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Metra M, O'Connor CM, Davison BA, Cleland JGF, Ponikowski P, Teerlink JR, Voors AA, Givertz MM, Mansoor GA, Bloomfield DM, Jia G, DeLucca P, Massie B, Dittrich H, Cotter G. Early dyspnoea relief in acute heart failure: prevalence, association with mortality, and effect of rolofylline in the PROTECT Study. Eur Heart J 2011; 32:1519-34. [PMID: 21388992 DOI: 10.1093/eurheartj/ehr042] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
AIMS Dyspnoea and pulmonary and/or peripheral congestion are the most frequent manifestations of acute heart failure (AHF) and are important targets for therapy. We have assessed changes in dyspnoea, their relationship with mortality, and the effects of the adenosine A1 receptor antagonist rolofylline on these endpoints in patients enrolled in the PROTECT trial. METHODS AND RESULTS PROTECT was a prospective, double-blind, placebo-controlled study assessing the effect of rolofylline in patients hospitalized for AHF with dyspnoea, fluid overload, increased plasma natriuretic peptides, and mild-to-moderate renal dysfunction. Early dyspnoea relief, prospectively defined as moderately or markedly better dyspnoea at both 24 and 48 h after the start of study drug administration, occurred in 49.8% of the patients. Early dyspnoea relief was associated with greater weight loss and with reduced mortality at Days 14 and 30 [hazard ratio (HR) 0.28, 95% confidence interval (CI): 0.15, 0.50; and 0.35, 95% CI: 0.22, 0.55, respectively]. Rolofylline administration was associated with an increase in the proportion of patients showing early dyspnoea relief (HR 1.30; 95% CI: 1.08, 1.57) and with a numerically lower mortality at 14 and 30 days, largely driven by the mortality due to HF [at 30 days, HR (95% CI, P-value): 0.65 (0.38-1.10, P= 0.107)]. Rolofylline did not reduce episodes of in-hospital worsening HF or post-discharge re-admissions, nor did it improve survival at 60 or 180 days. CONCLUSION The present analysis from PROTECT demonstrated that more weight loss was associated with early dyspnoea relief and reduced short-term mortality.
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Shemesh E, Annunziato RA, Weatherley BD, Cotter G, Feaganes JR, Santra M, Yehuda R, Rubinstein D. A randomized controlled trial of the safety and promise of cognitive-behavioral therapy using imaginal exposure in patients with posttraumatic stress disorder resulting from cardiovascular illness. J Clin Psychiatry 2011; 72:168-74. [PMID: 20441725 DOI: 10.4088/jcp.09m05116blu] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2009] [Accepted: 08/14/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We investigated the physical safety of cognitive-behavioral therapy (CBT) utilizing imaginal exposure in patients who suffered from posttraumatic stress disorder (PTSD) following a life-threatening cardiovascular event. METHOD In this phase I, prospective, single-blind trial conducted from April 2006 through April 2008, we randomly assigned 60 patients to receive either 3 to 5 sessions of imaginal exposure therapy (experimental group) or 1 to 3 educational sessions only (control group). Criteria for PTSD and other mental health disorders were evaluated according to DSM-IV using the full Structured Clinical Interview for DSM-IV (SCID). Safety assessments included patients' blood pressure and pulse before and after each study session and the occurrence of deaths, hospitalizations, repeat myocardial infarctions, or invasive procedures. We also investigated the effects of the treatment on PTSD symptoms (Impact of Event Scale and Posttraumatic Stress Disorder Scale), depression (Beck Depression Inventory-II), and the Clinical Global Impressions-Severity of Illness (CGI-S) scale. RESULTS There were no significant differences between the experimental and control groups and between exposure and nonexposure sessions in any of the safety measures. In addition, confidence intervals were such that the nonsignificant effects of exposure therapy were not of clinical concern. For example, the mean difference in systolic pressure between control and exposure sessions was 0.5 mm Hg (95% CI, -6.1 to 7.1 mm Hg). Nonsignificant improvements were found on all psychiatric measures in the experimental group, with a significant improvement in CGI-S in the entire cohort (mean score difference, -0.6; 95% CI, -1.1 to -0.1; P = .02) and a significant improvement in PTSD symptoms in a subgroup of patients with acute unscheduled cardiovascular events and high baseline PTSD symptoms (mean score difference, -1.2; 95% CI, -2.0 to -0.3; P = .01). CONCLUSIONS Cognitive-behavioral therapy that includes imaginal exposure is safe and promising for the treatment of posttraumatic stress in patients with cardiovascular illnesses who are traumatized by their illness. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00364910.
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Milo-Cotter O, Teerlink JR, Metra M, Felker GM, Ponikowski P, Voors AA, Edwards C, Weatherley BD, Greenberg B, Filippatos G, Unemori E, Teichman SL, Cotter G. Low lymphocyte ratio as a novel prognostic factor in acute heart failure: results from the Pre-RELAX-AHF study. Cardiology 2010; 117:190-6. [PMID: 21088400 DOI: 10.1159/000321416] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 08/11/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies have suggested that a lower lymphocyte ratio (Ly%) in the white blood cell (WBC) differential count is related to worse outcomes in patients with acute heart failure (AHF) and other cardiovascular disorders. METHODS In the Pre-RELAX-AHF study, 234 patients with AHF, systolic blood pressure >125 mm Hg and brain natriuretic peptide ≥350 pg/ml or equivalent were randomized to 1 of 4 intravenous doses of relaxin or placebo and followed up for 6 months following randomization. Complete blood count and differential were performed by a central laboratory at baseline and then daily to day 5 and on day 14. RESULTS The WBC count by itself was not associated with measures of disease severity or outcome, and patients with Ly% <13% had similar baseline characteristics to patients with Ly% >13%, except for a higher baseline WBC count, elevated baseline glucose, older age and higher rates of peripheral vascular disease. However, patients with Ly% <13% had less improvement of dyspnea, greater worsening of heart failure, longer length of initial hospital stay and fewer days alive and out of hospital. Statistical significance was reached for all-cause death by days 60 and 180 (hazard ratio = 1.11 per percent decrease, 95% confidence interval 1.03-1.19; p = 0.0048). CONCLUSIONS Despite no association with any baseline characteristic known to strongly predict outcome in AHF, low Ly% is associated with less symptom relief and worse in-hospital and postdischarge clinical outcomes.
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Massie BM, O'Connor CM, Metra M, Ponikowski P, Teerlink JR, Cotter G, Weatherley BD, Cleland JGF, Givertz MM, Voors A, DeLucca P, Mansoor GA, Salerno CM, Bloomfield DM, Dittrich HC. Rolofylline, an adenosine A1-receptor antagonist, in acute heart failure. N Engl J Med 2010; 363:1419-28. [PMID: 20925544 DOI: 10.1056/nejmoa0912613] [Citation(s) in RCA: 398] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Worsening renal function, which is associated with adverse outcomes, often develops in patients with acute heart failure. Experimental and clinical studies suggest that counterregulatory responses mediated by adenosine may be involved. We tested the hypothesis that the use of rolofylline, an adenosine A1-receptor antagonist, would improve dyspnea, reduce the risk of worsening renal function, and lead to a more favorable clinical course in patients with acute heart failure. METHODS We conducted a multicenter, double-blind, placebo-controlled trial involving patients hospitalized for acute heart failure with impaired renal function. Within 24 hours after presentation, 2033 patients were randomly assigned, in a 2:1 ratio, to receive daily intravenous rolofylline (30 mg) or placebo for up to 3 days. The primary end point was treatment success, treatment failure, or no change in the patient's clinical condition; this end point was defined according to survival, heart-failure status, and changes in renal function. Secondary end points were the post-treatment development of persistent renal impairment and the 60-day rate of death or readmission for cardiovascular or renal causes. RESULTS Rolofylline, as compared with placebo, did not provide a benefit with respect to the primary end point (odds ratio, 0.92; 95% confidence interval, 0.78 to 1.09; P=0.35). Persistent renal impairment developed in 15.0% of patients in the rolofylline group and in 13.7% of patients in the placebo group (P=0.44). By 60 days, death or readmission for cardiovascular or renal causes had occurred in similar proportions of patients assigned to rolofylline and placebo (30.7% and 31.9%, respectively; P=0.86). Adverse-event rates were similar overall; however, only patients in the rolofylline group had seizures, a known potential adverse effect of A1-receptor antagonists. CONCLUSIONS Rolofylline did not have a favorable effect with respect to the primary clinical composite end point, nor did it improve renal function or 60-day outcomes. It does not show promise in the treatment of acute heart failure with renal dysfunction. (Funded by NovaCardia, a subsidiary of Merck; ClinicalTrials.gov numbers, NCT00328692 and NCT00354458.).
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Ponikowski P, Mitrovic V, O'Connor CM, Dittrich H, Cotter G, Massie BM, Givertz MM, Chen E, Murray M, Weatherley BD, Fujita KP, Metra M. Haemodynamic effects of rolofylline in the treatment of patients with heart failure and impaired renal function. Eur J Heart Fail 2010; 12:1238-46. [PMID: 20823097 DOI: 10.1093/eurjhf/hfq137] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS The direct effects of adenosine A1 receptor antagonists on haemodynamic parameters in patients with acute heart failure (HF) remain largely unknown. METHODS AND RESULTS We evaluated the haemodynamic effects of the AA(1)RA rolofylline in 59 HF patients with concomitant renal impairment (estimated creatinine clearance 20-80 mL/min). Placebo or rolofylline 30 mg was administered as a 4 h infusion followed by intravenous (i.v.) loop diuretic administration. Haemodynamic measurements were carried out hourly up to 8 h post-dosing by pulmonary artery catheterization. Urine output, fractional excretion of sodium, potassium, urea, and uric acid, and blood urea nitrogen (BUN) and creatinine levels were also measured. In both groups, the changes from baseline in all haemodynamic indices except mean pulmonary artery pressure (PAP) were not clinically significant. Mean [95% confidence interval (CI)] PAP showed a placebo-adjusted decrease with rolofylline of -1.5 (-4.1, 1.1)mmHg at Hour 4 and -3.5 mmHg (95% CI: -6.2, -0.2) at Hour 8. There was a significant increase with rolofylline in diuresis [placebo-corrected mean (95% CI) change of 68 (20, 116)mL/h at Hour 2-4 and 103 (21, 185)mL/h at Hour 4-8] and in fractional excretion of sodium, potassium, and uric acid. Placebo-corrected changes in plasma levels of creatinine and BUN with rolofylline were non-significant. CONCLUSION Single administration of rolofylline in patients with HF and impaired renal function produced a slight decrease in mean PAP and consistently increased diuresis and natriuresis without compromising renal function, both before and after administration of i.v. loop diuretics.
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Metra M, Teerlink JR, Felker GM, Greenberg BH, Filippatos G, Ponikowski P, Teichman SL, Unemori E, Voors AA, Weatherley BD, Cotter G. Dyspnoea and worsening heart failure in patients with acute heart failure: results from the Pre-RELAX-AHF study. Eur J Heart Fail 2010; 12:1130-9. [PMID: 20732868 PMCID: PMC2944016 DOI: 10.1093/eurjhf/hfq132] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aims Although dyspnoea is the most common cause of admission for acute heart failure (AHF), more needs to be known about its clinical course and prognostic significance. Methods and results The Pre-RELAX-AHF study randomized 232 subjects with AHF to placebo or four doses of relaxin and evaluated early (6–24 h Likert scale) and persistent [change in visual analogue scale area under the curve (VAS AUC) through Day 5] dyspnoea relief. Worsening heart failure (WHF) was defined as worsening AHF signs and symptoms requiring additional therapy. Patients were followed until Day 180. Early dyspnoea relief was observed in only 25% of all patients, and VAS AUC at 5 days was 45% over baseline values in all patients (32% placebo; 50% all relaxin-treated patients). Worsening heart failure to Day 5 was observed in 16% of all patients (21% placebo; 14% relaxin). Lack of persistent dyspnoea relief and WHF were associated with a longer length of initial hospital stay and worse 60-day outcomes. Conclusion Dyspnoea relief in patients admitted with AHF is often incomplete, and many may show WHF after the initial stabilization. Both lack of persistent dyspnoea relief and in-hospital WHF predict a longer length of stay and worse outcome.
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Abstract
Relaxin is a naturally occurring human peptide initially identified as a reproductive hormone. More recently, relaxin has been shown to play a key role in the maternal hemodynamic and renal adjustments that accommodate pregnancy. An understanding of these physiologic effects has led to the evaluation of relaxin as a pharmacologic agent for the treatment of patients with acute heart failure. Preliminary results have been encouraging. In addition, the other known biologic properties of relaxin, including anti-inflammatory effects, extracellular matrix remodeling effects, and angiogenic and anti-ischemic effects, all may play a role in potential benefits of relaxin therapy. Ongoing, large-scale clinical testing will provide additional insights into the potential role of relaxin in the treatment of heart failure.
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Milo-Cotter O, Bettari L, Kleijn L, Bugatti S, Lombardi C, Rund M, Metra M, Voors AA, Cotter G, Kaluski E, Weatherley BD. The management of acute heart failure. Panminerva Med 2010; 52:53-66. [PMID: 20228726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Hospitalization for acute heart failure (AHF) is one of the burdensome aspects of 21st century medicine, leading to significant debilitating symptoms, high morbidity and mortality and consuming significant portion of the health care budget. Management of AHF is thought-provoking given the heterogeneity of the patient population, absence of a universally accepted definition, incomplete understanding of the pathophysiology and the beneficial and adverse effects of currently used therapies and lack of robust evidence-based guidelines. The article will discuss the clinical approach to the patients admitted with AHF, reviewing types of intervention (both approved and investigational) and will delineate their role and timing in specific AHF presentations. One of the challenges of AHF management is to effectively treat the subsets of patients with slow improvement or those with refractory AHF or early recurrence (worsening HF) during their initial admission. Unfortunately, the majority of these patients are at increased risk for subsequent complications and adverse outcomes. Therefore, considerable efforts in AHF management should be directed towards this population. Regretfully, to date no specific targeted therapy was proven beneficial for these patients, being one of the leading reasons for the lack of improvement in AHF outcomes over the last 30 years.
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Cotter G, Metra M, Weatherley BD, Dittrich HC, Massie BM, Ponikowski P, Bloomfield DM, O’Connor CM. Physician-Determined Worsening Heart Failure: A Novel Definition for Early Worsening Heart Failure in Patients Hospitalized for Acute Heart Failure – Association with Signs and Symptoms, Hospitalization Duration, and 60-Day Outcomes. Cardiology 2010; 115:29-36. [DOI: 10.1159/000249280] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2009] [Accepted: 07/24/2009] [Indexed: 11/19/2022]
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Cotter G, Voors AA, Weatherley BD, Pang PS, Teerlink JR, Filippatos G, Ponikowski P, Milo-Cotter O, Dittrich H, Teichman SL, Adams KF, Gheorghiade M, Metra M. Acute Heart Failure Clinical Drug Development: From Planning to Proof of Activity to Phase III. Cardiology 2010; 116:292-301. [DOI: 10.1159/000318048] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 05/26/2010] [Indexed: 11/19/2022]
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186
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Milo-Cotter O, Felker GM, Uriel N, Kaluski E, Edwards C, Rund MM, Weatherley BD, Cotter G. Patterns of leukocyte counts on admissions for acute heart failure--presentation and outcome--results from a community based registry. Int J Cardiol 2009; 148:17-22. [PMID: 19932515 DOI: 10.1016/j.ijcard.2009.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Revised: 08/26/2009] [Accepted: 10/18/2009] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the correlation between differential white blood cell (WBC) count and characteristics and outcome of acute heart failure (AHF) syndromes. BACKGROUND Previous studies suggested that different white blood cell count patterns are related to outcome in patients with heart failure (HF) and other cardiovascular disorders. METHODS Data from all qualifying AHF admissions to a city hospital (n=340) was prospectively collected. Patients were followed from admission up to 6 months post-discharge. The relationship between patients' demographics, clinical and laboratory characteristics and outcome were assessed in relation to WBC count and lymphocyte to WBC ratio (LWR). RESULTS WBC count >10,100×10 (9)/L (upper tertile) on admission was associated with higher admission blood pressure, lower oxygen saturation, higher heart rate and increased troponin, with no impact on either short-term worsening HF or long-term adverse outcome. Lower LWR was associated with higher BUN and troponin and lower hemoglobin, but not with a distinct clinical presentation. The lower LWR tertile (≤13%) was associated with a 60% increase in worsening HF risk and a substantially higher 1 month (15% versus 2%) and 6 months mortality (23% vs. 3%) for lowest versus highest quartile (p<0.0001). CONCLUSIONS While increased WBC count is associated with a more "vascular presentation" and certain severity markers, it is not related to worse patient outcome. Low LWR (≤13%) is predictive of worse outcome and higher mortality. It is also associated with certain laboratory abnormalities, but not related to a specific clinical profile.
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Shemesh E, Annunziato RA, Rubinstein D, Sultan S, Malhotra J, Santra M, Weatherley BD, Feaganes JR, Cotter G, Yehuda R. Screening for depression and suicidality in patients with cardiovascular illnesses. Am J Cardiol 2009; 104:1194-7. [PMID: 19840561 DOI: 10.1016/j.amjcard.2009.06.033] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 06/16/2009] [Accepted: 06/16/2009] [Indexed: 10/20/2022]
Abstract
The American Heart Association (AHA) and the American Psychiatric Association jointly recommend screening for depression in cardiology clinics. This includes screening for suicidality. It is not known how frequently patients disclose suicidal thinking (ideation) in this setting, and what proportion of those will turn out to have suicidal intent. Patients were screened for depression using a protocol identical to the one endorsed by the AHA in a cardiology community clinic in Elmhurst (Queens, New York). Depression was assessed using the Patient Health Questionnaire. Reports of suicidal ideation were immediately evaluated by a mental health professional. We determined the degree to which suicidal ideation was identified, the proportion of patients with suicidal intent of those reporting suicidal ideation, and the relation between depression and suicidal ideation in this setting. One thousand three patients were screened; 886 had complete Patient Health Questionnaire data. Of those, 12% (109 patients) expressed suicidal ideation. Four of those were hospitalized for suicidal intent (0.45% of all screened patients). Suicidal ideation and depression were correlated (point biserial correlation coefficient 0.478). In conclusion, suicidal ideation can and will be identified using the AHA depression screening recommendations, but only a very small fraction (0.45%) of screened patients will turn out to have suicidal intent. Discovery and stabilization of suicidal patients is an important benefit of the screening, but the fact that >12% of all screened patients will need to be immediately evaluated for suicidal intent has important implications for resource allocation to screening programs.
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Weatherley BD, Milo-Cotter O, Michael Felker G, Uriel N, Kaluski E, Vered Z, O’Connor CM, Adams KF, Cotter G. Early worsening heart failure in patients admitted with acute heart failure - a new outcome measure associated with long-term prognosis? Fundam Clin Pharmacol 2009; 23:633-9. [DOI: 10.1111/j.1472-8206.2009.00697.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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189
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Torre-Amione G, Milo-Cotter O, Kaluski E, Perchenet L, Kobrin I, Frey A, Rund MM, Weatherley BD, Cotter G. Early Worsening Heart Failure in Patients Admitted for Acute Heart Failure: Time Course, Hemodynamic Predictors, and Outcome. J Card Fail 2009; 15:639-44. [DOI: 10.1016/j.cardfail.2009.04.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2008] [Revised: 03/31/2009] [Accepted: 04/08/2009] [Indexed: 11/30/2022]
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Metra M, Dittrich HC, Cotter G, Massie BM, Ponikowski P, Jia G, Fujita KP, O'Connor CM. Troponin Release in Patients Admitted with Acute Decompensated Heart Failure and Renal Dysfunction: Results from the Pilot Phase of the PROTECT Trial. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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191
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Weatherley BD, Cotter G, Felker G, Teerlink J, Filippatos G, Greenberg B, Voors A, Metra M, Teichman S, Unemori E. In Hospital Early (Within 5 Days) Worsening HF Predicts Adverse Outcome in Patients Admitted for AHF – Results from the Pre-RELAX-AHF Study. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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192
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Felker GM, Voors AA, Metra M, Teerlink JR, Ponikowski P, Greenberg BH, Unemori E, Cotter G, Teichman SL. Worsening Renal Function in Acute Heart Failure: Change in Blood Pressure and Effects of Relaxin. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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193
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Metra M, Teerlink JR, Weatherley BD, Greenberg BH, Felker GM, Ponikowski P, Voors AA, Filippatos G, Feaganes J, Unemori E, Teichman SL, Cotter G. Changes in Dyspnea during Treatment of Acute Heart Failure Are Correlated with Clinical Signs, Rehospitalizations and Mortality. Results from the Pre-RELAX-AHF Trial. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.190] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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194
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Teerlink JR, Metra M, Felker GM, Voors AA, Greenberg BH, Ponikowski P, Teichman SL, Cotter G. Vasodilators in Acute Heart Failure (AHF): Does Blood Pressure Matter? Results from Pre-Relax-AHF. J Card Fail 2009. [DOI: 10.1016/j.cardfail.2009.06.169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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195
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Gheorghiade M, Adams KF, Cleland JG, Cotter G, Felker GM, Filippatos GS, Fonarow GC, Greenberg BH, Hernandez AF, Khan S, Komajda M, Konstam MA, Liu PP, Maggioni AP, Massie BM, McMurray JJ, Mehra M, Metra M, O'Connell J, O'Connor CM, Pang PS, Piña IL, Sabbah HN, Teerlink JR, Udelson JE, Yancy CW, Zannad F, Stockbridge N. Phase III clinical trial end points in acute heart failure syndromes: a virtual roundtable with the Acute Heart Failure Syndromes International Working Group. Am Heart J 2009; 157:957-70. [PMID: 19464405 DOI: 10.1016/j.ahj.2009.04.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Accepted: 04/15/2009] [Indexed: 10/20/2022]
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Teerlink JR, Metra M, Felker GM, Ponikowski P, Voors AA, Weatherley BD, Marmor A, Katz A, Grzybowski J, Unemori E, Teichman SL, Cotter G. Relaxin for the treatment of patients with acute heart failure (Pre-RELAX-AHF): a multicentre, randomised, placebo-controlled, parallel-group, dose-finding phase IIb study. Lancet 2009; 373:1429-39. [PMID: 19329178 DOI: 10.1016/s0140-6736(09)60622-x] [Citation(s) in RCA: 341] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Most patients admitted for acute heart failure have normal or increase blood pressure. Relaxin is a natural human peptide that affects multiple vascular control pathways, suggesting potential mechanisms of benefit for such patients. We assessed the dose response of relaxin's effect on symptom relief, other clinical outcomes, and safety. METHODS In a placebo-controlled, parallel-group, dose-ranging study, 234 patients with acute heart failure, dyspnoea, congestion on chest radiograph, and increased brain natriuretic peptide (BNP) or N-terminal prohormone of BNP, mild-to-moderate renal insufficiency, and systolic blood pressure greater than 125 mm Hg were recruited from 54 sites in eight countries and enrolled within 16 h of presentation. Patients were randomly assigned, in a double-blind manner via a telephone-based interactive voice response system, to standard care plus 48-h intravenous infusion of placebo (n=62) or relaxin 10 microg/kg (n=40), 30 microg/kg (n=43), 100 microg/kg (n=39), or 250 microg/kg (n=50) per day. Several clinical endpoints were explored to assess whether intravenous relaxin should be pursued in larger studies of acute heart failure, to identify an optimum dose, and to help to assess endpoint selection and power calculations. Analysis was by modified intention to treat. This study is registered with ClinicalTrials.gov, number NCT00520806. FINDINGS In the modified intention-to-treat population, 61 patients were assessed in the placebo group, 40 in the relaxin 10 microg/kg per day group, 42 in the relaxin 30 microg/kg per day group, 37 in the relaxin 100 microg/kg per day group, and 49 in the relaxin 250 microg/kg per day group. Dyspnoea improved with relaxin 30 microg/kg compared with placebo, as assessed by Likert scale (17 of 42 patients [40%] moderately or markedly improved at 6 h, 12 h, and 24 h vs 14 of 61 [23%]; p=0.044) and visual analogue scale through day 14 (8214 mm x h [SD 8712] vs 4622 mm x h [9003]; p=0.053). Length of stay was 10.2 days (SD 6.1) for relaxin-treated patients versus 12.0 days (7.3) for those given placebo, and days alive out of hospital were 47.9 (10.1) versus 44.2 (14.2). Cardiovascular death or readmission due to heart or renal failure at day 60 was reduced with relaxin (2.6% [95% CI 0.4-16.8] vs 17.2% [9.6-29.6]; p=0.053). The number of serious adverse events was similar between groups. INTERPRETATION When given to patients with acute heart failure and normal-to-increased blood pressure, relaxin was associated with favourable relief of dyspnoea and other clinical outcomes, with acceptable safety.
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Milo-Cotter O, Cotter G, Kaluski E, Rund MM, Felker GM, Adams KF, O’Connor CM, Weatherley BD. Rapid Clinical Assessment of Patients with Acute Heart Failure: First Blood Pressure and Oxygen Saturation – Is That All We Need? Cardiology 2009; 114:75-82. [DOI: 10.1159/000213051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2008] [Accepted: 12/11/2008] [Indexed: 11/19/2022]
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Kaluski E, Milo-Cotter O, Cotter G. ‘Death and Life Are in the Power of the Tongue’? Cardiology 2009; 114:39-41. [DOI: 10.1159/000212059] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Accepted: 02/07/2009] [Indexed: 11/19/2022]
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199
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Annunziato RA, Rubinstein D, Murgueitio M, Santra M, Sultan S, Maurer M, Cotter G, Yehuda R, Shemesh E. Psychiatric symptom presentation in ethnically diverse cardiology patients. Ethn Dis 2009; 19:271-275. [PMID: 19769008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023] Open
Abstract
OBJECTIVES The purpose of our study was to examine rates of depression and distress among different ethnic groups receiving care in an outpatient cardiology clinic. DESIGN Cross sectional study. SETTING Participants were recruited from an urban cardiology clinic. PARTICIPANTS Data are presented for 1003 patients screened between June 2005 and November 2007. The ethnic groups represented were Hispanics (504 patients or 50% of the sample), Southeast Asians (229 patients or 23%), Caucasians (114 patients or 11%), East Asians (89 patients or 9%), Africans (53 patients or 5%), and 14 patients (2%) of unknown or other ethic backgrounds. MAIN OUTCOME MEASURES All patients registered for an outpatient visit received questionnaires, in English or Spanish, screening for depression (Patient Health Questionnaire [PHQ-9]) and distress (the impact of Events Scale [IES]). RESULTS Overall, significantly more patients screened positive for distress than depression (33% vs 27%, X2 = 130.11, P = .00). The ANOVA comparing PHQ scores by ethnic group was significant, F(4, 867) = 4.46, P = .01 with Hispanics and Southeast Asians scoring significantly higher than East Asians. An ANOVA comparing IES scores by ethnic group was also significant, F (4, 760) = 3.63, P = .01.with Southeast Asians scoring significantly higher than Caucasians. CONCLUSIONS Elevated levels of psychiatric symptoms are common across ethnic groups in medical settings, particularly in patients of Hispanic and Southeast Asian origin. Devising culturally sensitive procedures is imperative to successful screening and evaluation.
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Teichman SL, Unemori E, Dschietzig T, Conrad K, Voors AA, Teerlink JR, Felker GM, Metra M, Cotter G. Relaxin, a pleiotropic vasodilator for the treatment of heart failure. Heart Fail Rev 2008; 14:321-9. [PMID: 19101795 PMCID: PMC2772950 DOI: 10.1007/s10741-008-9129-3] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 11/28/2008] [Indexed: 12/22/2022]
Abstract
Relaxin is a naturally occurring peptide hormone that plays a central role in the hemodynamic and renovascular adaptive changes that occur during pregnancy. Triggering similar changes could potentially be beneficial in the treatment of patients with heart failure. The effects of relaxin include the production of nitric oxide, inhibition of endothelin, inhibition of angiotensin II, production of VEGF, and production of matrix metalloproteinases. These effects lead to systemic and renal vasodilation, increased arterial compliance, and other vascular changes. The recognition of this has led to the study of relaxin for the treatment of heart failure. An initial pilot study has shown favorable hemodynamic effects in patients with heart failure, including reduction in ventricular filling pressures and increased cardiac output. The ongoing RELAX-AHF clinical program is designed to evaluate the effects of relaxin on the symptoms and outcomes in a large group of patients admitted to hospital for acute heart failure. This review will summarize both the biology of relaxin and the data supporting its potential efficacy in human heart failure.
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