated with greater sodium intake included male gender, lower education, lower income and no reported diagnosis of hypertension. Mean potassium intake was 2,367 mg/day, with no differences by type of diuretic used or renal disease status. Adherence rates to established guidelines for other nutrients were 13% for calcium, 10% for magnesium, 2% for fish oils, 13% for saturated fat and 4% for fiber.

CONCLUSIONS

Dietary quality of persons with self-reported heart failure was poor. Public health approaches and clinical dietary interventions are needed for persons with this increasingly prevalent clinical syndrome.

Glucose, obesity, metabolic syndrome, and diabetes relevance to incidence of heart failure

Heart failure (HF) is common, results in poor clinical outcomes, and is associated with large health care costs. The incidence of HF continues to rise, with approximately 670,000 new cases per year and a 20% lifetime risk of HF for persons 40 years and older in the U.S. Risk factors for HF have been identified, and thus preventative strategies should have a positive effect on disease burden, morbidity, and mortality. Although coronary artery disease and hypertension have traditionally been considered among the most important modifiable risk factors for the development of HF, recent studies have highlighted the importance of increasingly prevalent metabolic risk factors: glucose, diabetes, obesity, and the metabolic syndrome. This report will present evidence for the link between glucose, diabetes, obesity, metabolic syndrome, and incident HF. Furthermore, we will discuss how risk factor modification and other preventive therapies may help curb the rising incidence of HF.

A high ankle brachial index is associated with greater left ventricular mass MESA (Multi-Ethnic Study of Atherosclerosis)

OBJECTIVES

This study sought to determine the association of high ankle brachial index (ABI) measurements with left ventricular (LV) mass, and to compare its strength with that of low ABI with LV mass.

BACKGROUND

Arterial stiffness leads to LV mass through nonatherosclerotic pathways in mice. In humans, a high ABI indicates stiff peripheral arteries and is associated with cardiovascular disease (CVD) events. Whether high ABI is associated with LV mass in humans and whether this might reflect consequences of arterial stiffness, atherosclerosis, or both is unknown.

METHODS

Among 4,972 MESA (Multi-Ethnic Study of Atherosclerosis) participants without clinical CVD, we used linear regression to evaluate the association of low (<0.90) and high (>1.40 or incompressible) ABI with LV mass by cardiac magnetic resonance imaging (MRI). Intermediate ABIs served as the reference category. To determine the effect of subclinical atherosclerosis, models were adjusted for common and internal carotid intima media thickness (cIMT) and natural log-transformed coronary artery calcification.

RESULTS

Compared with subjects with intermediate ABI, LV mass was higher with either low (2.70 g/m(2) higher, 95% confidence interval: 0.65 to 4.75) or high ABI (6.84 g/m(2) higher, 95% confidence interval: 3.2 to 10.47) after adjustment for traditional CVD risk factors, kidney function, and C-reactive protein. However, further adjustment for cIMT and CAC substantially attenuated the association of low ABI with LV mass index (1.24 g/m(2) higher, 95% confidence interval: -0.84 to 3.33), whereas the association of high ABI was minimally altered (6.01 g/m(2) higher, 95% confidence interval: 2.36 to 9.67).

CONCLUSIONS

High ABI is associated with greater LV mass; an association that is not attenuated with adjustment for subclinical atherosclerosis in nonperipheral arterial beds. High ABI might lead to greater LV mass through nonatherosclerotic pathways.

Novel aspects of the roles of Rac1 GTPase in the cardiovascular system

Rac1 GTPase is an established master regulator of cell motility through cortical actin re-organization and of reactive oxygen species generation through regulation of NADPH oxidase activity. Numerous molecular and cellular studies have implicated Rac1 in various cardiovascular pathologies: vascular smooth muscle proliferation, cardiomyocyte hypertrophy, and endothelial cell shape change. The physiological relevance of these in vitro findings, however, is just beginning to be reassessed with the newly developed, conditional mouse mutagenesis technology. Conditional gene targeting has also revealed unexpected, cell type-specific roles of Rac1. The aim of this review is to summarize the recent advance made in Rac1 research in the cardiovascular system, with special focus on its novel roles in the regulation of endothelial function, angiogenesis, and endothelium-mediated neuroprotection.

Central nervous system changes in pediatric heart failure: a volumetric study

Autonomic dysfunction, mood disturbances, and memory deficits appear in pediatric and adult heart failure (HF). Brain areas controlling these functions show injury in adult HF patients, many of whom have comorbid cerebrovascular disease. We examined whether similar brain pathology develops in pediatric subjects without such comorbidities. In this study, high-resolution T1 brain magnetic resonance images were collected from seven severe HF subjects age (age 8-18 years [mean 13]; left ventricular shortening 9 to 19% [median 14%]) and seven age-matched healthy controls (age 8-18 years [mean 13]). After segmentation into gray matter (GM), white matter, and cerebrospinal fluid (CSF), regional volume loss between groups was determined by voxel-based morphometry. GM volume loss appeared on all HF scans, but ischemic changes and infarcts were absent. HF subjects showed greater CSF volume than controls (mean ± SD 0.30 ± 0.04 vs. 0.25 ± 0.04 l, P = 0.03), but total intracranial volume was identical (1.39 ± 0.11 vs. 1.39 ± 0.09 l, P = NS). Regional GM volume reduction appeared in the right and left posterior hippocampus, bilateral mid-insulae, and the superior medial frontal gyrus and mid-cingulate cortex of HF subjects (threshold P < 0.001). No volume-loss sites appeared in control brains. We conclude that pediatric HF patients show brain GM loss in areas similar to those of adult HF subjects. Substantial changes emerged in sites that regulate autonomic function as well as mood, personality and short-term memory. In the absence of thromboembolic disease and many comorbid conditions found in adult HF patients, pediatric HF patients show significant, focal GM volume loss, which may coincide with the multiple neurologic and psychological changes observed in patients with HF.

Natriuretic Peptide system and cardiovascular disease

The mammalian Natriuretic Peptide (NP) system consists of neuro-hormones, such as atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), c-type natriuretic peptide (CNP), and the N-Terminal fragment of BNP (NT-pro-BNP). In response to some cardiovascular derangement the heart (acting as an endocrine organ), brain and other structures secretes natriuretic peptides in an attempt to restore normal circulatory conditions. Their actions are modulated through membrane-bound guanylyl cyclased (GC) receptors. They induce diuresis, natriuresis and vasodilation in the presence of congestive heart failure. These neuro-hormones also play a role in the suppression of neointimal formation after vascular injury. In addition, they act as antifibrotic and antihypertrophic agents preventing cardiac remodeling after myocardial infarction. Further, NP have diagnostic and prognostic role in heart failure, vasoconstriction, left ventricular late remodeling after MI and others. At present, some drugs such as Nesiritide, NEP inhibitors and vasopeptidase inhibitors were synthetized from NP, to antagonize these cardiovascular derengements. In future, it will be possibile to elaborate some drugs similar to petidase inhibitors and some CNP-like drugs able to reduce many symptoms of cardiovascular derangements without significant side effects.

Sarcoplasmic reticulum Ca(2+) ATPase as a therapeutic target for heart failure

The cardiac isoform of the sarco/endoplasmic reticulum Ca(2+)ATPase (SERCA2a) plays a major role in controlling excitation/contraction coupling. In both experimental and clinical heart failure, SERCA2a expression is significantly reduced which leads to abnormal Ca(2+) handling and deficient contractility. A large number of studies in isolated cardiac myocytes and in small and large animal models of heart failure showed that restoring SERCA2a expression by gene transfer corrects the contractile abnormalities and improves energetics and electrical remodeling. Following a long line of investigation, a clinical trial is underway to restore SERCA2a expression in patients with heart failure using adeno-associated virus type 1. This review addresses the following issues regarding heart failure gene therapy: i) new insights on calcium regulation by SERCA2a; ii) SERCA2a as a gene therapy target in animal models of heart failure; iii) advances in the development of viral vectors and gene delivery; and iv) clinical trials on heart failure using SERCA2a. This review focuses on the new advances in SERCA2a- targeted gene therapy made in the last three years. In conclusion, SERCA2a is an important therapeutic target in various cardiovascular disorders. Ongoing clinical gene therapy trials will provide answers on its safety and applicability.

Quality of care for heart failure among disabled Medicaid recipients with and without severe mental illness

OBJECTIVE

To examine the association between severe mental illness (SMI) and quality of care in heart failure.

METHODS

We conducted a cohort study between 2001 and 2004 of disabled Maryland Medicaid participants with heart failure. Quality measures and clinical outcomes were compared for individuals with and without SMI.

RESULTS

Of 1801 individuals identified with heart failure, 341 had comorbid SMI. SMI was not associated with differences in quality measures, including left ventricular assessment [adjusted relative risk (aRR) 0.99; 95% CI 0.91-1.07], utilization of angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) (aRR 1.04; 95% CI 0.92-1.17), or beta-blocker use (aRR 1.13; 95% CI 0.99-1.29). During the study period, 52.2% of individuals in the cohort filled a prescription for an ACE inhibitor or ARB and 45.5% filled a beta-blocker prescription. Individuals with and without SMI had similar rates of clinical outcomes, including hospitalizations, readmissions, and mortality. Both medication interventions were associated with improved mortality.

CONCLUSIONS

In this sample of disabled Medicaid recipients with heart failure, persons with SMI received similar quality of care as those without SMI. Both groups had low rates of beneficial medical treatments. Quality improvement programs should consider how best to target these vulnerable populations.

LateTIME: a phase-II, randomized, double-blinded, placebo-controlled, pilot trial evaluating the safety and effect of administration of bone marrow mononuclear cells 2 to 3 weeks after acute myocardial infarction

A realistic goal for cardiac cell therapy may be to attenuate left ventricular remodeling following acute myocardial infarction to prevent the development of congestive heart failure. Initial clinical trials of cell therapy have delivered cells 1 to 7 days after acute myocardial infarction. However, many patients at risk of developing congestive heart failure may not be ready for cell delivery at that time-point because of clinical instability or hospitalization at facilities without access to cell therapy. Experience with cell delivery 2 to 3 weeks after acute myocardial infarction has not to date been explored in a clinical trial. The objective of the LateTIME study is to evaluate by cardiac magnetic resonance the effect on global and regional left ventricular function, between baseline and 6 months, of a single intracoronary infusion of 150 × 106 autologous bone marrow mononuclear cells (compared with placebo) when that infusion is administered 2 to 3 weeks after moderate-to-large acute myocardial infarction. The 5 clinical sites of the Cardiovascular Cell Therapy Research Network (CCTRN) will enroll a total of 87 eligible patients in a 2:1 bone marrow mononuclear cells-to-placebo patient ratio; these 87 will have undergone successful percutaneous coronary intervention of a major coronary artery and have left ventricular ejection fractions ≤0.45 by echocardiography. When the results become available, this study should provide insight into the clinical feasibility and appropriate timing of autologous cell therapy in high-risk patients after acute myocardial infarction and percutaneous coronary intervention.

Comparison of once-daily versus twice-daily dosing of valsartan in patients with chronic stable heart failure

BACKGROUND

The safety of once-daily (qd) dosing of valsartan in heart failure (HF) patients is not known.

HYPOTHESIS

This 10-week, double-blind trial examined the relative safety and efficacy of valsartan administered qd versus twice-daily (bid).

METHODS

HF patients (NYHA class II-III) receiving diuretics (87%), angiotensin-converting enzyme inhibitors (98%), beta-blockers (92%), aldosterone antagonists (25%), or digoxin (32%) were randomized to valsartan 40 mg bid (n = 60) or 80 mg qd (n = 55) and titrated to a maximum dose of 320 mg/day; doubling the dose every 2 weeks. Clinical and biochemical parameters were measured at Weeks 2, 4, 6, and 10.

RESULTS

The average dose of valsartan at the end of study was 245 mg in the bid group vs 256 mg in the qd group (P = NS). Similar proportions of patients tolerated qd vs bid dosing (bid 67% vs qd 68%). Outcome measures including reduction in blood pressure, incidence of hypotension, renal impairment, orthostatic dizziness or fatigue, changes in serum K(+), creatinine, cystatin-C, and estimated glomerular filtration rate were similar between the 2 groups at all time-points. Brain natriuretic peptide levels decreased and plasma renin activity increased from baseline by the same amount in both groups at all time-points.

CONCLUSION

Valsartan administered qd has a similar safety and tolerability profile with comparable 24-hour RAAS blockade, as assessed by increases in PRA, as bid dosing in patients with moderate to severe (NYHA class II-III) heart failure.

Water and sodium regulation in heart failure

Heart failure is the pathophysiological state characterized by ventricular dysfunction and associated clinical symptoms. Decreased cardiac output or peripheral vascular resistance lead to arterial underfilling. That is an important signal which triggers multiple neurohormonal systems to maintain adequate arterial pressure and peripheral perfusion of the vital organs. The kidney is the principal organ affected when cardiac output declines. Alterations of hemodynamics and neurohormonal systems in heart failure result in renal sodium and water retention. Activation of sympathetic nervous system, renin-angiotensin-aldosterone system and non-osmotic vasopressin release stimulate the renal tubular reabsorption of sodium and water. Dysregulation of aquaporin-2 and sodium transporters also play an important role in the pathogenesis of renal sodium and water retention.

Conivaptan and its role in the treatment of hyponatremia

Hyponatremia is the most common electrolyte abnormality in hospitalized patients and is associated with increased morbidity and mortality. The recognition of the central role that arginin vasopressin plays in the pathogenesis of hyponatremia and the discovery that its actions are mediated by stimulation of V(1A) and V(2) receptors have led to the development of a new class of drugs, the arginin vasopressin antagonists. Conivaptan is a nonselective V(1A) and V(2) receptors antagonist that was the first of this class to be approved by the FDA for the management of euvolemic and hypervolemic hyponatremia. Its short-term safety and efficacy for the correction of hyponatremia have been established by multiple double-blind, randomized, controlled studies. Blocking the effects of arginin vasopressin on V(2) receptors produces aquaresis--the electrolyte-sparing excretion of water--an ideal approach to correct hypervolemic hyponatremia. The nonselectivity of conivaptan offers a theoretical advantage for its use in heart failure that may merit further exploration.