751
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Schleman KA, Lindenfeld JA, Lowes BD, Bristow MR, Ferguson D, Wolfel EE, Abraham WT, Zisman LS. Predicting response to carvedilol for the treatment of heart failure: a multivariate retrospective analysis. J Card Fail 2001; 7:4-12. [PMID: 11264544 DOI: 10.1054/jcaf.2001.22491] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Carvedilol has been shown to decrease the progression of heart failure and improve left ventricular function and survival in patients with a left ventricular ejection fraction (LVEF) less than 35%. However, not all patients respond uniformly to this therapy. We proposed to identify variables that could, potentially, be used to predict response to carvedilol therapy as measured by the change in LVEF after treatment (Delta LVEF), and to identify pretreatment variables associated with hospitalization for heart failure after carvedilol therapy. METHODS AND RESULTS A retrospective analysis of 98 patients treated with open-label carvedilol for a mean period of 16 months was performed by using bivariate and step-wise multivariate analyses. Bivariate analysis showed a positive correlation of Delta LVEF with heart rate at baseline (P =.001). There was a negative correlation of Delta LVEF with baseline LVEF (P <.01), diabetes mellitus (P =.04), and ischemic cardiomyopathy (P =.0002). Multivariate analysis showed a positive correlation of Delta LVEF with heart rate at baseline (P =.01) and a negative correlation with initial LVEF (P =.02) and ischemic cardiomyopathy (P =.006). Variables associated with hospitalization after initiation of carvedilol therapy were New York Heart Association (NYHA) classification (P =.001), lower extremity edema (P =.001), presence of an S3 (P =.02), hyponatremia (P =.02), elevated blood urea nitrogen (BUN) (P =.002), atrial fibrillation (P =.001), diabetes mellitus (P =.02), and obstructive sleep apnea (P =.009). CONCLUSIONS Heart failure patients with the lowest LVEF or the highest heart rate at baseline had the greatest gain in LVEF after treatment with carvedilol. Patients with ischemic cardiomyopathy derived less benefit. Patients with clinical evidence of decompensated heart failure were at greater risk for hospitalization after initiation of carvedilol therapy.
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Affiliation(s)
- K A Schleman
- University of Colorado Health Sciences Center, Denver, Colorado, USA
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752
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Estes NA, DeNofrio D. The challenge of prediction and prevention of sudden cardiac death in congestive heart failure. J Interv Card Electrophysiol 2001; 5:5-8. [PMID: 11248769 DOI: 10.1023/a:1009817705111] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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753
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Deng MC, Smits JM, De Meester J, Hummel M, Schoendube F, Scheld HH. Heart transplantation indicated only in the most severely ill patient: perspectives from the German heart transplant experience. Curr Opin Cardiol 2001; 16:97-104. [PMID: 11224640 DOI: 10.1097/00001573-200103000-00004] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The COCPIT study, performed in a complete national cohort of adult patients consecutively listed for cardiac transplantation in Germany in 1997, found a beneficial effect only in the group that was at high risk of dying from heart failure without transplantation. If these results can be reproduced in other countries, the discussion on the respective roles of pharmacological and organ-saving surgical therapies for advanced heart failure, medical urgency and waiting time as heart transplantation allocation criteria, and the feasibility of a randomized clinical trial testing the survival benefit of transplantation must be reopened.
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Affiliation(s)
- M C Deng
- The Heart Failure Center, Columbia University College of Physicians & Surgeons, New York Presbyterian Hospital, 177 Fort Washington Avenue, New York, NY 10032, USA.
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754
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755
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Stevenson LW, Kormos RL, Bourge RC, Gelijns A, Griffith BP, Hershberger RE, Hunt S, Kirklin J, Miller LW, Pae WE, Pantalos G, Pennington DG, Rose EA, Watson JT, Willerson JT, Young JB, Barr ML, Costanzo MR, Desvigne-Nickens P, Feldman AM, Frazier OH, Friedman L, Hill JD, Konstam MA, McCarthy PM, Michler RE, Oz MC, Rosengard BR, Sapirstein W, Shanker R, Smith CR, Starling RC, Taylor DO, Wichman A. Mechanical cardiac support 2000: current applications and future trial design. June 15-16, 2000 Bethesda, Maryland. J Am Coll Cardiol 2001; 37:340-70. [PMID: 11153769 DOI: 10.1016/s0735-1097(00)01099-8] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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756
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Abstract
Heart failure is associated with poor long term survival due to progressive refractory heart dysfunction and sudden cardiac death. Cardiac resynchronization through atrio-biventricular pacing has been introduced to treat patients affected by drug-refractory heart failure with desynchronized ventricular activation, as for complete left bundle branch block. The technique is aimed to overcome interventricular and intraventricular conduction delays leading to ventricular dysynchrony, paradoxical septal wall motion, presystolic mitral regurgitation and reduced diastolic filling times. Short term studies demonstrated that biventricular pacing (and perhaps left ventricular pacing alone) may improve both systolic and diastolic function. Initial studies in patients receiving long term pacing consistently showed significant QRS shortening associated with improvement in symptoms, left ventricular ejection fraction, exercise tolerance, quality of life and New York Heart Association functional class. As far as sudden cardiac death prevention in heart failure is concerned, implantable cardioverter defibrillator (ICD) implantation has been demonstrated to be the most effective therapy in patients with prior cardiac arrest due to ventricular fibrillation or poorly tolerated ventricular tachycardia. Low left ventricular ejection fraction, unsustained ventricular tachycardia and inducibility at electrophysiological study also may identify high risk patients requiring ICD implantation. Further studies are needed to evaluate the effect of cardiac resynchronization on hard end-points, such as survival and long term clinical outcome, and to upgrade risk stratification criteria to be used in selection of candidates for ICD implantation.
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Affiliation(s)
- M Santini
- Department of Cardiology, San Filippo Neri Hospital, Rome, Italy.
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757
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Auricchio A, Nisam S, Klein HU. Perspectives: does amiodarone increase non-sudden deaths? If so, why? J Interv Card Electrophysiol 2000; 4:569-74. [PMID: 11141201 DOI: 10.1023/a:1026505329169] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Despite the antiarrhythmic efficacy of amiodarone, a definitive correlation between amiodarone treatment and increased non-arrhythmic mortality in patients with heart failure and depressed ventricular function has been reported. Results from research in the field of cardiac resynchronization therapy in heart failure may provide some explanations to this observation. We discussed the hypothetical link between amiodarone and non-arrhythmic mortality, which might have a cause--effect relationship, based on cardiac electromechanical disarrangement provoked by electrophysiological properties of amiodarone.
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Affiliation(s)
- A Auricchio
- Department of Cardiology, University Hospital, Magdeburg, Germany.
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758
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Leclercq C, Cazeau S, Ritter P, Alonso C, Gras D, Mabo P, Lazarus A, Daubert JC. A pilot experience with permanent biventricular pacing to treat advanced heart failure. Am Heart J 2000; 140:862-70. [PMID: 11099989 DOI: 10.1067/mhj.2000.110570] [Citation(s) in RCA: 80] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The prognosis and quality of life of patients with advanced heart failure remain poor. The purpose of this study was to evaluate new nonpharmacologic approaches. Biventricular pacing was proposed in this indication, based on the encouraging results of acute hemodynamics studies. METHODS Fifty patients with drug-resistant heart failure (New York Heart Association [NYHA] class III/IV, 16 of 34) were consecutively implanted with biventricular pacemakers. All patients had severe dilated cardiomyopathy and intraventricular conduction delay. Survival, NYHA class, electrocardiogram, echocardiographic data, and exercise tolerance were assessed over a mean follow-up period of 15.4 +/- 10. 2 months. RESULTS At the end of follow-up, 55% of patients were alive without heart transplantation or left ventricular assistance device. The mortality rate was significantly lower in class III (12. 5%) than in class IV patients (52.5%). In survivors, biventricular pacing significantly improved symptoms (NYHA class 2.2 +/- 0.5 at follow-up vs 3.7 +/- 0.5 at baseline) and exercise tolerance ((. )VO(2) peak 15.5 +/- 3.4 mL/min per kilogram at follow-up vs 11.1 +/- 3 mL/min per kilogram at baseline). CONCLUSIONS Biventricular pacing appears to improve the functional status of patients with dilated cardiomyopathy with advanced heart failure. The technique appears to be attractive as an additive treatment, especially in class III patients. Controlled randomized studies are needed to validate this novel concept.
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Affiliation(s)
- C Leclercq
- Département de Cardiologie et Maladies Vasculaires, Centre Cardio-Pneumologique, Rennes Cedex, France.
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759
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Gaita F, Bocchiardo M, Porciani MC, Vivalda L, Colella A, Di Donna P, Caponi D, Bruzzone M, Padeletti L. Should stimulation therapy for congestive heart failure be combined with defibrillation backup? Am J Cardiol 2000; 86:165K-158K. [PMID: 11084118 DOI: 10.1016/s0002-9149(00)01229-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Biventricular pacing has been proposed to resynchronize ventricular contraction in patients with congestive heart failure (CHF) and interventricular conduction delay. However, the sudden death rate is still high despite the improvement in cardiac performance. Devices combining biventricular pacing with implantable cardioverter defibrillator (ICD) backup are now under clinical investigation to demonstrate whether they can decrease sudden death. From the first implant of an ICD with biventricular transvenous pacing on August 1998 to April 2000, 96 patients underwent such implants: 67 (70%) received pacemakers alone and 29 (30%), who had class I ICD indications, received combined pacemaker/ICD systems. During a mean follow-up of 283 +/- 170 days, 13 (14%) patients died: 5 of 29 (17%) in the ICD group and 8 of 67 (12%) in the pacemaker group. A total of 15 patients (52%) had ICD shocks and 6 patients (21%) had 113 episodes of ventricular tachyarrhythmias, of which 96 (85%) were converted to sinus rhythm with antitachypacing. The echocardiograms showed a narrowing of the delay between the onset of right and left ventricular outflow from 40 +/- 37 msec to 17 +/- 16 msec (p = 0.03) and a reduction of the mitral regurgitation area from 7 +/- 3.8 cm2 to 5 +/- 4 cm2 (p = 0.04) at 3 months. Functional class improved from 2.8 +/- 0.7 to 1.6 +/- 0.5 (p <0.001) 3 months after implant. Thus, ischemic patients with reduced left ventricular ejection fraction and ventricular tachyarrhythmias seem good candidates for biventricular pacing with ICD backup. The sudden death risk for those with idiopathic dilated cardiomyopathy, however, is difficult to stratify, and the choice of ICD backup has to be considered on the basis of patient safety, as well as of costs.
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Affiliation(s)
- F Gaita
- Division of Cardiology, Ospedale Civile of Asti, Asti, Italy
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760
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Ali O, Ventura HO, Stapleton DD, Smart FW. Difficult cases in heart failure: Ventricular resynchronization in refractory heart failure. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2000; 6:333-336. [PMID: 12189340 DOI: 10.1111/j.1527-5299.2000.80178.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The use of a multisite transvenous pacemaker in a patient with refractory heart failure who experienced short-term symptomatic improvement is described. The improvement in heart failure symptoms was most likely related to resynchronization of atrioventricular and interventricular asynchrony. Large, multicenter, randomized trials of this technology are being performed to evaluate the importance of this therapeutic modality in the treatment of heart failure. (c)2000 by CHF, Inc.
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Affiliation(s)
- O Ali
- Department of Medicine, Section of Cardiology, Tulane University Medical Center, New Orleans, LA 70112
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761
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Auricchio A, Spinelli J. Cardiac resynchronization for heart failure: present status. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2000; 6:325-329. [PMID: 12189338 DOI: 10.1111/j.1527-5299.2000.80173.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Ventricular dysfunction is a hallmark of heart failure, and is often linked to ventricular dilatation and ventricular conduction delays. Recent studies have demonstrated that systolic function can be improved in patients with left bundle branch block by pre-exciting the site of late activation, usually the left ventricular free wall. Furthermore, it has been recently reported that this improvement is associated with a decrease in myocardial oxygen consumption. We hypothesize that the pre-excitation of the region covered by the blocked bundle acts as an "electrical bypass," resynchronizing the contraction of the septum and the left ventricular free wall. In addition, optimization of the electronic atrioventricular delay allows the simultaneous resynchronization of the atrioventricular contractions, and minimization of diastolic mitral regurgitation. Systolic mitral regurgitation may also be reduced by removing the geometric distortion introduced by the left bundle branch block. The recently reported positive outcome of the PATH-CHF I controlled trial reinforces that the positive acute and chronic results that have been reported up to now may translate into long-term clinical benefit for patients with heart failure and conduction defects. Larger studies are needed to confirm these initial results and to establish the impact of this new therapeutic modality on morbidity and mortality. (c)2000 by CHF, Inc.
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Affiliation(s)
- A Auricchio
- Department of Cardiology, University Hospital, "Otto-von-Guericke Universität," 44D-39120 Magdeburg, Germany
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762
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Kolias TJ, Aaronson KD, Armstrong WF. Doppler-derived dP/dt and -dP/dt predict survival in congestive heart failure. J Am Coll Cardiol 2000; 36:1594-9. [PMID: 11079663 DOI: 10.1016/s0735-1097(00)00908-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the ability of novel Doppler indices of left ventricular (LV) systolic and diastolic function to predict survival in patients with congestive heart failure (CHF). BACKGROUND Congestive heart failure is associated with an increased risk of death or cardiac transplantation, yet techniques to predict survival are limited. METHODS Doppler-derived dP/dt and - dP/dt were determined prospectively from the continuous-wave Doppler spectrum of the mitral regurgitation jet (dP/dt = 32/time between 1 and 3 m/s; -dP/dt = 32/time between 3 and 1 m/s) in 56 patients with chronic CHF (age, 60 +/- 15 years; LV ejection fraction, 23 +/- 9%). Baseline clinical and echocardiographic variables were also obtained, and clinical follow-up was performed in all patients. RESULTS Twenty-four patients experienced a primary event of cardiac death (n = 15), United Network for Organ Sharing status I (inotrope-dependent) heart transplant (n = 3) or urgent implantation of a LV assist device (n = 6). Doppler-derived dP/dt (dichotomized to > or = or <600 mm Hg/s; p = 0.0002) and -dP/dt (trichotomized to <450, 450 to 550 and >550 mm Hg/s; p = 0.0001) predicted event-free survival, as did Doppler-derived risk groups determined by the combination of the two (low risk, dP/dt > or = 600; intermediate risk, dP/dt < 600 and -dP/dt > or = 450; high risk, dP/dt < 600 and -dP/dt < 450; p = 0.0001). Multivariable analysis revealed Doppler-derived risk groups, intravenous inotrope requirement and blood urea nitrogen as significant independent predictors of outcome. CONCLUSION New Doppler indices of dP/dt, - dP/dt and risk groups defined by the combination of dP/dt and -dP/dt predict event-free survival in patients with CHF.
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Affiliation(s)
- T J Kolias
- Division of Cardiology, University of Michigan Medical Center, Ann Arbor 48109-0273, USA.
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763
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Deng MC, De Meester JM, Smits JM, Heinecke J, Scheld HH. Effect of receiving a heart transplant: analysis of a national cohort entered on to a waiting list, stratified by heart failure severity. Comparative Outcome and Clinical Profiles in Transplantation (COCPIT) Study Group. BMJ (CLINICAL RESEARCH ED.) 2000; 321:540-5. [PMID: 10968814 PMCID: PMC27468 DOI: 10.1136/bmj.321.7260.540] [Citation(s) in RCA: 177] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine whether there is a survival benefit associated with cardiac transplantation in Germany. DESIGN Prospective observational cohort study. SETTING All 889 adult patients listed for a first heart transplant in Germany in 1997. MAIN OUTCOME MEASURE Mortality, stratified by heart failure severity. RESULTS Within 1 year after listing, patients with a predicted high risk had the highest global death rate (51% v 32% and 29% for medium and low risk patients respectively; P<0.0001), had the highest risk of dying on the waiting list (32% v 20% and 20%; P=0.0003), and were more likely to receive a transplant (48% v 45% and 41%; P=0.01). Differences between the risk groups in outcome after transplantation did not reach significance (P=0.2). Transplantation was not associated with a reduction in mortality risk for the total cohort, but it did provide a survival benefit for the high risk group. CONCLUSION Cardiac transplantation in Germany is currently associated with a survival benefit only in patients with a predicted high risk of dying on the waiting list. Patients with a predicted low or medium risk have no reduction in mortality risk associated with transplantation; they should be managed with organ saving approaches rather than transplantation.
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Affiliation(s)
- M C Deng
- Department of Cardiothoracic Surgery, Muenster University, D-48129 Muenster, Germany.
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764
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La Vecchia L, Mezzena G, Zanolla L, Paccanaro M, Varotto L, Bonanno C, Ometto R. Cardiac troponin I as diagnostic and prognostic marker in severe heart failure. J Heart Lung Transplant 2000; 19:644-52. [PMID: 10930813 DOI: 10.1016/s1053-2498(00)00120-0] [Citation(s) in RCA: 146] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Cardiac cell death has been shown to occur in heart failure and has been implicated as one of the mechanisms responsible for progression of the disease. Cardiac Troponin I (cTnI) represents a highly sensitive marker for myocardial cell death. Based on previous studies reporting that cTnI may be detected in patients with heart failure, we evaluated the clinical correlates and prognostic implications of detectable cTnI in a consecutive series of patients with severe heart failure. METHODS Thirty-four patients were examined. Upon admission, we measured serum levels of cTnI by conventional immunoenzymatic assay (Stratus Dade II). According to the results of this assay, patients were divided into 2 groups, based on the presence (cTnI+) or absence (cTnI-) of detectable cTnI. These 2 groups were compared by non-parametric analysis for their clinical characteristics, instrumental findings, and short-term outcome. RESULTS The cTnI+ group included 10 patients (29%) with a mean serum cTnI of 0.7 +/- 0.3 ng/ml. Compared with the cTnI- group, these patients had significantly lower left ventricular ejection fractions (20% +/- 5% vs 26% +/- 7%, p = 0.023) and a trend for higher systolic pulmonary artery pressure (59 +/- 17 mm Hg vs 49 +/- 13 mm Hg, p = 0.08). In cTnI+ patients, the correlation between cTnI levels upon admission and ejection fraction was r = -0.530 (p = 0.11). We found ischemic etiology was equally present in the 2 groups, whereas we never found histologic signs of acute myocarditis. Other clinical characteristics (functional class, daily diuretic dose, need for intravenous inotropes) were not statistically different in the 2 groups. In cTnI+ patients who improved after admission, cTnI became undetectable after a few days; in patients with refractory heart failure who were hospitalized until death, cTnI persisted in detectable levels throughout the observation period. Using the Cox proportional hazard model, a positive cTnI was the most powerful predictor of mortality at 3 months (p = 0.013; hazard ratio 6.86; 95% confidence interval 1.32 to 35.4). CONCLUSIONS These observations suggest that cTnI is detected in the blood of 25% to 33% of patients with severe heart failure; its presence may help to identify a high-risk sub-group who faces very poor short-term prognosis.
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Affiliation(s)
- L La Vecchia
- Divisione di Cardiologia, Ospedale S. Bortolo, Vicenza, Italy
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765
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Hauff H, Castro M. Reducing transplant evaluation costs by early identification of unsuitable patients. Prog Transplant 2000. [DOI: 10.7182/prtr.10.2.u81t543j811872k2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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766
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Hauff H, Castro M. Reducing transplant evaluation costs by early identification of unsuitable patients. Prog Transplant 2000; 10:122-5. [PMID: 10933766 DOI: 10.1177/152692480001000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Many patients undergo a full transplant evaluation and are rejected for transplant on the basis of the test results. Some of these patients could be identified earlier in the evaluation process, thus reducing the cost of undergoing a full evaluation. Subjects in this study were 117 patients who had undergone a heart transplant evaluation over a 6-month period. The rates of acceptance, rejection, deferral, and those deferred and later listed were monitored: 53% were accepted, 17.1% rejected, 18.8% deferred, and a further 11.1% were deferred and then later listed. Of the group that was rejected, 45% were rejected on the basis of the cardiopulmonary exercise test and deemed too well for transplant. Other reasons for patients being rejected were obesity, psychological or social issues, and as a result of other diagnostic testing. The transplant evaluation process can be modified so that the cardiopulmonary exercise test is performed first, which would reduce the ultimate cost of a transplant evaluation from $11,330 to $680. The cardiopulmonary exercise test has become an intrinsic part of the cardiac evaluation process and is a strong indicator of a patient's suitability for transplant.
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Affiliation(s)
- H Hauff
- Columbia-Presbyterian Medical Center, New York, NY, USA
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767
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Cowie MR, Wood DA, Coats AJ, Thompson SG, Suresh V, Poole-Wilson PA, Sutton GC. Survival of patients with a new diagnosis of heart failure: a population based study. Heart 2000; 83:505-10. [PMID: 10768897 PMCID: PMC1760808 DOI: 10.1136/heart.83.5.505] [Citation(s) in RCA: 340] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To describe the survival of a population based cohort of patients with incident (new) heart failure and the clinical features associated with mortality. DESIGN A population based observational study. SETTING Population of 151 000 served by 82 general practitioners in west London. PATIENTS New cases of heart failure were identified by daily surveillance of acute hospital admissions to the local district general hospital, and by general practitioner referral of all suspected new cases of heart failure to a rapid access clinic. INTERVENTIONS All patients with suspected heart failure underwent clinical assessment, and chest radiography, ECG, and echocardiogram were performed. A panel of three cardiologists reviewed all the data and determined whether the definition of heart failure had been met. Patients were subsequently managed by the general practitioner in consultation with the local cardiologist or admitting physician. MAIN OUTCOME MEASURES Death, overall and from cardiovascular causes. RESULTS There were 90 deaths (83 cardiovascular deaths) in the cohort of 220 patients with incident heart failure over a median follow up of 16 months. Survival was 81% at one month, 75% at three months, 70% at six months, 62% at 12 months, and 57% at 18 months. Lower systolic blood pressure, higher serum creatinine concentration, and greater extent of crackles on auscultation of the lungs were independently predictive of cardiovascular mortality (all p < 0.001). CONCLUSIONS In patients with new heart failure, mortality is high in the first few weeks after diagnosis. Simple clinical features can identify a group of patients at especially high risk of death.
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Affiliation(s)
- M R Cowie
- Cardiac Medicine, Imperial College School of Medicine at the National Heart and Lung Institute, London SW3, UK.
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768
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Alla F, Briançon S, Juillière Y, Mertes PM, Villemot JP, Zannad F. Differential clinical prognostic classifications in dilated and ischemic advanced heart failure: the EPICAL study. Am Heart J 2000; 139:895-904. [PMID: 10783225 DOI: 10.1016/s0002-8703(00)90023-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The clinical management of severe congestive heart failure (CHF) should be graded according to the prognosis of each individual patient. Our objective was to elaborate a prognostic rating system for severe CHF. METHODS The EPICAL program (Epidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine) identified patients with severe CHF defined by hospitalization accompanied by class III/IV dyspnea, edema, or hypertension; an ejection fraction </=30% or a cardiothoracic index >/=60%. Baseline variables were tested in Cox multivariate models. RESULTS Patients with ischemic heart disease (n = 219) had a lower 1-year survival rate (57.6%) than patients with dilated cardiomyopathy (n = 182) (69. 1%). Multivariate analysis identified 5 prognostic factors for ischemic CHF and 7 for CHF caused by dilated cardiomyopathy. These variables were used to classify patients within prognostic subgroups of good (>75%), intermediate, or poor (</=25%) 1-year survival. CONCLUSION A score for prognostic prediction was further derived from readily available data to help physicians improve decision making and to assist in clinical trials as a stratification tool.
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Affiliation(s)
- F Alla
- Department of Epidemiology and Cardiology, University Hospital, Nancy, France.
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769
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Mohacsi P, Deng MC, Murphy R, Bergh CH, Gronda E, Komajda M, Pacher R, Spinar J, Swedberg K, Cleland JF. Implantable left ventricular assist systems (LVAS): recent results. A report from a series of meetings sponsored by the Study Group on Advanced Heart Failure of the Working Group on Heart Failure. Eur J Heart Fail 2000; 2:13-8. [PMID: 10742698 DOI: 10.1016/s1388-9842(00)00055-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Implantable left ventricular assist systems (LVAS) consist of implantable pumps with small control consoles and power sources that can be worn externally. These systems provide far greater patient mobility and independence than external pumps with bulky control consoles. Patients with implantable LVAS can be discharged from hospital and are able to return to work and resume active sports. Most patients have received these systems as a bridge to heart transplantation. Clinical status and quality of life improve dramatically after device implantation and survival on support (60-70% after approx. 100 days of support) is acceptable compared with transplant candidates on medical therapy. Patient selection and adverse events, primarily bleeding, thromboembolism and infection, are important issues with LVAS. In the future, long-term support and bridging to myocardial recovery may become important indications for LVAS.
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Affiliation(s)
- P Mohacsi
- Cardiology, Swiss Cardiovascular Center Bern, University Hospital, CH-3010, Bern, Switzerland.
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770
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Morris-Thurgood JA, Frenneaux MP. Pacing in congestive heart failure. CURRENT CONTROLLED TRIALS IN CARDIOVASCULAR MEDICINE 2000; 1:107-114. [PMID: 11714422 PMCID: PMC59611 DOI: 10.1186/cvm-1-2-107] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/09/2000] [Revised: 08/03/2000] [Accepted: 08/14/2000] [Indexed: 11/23/2022]
Abstract
Despite the major advances in medical drug therapy, heart failure remains a syndrome associated with high mortality and morbidity. Biventricular or left ventricular (LV) short atrioventricular (AV) delay pacing is being tested in congestive heart failure patients with left bundle branch block. The aim is to resynchronise the dyscoordinate LV contraction. A number of studies are underway, but it is clear that while some patients respond remarkably, this is highly variable. Accurate identification of patients likely to benefit will be crucial. The mechanism of benefit is unclear. A greater understanding of the physiological consequences of pacing will be necessary to accurately identify these patients.
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771
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Brunner-La Rocca HP, Weilenmann D, Kiowski W, Maly FE, Candinas R, Follath F. Within-patient comparison of effects of different dosages of enalapril on functional capacity and neurohormone levels in patients with chronic heart failure. Am Heart J 1999; 138:654-62. [PMID: 10502210 DOI: 10.1016/s0002-8703(99)70179-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Angiotensin-converting enzyme (ACE) inhibitors are established as first-line therapy in chronic heart failure (CHF). However, conflicting results exist regarding the dose-effect relation of ACE inhibitors. METHODS We investigated 45 patients (age 55 +/- 10 years) with stable CHF who presented with a maintenance dosage of enalapril of either 5 mg given twice daily (E10; n = 16), 10 mg given twice daily (E20; n = 18), or 20 mg given twice daily (E40; n = 11). This dosage was changed 3 times to treat all patients with lower, higher, and the initial dosages for 4 weeks each. Neurohormones (atrial natriuretic peptide [ANP], brain natriuretic peptide [BNP], and norepinephrine) and enalaprilat trough levels were measured, and ergospirometry was performed. RESULTS Changes in enalapril dose and enalaprilat level were concordant in 82% of patients, indicating good compliance. After augmentation of enalapril to 40 mg daily, patients in the E10 group showed an increase in maximal oxygen consumption and a decrease in neurohormonal stimulation, whereas the opposite changes were observed after reduction of enalapril to 10 mg daily in patients in the E20 and E40 groups (maximal oxygen consumption: Delta1.1 +/- 2.0 vs -1.0 +/- 1.9 mL. kg(-1). min(-1), P <.01; ANP: Delta-63 +/- 106 vs 19 +/- 54 pg/mL, P <.01; BNP: Delta-62 +/- 104 vs 18 +/- 89 pg/mL, P <.05; norepinephrine: Delta-1.3 +/- 2.9 vs 0.6 +/- 1.8, P <.05). Within-patient comparison showed that neurohormone levels were higher and exercise capacity lower while patients were receiving 10 mg of enalapril per day than when they were receiving 40 mg per day (ANP: 172 +/- 148 vs 139 +/- 122 pg/mL, P <.01; BNP: 193 +/- 244 vs 152 +/- 225 pg/mL, P <.005; norepinephrine: 4.2 +/- 2.2 vs 3.5 +/- 1. 6 nmol/L, P <.05; maximal oxygen consumption 22.0 +/- 4.4 vs 21.3 +/- 4.3 mL. kg(-1). min(-1) P <.05). Similar differences were observed when comparing these variables, and patients had lowest and highest enalaprilat trough levels. CONCLUSIONS High doses of enalapril resulted in an improvement of exercise capacity and reduction of neurohumoral stimulation, whereas these parameters worsened after reduction of enalapril dose. Thus patients with congestive heart failure may benefit from increasing dosage of ACE inhibitors.
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Affiliation(s)
- H P Brunner-La Rocca
- Division of Cardiology, Institute of Clinical Chemistry, Department of Internal Medicine, University Hospital, Zurich, Switzerland
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772
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Brunner-La Rocca HP, Weilenmann D, Schalcher C, Schlumpf M, Follath F, Candinas R, Kiowski W. Prognostic significance of oxygen uptake kinetics during low level exercise in patients with heart failure. Am J Cardiol 1999; 84:741-4, A9. [PMID: 10498150 DOI: 10.1016/s0002-9149(99)00426-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Oxygen uptake kinetics during low-intensity exercise were investigated in 48 patients with congestive heart failure to assess their prognostic value compared with established predictors of prognosis including neurohumoral stimulation. Mean response time of oxygen uptake during low-intensity exercise, which does not require the patient's maximal effort, appears to be an important predictor of prognosis in these patients.
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773
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Auricchio A, Klein H, Spinelli J. Pacing for heart failure: selection of patients, techniques and benefits. Eur J Heart Fail 1999; 1:275-9. [PMID: 10935675 DOI: 10.1016/s1388-9842(99)00037-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
Affiliation(s)
- A Auricchio
- Department of Cardiology, University Hospital, Magdeburg, Germany.
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774
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Daubert JC, Cazeau S, Leclercq C. Do we have reasons to be enthusiastic about pacing to treat advanced heart failure? Eur J Heart Fail 1999; 1:281-7. [PMID: 10935676 DOI: 10.1016/s1388-9842(99)00042-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- J C Daubert
- Département de Cardiologie et Maladies Vasculaires, Centre Cardio-Pneumologique, Hôpital Pontchaillou, Rennes, France
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775
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Shamim W, Francis DP, Yousufuddin M, Varney S, Pieopli MF, Anker SD, Coats AJ. Intraventricular conduction delay: a prognostic marker in chronic heart failure. Int J Cardiol 1999; 70:171-8. [PMID: 10454306 DOI: 10.1016/s0167-5273(99)00077-7] [Citation(s) in RCA: 276] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Chronic heart failure (CHF) is associated with high mortality, and there are several established clinical and laboratory parameters that predict mortality in CHF. The purpose of this study was (a) to identify the best ECG parameter that predicts mortality, (b) to evaluate the prognostic marker of ECG against well-established indicators of prognosis. Relevant data from 241 CHF patients were analysed retrospectively. Cardiopulmonary exercise testing and radionuclide ventriculogram were also performed where possible. The mean follow-up period was 31 months. On univariate analysis by the Cox proportional Hazard method, intraventricular conduction delay (IVCD) [P<0.0001, hazard ratio 1.017 (1.011-1.024)] and QTc [P<0.0001, hazard ratio 1.012 (1.006-1.017)] were identified as predictors of mortality. On bivariate analysis, IVCD and MVO2 were better predictors when combined together. A model based on multivariate analysis showed that IVCD, MVO2 and left ventricular ejection fraction (LVEF) were the best predictors of mortality. The addition of plasma sodium, age and NYHA class had no added benefit on the predictive power of the model. Further analysis of IVCD and QTc showed that, for different cut-off values, IVCD is better than QTc, and that there is a graded increase in mortality with increasing value of IVCD. We have found that IVCD is an important ECG predictor of prognosis in patients with CHF.
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Affiliation(s)
- W Shamim
- Royal Brompton Hospital and National Heart and Lung Institute, Cardiac Medicine Department, London, UK.
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776
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Mahoney P, Kimmel S, DeNofrio D, Wahl P, Loh E. Prognostic significance of atrial fibrillation in patients at a tertiary medical center referred for heart transplantation because of severe heart failure. Am J Cardiol 1999; 83:1544-7. [PMID: 10363868 DOI: 10.1016/s0002-9149(99)00144-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Atrial fibrillation (AF) occurs frequently in advanced heart failure. The prognostic significance of AF remains controversial. To determine the relation of AF to survival in patients with advanced heart failure, 234 consecutive patients referred for heart transplantation evaluation from January 1993 to June 1996 were studied to determine the effect of AF on event-free survival (freedom from death, heart transplantation, or placement of a left ventricular assist device). Clinical characteristics of the study population included: age, 51 +/- 17 years; maximum exercise oxygen consumption, 14.2 +/- 5.3 ml/kg/min; left ventricular ejection fraction, 24 +/- 11%; pulmonary capillary wedge pressure, 23 +/- 9 mm Hg; and ischemic etiology, 52%. Medical therapy included: diuretics (86%), angiotensin-converting enzyme inhibitors (80%), digoxin (80%), and anticoagulation therapy (72%). Mean duration of follow-up was 1.1 +/- 1.0 years. Sixty-two patients (27.4%) had AF. One-year event-free survival of the study population was 48%. No difference in event-free survival between patients with and without AF was observed. Univariate predictors of decreased event-free survival included: (1) advanced New York Heart Association class; (2) higher pulmonary capillary wedge pressure; (3) lower cardiac index; (4) lower maximum exercise oxygen consumption; (5) use of inotropic therapy; and (6) greater pulmonary artery systolic pressure. By multivariate analysis, independent predictors of decreased event-free survival included advanced New York Heart Association class (p <0.002) and higher pulmonary capillary wedge pressure (p = 0.02). Thus, AF in patients with advanced heart failure is not associated with decreased event-free survival.
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Affiliation(s)
- P Mahoney
- Department of Medicine, and Center for Clinical Epidemiology and Biostatistics, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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777
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Aaronson KD, Mancini DM. Mortality remains high for outpatient transplant candidates with prolonged (>6 months) waiting list time. J Am Coll Cardiol 1999; 33:1189-95. [PMID: 10193715 DOI: 10.1016/s0735-1097(98)00697-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The study aimed to determine the risk of death or urgent transplant for patients who survived an initial 6 months on the outpatient heart transplant waiting list when criteria emphasizing reduced peak oxygen consumption are used for transplant candidate selection. BACKGROUND Waiting time is a key criterion for heart donor allocation. A recent single-center investigation described decreasing survival benefit from transplant for patients who survived an initial 6 months on the outpatient waiting list. METHODS Kaplan-Meier survival analyses were performed for 80 patients from the Hospital of the University of Pennsylvania (HUP) listed from July 1986 to January 1991, and 132 patients from Columbia-Presbyterian Medical Center (CPMC) listed from September 1993 to September 1995. Survival from the time of outpatient listing for the entire group (ALL) was compared to subsequent survival from 6 months onward for those patients who survived the initial 6 months after placement on the outpatient list (6M). Both urgent transplant and left ventricular assist device implantation were considered equivalent to death; elective transplant was censored. RESULTS Survival for 6M was not significantly better than ALL at HUP (subsequent 12 months: 60+/-7 vs. 60+/-6% [mean+/-SD]; p = 0.89) nor at CPMC (subsequent 12 months: 60+/-6 vs. 48+/-5%; p = 0.35). Survival for 6M at both centers was substantially lower than survival following transplant from the outpatient list in the United States in 1995. CONCLUSIONS When high-risk patients are selected for nonurgent transplant listing, mortality remains high, even among those who survive the initial six months after listing. Time accrued on the waiting list remains an appropriate criterion for donor allocation.
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Affiliation(s)
- K D Aaronson
- Division of Cardiology, University of Michigan Medical School, Ann Arbor, USA.
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778
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Metra M, Faggiano P, D'Aloia A, Nodari S, Gualeni A, Raccagni D, Dei Cas L. Use of cardiopulmonary exercise testing with hemodynamic monitoring in the prognostic assessment of ambulatory patients with chronic heart failure. J Am Coll Cardiol 1999; 33:943-50. [PMID: 10091820 DOI: 10.1016/s0735-1097(98)00672-x] [Citation(s) in RCA: 86] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We studied whether direct assessment of the hemodynamic response to exercise could improve the prognostic evaluation of patients with heart failure (HF) and identify those in whom the main cause of the reduced functional capacity is related to extracardiac factors. BACKGROUND Peak exercise oxygen consumption (VO2) is one of the main prognostic variables in patients with HF, but it is influenced also by many extracardiac factors. METHODS Bicycle cardiopulmonary exercise testing with hemodynamic monitoring was performed, in addition to clinical evaluation and radionuclide ventriculography, in 219 consecutive patients with chronic HF (left ventricular ejection fraction, 22 +/- 7%; peak VO2, 14.2 +/- 4.4 ml/kg/min). RESULTS During a follow-up of 19 +/- 25 months, 32 patients died and 6 underwent urgent transplantation with a 71% cumulative major event-free 2-year survival. Peak exercise stroke work index (SWI) was the most powerful prognostic variable selected by Cox multivariate analysis, followed by serum sodium and left ventricular ejection fraction, for one-year survival, and peak VO2 and serum sodium for two-year survival. Two-year survival was 54% in the patients with peak exercise SWI < or = 30 g x m/m2 versus 91% in those with a SWI >30 g x m/m2 (p < 0.0001). A significant percentage of patients (41%) had a normal cardiac output response to exercise with an excellent two-year survival (87% vs. 58% in the others) despite a relatively low peak VO2 (15.1 +/- 4.7 ml/kg/min). CONCLUSIONS Direct assessment of exercise hemodynamics in patients with HF provides additive independent prognostic information, compared to traditional noninvasive data.
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Affiliation(s)
- M Metra
- Cattedra di Cardiologia, Universitá di Brescia, Italy.
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779
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Beniaminovitz A, Mancini DM. The role of exercise-based prognosticating algorithms in the selection of patients for heart transplantation. Curr Opin Cardiol 1999; 14:114-20. [PMID: 10191969 DOI: 10.1097/00001573-199903000-00007] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The selection of patients for heart transplantation involves the use of multiple prognostic variables. Because of the complexity of the clinical syndrome of heart failure, central cardiac and peripheral maladaptations occur. Exercise capacity simultaneously assesses cardiovascular reserve and evaluates the peripheral maladaptations; accordingly, exercise testing has become an increasingly important tool in the risk stratification of these patients. Established prognostic indicators in heart failure are reviewed. The role exercise testing plays in selecting ambulatory patients for heart transplantation is emphasized.
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Affiliation(s)
- A Beniaminovitz
- Columbia Presbyterian Medical Center, Department of Medicine, New York, NY 10032, USA
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780
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Brunner-La Rocca HP, Weilenmann D, Follath F, Schlumpf M, Rickli H, Schalcher C, Maly FE, Candinas R, Kiowski W. Oxygen uptake kinetics during low level exercise in patients with heart failure: relation to neurohormones, peak oxygen consumption, and clinical findings. Heart 1999; 81:121-7. [PMID: 9922345 PMCID: PMC1728933 DOI: 10.1136/hrt.81.2.121] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To investigate whether oxygen uptake (VO2) kinetics during low intensity exercise are related to clinical signs, symptoms, and neurohumoral activation independently of peak oxygen consumption in chronic heart failure. DESIGN Comparison of VO2 kinetics with peak VO2, neurohormones, and clinical signs of chronic heart failure. SETTING Tertiary care centre. PATIENTS 48 patients with mild to moderate chronic heart failure. INTERVENTIONS Treadmill exercise testing with "breath by breath" gas exchange monitoring. Measurement of atrial natriuretic factor (ANF), brain natriuretic peptide (BNP), and noradrenaline. Assessment of clinical findings by questionnaire. MAIN OUTCOME MEASURES O2 kinetics were defined as O2 deficit (time [rest to steady state] x DeltaVO2 -sigmaVO2 [rest to steady state]; normalised to body weight) and mean response time of oxygen consumption (MRT; O2 deficit/DeltaVO2). RESULTS VO2 kinetics were weakly to moderately correlated to the peak VO2 (O2 deficit, r = -0.37, p < 0.05; MRT, r = -0.49, p < 0.001). Natriuretic peptides were more closely correlated with MRT (ANF, r = 0.58; BNP, r = 0.53, p < 0.001) than with O2 deficit (ANF, r = 0.48, p = 0.001; BNP, r = 0.37, p < 0.01) or peak VO2 (ANF, r = -0.40; BNP, r = -0.31, p < 0.05). Noradrenaline was correlated with MRT (r = 0. 33, p < 0.05) and O2 deficit (r = 0.39, p < 0.01) but not with peak VO2 (r = -0.20, NS). Symptoms of chronic heart failure were correlated with all indices of oxygen consumption (MRT, r = 0.47, p < 0.01; O2 deficit, r = 0.39, p < 0.01; peak VO2, r = -0.48, p < 0. 01). Multivariate analysis showed that the correlation of VO2 kinetics with neurohormones and symptoms of chronic heart failure was independent of peak VO2 and other variables. CONCLUSIONS Oxygen kinetics during low intensity exercise may provide additional information over peak VO2 in patients with chronic heart failure, given the better correlation with neurohormones which represent an index of homeostasis of the cardiovascular system.
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Affiliation(s)
- H P Brunner-La Rocca
- Department of Internal Medicine, Division of Cardiology, University Hospital, Zurich, Switzerland
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781
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782
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Affiliation(s)
- K F Adams
- Department of Medicine, School of Medicine, University of North Carolina, Chapel Hill 27599-7075, USA
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783
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Opasich C, Pinna GD, Bobbio M, Sisti M, Demichelis B, Febo O, Forni G, Riccardi R, Riccardi PG, Capomolla S, Cobelli F, Tavazzi L. Peak exercise oxygen consumption in chronic heart failure: toward efficient use in the individual patient. J Am Coll Cardiol 1998; 31:766-75. [PMID: 9525544 DOI: 10.1016/s0735-1097(98)00002-3] [Citation(s) in RCA: 118] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study sought to 1) assess the short-, medium-and long-term prognostic power of peak oxygen consumption (VO2) in patients with heart failure; 2) verify the consistency of a nonmeasurable anaerobic threshold (AT) as a criterion of nonapplicability of peak VO2; 3) develop simple rules for the efficient use of peak VO2 in individualized prognostic stratification and clinical decision making. BACKGROUND Peak VO2, when AT is identified, is among the indicators for heart transplant eligibility. However, in clinical practice the application of defined peak VO2 cutoff values to all patients could be inappropriate and misleading. METHODS Six hundred fifty-three patients consecutively considered for eligibility for heart transplantation were followed up. Outcomes (cardiac death and urgent transplantation) were determined when all survivors had a minimum of 6 months of follow-up. RESULTS Contraindication to the exercise test identified very high risk patients. The relatively small sample of women did not allow inferences to be drawn. In men, peak VO2 stratified into three levels (< or = 10, 10 to 18 and >18 ml/kg per min) identified groups at high, medium and low risk, respectively. The prognostic power of peak VO2 < or = 10 ml/kg per min was maintained even when the AT was not detected. In patients in New York Heart Association functional class III or IV, peak VO2 did not have prognostic power. In patients in functional class I or II, peak VO2 stratification was prognostically valuable, but less so at 6 than at 12 or 24 months. Age did not influence peak VO2 prognostic stratification. CONCLUSIONS A contraindication to exercise testing should be considered a priority for listing patients for heart transplantation. Only in less symptomatic male patients does a peak VO2 < or = 10 ml/kg per min identify short-, medium- and long-term high risk groups. A peak VO2 >18 ml/kg per min implies good prognosis with medical therapy.
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Affiliation(s)
- C Opasich
- Salvatore Maugeri Foundation, Institute of Care and Scientific Research, Medical Center of Montescano (Pavia), Italy
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